THE SURGICAL TREATMENT OF CHRONIC ROARING. 33 



anterior margin, therefore, which principally restores the covering of 

 the parts ; and when repair occurs regularly, without excessive new 

 tissue formation, the upper portion of the larynx is and remains 

 distinctly concave at its left side, /. c. at the site of operation. Under 

 these conditions the vocal cord can neither be pushed nor drawn 

 towards the median line. It is fixed in the position it occupies or 

 drawn slightly outwards. 



Unfortunately, our subjects do not voluntarily allow anything to be 

 done. It is impossible to follow the progress of the wound, to super- 

 intend the healing, or to repress the excessive granulations which may 

 form, and thus to obtain a flat cicatrix — an essential condition for the 

 disappearance or diminution of roaring. 



Attempts have been made to still further enlarge the passage by 

 excising, along with the arytgenoid, either the vocal cord, or the vocal 

 cord and internal wall of the laryngeal ventricle. These are old 

 methods. Ablation of the arytaenoid and of the vocal cord is not 

 nearly so valuable as simple ar3'taenoidectomy. After a large experience 

 I regard the benefit sought by removing the vocal cord as illusory. 

 The mucous wound is greatly enlarged, and its inferior part, whence 

 the cord is removed, is precisel}^ that which most readily vegetates 

 and gives rise to excessive granulations. 



There remains, then, arytasnoidectomy, completed by removal of 

 the internal wall of the laryngeal ventricle. The advantage of 

 enlarging the air inlet throughout its extent, without sensibly in- 

 creasing the surface of the excision wound, was claimed for this opera- 

 tion. It has been given up because most horses upon which it was 

 performed died from mechanical pneumonia, due to passage of particles 

 of food into the lungs. I avoided this by feeding my patients in the 

 same way as human beings who have undergone arytaenoidectom}-, and 

 by exercising the same care after operation. 



The procedure was as follows : — I commenced by performing ary- 

 taenoidectomy, following the ordinary method and suturing the borders 

 of the wound. I afterwards passed the index finger into the ventricle 

 of the larynx ; with one limb of a pair of straight scissors, introduced 

 into the ventricle, I vertically divided the inner wall of the latter 

 throughout its depth. Grasping the anterior flap with forceps, I 

 partially excised it with curved scissors, avoiding injury to the 

 epiglottis. I next grasped the posterior flap, covered by the vocal 

 cord, in the same way, and removed it from below upwards with a 

 button-pointed bistoury. The dressing and the subsequent precau- 

 tions adopted were similar to those after arytaenoidectomy. 



c 



