Subglottic Neoplasms. 
BY 
JONATHAN WRIGHT, M.D., 
OF NEW YORK. 
Read before the Section of Otology and Laryngology, at the Forty- 
second Annual Meeting of the American Medical Association, 
held at Washington, D. C, May, iBgi. 
Reprinted from “ The Journal of the American Medical 
Association,” September 26, 1891.' 
CHICAGO ; 
Printed at the Office of the Association 
1891. SUBGLOTTIC NEOPLASMS. 
BY JONATHAN WRIGHT, M.D. 
OF NEW YORK. 
From clinical experience in hospital and pri- 
vate practice in diseases of the nose and throat, 
including a large number of cases, it seems evi- 
dent to me that disease of the larynx and trachea 
of any description is not so frequently met with 
in New York, as the records of foreign, especially 
German and French, experience would lead us to 
believe. Neoplasms of the larynx are certainly 
not as frequently met with, either benign or ma- 
lignant, as they are in Europe, or else they are 
given an undue prominence in foreign literature. 
While it may be true that benign laryngeal neo- 
plasms exist in the proportion of i to percent, 
of all laryngeal cases in this country, larjmgeal 
affections in general are much less common than 
abroad. This personal opinion may not be sus- 
tained by the experience of other Americans, but 
there is reason to believe that I am not alone in 
the observation. 
Various localities in the air passages have been 
mentioned as the most common situation of be- 
nign growths, but a careful perusal of literature will, I think, show, notwithstanding considera- 
ble discrepancies of statement, that the most com- 
mon place of development is on the vocal cords 
or at either commissure. ‘ It is conceded that 
their etiology depends largely upon irritation. 
Such being the case the places where we should 
naturally expect to find them would be the most 
mobile parts of the larynx and those parts most 
exposed to the irritation of air, dust and secre- 
tions. The subglottic space being the most pro- 
tected and the most immobile part we should ex- 
pect less morbid action there. This conforms to 
clinical observation. Of 1,100 cases, collected by 
von Bruns, of laryngeal neoplasms, 836 were on 
the vocal cords. Subglottic tumors are, how- 
ever, of great rarity, nine only of Fauvel’s 300 
cases being infra-glottic. 
The following history of a case which has lately 
come under my observation may not be lacking 
in interest and may at least illustrate some im- 
portant points to remember in connection with 
subglottic growths. 
M. C., a housemaid, aet. 20. Single; born in 
Hungary, came to the Demilt in May 
1890. Her family history was good. Three 
years ago she had been troubled with frontal 
headaches and pains in the bones which were 
worse at night. At that time she began to have a 
hoarse cough and some muco-purulent expector- 
ation. Her nose was stopped up and she picked 
it making it sore inside. These symptoms in- 
creased. For the last year she had gradually 3 
been growing short of breath on exertion, having, 
however, no difficulty while quiet except at times 
on severe coughing, of which she had several at- 
tacks each day. At times for the last year she 
had noticed some huskiness of the voice, but as 
a rule there had been no marked change in it. 
For the last three weeks she had been feeling 
weak and unfit for work. Specific history was 
denied. 
Examination:—Pulse and temperature were 
normal. Respiration 24. She had slight stridor 
but no dyspnoea. 
There was some enlargement of the cervical 
glands but no other evidence of specific disease. 
On the left side of the nasal septum in front 
there was a papillary growth extending over the 
floor of the nose and to some extent over the an- 
terior end of the inferior turbinated bone. It was 
covered with inspissated bloody mucus. There 
was marked thickening of the mucous membrane 
in the right nostril. The posterior border of the 
Vomer had also several wart-like growths, espe- 
cially where it joins the base of the skull. There 
were two or three about the size of barley grains 
on the posterior surface of the soft palate. 
Below the vocal cords there was a large con- 
gested looking mass which at first glance seemed 
to block the whole lumen of the trachea. During 
the greatest possible abduction of the vocal cords, 
however, it was seen that the base of the growth 
was attached to the left side of the cricoid carti- 
lage and the tracheal rings, and projected to the 4 
other side beyond, but considerably below the 
edge of the right vocal cord during quiescence. 
