SOME INTERESTING LARYNGEAL NEOPLASMS 
BY 
WALTER F. CHAPPELL, M.D., M.R.C.S., ENG. 
SURGEON TO MANHATTAN EYE, EAR, AND THROAT HOSPITAL 
NEW YORK 
Reprinted from Manhattan Eye and Ear Hospital Reports, Jan., 1895 LARYNGEAL NEOPLASMS. 
WALTER F. CHAPPELL, M.D., M.R.C.S., ENG. 
DURING the past year an unusually large number of 
laryngeal diseases have been treated in my service at 
the hospital. Although they are not all of equal importance, 
every affection of this part of the respiratory tract may be con- 
sidered as having an interest of more or less individual na- 
ture. Especially is this true when the larynx is the seat of a 
new growth, the size, shape, situation, and nature of which 
may seriously alter the character of the vocal sounds and in- 
terfere with the functions of respiration and deglutition to 
such a degree as to imperil the life of the patient. Unfortu- 
nately, this condition is often reached before a physician has 
been consulted. Hoarseness, with impaired respiration and 
deglutition, are most frequently the initial symptoms of a seri- 
ous disease of the larynx ; their appearance, however, is usually 
so insidious that they may have existed for months without 
attracting much attention or causing discomfort. In due time 
something occurs which determines the necessity of a laryngeal 
examination, and the serious import of the symptoms is appre- 
ciated. Who can estimate how many lives might be saved if 
it were possible to see and make an early diagnosis of every' 
case of tubercular and cancerous disease of the larynx ? The 
histories of the following five patients are selected, as being 
the most unusual and interesting cases of laryngeal neoplasms, 
which were treated in my service in the throat department of 
the hospital during the year : 
Case i. Nora Ring, aged 5 years, came to the hos- 
pital March 19, 1894. Her mother said the child had been 
somewhat hoarse since birth, and suffered from frequent at- 
tacks of croup, especially during the winter months. For the 
past six months her breathing had been labored and was 
Reprinted from Manhattan Eye and Ear Hospital Reports, Jan., 1895 107 
LARYNGEAL NEOPLASMS. 
accompanied by choking and suffocative attacks at night. 
Three weeks before her visit to the hospital she contracted 
measles, and during the attack there was considerable irrita- 
tion of the upper respiratory tract. The recovery from the 
exanthem was uneventful, but the laryngeal symptoms con- 
tinued. Her condition on visiting the hospital was one of 
great discomfort-face pale and anxious, with bluish lips and 
alae nasi much distended at each inspiration ; the latter was 
difficult and labored, calling into action the accessory muscles 
during each inspiratory effort. The noisy respiration could 
be heard several feet away. Owing to the distressed breath- 
ing, no examination of the larynx could be made at this visit. 
Hot steam inhalations, with fomentations and a -fa of a grain 
Congenital Papillomata. 
Fig. t. 
of bichloride of mercury, were prescribed three times a day, 
and the child sent home. The temperature at this time was 
ioo° F. and pulse no. 
On the evening of March 20th the respiration became so 
labored that my assistant, Dr. Frank K. Roarke, was called. 
He introduced an O'Dwyer tube, but owing to the thick, tena- 
cious character of the mucus in the larynx and trachea, air 
would not pass readily through the tube. Respiration being 
more embarrassed by its introduction, it was removed, a high 
tracheotomy performed, and a small tracheal tube introduced. 
The next day the patient was admitted to the hospital, the 
pulse rate being at this time 136 and the temperature io2f° F. 
Recovery from the tracheotomy was uneventful, and on the 
7th of April the patient was able to walk about the ward. 
During the three weeks following admission to the hospital, a 
spasmodic cough became a troublesome feature, accompanied 
by the expectoration of yellow, ill-smelling, stringy mucus. CHAPPELL. 
