Henry Gray (1821–1865). Anatomy of the Human Body. 1918. 1a. The Larynx The larynx or organ of voice is placed at the upper part of the air passage. It is situated between the trachea and the root of the tongue, at the upper and forepart of the neck, where it presents a considerable projection in the middle line. It forms the lower part of the anterior wall of the pharynx, and is covered behind by the mucous lining of that cavity; on either side of it lie the great vessels of the neck. Its vertical extent corresponds to the fourth, fifth, and sixth cervical vertebræ, but it is placed somewhat higher in the female and also during childhood. Symington found that in infants between six and twelve months of age the tip of the epiglottis was a little above the level of the fibrocartilage between the odontoid process and body of the axis, and that between infancy and adult life the larynx descends for a distance equal to two vertebral bodies and two intervertebral fibrocartilages. According to Sappey the average measurements of the adult larynx are as follows:
In males. In females.
Length 44 mm. 36 mm. Transverse diameter 43 mm. 41 mm. Antero-posterior diameter 36 mm. 26 mm. Circumference 136 mm. 112 mm.
Until puberty the larynx of the male differs little in size from that of the female. In the female its increase after puberty is only slight; in the male it undergoes considerable increase; all the cartilages are enlarged and the thyroid cartilage becomes prominent in the middle line of the neck, while the length of the rima glottidis is nearly doubled. The larynx is broad above, where it presents the form of a triangular box flattened behind and at the sides, and bounded in front by a prominent vertical ridge. Below, it is narrow and cylindrical. It is composed of cartilages, which are connected together by ligaments and moved by numerous muscles. It is lined by mucous membrane continuous above with that of the pharynx and below with that of the trachea. The Cartilages of the Larynx (cartilagines laryngis) (Fig. 950) are nine in number, three single and three paired, as follows: Thyroid.
The Thyroid Cartilage (cartilago thyreoidea) is the largest cartilage of the larynx. It consists of two laminæ the anterior borders of which are fused with each other at an acute angle in the middle line of the neck, and form a subcutaneous projection named the laryngeal prominence (pomum Adami). This prominence is most distinct at its upper part, and is larger in the male than in the female. Immediately above it the laminæ are separated by a V-shaped notch, the superior thyroid notch The laminæ are irregularly quadrilateral in shape, and their posterior angles are prolonged into processes termed the superior and inferior cornua The outer surface of each lamina presents an oblique line which runs downward and forward from the superior thyroid tubercle situated near the root of the superior cornu, to the inferior thyroid tubercle on the lower border. This line gives attachment to the Sternothyreoideus, Thyreohyoideus, and Constrictor pharyngis inferior. The inner surface is smooth; above and behind, it is slightly concave and covered by mucous membrane. In front, in the angle formed by the junction of the laminæ, are attached the stem of the epiglottis, the ventricular and vocal ligaments, the Thyreoarytænoidei, Thyreoepiglottici and Vocales muscles, and the thyroepiglottic ligament. The upper border is concave behind and convex in front; it gives attachment to the corresponding half of the hyothyroid membrane. The lower border is concave behind, and nearly straight in front, the two parts being separated by the inferior thyroid tubercle. A small part of it in and near the middle line is connected to the cricoid cartilage by the middle cricothyroid ligament. The posterior border thick and rounded, receives the insertions of the Stylopharyngeus and Pharyngopalatinus. It ends above, in the superior cornu, and below, in the inferior cornu. The superior cornu is long and narrow, directed upward, backward, and medialward, and ends in a conical extremity, which gives attachment to the lateral hyothyroid ligament. The inferior cornu is short and thick; it is directed downward, with a slight inclination forward and medialward, and presents, on the medial side of its tip, a small oval articular facet for articulation with the side of the cricoid cartilage. During infancy the laminæ of the thyroid cartilage are joined to each other by a narrow, lozenge-shaped strip, named the intrathyroid cartilage This strip extends from the upper to the lower border of the cartilage in the middle line, and is distinguished from the laminæ by being more transparent and more flexible. The Cricoid Cartilage (cartilago cricoidea) is smaller, but thicker and stronger than the thyroid, and forms the lower and posterior parts of the wall of the larynx. It consists of two parts: a posterior quadrate lamina and a narrow anterior arch one-fourth or one-fifth of the depth of the lamina. The lamina (lamina cartilaginis cricoideæ; posterior portion) is deep and broad, and measures from above downward about 2 or 3 cm.; on its posterior surface, in the middle line, is a vertical ridge to the lower part of which are attached the longitudinal fibers of the esophagus; and on either side of this a broad depression for the Cricoarytænoideus posterior. 13
