UNSUCCESSFUL OPERATION FOR ROARING. 
331 
fluence, tending to annoy and disturb our confidence in the 
future stages of the operation. 
The next and really essential difficulty encountered was 
the hemorrhage from the excision wound. The removal of 
the cartilage was performed as carefully as possible, and 
probably as well as most inexperienced operators could be 
expected to do at the first attempt. The cartilage came away 
quite clean, almost wholly free from other tissues, so we are 
unprepared to say if either through our inexperience or in¬ 
adequate instruments, we unnecessarily wounded important 
blood vessels, or if the case was an unusual one in this respect. 
The manipulation, application of styptics, etc., necessary 
to control this hemorrhage, no doubt aggravated the unavoid¬ 
able infiammation in the wound of excision, and was probably 
largely responsible for the unfavorable contraction of the 
cicatrix and consequent narrowing of the superior laryngeal 
opening, and its further occlusion by the right arytoenoid 
cartilage being drawn downwards and inwards. 
The very marked hypertrophy of the cricoid cartilage, 
and the consequent constriction of the inferior laryngeal 
opening, is not so readily explained, for although the same 
manipulation on account of the hemorrhage may have caused 
some irritation of this part, it seems very improbable that it 
could be wholly responsible, and the tampon canula scarcely 
touching this cartilage can be illy blamed for the pathologi¬ 
cal change. 
The retention of the tampon canula for an unusual length 
of time was undoubtedly the sole, or at least main cause of 
the collapse of the tracheal rings involved in the primary in¬ 
cision, as such pathological conditions occasionally follow 
tracheotomy, and so far as observed, this result has happened 
only in those cases where, as in this case, a plain incision 
through the tracheal rings is made for the insertion of the 
tracheotomy tube instead of removing a sufficient part of the 
rings to admit it without straining or distorting the involved 
cartilages. 
We have, in this instance, departed from the general rule 
in recording cases of this operation, which has heretofore 
