Preventive and Curative Treatment. 143 



one, notwithstanding Giintber's misfortunes ; and that in- 

 jurious contraction from cicatrization was not hkely to 

 follow. 



It was found, however, that the small opening through the 

 middle crico-thyroid ligament, though permitting easy access 

 to the interior of the larynx, would not allow extensive intra- 

 laryngeal operations to be easily performed ; the incision was 

 therefore carried through this ligament, the cricoid cartilage, 

 the crico-tracheal ligament, and, when necessary, one or more 

 rings of the trachea. By this larger opening, removal of the 

 left arytsenoid cartilage could be easily effected, its passive 

 condition during swallowing (caused by passing the finger or 

 a long probe up towards the epiglottis) or active respiration, 

 being previously ascertained through the wound. Not only 

 was this the case, but for a day or two after the operation, 

 when swallowing was imperfectly performed, it was observed 

 that any food or water that passed into the larynx escaped 

 by this dependent opening ; while the healing process could 

 be watched and regulated for as long as there was any 

 chance of excessive granulation, or other cause, rendering 

 the cure less certain. 



The results were in some cases satisfactory, in others not 

 so ; and it was then discovered that, in the latter, the 

 persistence of the noise was due to the left vocal cord, 

 which, owing to cicatrisation of the wound not having 

 drawn it close to the thyroid cartilage, projected into the 

 larynx and caught the entering air. This was a practical 

 demonstration of the share this part takes in noise pro- 

 duction. Consequently, it was found necessary, in order to 

 ensure a more certain cure, to excise the vocal cord and 

 arytsenoid cartilage. This added very little to the operation 

 wound, as in removing the cord the incision was limited to 

 its fixed border, which is narrow, and the thyroid cartilage, 

 beino- lined by mucous membrane to the bottom of the 

 ventricle, was in no way endangered. 



This perfected operation has had most encouraging 