The surface looked uneven, covered with mucus, 
and as though it were very vascular (this proved 
otherwise however). The mucous membrane on 
the right side of the subglottic space was also 
seen to be thickened and roughened. 
Her imminent danger was explained to the pa- 
tient, who was somewhat incredulous, but who 
nevertheless promptly consented to enter the 
wards of Roosevelt Hospital. 
For diagnostic purposes iodide of potash was 
given in increasing doses. After a few days 
signs of iodism appeared and the patient had sud- 
denly almost fatal dyspnoea. A tracheotomy was 
done just below the cricoid cartilage, artificial 
respiration resorted to and the patient recovered. 
Four days later, Dr. Frank Hartley made a 
long incision dividing the thyroid cartilage and 
several rings of the trachea, exposing the interi- 
or and the growth, which proved to extend down- 
ward for about inches below the vocal cords 
and to involve of the circumference of the tra- 
chea at the point of greatest growth. It had all 
the macroscopic appearance of an ordinary papil- 
loma. As soon as the trachea was opened the 
patient ceased breathing and it required energetic 
artificial respiration and hypodermic stimulation 
to start the natural respiration again. It was 
found impossible to resume the ether, although 
several attempts were made causing cessation of 
the breathing. Of course etherization was com- 5 
menced through the tracheotoim- tube and later 
given through a tube inserted at the lower angle 
of the tracheal wound. The operation was there- 
fore finished under partial anaesthesia. The 
growth was found to be flattened by the pressure 
of the tracheotomy tube. It was cut away from 
its attachment, which included the under surface 
of the left vocal cord, by knife and scissors, the 
base and every vestige of suspicious looking 
mucous membrane, including the small growths 
on the right side, were thoroughly and deeply 
cauterized with the Paquelin cautery. 
A tracheotomy tube was left at the lower angle 
of the wound, and the upper part of the trachea 
and the larynx was packed with iodoform gauze. 
The latter was removed in a few days and some 
weeks later the tube was withdrawn and the 
wound closed without any untoward symptoms, 
but she remained totally aphonic. 
She was discharged from the hospital and 
again became an out-patient under my care. The 
growths were removed from her nose by cautery, 
snare, and forceps. 
At the anterior laryngeal commissure wras a 
pale, flabby growth about the size of a split pea. 
It was apparently a granulation nodule at the 
site of the thyrotomy incision. Failing with the 
forceps, this was destroyed by the galvano-cau- 
tery. 
The patient was kept under occasional obser- 
vation for six or seven months. Her voice did 
not return, but at the end of that time small ses- 6 
sile growths began to appear just beneath the 
right vocal cord. A small portion of these was 
removed with the laryngeal forceps. Since then 
the patient has disappeared from view. There 
was no deterioration of the general health, al- 
though the patient naturally became somewhat 
hypochondriacal. The left vocal cord in the 
process of cicatrization was almost completely 
destroyed, at least as far as its usefulness in pho- 
nation was concerned. 
Gerhardt has lately stated that the differential 
diagnostic point between syphilis of the trachea 
and tracheal cancer is that cough and signs of 
irritation do not occur in cancer as initial symp- 
toms, dyspnoea being the first sign of trouble. 
In this case, which, however, was a benign 
tumor, it will be noted that a harsh cough pre- 
ceded the dyspnoea by two years. 
In fact, it is remarkable how little dyspnoea the 
patient suffered when her trachea was all but 
occluded by the growth. It was only on exer- 
tion, or from some temporary increase of mucus 
or transient congestion from coughing, that she 
experienced much discomfort. Such cases show' 
how much larger than necessary for quiet respi- 
ration the trachea is, the extra size being Na- 
ture’s supplementary device for emergencies a 
device which makes violent and extraordinary 
exertion possible, and which renders simple in- 
flammatory conditions all but harmless. 
It illustrates a point too often forgotten in 
obstruction of the air passages, viz., that the 7 
dyspnoea is most frequently due not so much to 
the mechanical stenosis as to the spasmodic or 
paralytic condition of the vocal cords, which 
irritation of the mucous membrane or compres- 
sion or irritation of the nerve trunks may cause. 
