MULTIPLE PAPILLOMA OF THE LARYNX 
IN YOUNG CHILDREN, AND 
ITS TREATMENT. 
Clinical Lecture delivered at the Dartmouth Medical College. 
By FRANKLIN H. HOOPER. M.D.. 
Professor of Laryngology, Dartmouth Medical College; Instructor in Laryngology, 
Harvard University; Physician to the Throat Department, 
Massachusetts General Plospital. 
[Reprinted from International Clinics, October, 1891.] MULTIPLE PAPILLOMA OF THE LARYNX IN 
YOUNG CHILDREN, AND ITS TREATMENT. 
CLINICAL LECTURE DELIVERED AT THE DARTMOUTH MEDICAL COLLEGE. 
Professor of Laryngology, Dartmouth Medical College ; Instructor in Laryngology, 
Harvard University; Physician to the Throat Department, 
Massachusetts General Hospital. 
BY FRANKLIN H. HOOPER, M.D., 
Gentlemen,—We come to-day to the consideration of a disease 
occasionally met in infancy and early childhood that mechanically ob- 
structs the breathing, and unless recognized and treated in time destroys 
life by suffocation. 
This affection has its seat on the vocal cords and walls of the 
larynx, and is characterized by soft, whitish, multiple, and often rapidly- 
growing, warty growths called papillomata. It may sound like an 
extraordinary statement, but I believe I am correct in making it, that 
prior to the year 1850 all the children who were the subjects of this 
complaint died from asphyxiation, without having had any rational 
treatment and without even the nature of their trouble being sus- 
pected. Happily, the number was not large, as the disease is a very 
rare one. 
After what we learned the other day about the laryngoscope and its 
uses, you will naturally ask yourselves why, if these patients had 
symptoms referable to the larynx, some one did not look into that 
organ and find out if anything was wrong there. But it should be 
remembered that the laryngoscope was not invented until 1858. It was 
in the ante-laryngoscopic days, therefore, that these children fell vic- 
tims to an undiscovered and unsuspected disease. And this leads me 
to say that one of the happiest triumphs of laryngoscopy is that it 
enables us to discover foreign growths in the air-passages which, if not 
discovered and treated, may eventually cause death. It is odd, indeed, 
1 2 
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nowadays to read of cases like the following: Pelletan, a surgeon 
who lived in the early part of this century, lost a patient of from thirty 
to forty years of age by suffocation. The autopsy showed that the 
larynx was blocked by a solid tumor. Pelletan remarks that “ the 
cause of the accident could neither be known nor attacked ; dissection 
alone could reveal it.” In these days the laryngoscopic mirror would 
make everything clear to us. But in infants and young children who 
are rebellious, we find obstacles that render a laryngoscopic examina- 
tion impossible, because the co-operation of the patient is necessary 
to make such an examination thoroughly satisfactory. How, then, 
are we to manage with very young or unruly children? I shall 
speak of this fully when I come to, the treatment of the affection. I 
will merely say here that, after giving you the clinical picture of mul- 
tiple papilloma of the larynx, the two points I wish to impress upon 
your minds are : first, the practicability of examining young children 
with the laryngoscope when they are anaesthetized, and, second, the 
feasibility of operating upon them under ether in the manner employed 
in the adult without ether. I shall now call your attention to the his- 
tories of four typical cases of this affection that have come under my 
observation. • 
Case I.—G. E. C. D., a boy, aged five years, was first brought 
by his mother to the Throat Department of the Massachusetts Gen- 
eral Hospital, on October 22, 1888. He had been “croupy” since 
he was two years old. When he was three years of age he began to 
grow hoarse. The hoarseness steadily increased, until for the space 
of a year he had been unable to speak above a low whisper. There 
was no pain, but considerable dyspnoea on exertion, and at night his 
breathing was heavy and labored. His mother thought he breathed 
better at the time of consultation than he did four months previously. 
Nine months before his visit he had bronchitis which lasted two 
months. 
