A PAPER 
% 
ON 
INTRA-LARYNGEA L GROWTHS 
By CLINTON WAGNER, M.D., 
Physician to the Metropolitan Throat Hospital, Fellow of the New York Academy of 
Medicine, Fellow of the American Laryngological Society, etc., etc. 
[Reprinted from the Ohio Medical and Surgical Journal.] 
COLUMBUS? 
NEYINS & MYERS, BOOK PUBLISHERS. 
1878. INTRA-LARYHGEAL GROWTHS. 
CLINTON WAGNER, M.D. 
The following cases of intra-laryngeal growths are described 
somewhat at length, not from any special interest which they 
possess individually, for, with a few exceptions, they are of a 
character which any one engaged in throat practice may fre- 
quently observe, but taken collectively, they are valuable from a 
statistical standpoint, as they demonstrate the frequency of this 
interesting pathological condition, and may, perhaps, aid in re- 
futing certain objections that have been raised by a recent writer * 
against their removal per vias naturales. 
Before the introduction of the laryngoscope as a means <of 
diagnosis, polypus of the larynx was regarded as of very rare oc- 
currence. f Ehrman, in 1850, as a result of his researches, could 
find but twenty-six authenticated cases, all of which proved fatal 
except three. 
A few years later, Dr. Horace Green,| of New York, in an able 
monograph, gives the entire number of recorded cases as forty, 
thirty-seven of which resulted fatally. Seven or eight of the 
cases occurred in this country, four in his own practice extend- 
ing over a period of five or six years. When we reflect that Dr. 
Green had an immense special throat practice, we can realize in 
* The Throat and its Diseases, Lennox Browne. London. 1878. 
t Historic des Polypes da Larynx, C. H. Ehrman, 1850. 
1 Polypi of the Larynx, Horace Green, M.D., New York, 1859. 2 
a measure the large number of cases of growths that must have 
been overlooked for want of means of obtaining an accurate 
diagnosis—to quote his own language, “the symptoms indicative 
of the existence of these growths are not sufficiently defined to 
warrant us in laying down positive rules of diagnosis.” I ven- 
ture to assert that during the past five years, since the introduc- 
tion of the laryngoscope into general practice, one hundred and 
fifty would be a small estimate for the number of cases treated in 
this city alone. 
Sy?nfitojns.—Alteration of voice, cough, and dyspnoea, with a 
tendency to spasm of the glottis upon making the slightest exer- 
tion. 
Voice.—The alteration of voice may range from slight huski- 
ness or hoarseness to partial or complete aphonia ; it is distinc- 
tive through its peculiar vibratory tone and metallic ring, and 
differs strikingly from the soft whisper of functional aphonia 
from paralysis of the adductors, the disagreeable huskiness of 
syphilitic laryngitis, or the unpleasant squeaking falsetto fre- 
quently met with in uni-lateral paralysis of the adductors. I 
have in some cases been enabled to establish a diagnosis from the 
voice alone, even before making a laryngoscopic examination. 
Cough is by no means an invariable symptom, and, when pres- 
ent* is generally of a short, dry, hacking character, caused by a 
movable or pedunculated growth. 
Dyspnoea will be found only in those cases in which, from the 
size and position of the growth, the normal caliber of the larynx 
is greatly lessened. 
Treatment.—In the treatment of the following cases, I prac- 
ticed evulsion by means of Mackenzie’s forceps, the best adapted 
and safest instruments for the purpose that have yet been devised. 
They are greatly to be preferred to the guillotine of Stoerck, 
with which it is impossible to remove a sessile growth from the 
superior surface of the cords, or the awkwardly working tube for- 
ceps of Schrotter, and other continental laryngoscopists, on ac- 
count of the facility of introduction and the ease with which 
they can be opened or closed after having entered the larynx. 3 
Mr. Lennox Browne, * in advocating non-instrumental inter- 
ference by way of the mouth, states that serious complications or 
accidents are liable to follow the introduction of the forceps, 
such as ulceration, paralysis, perichondritis, caries, injury to the 
arytenoids, or death from spasm of the glottis. 