108 
■Creosote and terebene were given alternate weeks for a month, 
improving the character and diminishing the quantity of the 
mucus. The tracheal tube was removed daily, and the wound 
and as much of the tracheal wall as could be reached with bent 
probes was cleansed with cotton dipped in peroxide of hydro- 
gen. After the frothy mucus had been wiped away the tube 
was reintroduced. Vinum ferri citratis was given from March 
30th to April 17th, when it was discontinued and liq. potassii 
arsenitis administered until the 20th day of May. This 
greatly improved the physical condition. Prior to this time 
no air had passed through the larynx when the tube was re- 
moved, but some respiration was now possible. The catarrhal 
symptoms of the trachea and upper bronchial tubes having greatly 
diminished, a laryngoscopic examination was made. The rima 
glottidis was found to be packed with irregular, red papilloma- 
tous masses of various sizes and shapes, which were seemingly 
attached to the ventricular bands and completely covered the 
vocal cords. Shreds of yellow mucus occupied the spaces 
between the growths. Alkaline sprays were employed daily in 
the larynx for some weeks, and a laryngoscopic examination 
made from time to time. About the middle of June, the 
papillomatous masses had lost their oedematous appearance and 
diminished so much in size that their individual characters 
could be observed and their attachments well determined. 
Prior to this observation, the laryngeal obstruction seemed to 
result from large, fleshy, fringed masses, as already described, 
but from a sketch taken in June and represented in Fig. 1, it 
will be seen that there were really seven distinct papillomata, 
which, owing to the catarrhal laryngitis had become swollen 
and oedematous. There were two papillomata on each cord, 
one in the inter-arytenoid space, and another in the anterior 
commissure near the lower part of the cushion of the epiglottis, 
but above the cords ; while another was attached to the ante- 
rior wall of the trachea immediately below the cords. The 
latter growth could be seen through the opening in the trachea 
and, as will be related, was subsequently removed, through the 
tracheal wound. During the succeeding summer months, 
creosote was administered daily and the patient allowed as 
much out-of-door exercise as possible. The papillomata 
gradually diminished in size until by the 1st of October, those 
on the cords and the one in the posterior commissure had en- 
tirely disappeared, leaving the cords red and somewhat thick- 
ened. The growth in the anterior part of the larynx had 
diminished in size, but had a firm, nodular appearance. As 
the patient was anxious to leave the hospital, the removal of 
the remaining portions was decided upon, and effected after 109 
LARYNGEAL NEOPLASMS. 
considerable training of the throat. The removal of the 
papillomata above the cords was effected in three sittings with 
Mackenzie's forceps. The subglotic mass was also detached 
in part with the forceps from above, but the remaining portion 
was removed through the tracheal opening by a bent curette, 
the cutting surface being made angular to fit between the wings 
of the thyroid cartilage. On the 10th of October the tracheal 
tube was removed and the wound closed ; and on the 17th the 
child left the hospital with the tracheal wound healed. The 
vocal bands were of a pale pink color, and granular in appear- 
ance, and the voice of a hoarse, rasping character, considerably 
above a whisper. She has since visited the hospital once a 
week, and had the larnyx sprayed with a solution of chloride 
of zinc. The improvement of the voice gradually increased 
until it became quite distinct, but it remains somewhat weak. 
This case is of unusual interest, as there is every evidence 
from the history of the hoarseness, shortness of breath on ex- 
ertion, and frequent attacks of croup, that it was one of con- 
genital papillomata, and although Mackenzie, in 1871, 
considered congenital papillomata as unproven, their presence 
is now admitted by most observers. It furthermore raises the 
question whether tracheotomy, producing functional rest of the 
larynx, may not in some cases favor atrophy of the papillomata 
and their complete and permanent disappearance. Certainly 
in this case, although only three months have elapsed since 
the tracheal wound closed, there is not the slightest evidence 
of recurrence, and from week to week the cords become thinner 
and paler, and the voice improves in ratio. My somewhat 
limited experience with the treatment of laryngeal papillomata 
in children by thyrotomy has given much less favorable results, 
as the frequent recurrence of the growth required the operation 
to be performed two or more times on each case and left the 
voice much impaired. 
The next case, represented in Fig. 2, is one of sarcoma of 
the epiglottis, and I believe, is the largest one reported in the 
literature of laryngeal neoplasms as originating in this situation. 
The location is not an unusual one for cysts, papillomata, 
fibromata, etc., but only two authentic cases of sarcoma of the 
epiglottis have been reported ; one by Morrell Mackenzie in CHAPPELL. 