This child being very docile, and having a spacious pharynx for 
his age, a laryngoscopic examination was effected with ease, and revealed 
whitish, papillomatous masses lining the walls of the larynx. The 
larynx was not so completely filled by the growths as to prevent easy 
breathing during the day, unless the child made some exertion. He 
was not seen again until November 30. Meantime he had had an 
attack of jaundice, and after that there had been more difficulty in 
breathing. The respiration was now noisy by day, and still worse by 
night. For the past week he had awoke every night oppressed for 
breath and was unable to breathe for a few seconds. MULTIPLE PAPILLOMA OF THE LARYNX. 
3 
The laryngoscope showed that the growths had increased during 
the interval. They were attached to both walls of the larynx and 
reached to the level of the ary-epiglottic folds. It was, of course, im- 
possible to determine how deep was their attachment downward. 
Although the child submitted readily to laryngoscopic examination, 
he rebelled against every attempt at any operative measure through 
the mouth. 
Tracheotomy was advised, and he was admitted to the hospital in 
the service of Dr. J. C. Warren. 
During the night of December 2 the child had two coughing spells, 
breathed hard, and became cyanosed, but was relieved by hot applica- 
tions to the neck. The next day, December 3, the dyspnoea became 
much more urgent, the sternum being sucked in with each inspiration, 
with recession of the soft parts above the clavicles. Tracheotomy 
under ether was performed by Dr. Warren, just below the cricoid car- 
tilage. Four days later the stitches were removed. There was very 
little trouble, with the exception of a slight muco-purulent discharge 
through the tube. The child was now breathing freely through the 
tracheotomy-tube. This measure, it must be understood, was merely 
temporary and palliative, and the question now arose as to the proper 
means by which the obstructing growths in the larynx could be re- 
moved. The usual procedure in similar cases would be to perform 
thyrotomy and then cut or scrape away the growths from the interior 
of the larynx, an operation not very dangerous in itself, but apt to lead 
to serious complications, such as stricture of the larynx and permanent 
impairment of the voice. 
I explained to Dr. Warren a method I wished to try for the first 
time, as a substitute for thyrotomy, and by his courtesy the child was 
placed in my care. I waited for a day when the sun should shine 
brightly, which occurred on December 12, and then, in one sitting that 
lasted about an hour, the large papillomatous mass that you see here 
in this vial was removed through the mouth by the following methods : 
The child was thoroughly etherized, and was then seated upright in 
the lap of a nurse. The mouth was held open by a gag. The tongue 
was pulled gently forward and held by an assistant. The sunlight 
was then reflected into the pharynx, and witli a small-sized laryngo- 
scopic mirror I was enabled to obtain a perfect view of the interior 
of the larynx, all secretion having been previously wiped away. Then 
by means of the mirror, seeing perfectly what I was about, I pro- 
ceeded to remove the growths in the manner customarily adopted with 
adults not under the influence of an anaesthetic. The instruments used 4 
INTERNATIONAL CLINICS. 
were the laryngeal forceps and curette. Each instrument was intro- 
duced many times, and small pieces of the papilloma were successfully 
brought away until the larynx was free. The growths were found to 
be attached to the lateral and anterior walls of the larynx, to the ven- 
tricles, to the vocal cords, and to the sides of the trachea just below 
the vocal cords. The hemorrhage was slight, and no reaction followed 
the operation. 
The next day, December 13, a cork was placed in the tracheal 
opening and the child breathed freely through the natural channels. 
On December 14 the tracheotomy-tube was removed, and the opening 
in the neck closed. On December 16 the tracheal opening healed. On 
the 18th he was discharged from the hospital, breathing naturally, and 
being able to speak in a loud whisper. 
This child has since been seen at intervals, in the out-patient de- 
partment, but no treatment of any nature has been directed to the 
larynx. 
One of the characteristics of this form of growth is its tendency to 
recur. In this case a recurrence was detected in July, 1889, when a 
small nodule was seen on the left ventricular band, and a short time 
later the ventricular band on the opposite side also became involved. 