My experience includes many cases in addition to those re- 
ported in this paper, and I have never seen any unpleasant effects 
follow further than a slight congestion of the mucous membrane, 
lasting a day or two, and during which the introduction of the 
forceps was, of course, omitted. With reference to the objection 
that spasm of the glottis may arise, I would state that I have in- 
troduced the forceps and carried them to the sub-glottic region in 
cases in which the entire box of the larnyx was filled with growth, 
and no ill effects have followed, and I believe that, with a surgeon 
who has attained a fair amount of skill in the use of laryngeal 
instruments, the operation for the removal of growths through the 
mouth by means of Mackenzie’s forceps is as devoid of danger,, 
as the passing of a catheter into the bladder, a sound into the 
uterine cavity, or the needle of an aspirator into a purulent liver. 
CASE I.—Small Papilloma on Left Vocal Cord—Cure. 
Miss C., of New Jersey, aged twenty-five, consulted me in Sep- 
tember, 1874, at the suggestion of my friend Dr. Hackley, for a 
hoarseness, which for nearly two years had prevented her taking, 
the higher notes in singing, and had lately begun to show itself in. 
conversation. The patient was of a very frail, delicate organiza- 
tion, and her parents were inclined to attribute the huskiness in: 
her voice to phthisis pulmonalis, more particularly as they had 
lost one daughter from that disease. 
An examination which was made with great difficulty, owing to 
nervousness of the patient, irritability of the pharynx and a pendu- 
lous epiglottis, revealed nothing to account satisfactorily for the 
change of voice. The examination was not prolonged, but she 
was requested to call again in a few days. During the second 
* Op. Cit. 4 
examination, the patient gave a short, quick cough; at that 
moment, a small growth came into view, which proved to be 
attached to the under surface of the left vocal cord, at about the 
junction of the anterior with the middle third. During quiet 
breathing the growth could not be 
seen, but whenever a violent effort was 
made, for instance, during loud talk- 
ing, singing or coughing, it was thrown 
upwards and caught between the cords, 
but was so small, soft, and compres- 
sible, that it did not prevent approximation, but interferred only 
with the fine or more rapid vibrations of the cord, accounting for 
the huskiness and explaining why there was not aphonia. 
The treatment of this case in overcoming the sensitiveness of 
the larynx, and the natural timidity of the patient was tedious 
and prolonged, but finally, after I had succeeded in introducing 
the forceps without provoking instant spasm of the glottis, I in- 
structed her to give a short, violent cough, while the instrument 
was in the larynx. This, as I expected, threw the growth up- 
wards and between the cords, at which moment I succeeded in 
seizing and removing it. The patient recovered a singing voice, 
but? not a mezzo-soprano. She sings in contralto, clearly and 
without effort. I must confess that I cannot explain the cause of 
this change of key. I have examined this patient quite recently, 
three and ahalf years after the operation, there has been no recur- 
rence of the neoplasm, voice and general condition excellent. 
CASE II.—Large Fibroma Attached to Under Surface of 
Right Vocal Cord—Cure. 
George E. ; occupation, butcher ; German ; age, thirty-six; 
large, muscular, and robust, stated that he first observed hoarse- 
ness about two years ago, the consequence he thinks of a severe 
cold. He has no cough, but complains of a constant tickling in 
his throat; at times he is quite aphonic, but generally his voice 
has the peculiar metallic, vibratory ring, so distinctive of laryn- 
geal growths. 5 
An examination with the laryngoscope revealed a large fibrous 
growth about the size of [and somewhat resembling a bean, 
attached by a pedicle to surface of the right cord at 
about its junction with the middle and anterior thirds. During 
quiet breathing the tumor would drop below the cords and almost 
disappear from view (as represented in the adjoining cut), but 
during the act of phonsting it was forced 
upwards and lay either upon the surface of 
the cords or between them. 
The epiglottis in this case was very 
pendulous, and the larynx difficult to illu- 
minate, owing to which and the thickness 
of the base of the tongue, the best and most satisfactory view 
could only be obtained by depressing that organ with the spatula 
instead of causing it to be'protruded as in the ordinary examina- 
tion. 