110 
his essay on one hundred cases of laryngeal growths, and an- 
other by Dr. Burow in the Berlin, klin. Woch., No. 8, 1887. In 
Mackenzie's case, although the growth was comparatively 
small, it produced almost complete aphonia and extreme 
dyspnoea. Burow's patient, and the one now presented, al- 
though having much larger growths than Mackenzie's patient, 
gave little evidence in their voices of the size of the neoplasms. 
Burow describes the voice of his patient as being peculiar in 
tone. The voice of my patient was flat, and although the lips 
Sarcoma of the Epiglottis. 
Fig. 2. 
and tongue made the movements for vocalization, they seemed 
devoid of sound, the voice apparently coming from a distance. 
The difference in character of the vocal tones was doubtless 
due to the positions of the neoplasms which in one case infil- 
trated the cushion of the epiglottis, and was just large enough 
to insinuate itself between the cords and prevent their coapta- 
tion, and at the same time diminished the area of the respira- 
tory tract in its most important part. The large size of the 
other neoplasms and their higher attachment kept them well 
above the vocal bands, and interfered but little with their 
functions. 111 
LARYNGEAL NEOPLASMS. 
Case 2. Bridget O'R. Age 32 years. 
Came to the throat department of the hospital July 23, 
1894, complaining of choking sensation in the throat. Family 
history negative. 
Personal Hist. ry.-Always well until four years ago, when 
she had nervous prostration. About a year later she noticed 
that her voice was rather flat, and it required a little effort to 
produce a clear sound. Eighteen months from the first appear- 
ance of the vocal change, she experienced some difficulty in 
swallowing, and the solid particles of food seem to lodge near 
the root of the tongue. This condition rapidly increased, and 
for six months previous to her visit to the hospital, she had been 
unable to take anything but liquid nourishment. 
Present Condition.-Patient looks pale, emaciated, and some- 
what cyanotic, and coughs incessantly, owing to a tickling sensa- 
tion in the region of the larynx. Respiration about normal, 
while the patient is quiet, but slight exertion makes it rapid 
and labored. While asleep the respiratory efforts have become 
so alarming that the friends of the patient, with whom she 
stays, insisted that medical advice should be had at once, which 
accounts for her visiting the hospital. No pain had been ex- 
perienced and the performance of ordinary duties produced so 
little discomfort that she had never before consulted a physi- 
cian. 
On laryngoscopic examination, a round, somewhat lobulated 
white tumor about the size of a hen's egg was seen at the base 
of the tongue and behind the epiglottis, almost filling the oro- 
pharynx and covering the larynx. Its location and appearance 
is very well shown in Fig. 2. The mass was elastic and freely 
movable, and being attached by a rather long and narrow 
pedicle, it came well up into the back part of the cral cavity 
during deglutition. 
Several large vessels coursed over its upper surface. The 
white glistening appearance and feeling of fluctuation on pal- 
pitation, suggested a large cyst. A puncture was made well 
into the centre of the mass with a laryngeal knife, but resulted 
only in a severe hemorrhage. The patient was admitted to the 
hospital on the 25th of July and an attempt made to remove 
the growth, but the administration of both ether and chloro- 
form embarrassed the respiration to such a degree that a low 
tracheotomy was performed. The patient by this time was 
very cyanotic, respiration shallow, and the cardiac action so 
weak that considerable difficulty was experienced in reviving her. 
Convalescence from the tracheotomy was rapid and unevent- 
ful. On August 3d, after finding that the attachment was lim- 
ited to the margin of the epiglottis on the right side, an eight CHAPPELL. 
112 
per cent, solution of cocaine was applied and a loop of plat- 
inum wire thrown around the pedicle of the growth. An in- 
termittent electric current was passed through the platinum 
wire and within five minutes the pedicle was divided and the 
mass fell out of the mouth. Very little hemorrhage followed. 
The voice at once resumed its natural tone, and on examination 
the cords and larynx were found to be normal in appearance. 
The right half of the epiglottis and its accompanying growth 
had been removed. Very little pain or reaction followed the 
use of the cautery, and on the 5th of August the tracheal tube 
was removed and the opening closed. On the 8th, the patient 
was discharged from the hospital. 
Syphilitic Neoplasm. 
Fig. 3. 