The growth increased for a time, but in January, 1890, it had percep- 
tibly diminished, and the voice had greatly improved. This child was 
last examined in April, 1891, two years and four months after the op- 
eration. His general condition was excellent, and the breathing quite 
natural. The voice had gained in strength, but was still hoarse. The 
laryngoscopic examination showed that the interior of the larynx, to 
a point below the vocal cords, was rough, and here and there were 
noticed small nodules of the growth, the larger portions being on the 
lateral walls in the region of the ventricular bands. Unless the growth 
should again show a tendency to disappear spontaneously (which is not 
likely) attempts will be made to remove the remaining portions with a 
curette through the mouth. The child is now so much older that he 
may prove more tractable to intralaryngeal operations ; if, however, he 
should not submit, he will again be etherized and operated on as before, 
but without a preliminary tracheotomy being performed. 
Case II.—H. C. W., male, aged five, was referred to me at the 
Boston City Hospital by Dr. Charles W. Haddock, of Peabody, Mass., 
on May 13, 1889. The child was well nourished, and with the excep- 
tion of the condition of his larynx was a perfectly healthy boy. In 
the past year he had been steadily growing hoarse, which began with 
an attack of whooping-cough, and when first seen he was practically MULTIPLE PAPILLOMA OF THE LARYNX. 
5 
aphonic. He had considerable dyspnoea on exertion, and at night had 
great difficulty in breathing. 
The child was very tractable, and his confidence was easily gained, 
and a laryngoscopic examination was made at his first visit. It re- 
vealed a large whitish growth attached to the anterior wall of the 
larynx, between and above the vocal cords, and filling up about three- 
quarters of the lumen of the glottis. With forced respiration the 
growth moved up and down. 
All attempts to remove it in the customary manner through the 
mouth having failed, on June 27 the child was etherized, and, with 
the assistance of Dr. J. Payson Clark, I operated by means of the 
laryngoscope, the patient being seated upright in the lap of a nurse, as 
described in Case I. In this instance, however, the patient was not 
tracheotomized, which greatly added to the difficulty and danger of the 
operation, a point to which I shall again refer. The child took ether 
perfectly, there was no sign ©f spasm of the glottis, very little secretion, 
and no hemorrhage at all alarming. Two days after the operation the 
child was again examined, and a small portion of the growth was seen 
remaining between the angle of the vocal cords. The breathing had 
become normal at night, and he was able to speak in a hoarse voice. 
He was not seen again until December, 1889. The growth between 
the vocal cords had increased in size. This was removed by the curette 
in the ordinary way, the patient having become much more tolerant of 
the intralaryngeal procedure. 
In response to my call the child came to see me on April 22, 1891. 
There had been no return of the growth. His health is perfect. His 
voice has steadily improved and is now very good, indeed, although 
slightly muffled, owing to the anterior portions of the vocal cords 
being still a little thickened. 
Case III.—E. D., a negro child, aged five, was first seen at the 
Massachusetts General Hospital, November 14, 1889. His history 
closely resembled that of Case II. His symptoms were difficult 
breathing and aphonia. He began to grow hoarse one year previ- 
ously, and this had steadily increased until, when seen, his voice was a 
very low whisper, and it was with difficulty that he could be induced 
to utter any sound at all. His breathing, when awake, unless he 
made some exertion, was good, but at night it was distressingly labored, 
and some one was obliged to sit up with him for fear of suffocation. 
He was strong, well nourished, obstinate, and exceedingly difficult to 
examine with the laryngoscope. A perfect view, however, was finally 
obtained, and a large papillomatous mass was seen filling up the 6 
INTERNATIONAL CLINICS. 
laryngeal cavity. It appeared to be one distinct tumor, attached to 
the right side of the larynx. 
On November 26, preparations having been made for tracheotomy, 
in case it should be necessary, the child was etherized, seated upright 
in the nurse’s lap in the sunlight, and with the aid of the laryngoscope 
I proceeded to remove the growth. 