Several unsuccessful efforts were made to seize the tumor during 
quiet respiration. directed Tiim to make the ah / sound 
loudly and forcibly, during which I rapidly introduced the for- 
ceps and caught and severed the entire growth and pedicle from 
its attachments—voice returned at once. 
The following cut represents the growth and pedicle after 
removal, exact size : 
CASE III.—Small Papilloma of Right Vocal Cord—Re- 
moval—Cure. 
Professor S. ; native of Germany; age, forty-five ; principal 
of a large school for boys, consulted me for loss of voice in Feb- 
ruary, 1876. He stated that for several years he had suffered 
from a hoarseness, but about four months previous to consulting 
me, he became quite aphonic, and has remained so ever since. 6 
A laryngoscopic examination revealed upon the right cord and 
just anterior to the processus vocalis a polypus about the size of a 
small pea, overlapping the free edge of the cord and preventing 
approximation, thus accounting for 
the aphonia. The throat of this gen- 
tleman was capacious, well-developed, 
and the larynx could be entered with- 
out difficulty ; a /ew days were occu- 
pied in overcoming the irritability o 
the pharynx, when the forceps were introduced, the growth seized, 
crushed, and successfully removed at one sitting—voice returnee 
immediately. An examination made over two years .after the 
operation could detect no trace of the growth—voice excellent. 
CASE IV.—Small Papilloma on Left Vocal Cord—Re- 
moval—Cure. 
Patrick, get. 48 ; occupation, porter ; consulted me December 
10, 1877, at the Metropolitan Throat Hospital, for chronic hoarse- 
ness, which had existed for over a year, at times quite aphonic. 
An examination disclosed a small papilloma on the free edge of 
the left cord, in its anterior portion, preventing perfect approxi- 
mation. No preliminary training was 
adopted in this case; the growth was 
seized and removed upon the first in- 
troduction of the forceps. Voice was 
restored at once, and he informs me 
that he sings without difficulty in his 
Sunday-school. 
An examination a few weeks ago, and five months after the 
operation, could discover no trace of the growth. 
CASE V.—Large Papilloma on Both Cords—Removal— 
Improvement. 
Jennie M., jet. 19; occupation, singer; consulted me at the 
Metropolitan Throat Hospital, April 3, 1878. She stated that 7 
two years ago hoarseness came on slowly, and she was compelled 
to discontinue singing. Attributes the hoarseness to a severe 
cold. 
An examination revealed a large papilloma on the left ventricular 
band, almost completely obscuring the left vocal cord ; upon the 
right vocal cord was another covering the anterior third, and a 
still smaller one springing from the under surface of the same 
cord. 
Several days were consumed in over- 
coming the irritability of the pharynx 
and the general nervousness of the pa- 
tient, and, owing to the latter, three 
sittings were required for the removal 
of the mass. A small portion of that 
attached to the under surface of the right vocal cord still remained, 
but, as the improvement in her voice and breathing was so marked, 
she declined further operative interference for the present. 
CASE VI.—Small Cystic Growth on Epiglouts—Removal 
—Cure. 
J. R., aged thirty-eight; occupation, tailor; consulted me at 
Metropolitan Throat Hospital, March, 1874, for sore throat. In 
addition to a follicular Dharyngitis, I discovered a small cystic 
growth at the junction of the epi- 
glottis with ary-epiglottic fold, right 
side. It was crushed, without diffi- 
culty, with Mackenzie’s forceps. No 
return after several months. 
CASE VII.—Symmetrical Out-Growth on the Vocal 
Cords—Cure. 
Miss B., aged twelve; brought to me by her parents, in March, 
1875, f°r hoarseness, for which she had been compelled to dis- 
continue her singing lessons. Upon the anterior third of each 
cord I discovered a nodule, about the size of a very small pin 8 
head, apparently of a fibrous character, and seemingly thoroughly 
incorporated with the cord tissues; ap- 
proximation was scarcely interfered 
with, but the finer vibrations were. 
I did not deem instrumental interfer- 
ference prudent in this case, but ex- 
plained to the parents that a cure 
might be effected by topical applications, but that the treatment 
would be tedious. 