On the 15th of September, she visited the hospital again, but 
no trace of the neoplasm was apparent. The remaining half of 
the epiglottis had fallen over and partially occupied the place 
of the portion removed. 
Her general nutrition was much improved and she had 
gained ten pounds in weight. 
On examination the growth was found to weigh 360 grains 
and to be inches in its greatest circumference and'3-f- inches 
in its lesser. A microscopic examination was very kindly made 
for me by Dr. E. K. Dunham of the Carnegie Laboratory, who 
reported that the growth was a sarcoma of the variety called 
by the Vienna school "perithelioma," and that the prognosis 
was rather more favorable than in most other varieties of sar- 
comata. 113 
LARYNGEAL NEOPLASMS. 
Although many authorities on laryngeal neoplasms believe 
that an expert should have little difficulty in making a diagno- 
sis between syphilitic and malignant disease of the larynx, 
plates 3 and 4 of Cases Nos. 3 and 4, with their histories, illus- 
trate the perplexities which may be experienced. The age of 
one of these patients favors malignant disease, while that of 
the other favors syphilis. Neither admitted any knowledge of 
a specific primary affection, and although each was given five 
drachms of potassium iodide daily for a week, neither showed 
any diminution in the size of the laryngeal growths. They 
Epithelioma of the Larynx. 
Fig. 4. 
both complained of burning and stinging sensations in the 
larynx, and while one had chewed as much as an ounce of to- 
bacco daily for fifty-four years, the other followed cigar wrap- 
ping as his employment, and has kept daily small pieces of 
tobacco in his mouth for many years. My colleagues who saw 
the cases, agreed that in location, size, shape, formation, and 
color, the neoplasms bore a remarkable resemblance to one 
another, and it was the general opinion that they were malig- 
nant in character. Both seemingly arose from the left ventricu- 
lar band, which is probably the most frequent situation for the 
initial deposit of malignant neoplasms, and passed upwards CHAPPELL. 
114 
along the lateral walls of the pharynx to the posterior surface 
of the epiglottis into the left glosso-epiglottic fossa. After the 
administration of the first course of potassium iodide, a micro- 
scopic examination of a portion removed from the older man's 
throat proved the growth to be an epithelioma. No micro- 
scopic examination was made in the other case. Although 
bearing many appearances in common, these two cases were 
different in some important particulars and had characteristics 
representing their respective natures. The tissues surrounding 
the malignant neoplasms were very much irritated by an abun- 
dant secretion of thick mucus of the usual odor noticed in 
malignant cases ; this was not apparent in the specific case. 
The notes of patient No. 3 are of further interest as showing 
that a later administration of exceptionally large doses of 
potassium iodide and mercury proved the neoplasm to be a 
syphilitic growth of a somewhat unusual character. The pos- 
sible method of acquirement is also of interest in this case, as 
there is every reason to believe that the patient was truthful in 
denying any knowledge of syphilis. The complaints of a pro- 
longed tonsillar disease, with the history of subsequent sore 
throat, is suggestive as to the possible point of infection. 
Tertiary syphilitic deposits of the larynx require more than a 
moderate dose of potassium iodide before its full benefit is 
obtained. An ounce or more of this salt in divided doses during 
the twenty-four hours may be needed. This, of course, necessi- 
tates great care, rest in bed, stimulants, hypodermic injections 
of strychnia, and occasionally hot packs. The resolution of a 
syphilitic neoplasm and infiltrations may be hastened by the 
application of a solution containing 
Iodine. 
Carbolic acid, aa grs. 120. 
Potass, iodid. grs. 10. 
Spt. rect. 3 ii. 
Case 3. T. M. C., aged 37, worker in tobacco, came to the 
hospital October 10. 1894, complaining of difficult nasal respi- 
ration and a slight hoarseness and burning sensations in the 
throat. His father died at the age of 39 from pulmonary 
tuberculosis ; his brother at the age of 30 from tuberculosis of 115 
LARYNGEAL NEOPLASMS. 
the throat, lungs, and intestines. The personal history of Mr. 
C. was excellent. With the exception of an occasional sore 
throat, he had been perfectly well until May, 1892, when he 
began to suffer from pain and soreness in the left tonsil accom- 
panied by swelling of the anterior cervical glands. The tonsil 
increased in size until it became so large that it interfered with 
his breathing and taking nourishment and had to be removed. 