Intrinsic laryngeal tumors and extrinsic tumors 
pressing on the air passages, close alongside of 
which run the nerve Aliment's, may cause severe 
attacks of spasmodic dyspnoea, whatever the 
size or extent of the disease may be, while intra- 
tracheal disease rarely gives any dyspnoetic 
symptoms until the mechanical stenosis is very 
great. 
Koch,1 in his late article, said : 
“ If a tracheal tumor produces dyspnoea, that 
tumor is necessarily of large size, and of such a 
nature as to suffocate the patient at any moment. 
The laryngoscope gives us a defective idea of the 
size of the tumor on account of the inevitable 
shortening of the vertical diameter, while the in- 
tensity of the dyspnoea furnishes us with a more 
exact guide.” 
How suddenly, and with what little premoni- 
tory warning, an almost entire occlusion of the 
remaining air chink may take place, and the pa- 
tient pass from comparative comfort into a con- 
dition rapidly terminating in suffocation is shown 
in this case, and in others of a similar nature. 
In dyspnoea caused by spasmodic contraction of 
the vocal cords the dyspnoea of many cases of 
thoracic aneurism, of hysteria, of inflammation. 
1 Koch ; Ann. des nial de I’oreille, etc. Oct., iBqo. 8 
of laryngeal neoplasms—there is usually a certain 
leeway allowed for the performance of tracheoto- 
my, because, as soon as insensibility from the 
carbonic acid poisoning occurs, the spasmodic 
action of the glottis is usually suspended, though 
this is not inevitably the case. The sufferer may 
then gradually return to consciousness, or at 
least get enough air to keep his heart going for 
a time. Purely mechanical obstruction, howr- 
ever, is a different matter. 
Therefore, when the iodides are given for ob- 
structive disease of the air-passages wThich 
not be and even in cases where the 
diagnosis of specific disease is certain, especially 
when the obstruction is subglottic, it is well to 
remember that slight congestion is a very com- 
mon sequel of even moderate doses, and that 
even slight congestion may prove disastrous if 
immediate surgical aid is not at hand. 
More than half of all the cases of benign laryn- 
geal neoplasms reported have been recorded as 
papillomata. It is very suggestive of insufficient 
pathological discrimination that there should be 
such a preponderance of this growth. As to the 
character of the growth in the case reported, j-ou 
wall see from a drawing of a microscopic section 
made by Dr. Hodenpyl that it consists essentially 
of a mass of lymphoid tissue covered by pave- 
ment epithelium, which dips down into its sub- 
stance as digitations, and rises above the surface 
as papillae. These papillae, as well as the sub- 
stance of the growth, have for a framework the masses of lymphoid cells. There was more than 
the usual amount of fibrous tissue found in the 
ordinal so called adenoid growths, though in 
the section from whLh this drawing is made it 
is not apparent. 
If we regard this as a true tumor, the proper 
designation, according to the rules laid down by 
Virchow, would be “Lymphoma papillare.” If, 
however, we are to accept the definition of a 
tumor, “ that it is a non-inflammatory growth or 
new formation of tissue fulfilling no physiologi- 
cal purpose,” this, as well as all so-called adenoid 
vegetations, should be designated as a papillary 
lymphoid hypertrophy. This is a question for 
hystologists who are accustomed to arrange such 
matters to suit themselves, irrespective of clini- 
cal convenience and experience. 
Lymphoma of the larynx, according to all au- 
thorities who mention it, is of the greatest rarity, 
as are many of the other benign forms of tumors, 
although they are common enough on other mu- 
cous membranes. This is probably due to the 
fact that in the larynx, as is the case in the blad- 
der, morbid growths, either benign or malignant, 
are usually attended with the increase and hy- 
pertrophy, as well as the new formation of papil- 
lae, on their surfaces. 
Notwithstanding the protest of Virchow, and 
of many of the best histologists, these growths, 
when benign, are all classed under the head of 
“ papillomata,” whatever maybe the predomi- 
nant histological element in their structure. 11 
This leads to great clinical confusion, and to a 
mistaken conception of the nature and pathogen- 
esis of these growths. 
The only records of so-called lymphoma of the 
larynx which I have met with are two cases, one 
referred to by Gottstein in his book,'and another 
reported in the Lancet for October 15, 1887, by 
Beale; both of these accompanied general lym- 
phomatosis. Wolfenden and Martin, however, 
in their brochure, “Studies in Pathological Anat- 
omy,” give a drawing of lymphoid hypertrophy, 
which they call lymphoma, and which occurred 
in the larynx independent of any general affec- 
tion. 
