The history of the first laryngectomy and the attempts to restore voice is fascinating. A brief chronological summary of events is given. In the second half of the 19th century, the main German industries were chemicals and textiles. These were important to medicine because of industrial complimentary products like aniline dyes and anaesthetic gases. The first time that anaesthetic gas was applied to a human being was about 1848.20 Although the microscope was invented by Van Leeuwenhoek in the 17th century its use in medicine started only after Gehrlach showed, around 1850, that tissues could be stained differently with natural dyes. Aniline dyes further improved the quality of tissue staining which boosted histology and histopathology to new heights. Histology was started under Henle, Schwann and others. Virchow started histopathology in 1856.

During this era, laryngeal pathology could only be "diagnosed" on clinical grounds but not by visualization, let alone by pathological examination. Therefore, any laryngeal disease was rarely diagnosed. Important to the advances in laryngology was the discovery of the laryngoscope by Manual Garcia, a Spanish singing teacher, in 1854. Its usefulness in medicine was soon realized and people like Morell MacKenzie (1837-1892) and Czermak used this technique to explore the larynx. Garcia was invited to London in 1855 to demonstrate his technique of visualization of the larynx for the medical profession.

Indirect laryngoscopy to biopsy the larynx was perfected by MacKenzie in the 1870's. Before the discovery of cocaine as an anesthetic in the 1880's ice chips were used to suppress the gagging of the patient being examined. MacKenzie was the first to write a standard textbook on the throat.

The first laryngectomy, reported to the German Surgical Society in 1874 by Gussenbauer, was performed on a 36 year old religious instructor by Theodore Billroth (1829-1894).21 The patient had been hoarse for a period of 3 years and had been treated by cauterization with silver nitrate and liquor ferri injections. As the tumor grew it caused stridor which disappeared after removal of bits of tumor. The patient had a subglottic tumor that was mainly located on the left side. From the tissue samples, taken out of the larynx, the diagnosis epidermoid carcinoma was histologically made.

The patient was admitted to Professor Billroth's clinic in November 1873. Cautious, partly because of the prior work done by his assistant Vincenz Czerny, who in 1870 experimentally laryngectomized five dogs of which four died, Billroth decided to carry out a laryngofissure on November 21, 1873. The tumor was excised while preserving the right vocal cord. Unfortunately, by the middle of December laryngoscopy revealed massive granulations in the larynx. These were originally regarded as benign, but during Billroth's second operation on December 31, 1873, tumor recurrence was apparent. The patient was woken up and after explanation of the situation consensus was reached. The larynx was removed and the superior thyroid arteries ligated and the hyoid bone and epiglottis were left in place. The trachea was sutured to the skin. During this procedure the patient cleared blood from the trachea himself. The total operation took 1 hour and 45 minutes. Four hours after the operation bleeding occurred and was dealt with by compression with sponges. The patient was nourished with a gastric feeding tube through which supposedly mostly wine was passed. The 8th day the patient started to eat even though the pharynx was not surgically closed.

Four months after surgery, the patient was discharged, after having learned to speak with an artificial larynx designed by Gussenbauer. This artificial larynx shunted air from the trachea past a reed into the pharynx. The patient had a loud and clear monotonous voice. Billroth's patient died one year after surgery due to tumor recurrence.

Many surgeons realized this procedure had great potential and the second laryngectomy soon followed.22 Heine's patient died after six months. In 1881, Foulis reported on 27 recorded cases of total laryngectomy. Half of these patients died of pneumonia or other infections within the first week of surgery, another 25% died of tumor recurrence within ten months.23

Crown Prince Frederick of Germany, troubled by hoarseness, consulted a Berlin laryngologist in May 1887. The doctor found a lesion of the left vocal cord and the clinical diagnosis of cancer was made. MacKenzie was called from England to perform biopsies by indirect laryngoscopy. It is probable that MacKenzie advised the emperor, who had been a regular pipe smoker for more than 30 years, to stop smoking.24 He believed that nicotine was a systemic poison: it was hot smoke that harmed the voice.24 Virchow personally studied the slides and reported the tissue as benign. A second biopsy, performed in London five weeks later, gave the same result. Histology opposed the clear clinical diagnosis of cancer. The professors of surgery at the University of Berlin advocated laryngectomy on clinical grounds. Several months later the diagnosis of cancer was obvious. At the time of the definitive diagnosis, a tracheotomy was needed for subglottic obstructions which merely delayed Frederick's death.

By the beginning of the 20th century, Gluck reported the mortality of laryngectomy being 8.5%. An extreme low mortality rate when considering the major problems that occurred with anesthesia, wound infection and shock.25 In 1906, the mortality rate for radical neck dissections was 13%.26

The tragic story of Frederick underlined the long lasting disagreement between advocates of laryngeal biopsy and its skeptics. As late as 1922, practitioners opposed laryngeal biopsy being misleading and inducing spread of cancer.25

The importance of radiation therapy in modern treatment of laryngeal cancer has been well established. One of the pioneers in radiation therapy is of course Roentgen who discovered new rays that could penetrate opaque materials and which were emitted from a special vacuum tube in 1895. These rays could penetrate human tissue without direct pain or other feelings. It was recognized that these new rays did induce redness of the skin, blistering and ulcerations. The Curies isolated radium chloride in 1898, which was first used in 1901 in patients. X-rays were, in the early days, used for various ailments. In the beginning of this century, the low voltage X-ray machines were developed followed by the ortho-voltage machines. In 1922, the first laryngeal cancers were treated successfully with radiation therapy.27

During a regular meeting of the Chicago Laryngological and Otological Society Dr. M. Reese Guttman reported on the difficulties of voice rehabilitation and one remarkable patient.28 In Guttman's report the difficulties of electromechanical speech aids are discussed followed by esophageal speech related problems. He realized that certain anatomic conditions helped in regaining esophageal voice. " Roughly, patients can be divided into two classes, those that will talk and those that will not. Those that will talk apparently have the anatomic parts that are necessary to carry on conversation; by that is meant that they are able to swallow air into the esophagus and then belch it forth. They also have a well functioning cricopharyngeus, which apparently acts as a vicarious larynx."

During the same meeting Guttman also described one of his patients that was unable to communicate after his total laryngectomy. This patient however, used a heated ice pick with which he had made a fistula from the trachea into the hypopharynx. Whenever the patient occluded his tracheostoma air was shunted from the trachea towards the hypopharynx inducing resonance which made clear loud speech possible. The physicians were amazed. To avoid leakage of esophageal content into the airway and to avoid spontaneous closure of the fistula the patient used a goose quill.28 Inspired by his patient Guttman started performing this fistula technique using a diathermy needle. Nevertheless, results were disappointing. Fistula stenosis formed a recurrent problem.29

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