The instruments used were the laryngeal snare, Schrotter’s tube, 
forceps, and the curette. The operation lasted one hour and a quarter. 
The larger portion of the growth was taken away with the snare; 
the bleeding was insignificant, and during the process of etherization 
and the operation there was not the slightest indication for the perform- 
ance of tracheotomy. 
Examination ten days after the operation showed that a little of 
the growth still remained on the anterior portion of the right side of 
the larynx, apparently springing from the ventricle. The breathing, 
by day and by night, had become perfectly normal. The voice was 
very good, but hoarse. 
The child was not seen again for more than a year, when it was 
found that the right side of the larynx and the right vocal cord were 
perfectly healthy. The left ventricular band, however, is now occupied 
by the growth, which prevents the left cord from being seen. There 
is also a good-sized nodule attached to the anterior wall of the larynx, 
just under the right vocal cord, which moves freely with respiration. 
The voice is very good indeed, but husky. The breathing is unob- 
structed, and the child is perfectly healthy. Since he was last exam- 
ined he has become most tractable, and the laryngoscopic examination 
was effected as easily as on the adult. Another operation will be 
necessary in this case. 
Case IV.—I am indebted to the surgical records of the Massa- 
chusetts General Hospital for the early history of this child, and to 
the kindness of Dr. C. B. Porter for placing him under my care the 
second time he was admitted to the hospital. 
E. K., male, aged two years, first came to the out-patient depart- 
ment of the Massachusetts General Hospital, May 14, 1889. He was 
strong and healthy. He began to talk at the usual age, and could say 
a few words plainly. About three or four months ago a slight huski- 
ness was noticed in the voice, which grew rapidly worse, and for the 
past two months the voice has been lost entirely. Since then the res- 
piration has been very difficult and labored. He was seen by Drs. F. 
I. Knight and S. W. Langmaid, and recommended to the hospital for 
tracheotomy. He entered with labored breathing and loud whizzing MULTIPLE PAPILLOMA OF THE LAEYNX. 
7 
sound with each respiration; depression of epigastrium and supra- 
clavicular spaces very marked. He could make no sound, either of 
talking or crying. 
The patient was tracheotomized by Dr. J. W. Elliot. The opera- 
tion was performed without any especial difficulty, and was followed 
by great relief to the breathing. The child did well until six days 
after the operation, when he came down with an attack of measles. 
This proved to be mild, and soon subsided. He was discharged in 
excellent condition on June 6, as there was a case of diphtheria in the 
ward. The tube was still in, and he was told to return. He was not 
seen again until December 3, 1890, one year and seven months after 
being tracheotomized. He was brought back on account of difficult 
breathing. The tube was found to be in good position ; it could be 
easily removed and easily put back. With the tube out, the child 
inhaled perfectly through the mouth, but exhaled through the tube- 
hole. 
It was impossible for him to breathe with the tracheal opening 
closed. Owing to the child’s bad temper, all attempts to examine him 
with the laryngoscope were useless. Accordingly, on January 7,1891, 
he was etherized solely for diagnostic purposes, and with the sunlight 
a perfectly satisfactory laryngoscopic examination was made. He was 
held upright in the nurse’s lap, the mucus in the pharynx wiped away, 
the mouth held open by a gag, and, the pharynx being spacious for 
such a young child, a perfect view of the interior of the larynx was 
obtained, a small-sized rhinoscopic mirror being used. The cause of 
the difficulty was at once apparent. The larynx was seen to be com- 
pletely blocked by a whitish papillomatous mass attached to the ante- 
rior and lateral walls. On January 15 he was again placed under 
ether, and, with the laryngoscope, in the manner described in the pre- 
vious cases, I removed the growths. The operation, in which I was 
assisted by Dr. J. P. Clark and Dr. F. C. Cobb, lasted one hour. The 
instruments used were the laryngeal forceps and the curette. The papil- 
loma was exceedingly soft, and the bleeding was not at all troublesome. 