Notwithstanding this apparent rarity, I do not 
believe it can be so uncommon, but that some of 
these papillary tumors, if carefully examined, 
would be found to consist largely of lymphoid 
tissue. Sarcoma is also extremely rare in the 
trachea. 
Such mistakes in nomenclature have been 
largely avoided in malignant tumors, owing to 
the importance of the prognostic aspects in such 
cases; but malignant tumors of the mucous mem- 
branes are quite as likely to be supplied with 
fungous or papillary surfaces as are benign 
growths, if not more so. 
As observed above, it is rare that small tracheal 
growths come under observation, except where 
they coexist in the larynx. The question of 
treatment is in these cases frequently a puzzling 
one, and always an important consideration. 12 
Those rare forms of tracheal gummata occa- 
sionally seen are of course to be treated by large 
doses of iodide of potash, and it may always be 
advisable, with proper precautions, to give the 
iodides wrhere the diagnosis is not perfectly 
plain. 
Leaving malignant tumors out of the question, 
and confining ourselves to the class of cases of 
which the one reported is a type, there are three 
methods of extirpation where interference is ad- 
visable : 
1. Intubation with long O’Dwyer tubes. 
2. Intra-laryngeal operations; by 
a. Forceps or snare. 
b. Cautery, either galvanic or chemical. 
3. Extra-laryngeal operation. 
The procedure by means of intubation is yet 
in its infancy, and is, of course, applicable only 
to those subglottic cases where the disease lies 
close beneath the vocal cords. Rapid absorption 
of benign and even syphilitic growths have been 
reported by Simpson and others. Intubation can 
probably be advantageously employed in connec- 
tion with the intra-laryngeal use of the forceps 
or of the cautery. With this I have had no per- 
sonal experience, but it is certainly deserving of 
a trial, the dangers and difficulties which attend 
other methods being absent or reduced to a min- 
imum by intubation, and in event of failure, the 
toleration acquired from the intermittent use of 
a tube would be of the greatest advantage in 
intra-laryngeal operations. 13 
The greatest difference of opinion prevails as 
to the proper cases for intra- and extra-laryngeal 
operations, some going so far as to urge an ex- 
ternal operation even in supra-glpttic tumors in 
adults, while others go to the other extreme by 
urging that even in children infra-glottic growths 
may be removed per vicas naturales, cases having 
been reported where papillomata were removed 
from the fifth tracheal ring. The sanction of 
Fraenkel, of Berlin, to intra-laryngeal operations 
in cancer will not now be received with favor by 
the majority of laryngologists. 
In tracheal growths, in the vast majority of 
cases, the tumor will usually be of such a size 
when first seen that nothing but an external 
operation would be advisable. In small, benign 
growths, in a tolerant adult, attempts by the 
intra laryngeal method will often be met by the 
most brilliant immediate results even in the tra- 
chea, but recurrence will be frequent, because it 
is impossible to be sure that the growth is com- 
pletely eradicated. 
Where attempts are to be made in larger tra- 
cheal growths, through the natural passages, 
thorough preparation both of patient and attend- 
ants should be also made for an immediate ex- 
ternal operation, because, in event of failure to 
remove the growth, enough congestion and in- 
flammatory action may be set up to lead to com- 
plete tracheal occlusion. 
The choice of instruments will depend largely 
on the personal bias and skill of the operator and 
the character of the growth. Personally, for 
small sessile growths, I prefer the white hot 
guarded galvano-cautery electrode. For growths 
which project more onto the lumen of the tra- 
chea, McKenzie’s lateral or longitudinal forceps 
are preferable, with, however, more of a gradual curve at the angle than is seen in the usual pat- 
terns. 
Cauterization by chromic acid, although rec- 
ommended by some of the most experienced 
operators, seems to me of inferior value, except 
to cauterize the base of a tumor removed the 
forceps. When the epithelium is intact, these 
growths certainly are not as quickly destroyed 
by acids as by the actual cautery. (Of course, I 
speak principally from experience in other situa- 
tions than the trachea.) 
