[Reprinted from The Medical News, December 9, 1893.] 
MULTIPLE PAPILLOMATA IN A CHILD: 
Tracheotomy at Four Years of Age; Retention of Canula 
Thirteen Years; Evulsion of Multiple Laryngeal and 
Pharyngeal Neoplasms; Closure of the Tracheal 
Fistu/e by a Cutaneous Flap; Recurrent or 
Repullulant Growth at the Anterior 
Commissure of the Glottis. 
HONORARY PROFESSOR OF LARYNGOLOGY, JEFFERSON MEDICAL COLLEGE. 
J. SOLIS-COHEN, M.D., 
This instructive and long-time neglected case was sent 
to my clinic in April, 1892, by Dr. Harter, of Maytown,Pa. 
The patient, a girl seventeen years of age, but less 
fully developed than many a child of fourteen or even 
less, was completely aphonic, and was wearing a child’s 
tracheotomy-tube. 
Her story was that at four years of age, after suffering 
frequently with what was supposed to be croup, tumors 
in the larynx were diagnosticated by the late Dr. John 
Atlee, of Lancaster, Pa., than whom there have rarely 
been better surgeons. Dr. Atlee performed tracheotomy 
and inserted a double canula. This appliance was used 
for eleven years without any withdrawal of the outer 
tube by her attendants, when it was found to have be- 
come corroded. Then a new canula was inserted and 
this second one had not been removed up to the time 
the patient was brought to me. On removing it I found 
it so corroded that I deemed it imprudent to replace it, 
'and therefore substituted another. 
Laryngoscopic inspection revealed multiple neoplasms filling the upper portion of the larynx and extend- 
ing along the laryngeal face of the epiglottis almost 
to its very tip. There were likewise a few multiple 
neoplasms at the base of the tongue, and along the 
pharyngo-epiglottic and glosso-pharyngeal folds. 
The patient was admitted to the hospital, where my 
clinical aids, with some assistance from me, removed in 
a number of sittings all the morbid growths, chiefly 
with forceps; about a month being consumed in the 
procedures, and the voice returning in a satisfactory 
manner both for conversation and for singing. 
After waiting for a few weeks, without noting any evi- 
dence of recurrence or repullulation, I removed the 
canula definitely at the end of June, and sent the patient 
home with directions to report in October, when my 
clinical services at the hospital would be resumed. 
When she returned there was still no evidence ot re- 
currence. The fistule in the neck, however, was as 
large as ever, and I determined to close it with a cuta- 
neous flap. So on October 7th, before my clinical class, 
I dissected out the cicatricial tissue around the fistula, 
so as to leave an oval section in the integument, with 
bevelled edges from without inward. A flap of integument 
was then raised from over the sternum, and so bevelled on 
the edges that when the flap was turned up, skin-surface 
inward, its edges would fit into the bevelled seat pre- 
pared for it around the fistula, somewhat like a stone is 
set in a piece of jewelry. The parts were carefully 
stitched as far around to the pedicle of the flap as pos- 
sible. The fat of the flap was then snipped away with 
scissors, and the raw flap was dressed with sulphuric 
ether so as to dissolve any remaining fat during the 
healing process. The wound in the tissue from which 
the flap had been raised, and which had gaped widely 
by retraction during the fitting of the flap in its new 
and reversed position, was drawn together with sutures, 
except a triangular portion superiorly and just beneath the pedicle of the inversion, and which had to be left to 
heal by granulation. 
The flap adhered well and thoroughly to the parts to 
which it had been stitched, and there was no necessity 
to release the pedicle to fill in the gap in the healthy 
tissues. Nature’s unaided efforts were sufficient to 
cause absorption of the exuberant duplicature at the 
pedicle, and to gradually skin the raw surface of the 
flap with cicatricial tissue, so that there was no further 
occasion for professional supervision at the end of a 
month, when the patient was dismissed with instructions 
to report at the end of a year, or sooner, should any- 
thing untoward occur. 
On October 17, 1893, the patient reported at the clinic 
very much improved in appearance, and with a clear 
voice of greatly increased volume. She had gained ten 
pounds in weight. The cicatricial tissue over and 
around the position of the fistula was in excellent con- 
dition, and except for a glossy aspect was not notably 
distinguishable from normal integument. 
On examining the larynx, I detected a small, red, 
pedunculated pyramidal growth, about the size of a 
small pea, at the anterior commissure of the glottis and 
hanging below the vocal bands so that it did not inter- 
fere sufficiently with phonation to produce hoarseness. 
The voice, indeed, was shrill rather than deep. Whether 
this was a recurrent growth, or a repullulation from frag- 
ments left in extracting the growths the year previously, 
cannot be determined. It might be of either, but was 
probably of the latter character. It had occasioned no 
symptoms whatever indicative of laryngeal disorder. 
This little growth was readily removed with forceps.