Owing to the apparent growth of the tonsil between the opera- 
tions, it had to be excised three times After the last opera- 
tion considerable pain was experienced. A thick, yellow mem- 
brane formed on the tonsillar wound and remained two or 
three weeks ; accompanied by high temperature and severe 
systemic disturbance. About a month after his recovery Mr. 
C. began to have a dry and burning sensation with some tick- 
ling on the left side of his throat near the root of the tongue, 
especially noticeable during deglutition. These sensations 
continued with varying intensity from June 9th to the latter 
part of August, 1894, when a slight hoarseness appeared, and 
rapidly increased until the tones were of a husky and rasping 
character. On examination, Mr. C.'s general condition was 
found to be good. The remaining portion of the left tonsil 
was hard and surrounded by considerable cicatricial tissue. 
The right ventricular band was thickened, and both cords were 
also somewhat red and thickened. The right cord moved freely 
but the movement of the left was somewhat impaired. The 
anterior two thirds of the left ventricular band was covered 
with a pale, yellow nodular mass, as shown in Figure 3. It 
passed upwards over the posterior surface of the epiglottis and 
into the left glosso-epiglottic fossa. 
The margin of the neoplasm was distinct, and did not ap- 
parently infiltrate the surrounding tissues. The papillae and 
follicles at the base of the tongue were considerably hyper- 
trophied ; otherwise, the upper respiratory tract seemed healthy. 
Potassium iodide was administered in increasing doses from 
October 15th to the 26th until five drachms a day were taken 
without any apparent diminution in the size of the growth. On 
the 31st of October, the potassium was renewed and continued 
until November 5th, when the dose of the salt had reached one 
ounce per day. The neoplasm then began to diminish in size. 
Complete rest was enjoined and the large dose of potash con- 
tinued with the addition of ten drops of the tincture of nux 
vomica three times a day until the 14th, when the potassium 
was discontinued. The mass by this time had grown much 
smaller ; the margins were more clearly defined and the pain 
and burning in the throat greatly lessened. Hydrarg. bichlorid. 
was then prescribed and continued December 3d, when the CHAPPELL. 
116 
potassium salt was again administered. The last course of 
potash with several applications of solid nitrate of silver and 
chromic acid completed the removal of the neoplasm and has 
left the larynx nearly normal in appearance and the patient is 
still under observation. 
Case 4. William M., aged 69, presented himself at the hos- 
pital on the 15th day of October, 1894, complaining of hoarse- 
ness and shortness of breath with difficult respiration and 
regurgitation of food. Family history negative. He had 
chewed tobacco for fifty-four years, but had enjoyed perfect 
health until eight months ago, when his throat began to feel 
sore, and a spasmodic cough, especially violent at night, soon 
followed. His physical condition was much impaired, and his 
loss in weight during the past three months had reached over 
thirty pounds. He spoke in a hoarse whisper, coughed con- 
tinuously and expectorated quantities of a glairy, frothy, ill- 
smelling mucus. When he accidentally swallowed some tobacco 
juice, it caused severe pain and a paroxysm of coughing and 
strangulation. For some time past he could take only liquid 
nourishment, as an effort to take solid food resulted in severe 
choking, the food lodging near the root of the tongue. 
Laryngoscopic examination showed the mucous membrane 
of the larynx to be very red and covered with mucus ; the 
right cord slightly red and movable ; and the left cord per- 
fectly immovable, and owing to its infiltration by the neighbor- 
ing neoplasm, it could not be distinguished. The left ventricular 
band was completely covered by a yellow, nodular-looking 
mass which passed upwards along the laryngeal surface of the 
epiglottis nearly to its tip, and then into the left glosso-epiglot- 
tic fossa. The surrounding tissues were considerably infiltrated, 
and the anterior cervical glands somewhat enlarged and tender. 
He complained of pain running up to the left ear and down 
the anterior portion of the sterno-mastoid muscle. 