A very practical point in these intra-laryngeal 
operations is the way in which the patient reacts 
to the application of cocaine. In many patients 
it leaves nothing in the way of local anaesthesia 
to be desired. In others it seems impossible to 
produce satisfactory results with any safe dosage, 
this applying to the 20 per cent, strength as well 
as to weaker solutions. Cases are not rare where 
severe constitutional symptoms of the drug may 
appear before any practical local action is ob- 
served. It is at once the most useful and the 
most uncertain of drugs. 
In considering the question of an external op- 
eration, the operator should be well satisfied of 
the impractibility of the operation by the natural 
passages. In many cases a preliminary attempt 
may be made by intra-laryngeal methods, and in 
event of failure, the external operation immedi- 
ately done. 
The dangers of the external operation are not 
only that to life, but also to the integrity of the 
voice. It is unnecessary to dilate upon the dan- 
gers of fatal pneumonia or bronchitis following 
the operation. This case illustrates a danger 
which is not satisfactorily explained, namely, the 
occasional prompt cessation of respiration or of 
the heart’s action the moment the trachea is opened. I have had two cases of tracheotomy 
where the heart was paralyzed at the moment of 
opening the trachea, although the pulse had 
been a moment before fairly good. There seems 
good grounds for the belief that there exist areas 
below the glottis, the excitation of which may 
profoundly affect the functions of the heart and 
lungs. It is possible that these areas may also 
exist outside of the trachea in the anterior cervi- 
cal region. At any rate, there are enough cases 
on record to demonstrate that this operation has 
dangers beyond those usually ascribed to it. 
In trachael tumors there is the added danger 
of haemorrhage from an incision of the tumor 
itself in opening the trachea. When a vascular 
tumor is attached to the anterior wall, this may 
cause very great embarrassment to the operator, 
and a fatal termination may ensue. 
The danger to the integrity of the voice is of 
course not to be weighed in the balance with the 
patient’s life, and should be entirely a secondary 
consideration. It is probable that the early 
writers have exaggerated this danger even in 
laryngeal growths. The simple separation one 
from another of the wings of the thyroid cartilage, 
bearing with them the attachments of the vocal 
cords, is probably a minor factor in the produc- 
tion of future aphonia or dysphonia. The dan- 
ger comes from damage to the vocal cords them- 
selves, and this may occur in endo-laryngeal 
operations as well. In the eradication of tra- 
cheal growths by an external operation, the di- 
vision of the thyroid cartilage will usually be 
found necessary to gain room, and should not be 
omitted for fear of damage to the vocal apparatus. 
A preliminary low tracheotomy is not a neces- 
sity, nor always of advantage, in spite of what 
Koch says at the end of his article, although in some cases it may facilitate matters. It would 
be encroaching on the domain of general surgery 
to go further into the question of the technique 
of an external operation for these tracheal 
growths, suffice it to say that the indication is 
usually perfectly plain, and should be promptly 
met, as every moment of delay is fraught with 
danger to the patient. 
In sections made from the fragments removed 
from the recurrence on the right side of the sub- 
glottic space, the microscopic appearance had 
more the resemblance of a small, round-celled 
sarcoma. 
The difficulty in distinguishing lymphoid 
growths of the mucous membrane from small- 
celled sarcoma by microscopic examination is 
often very great. In the last year I have been 
puzzled in several cases, and submitted the sec- 
tions to several experienced microscopists. In 
every instance I met with a diversity of opinion 
as to the character of the growth. 
I have a number of such sections in my pos- 
session, and the similarity between the simple 
lymphoid growths and those which afterward 
proved to be malignant is striking. 
In one case, I followed by repeated microscopic 
examinations of fragments removed at different 
times the course of a small, round-celled sarcoma 
of the nose. The first specimen was universally 
regarded as of a benign lymphoid character. It 
gradually changed in appearance to that of un- 
doubted sarcoma, of the small, round-celled 
variety. The clinical history and situation made 
the diagnosis of sarcoma probable, even at first. 
P. S.—Sept. 25, 1891.—I have recently seen the pa- 
tient whose history is given above. There is no recur- 
rence and she is in good health and spirits, though still 
aphonic.