For about two years, applications of zinci chlorid., grs. xv to 
water one ounce, were made at intervals varying from five days 
to several weeks ; occasionally the solid nitrate of silver was ap- 
plied, but I found the zinc decidedly more efficacious. The no- 
dule has entirely disappeared from the left cord, and but a mere 
trace remains on the right cord. The voice is clear, and she 
sings without difficulty. 
CASE IX.—Ecchondrosis of Left Side of Thyroid—No 
Relief. 
J. H., aged thirty; Irish; consulted me at the Metropolitan 
Throat Hospital, at the suggestion of Dr. Moore, of Troy. 
About a year previous tracheotomy had been performed for 
laryngeal dyspnoea, which had suddenly become alarming; since 
then has worn the canula; has had syphilis. 
An examination revealed a large rounded mass on the left side 
of the larynx, just anterior to the left arytenoid, and filling almost 
its entire cavity. I performed thyrotomy, and found that the 
tumor grew from the thyroid, very hard and firm, and, without 
doubt, of the very rare variety known as an ecchondrosis. I 
could make no impression upon it, either with gouge or knife, 
and attempts at removal brought on violent paroxysms of 
spasmodic coughing, although the patient was fully under the in- 
fluence of ether. 
I saw and examined him about fourteen months after the opera- 
tion ; apparently no change had taken place. CASE X.—Papillomatous Growth—Posterior Wall of 
Larynx—Operation Deferred. 
Mrs. B., aged thirty-seven ; German ; consulted me at the Metro- 
politan Throat Hospital, for complete aphonia, which had existed 
for several months. Slight dyspnoea was also present. 
An examination discovered a large papilloma growing from the 
posterior wall of the larynx and filling 
the interarytenoid space and preventing 
approximation of the cords. 
This woman was very nervous and 
timid, and as she was six months ad- 
vanced in pregnancy, I deemed it pru- 
dent to defer operative measures. 
CASE XI.—Papilloma Left Vocal Cord—Improvement. 
T. L., a German, aged forty-two ; consulted me February, 1878, 
at the Metropolitan Throat Hospital, for hoarseness and tickling 
in his throat, which he first noticed a little over a year ago; his 
voice had the peculiar metallic ring so frequently observed in 
laryngeal growths. 
A laryngoscopic examination revealed a papillomatous growth 
upon the posterior third of the left 
vocal cord, projecting but slightly over 
the free edge. The greater portion 
was removed without difficulty in three 
sittings, when he discontinued his at- 
tendance at my clinic. 
CASE XII.—Malignant Growth of Right Side of Larynx— 
Thyrotomy Performed Four Times—Recurrence. 
Mr. C., aged forty-seven; occupation, farmer ; consulted me 
in October, 1875. He stated that about two years previous he 
first noticed the hoarseness, which increased until at the time of 
consulting me he was quite aphonic. 
An examination revealed on the right cord, covering the mid- 
dle and extending well into the anterior third, a sessile growth 10 
which projected over the free edge of the cord and prevented 
approximation. At this time, I had 
no doubt from its general appearance 
that the growth was of a papillomatous 
character. I removed the greater por- 
tion with the forceps, after which I 
resorted from time to time to local 
astringent and caustic applications to destroy the little that 
remained. 
In November, 1876, but a small portion remained ; he then 
informed me that he probably would not be able to visit my office 
for about one month. He did not return, however, until the fol- 
lowing April, at which time a great change had taken place ; the 
growth had extended backwards and upwards, filling almost the 
entire right side of the larynx. I made no 
attempt at removal on that day, as he pre- 
ferred waiting. He left intending to re- 
turn within a week ; I cautioned him to 
lose no time in doing so, if his breathing 
became at all impaired. He returned in 
about a month for treatment, at which time there was great 
dyspnoea, the growth had extended downwards below the right 
cord, producing considerable lessening of the laryngeal calibre. 
After a consultation with several medical friends, I determined 
to temporize and attempt again the removal by the mouth. A 
large amount was taken out in this way, sufficient to fill a small 
homoepathic vial, but it was reproduced so rapidly that it seemed 
almost to increase under my eyes. 