On his next visit to the hospital. Oct. 21st, Mr. M. reported 
that his breathing had been much better for the three previous 
days without any apparent reason. He was admitted to the 
hospital and given potassium iodide until the 31st, when the 
daily dose had risen to 5 drachms without any diminution in 
the size of the growth ; on the contrary, it seemed much more 
irritable, and several alarming suffocative attacks had occurred 
during the night. 
A small piece of the growth was removed for examination, and 
proved to be an epithelioma. Tracheotomy was decided upon, 
and a low operation performed with cocaine as an anaesthetic. 
It proved very satisfactory in relieving the pain and discomfort 117 
LARYNGEAL NEOPLASMS. 
of the operation. He rallied well from the operation and ex- 
perienced considerable relief. Twenty-four hours later the 
nurse noticed that there was no respiration through the tube, 
and an examination showed that the surrounding tissues had 
become so infiltrated from the traumatic inflammation follow- 
ing the operation, that they had gradually lifted the tube out, 
and in front of the trachea. The tracheal wound was covered 
with a yellow, organized, fibrinous tissue which infiltrated the 
surrounding parts for some distance. Considerable difficulty 
was experienced in finding the original opening in the trachea 
and in reintroducing the tube. Although a longer tube was 
substituted, it was found in a few days that it also was being 
lifted out of the trachea. This early discovery prevented the 
formation of the fibrinous exudation which had previously 
taken place, and no difficulty was experienced in finding the 
tracheal wound the second time. A specially long tube was 
now made and after its introduction no further trouble was ex- 
perienced. The cough and all the distressing symptoms were 
ameliorated and a condition of comparative comfort resulted. 
On the 21st of November, considerable pain in the left side 
of the neck was experienced, especially severe on swallowing. 
This was found to result from an infiltration and contraction 
of the anterior belly of the stylo-hyoid muscle. Laryngoscopic 
examination showed that the surface of the neoplasm was 
ulcerating near the tip of the epiglottis and that infiltration 
was spreading laterally, and up the side of the pharynx. 
Liquid nourishment was taken without much discomfort, and 
after a time the muscular tenderness abated ; and as there was 
no occasion for a longer stay in the hospital, he was sent home 
on the 30th of November. 
He has been heard from several times during the past month 
and the reports are of easy respiration and deglutition, with a 
general condition of comparative comfort. 
The next case, represented in Figure 5, has several interest- 
ing features. The history, appearance, location, and many of 
the symptoms of this neoplasm bore a strong resemblance to 
those of a papilloma of the vocal cords, but on removal the 
tumor proved to be a hard, fasciculated fibroma. It is difficult 
to account for the pain experienced by this patient, as it was un- 
usually severe and out of all proportion to the size of the growth. 
Case 5. Lena M., aged 35, came to the hospital Octo- CHAPPELL. 
118 
ber 29th, complaining of severe pain in the left side of her 
throat, especially when she swallowed. Family history nega- 
tive. Personal history good until one year ago, when after 
talking considerably she became hoarse. This condition 
gradually increased until the present time, when she is able to 
speak only in a hoarse whisper. Two weeks before her visit 
to the hospital she began to have pain in the left side of the 
larynx, which soon became especially severe on swallowing and 
at night. An itchy, scratchy feeling caused considerable irrita- 
tion of the throat. A laryngoscopic examination showed the 
right cord to be normal. On the left cord, at the junction of 
the anterior and middle third, a small round mass was visible, 
Fibroma of the Vocal Cord. 
Fig. 5. 
seemingly growing from the free margin of the cord, and 
during ordinary respiration standing out in the rima glottidis, 
as shown in Fig. 5. When the cords were approximated, the 
neoplasm turned upwards on the superior surface of the left 
cord. Several vascular points were visible over the surface of 
the growth even after the application of cocaine. The rest of 
the larynx and upper respiratory tract was normal in appear- 
ance. At subsequent visits on October 31st, November 5th 
and 7th, the patient's chief anxiety was to be relieved of the 
severe pain which she said was increasing rapidly. A 20$ 
solution of cocaine was applied to the larynx on November 
7th, and the growth removed by Mackenzie's antero-posterior 
laryngeal forceps There was considerable hemorrhage from 
the point of the attachment of the growth to the cord, and 
during the evening following the operation the patient became 
completely aphonic. The next morning the voice was almost 119 
LARYNGEAL NEOPLASMS. 
normal in character and the pains and scratchy sensations in 
the throat had disappeared. The latter returned after a few 
days, but were soon stopped by a spray of 20-grain solution of 
chloride of zinc. When the patient last visited the hospital, 
November 30th, it was difficult to tell which vocal cord had 
been the seat of the growth. The vocal sounds were natural, 
and there were no abnormal sensations in the larynx. 