On January 16 the temperature was normal and the general condi- 
tion excellent. On January 17 a cork was placed in the tracheotomy 
tube and retained there for some time, the child breathing perfectly 
through the natural channels. The tube was removed and the tracheal 
opening closed with plaster. On January 20 the opening in the neck 
had healed, he breathed naturally, his voice could be heard across the 
ward, and he was improving daily. The child remained in the hos- 
pital until February 23, when he was discharged in excellent condition. 8 
INTERNATIONAL CLINICS. 
The salient symptoms common to all the cases related above, as 
will have been noticed, pertain to the alteration in the tone of the 
voice and to the difficulty in breathing. In all similar cases the his- 
tory will be the same. It is rare for these growths to be congenital, 
yet there are a few instances recorded. It is usually at about the first, 
second, or third year that the symptoms begin to manifest themselves, 
and the first thing noticed is that the child is hoarse. This, however, 
instead of passing off in a few days, as is usually the case, persists and 
constantly grows worse, until the voice is reduced to a low whisperer 
even, as in Case IV., no sound whatever can be made. 
The next symptom to make its appearance is a difficulty iff breath- 
ing. This comes on at varying intervals, according to the case, some- 
times in a few months, and sometimes not for years after the first alter- 
ation in the voice. It is at night, while the child is asleep, that the 
labored breathing first manifests itself. During the dliild may 
be running about and playing, the picture of health, and breathing 
freely, but as soon as he falls asleep, the will-power being gonp,'the parts 
become relaxed and the respiration labored and noisy. As time goes 
on and the growths increase in size, the breathing by cloy, becomes 
difficult, especially when any exertion is made. If the child Is at rest, 
the breathing may not attract attention as being abnormal, and yet the 
larynx may be nearly filled by the growths. Do not allow yourselves 
to be deceived and caught napping by this peculiarity of the breathing. 
It is remarkable how easy the breathing may be when there is almost 
complete occlusion of the larynx, provided the individual be awake and 
not making any effort. Be on your guard, therefore, in respect to this 
insidious symptom. Suspect papillomata of the larynx when you meet 
with these sturdy, healthy-looking children who have a history of long- 
continued, labored breathing, and hoarseness or loss of voice. 
Other symptoms which may be present are cough, rarely trouble 
in swallowing, and pain. You will have remarked that all the cases 
I have reported were boys. This affection is much more frequent 
in males than in females. Causit,1 who has written a most complete 
monograph on the subject, estimates the predominance of males over 
females, attacked by this disease, to be in the proportion of twenty- 
eight to fourteen. It is difficult—in fact, at present it is impossible 
—to say what causes this affection in children. Diphtheria, croup, 
measles, and whooping-cough are said to be predisposing factors. The 
children who came under my observation were robust, vigorous, and 
1 Etude sur les Polypes du Larynx, Paris, 1867. MULTIPLE PAPILLOMA OP THE LARYNX. 
9 
healthy-looking boys, sound iu every organ with the exception of this 
local growth in the larynx. 
Authors, such as Ehrmann, Horace Green, and Sir Morell Macken- 
zie, who have written well-known works on the subject of growths in 
the larynx, are of the opinion that any prolonged irritation may lead 
to the formation of these pathological products. Our New England 
climate occasions much irritation and chronic congestion in various 
portions of the air-tract in the larger proportion of the inhabitants, 
yet papilloma of the larynx is, fortunately, seldom met with, and the 
fact that it may be congenital leads me to think that its most impor- 
tant etiological factor is unknown. 
We come now to the practical questions of diagnosis and treatment. 
Ehrmann, who lived before the invention of the laryngoscope, 
said that there was but one certain sign of the existence of this dis- 
ease,—viz., the discharge by expectoration of some portions of the 
tumor. We can now affirm that the one certain method of deter- 
mining the presence of the growth is by employing the laryngoscopic 
mirror. 
Provided we can gain the confidence of young children, laryngo- 
scopic examinations can be easily made on them; otherwise they are 
impossible. In Case IV., detailed above, the child fought, kicked, 
and vomited at every attempt made to examine him, and nothing was 
ever effected with the laryngoscope until he was placed under ether. 