At this time the stenosis was so great that he breathed with 
difficulty, especially upon making the slightest exertion, such 
even as walking across my office. 
Deeming it unsafe to defer tracheotomy any longer, on the 10th 
of June, 1877, this operation was performed at the Metropolitan 
Throat Hospital, immediately after which a thyrotomy, the 
growth extended downwards to the cricoid cartilage ; it was thor- 11 
oughly removed, the cord destroyed, and the galvano-cautery 
freely applied to all the surface which had been covered by it. 
Two months later in August the operation of thyrotomy was 
repeated, again in October and March of this year, omitting in the 
last two the galvano-cautery and substituting a solution of 
zinci chlorid, grs. xxx to gi aq. 
The portions of growth removed by evulsion and also by thy- 
rotomy were submitted to several eminent microscopists of this 
city for examination. 
The first pronounced it an “hypertrophy caused by lymphoid 
infiltration.” “There are no distinct characteristics of a new 
growth.” But upon being told the clinical history of the case, 
called it a “small round cell sarcoma.” 
The second reported that it belonged to the class usually called 
“papilloma,” while the third regarded it as a “mixed” growth 
of the variety known as “epithelioma-papilloma.” “Such tu- 
mors are of tolerably frequent occurrence on the mucous mem- 
branes, and their prognosis is usually very good.” 
The severe and constant pain which the patient has suffered 
from for some months past, together with the infiltration of the 
surrounding soft parts, the caries of the cartilages of the right 
side, the rapidity of recurrence after thorough removal, and the 
excessive vascularity of the neoplasm, leave no doubt in my own 
mind of its malignant character. Whether sarcoma or epitheli- 
oma-papilloma I am not prepared to decide; but simple or 
ordinary papilloma it cannot be. 
The non-engorgement of the cervical lymphatics, the excellent 
condition of his general health, the non-extension of the disease 
to the pharynx, left side of the larynx, or the trachea induce me 
to regard its malignancy as of a mild type. 
Removal of the larynx has been considered and proposed to 
the patient, but he declined an operation which, in his case at 
least, could not promise a prolongation of his days. 
I shall perform thyrotomy at least once more in this case, and 
still again, should the circumstances justify it, as they hitherto 
have done. 12 
CASE XIII.—Large Papillomatous Growth, Left Side of 
Larynx. 
L. R., aged fifty-nine; American; occupation, farmer; con- 
sulted me at the Metropolitan Throat Hospital, November 12th, 
1874. He stated that hoarseness came about twenty-two months 
previous, but about eight months ago lost his voice entirely. 
An examination revealed a large mass on the left side of the 
larynx, starting from base of epiglottis, partly covering ary-epi- 
glottic fold, and reaching to the left cord, which was not visible. 
The growth was evidently of a papil- 
lomatous character; there was dyspnoea 
from the stenosis. He left the hospital, 
promising to return for operation, but 
failed to do so. 
CASE XIV.—Cancer of the Larynx—Tracheotomy—Death, 
J. L,, aged fifty-six; German; consulted me at the Metro- 
politan Throat Hospital, May, 1874, for loss of voice and pain 
in his throat, which had begun, as nearly as he could remember, 
about eighteen months previous. 
The patient was quite aphonic, and suffering greatly from 
dyspnoea; no enlargement or engorgement of the cervical lym- 
phat s. 
A laryngoscopic examination revealed an irregular nodulated 
mass covering the entire left side of the larynx, from the base of 
the epiglottis to the sub-glottic region, and producing decided 
stenosis. There was no evidence of tuberculosis, nor was there a 
syphilitic history; however, he was given the benefit of the doubt, 
and specific treatment was fairly tried, without beneficial result. 
The dyspnoea increasing, tracheotomy was performed to escape 
the fatal consequences of sudden spasm of the glottis. I had, 
also, decided upon removal of the larynx at a later period, the 
patient having given his consent, but, after the tracheotomy, he 
failed rapidly, and died on the sixtieth day. 
A post-mortem showed that the disease extended below the 13 
cricoid, involving that as well as the other cartilages of the 
larynx. 