The remarkable tolerance which may be established in the 
larynx and oro-pharynx when the encroachment is slow and 
unaccompanied by pain, is well illustrated in a resume of some 
of these cases. Of course, much depends on the size, shape, 
and situation of a neoplasm. If the initial development impli- 
cates the cords, ventricular bands, or either commissure on a 
plane with the cords, the voice is at once impaired from their 
fixation or prevention of coaptation. If the anterior commis- 
sure is implicated, the smallest growth may give early evidence 
of its presence ; on the other hand, the upper part of the inter- 
arytenoid space and the arytenoid cartilages will tolerate neo- 
plasms of considerable size. One of the patients recently at 
the clinic had several large condylomata in the superior part 
of the inter-arytenoid space, without producing any change in 
the vocal sound or respiration ; they were discovered during a 
routine examination, when the patient visited the hospital for 
some nasal difficulty. Extrinsic parts of the larynx are more 
tolerant, especially if the growth begins in the upper part of 
the epiglottis. The tolerance to these large and numerous 
growths does not make them less dangerous, as an attack of 
indigestion, cold, fear, excitement, etc., may result in an attack 
of suffocation which may prove fatal before medical aid can 
be obtained. The favorable result obtained by the tracheotomy 
performed in Case r was most gratifying, and in cases of 
congenital papillomata, attacked with membranous or catarrhal 
laryngitis, this method gives immediate and permanent benefit. 
In laryngeal papillomata in children, if the symptoms are 
not urgent, considerable success may be expected from endo- 
laryngeal treatment. The chief difficulty arises from the vio- 
lent struggles of the child and the quantity of mucus in the 
throat. I have adopted a method in three children, aged re- 
spectively 2 years, 3 years, and 31 years, which has enabled CHAPPELL. 
120 
me to remove the papillomatous masses with comparatively 
little trouble. The day before the operation, belladonna is 
given in small doses and increased until dilatation of the pupils 
and dryness of the throat are produced. An hour before the 
operation some preparation of opium, such as paregoric or 
Dover's powder, is administered until the patient is well under 
its influence. The resulting condition is more satisfactory for 
these operations than ether or chloroform anaesthesia, as com- 
plete muscular relaxation is not produced, but just sufficient 
resistance remains to make it an easy matter to hold the child 
in the upright position. This is done by one assistant, who places 
the child in O'Dwyer's position for intubation, and holds out 
the tongue. A second assistant steadies the head and holds 
the gag. An application of 2 per cent, solution of cocaine is 
then made, and the child is ready for the introduction of the 
laryngeal mirror and forceps. There is little difficulty in ob- 
taining a good view of the larynx, as the child is quite passive, 
and owing to the dryness produced by the belladonna the view 
will not be obstructed by mucus The papillomata may readily 
be grasped and removed in the usual way. Recurrence of 
papillomata after treatment by the endolaryngeal method is 
also frequent, as it is after their treatment by thyrotomy, and 
occasionally after tracheotomy. If once removed, the papil- 
lomata are usually several months in recurring, and the older 
the child, the easier it is to carry out the endolaryngeal treat- 
ment. If tracheotomy is performed, months pass before a 
favorable termination is reached, and, moreover, it is not 
always successful. Added to this, there is an element of dan- 
ger in opening the wind-pipe, and the disfigurement of the neck 
is also of great moment in some cases. All things considered, 
it seems that every effort should be made to employ the endo- 
laryngeal method for children ; it is safer, the voice is always 
left in better condition, and it does not disfigure. Trache- 
otomy may be used to relieve the acute symptoms which occa- 
sionally occur in cases of neglected papillomata and in the 
laryngitis resulting from exanthemata. 
It would seem better to defer thyrotomy in these cases until 
the other methods at our disposal have been tried. cbe Uutfckerbocker press, IRcw JtJorh