LAEYNGOTOMY AEYTENECTOMY. 467 



membrane, into the arytenoid ligament and arytenoid muscle, as 

 close to the margin of the cartilage as possible, beginning between 

 the cartilage of Santorini, downward and then upward and the 

 vocal process at the insertion of the vocal cord (Fig. 407). The 

 hook is inserted in the vocal process, which is raised, and the 

 vocal cord is separated from the cartilage by the scissors ; then 

 the muscles on the outside of the cartilage are cut with the bent 

 knife, or, what is better, pushed from its surface as close as possi- 

 ble. The hook is removed, and the body of the cartilage seized 

 with the rachet forceps. The mucous membrane connecting the 

 cartilage with the vocal pouch is divided, with the curved scissors, 

 cutting as close to the cartilage as possible, to save the membrane. 



"The arytenoid cartilage is now free, except at its articular 

 tion with the cricoid, and it may either be disarticulated or cut 

 through -with, the scalpel at this point, care being taken to leave 

 no loose portions or shreds. The cartilage be,ing now only retained 

 by the soft parts at the upper portion (or base of the arytenoid 

 cartilage), these are cut through, close to it, with the scissors, when 

 it is altogether detached. 



" Care must be taken to avoid wounding the other cartilages, 

 or the pharyngeal mucous membrane, and to spare that membrane 

 in proximity to the arytenoid cartilage as much as possible, remov- 

 ing only that which covers its surface and the cartilage of 

 Santorini. 



" The vocal cord is now removed close to its attachment to the 

 thyroid cartilage, in front and at its fixed border (Fig. 407). This 

 can be done with the scissors, a finger being passed to the bottom 

 of the ventricle to facilitate the excision ; or the cord may be 

 drawn from the side by inserting a hook in it, to allow plenty of 

 room for the scissors. 



" If the hemorrhage is troublesome, which it seldom is, the 

 blood can be mopped out of the trachea with the sponges. It 

 cannot pass down that tube, owing to the position of the neck. 

 If necessary, the electric lamp may be employed to ascertain how 

 the operation has been performed, or even during it performance ; 

 but after a Uttle experience this is unnecessary." 



Third Stage. — "The trachea being completely freed from 

 blood, and the tampon canula introduced, the bag being inflated 

 after it has been properly placed into the trachea by means of the 

 air-pump, the canula is secured in position by a tape around the 