The following cases were reported by me in the New York 
Medical Journal, for March, 1874. I have seen both patients 
•quite recently, nearly five years have elapsed since the operations, 
voices are excellent, and no recurrence or trace of the growths. 
G. S., aged thirty-one, native of Ireland, occupation laborer, 
sent me for treatment, September 18, 1874, by Dr. J. H. Pooley, 
of Yonkers (now Professor of Surgery in Starling Medical Col- 
lege, Columbus, Ohio.) 
He stated that hoarseness had begun about four years ago. 
During the past six months it had increased, and, at the time of 
reporting to me, he was quite aphonic. On laryngoscopic exami- 
nation, the papillomatous growths were seen, the larger covering 
the right vocal cord for nearly two-thirds its length, a portion of 
which was attached by pedicle to the right ventricular band; a 
small growth occupied the middle third of left vocal cord. 
The operation was performed after 
three days’ preliminary training, and 
completed at one sitting. A small por- 
tion of the pedicle by which the tumor 
was attached to the right ventricular 
band, and also part of the growth on 
the left vocal cord were left for a sub- 
sequent operation, in consequence of 
the hemorrhage which ensued. 
The case was presented to the New York Laryngological 
Society three and a half months after the operation—voice perfect, 
and no return of growths. 
Case XVI.—H. J., aged thirty-eight; native of Germany; 
occupation merchant, has suffered from hoarseness for two years, 
at times scarcely able to speak above a whisper. 
A laryngoscopic examination showed a papillomatous growth, 
on the right vocal cord, about the size of a large pea, and extend- ing from the floor of the ventricle to the free edge of the cord, 
over which it projected, preventing approximation. 
This patient’s larynx was very nar- 
row, and extremely sensitive to the 
introduction of instruments. The 
entire growth was removed after 
several trials, excepting a portion 
about the size of a pin’s head, which 
disappeared without further opera- 
tive interference. 
In the same number of the New York Medical Journal, j 
reported a case very similar to Case VII. She was under treat- 
ment for six months, there was 
marked improvement in the voice at 
the expiration of that period, but 
scarcely any diminution in the size 
of the nodules. Another case of 
precisely the same character has 
quite recently consulted me, and is 
at the present time under treatment- 
Since writing the above, I have performed the fifth thyrotomy 
upon Mr. C. (case XII.) The operation was performed at the 
Metropolitan Throat Hospital, July 9, 1878. No anaesthetic was 
given, ihe parts were very vascular, and the hemorrhage pro- 
fuse. A larger quantity of growth was removed than in any of 
the preceding operations. Zinci chlorid. grs. xxx to 3i aq. was 
freely applied to the surface after its removal. At the time of 
writing, July 18, the patient’s general condition is excellent. No 
recurrence of the growth has as yet taken place. 
The following interesting case has quite recently come under 
my care : 
CASE XVIII.—Large Papilloma filling Anterior Commis- 
sure and Cohering One-third of Right Cord—Hoarse for 
Thirty-one Years—Removal—Cure. 
W. N., aged fifty-one years; native of Scotland; occupation,. 15 
printer. Consulted me at the Metropolitan Throat Hospital 
July 9, for loss of voice. He stated that thirty-one years ago 
while a soldier in the British army, he contracted a severe cole 
from exposure on the march, since which time he has been almosi 
completely aphonic. In 1850 he consulted Dr. Hughes Bennett 
of Edinburgh, who suspected the presence of a polypus, and im 
troduced a sponge probang charged with a strong solution o 
argent, nitras. He subsequently consulted another eminent Seotcl 
physician, who advised a mercurial course for the hoarseness, 
This the patient declined. 
For the past ten years he has had no treatment except syrups, 
cough mixtures, and troches. 
An examination with the laryngoscope revealed a very large 
papilloma filling the anterior commissure above and below the 
insertions of the cords, and covering 
completely the anterior third of the 
right cord. 
Without preliminary training the 
forceps were introduced, and aboui 
one-half of the mass removed. The 
remainder was taken away in two subsequent sittings. Voice 
excellent. 
53 West Thirty-fifth Street, New York.