I would suggest that laryngoscopic examinations under ether should 
always be attempted for diagnostic purposes iu unruly children. Such 
examinations are facilitated by using sunlight for illuminating pur- 
poses. Then, after wiping away all accumulations of mucus in the 
pharynx, a perfect view of the larynx can be obtained, especially if 
the child has ample space between the base of the tongue and the 
posterior pharyngeal wall. 
Children vary greatly in this respect. They also vary greatly in 
the amount of secretion in the pharynx, which is the chief obstacle to 
these examinations under ansesthesia. But,, so far as my experience 
goes, after the child is thoroughly etherized and the mucus once care- 
fully wiped away, it is not again secreted rapidly enough or in sufficient 
quantity to hinder the examination. 
The presence of the growths having been determined, their removal 
should be effected in one sitting under ether, according to the method 
described in Case I. That child, it will be remembered, had been pre- 
viously tracheotomized, but iu Cases II. and III. the growths were 
removed in the same manner without a preliminary tracheotomy. The 10 
INTERNATIONAL CLINICS. 
operation by this method, difficult under any circumstances, is greatly 
facilitated if tracheotomy has been previously performed. But it is 
well to avoid this operation if possible. Whether tracheotomy should 
be done or not must be decided by the urgency of the case in refer- 
ence to the dyspnoea. If the growths occlude the larynx to such an 
extent as to cause labored and stridulous breathing by day when the 
child is not making any exertion, a preliminary tracheotomy should be 
done. If the breathing, however, is tolerably free, tracheotomy can 
be dispensed with. The admission of blood into the lungs is to be 
guarded against. In Cases II. and III., operated upon without trache- 
otomy, as soon as a portion of the growth was removed the child was 
reversed, and held witli its head down to allow what blood there was 
to escape by the mouth. The bleeding in the cases reported was not 
profuse and not at all troublesome. 
The instruments at our command to remove the growths are the 
forceps, the cold snare, and the curette. The selection of any particu- 
lar instrument will depend upon each individual case. These papillo- 
mata are friable, and cover a large surface in a very narrow organ. 
The instrument that has given me the most satisfaction is the curette. 
This instrument was made for me bv Codman & Slmrtleff, of Boston, 
and consists of a solid back so shaped that when the growth is scraped 
off it is caught in the depression at the lower end of the curette and 
thereby prevented from dropping down the trachea. The instrument 
is attached to a shank having the Schrotter curve, and can be readily 
watched while it is being manipulated in the larynx. This is an es- 
pecial advantage in young children, where the larynx is very small. 
When the growths have been cleared away no further treatment should 
be directed to the interior of the larynx. By this I mean to advise 
against cauterizing the seat of attachment of the growths in the hope 
of preventing their recurrence. You will find that the galvano-cau- 
tery, chromic acid, nitrate of silver, and other caustics, are recom- 
mended by many for this purpose, but experience has shown that such 
applications do little in preventing a regrowth, and there is danger of 
the cauterization being followed by adhesion between the vocal cords, 
which would be a serious complication. In my judgment, therefore, 
since cauterizations do not prevent a recurrence, in cases where the 
growths extend over a large surface the wisest course to pursue is to 
remove the obstruction as completely as possible so that free respira- 
tion may be established, and wait for the time when the growths shall 
cease to recur, removing them, meantime, if they should reach a size 
sufficient to impede the breathing. MULTIPLE PAPILLOMA OF THE LARYNX. 
11 
In closing, let me remind you that the disease we have been dis- 
cussing is an extremely rare one. Do not hastily conclude that the 
first children coming under your care who happen to be hoarse are the 
subjects of papilloma of the larynx. Many of you will pass the whole 
of your professional lives without meeting with a single case. But in 
view of the fatal nature of the affection if not recognized, your atten- 
tion should be called to it; and I trust that what has been said will 
enable you to detect it.