FIG. 950– The cartilages of the larynx. Posterior view. (Picture From the Classic Gray's Anatomy) The arch (arcus cartilaginis cricoideæ; anterior portion) is narrow and convex, and measures vertically from 5 to 7 mm.; it affords attachment externally in front and at the sides to the Cricothyreiodei, and behind, to part of the Constrictor pharyngis inferior. 14 On either side, at the junction of the lamina with the arch, is a small round articular surface, for articulation with the inferior cornu of the thyroid cartilage. 15 The lower border of the cricoid cartilage is horizontal, and connected to the highest ring of the trachea by the cricotracheal ligament. 16 The upper border runs obliquely upward and backward, owing to the great depth of the lamina. It gives attachment, in front, to the middle cricothyroid ligament; at the side, to the conus elasticus and the Cricoarytænoidei laterales; behind, it presents, in the middle, a shallow notch, and on either side of this is a smooth, oval, convex surface, directed upward and lateralward, for articulation with the base of an arytenoid cartilage. 17 The inner surface of the cricoid cartilage is smooth, and lined by mucous membrane. 18 The Arytenoid Cartilages (cartilagines arytænoideæ) are two in number, and situated at the upper border of the lamina of the cricoid cartilage, at the back of the larynx. Each is pyramidal in form, and has three surfaces, a base, and an apex. 19 The posterior surface is a triangular, smooth, concave, and gives attachment to the Arytænoidei obliquus and transversus. 20 The antero-lateral surface is somewhat convex and rough. On it, near the apex of the cartilage, is a rounded elevation (colliculus) from which a ridge (crista arcuata) curves at first backward and then downward and forward to the vocal process. The lower part of this crest intervenes between two depressions or foveæ an upper, triangular, and a lower oblong in shape; the latter gives attachment to the Vocalis muscle. 21 The medial surface is narrow, smooth, and flattened, covered by mucous membrane, and forms the lateral boundary of the intercartilaginous part of the rima glottidis. 22 The base of each cartilage is broad, and on it is a concave smooth surface, for articulation with the cricoid cartilage. Its lateral angle is short, rounded, and prominent; it projects backward and lateralward, and is termed the muscular process it gives insertion to the Cricoarytænoideus posterior behind, and to the Cricoarytænoideus lateralis in front. Its anterior angle, also prominent, but more pointed, projects horizontally forward; it gives attachment to the vocal ligament, and is called the vocal process 23 The apex of each cartilage is pointed, curved backward and medialward, and surmounted by a small conical, cartilaginous nodule, the corniculate cartilage 24 The Corniculate Cartilages (cartilagines corniculatæ; cartilages of Santorini) are two small conical nodules consisting of yellow elastic cartilage, which articulate with the summits of the arytenoid cartilages and serve to prolong them backward and medialward. They are situated in the posterior parts of the aryepiglottic folds of mucous membrane, and are sometimes fused with the arytenoid cartilages. 25 The Cuneiform Cartilages (cartilagines cuneiformes; cartilages of Wrisberg) are two small, elongated pieces of yellow elastic cartilage, placed one on either side, in the aryepiglottic fold, where they give rise to small whitish elevations on the surface of the mucous membrane, just in front of the arytenoid cartilages. 26 The Epiglottis (cartilago epiglottica) is a thin lamella of fibrocartilage of a yellowish color, shaped like a leaf, and projecting obliquely upward behind the root of the tongue, in front of the entrance to the larynx. The free extremity is broad and rounded; the attached part or stem is long, narrow, and connected by the thyroepiglottic ligament to the angle formed by the two laminæ of the thyroid cartilage, a short distance below the superior thyroid notch. The lower part of its anterior surface is connected to the upper border of the body of the hyoid bone by an elastic ligamentous band, the hyoepiglottic ligament 27 The anterior or lingual surface is curved forward, and covered on its upper, free part by mucous membrane which is reflected on to the sides and root of the tongue, forming a median and two lateral glossoepiglottic folds the lateral folds are partly attached to the wall of the pharynx. The depressions between the epiglottis and the root of the tongue, on either side of the median fold, are named the valleculæ The lower part of the anterior surface lies behind the hyoid bone, the hyothyroid membrane, and upper part of the thyroid cartilage, but is separated from these structures by a mass of fatty tissue. 28 The posterior or laryngeal surface is smooth, concave from side to side, concavo-convex from above downward; its lower part projects backward as an elevation, the tubercle or cushion When the mucous membrane is removed, the surface of the cartilage is seen to be indented by a number of small pits, in which mucous glands are lodged. To its sides the aryepiglottic folds are attached. 29 Structure—The corniculate and cuneiform cartilages, the epiglottis, and the apices of the arytenoids at first consist of hyaline cartilage, but later elastic fibers are deposited in the matrix, converting them into yellow fibrocartilage, which shows little tendency to calcification. The thyroid, cricoid, and the greater part of the arytenoids consist of hyaline cartilage, and become more or less ossified as age advances. Ossification commences about the twenty-fifth year in the thyroid cartilage, and somewhat later in the cricoid and arytenoids; by the sixty-fifth year these cartilages may be completely converted into bone. 30
FIG. 951– The ligaments of the larynx. Antero-lateral view. (Picture From the Classic Gray's Anatomy) Ligaments—The ligaments of the larynx (Figs. 951, 952) are extrinsic i. e those connecting the thyroid cartilage and epiglottis with the hyoid bone, and the cricoid cartilage with the trachea; and intrinsic those which connect the several cartilages of the larynx to each other. 31 Extrinsic Ligaments—The ligaments connecting the thyroid cartilage with the hyoid bone are the hyothyroid membrane, and a middle and two lateral hyothyroid ligaments. 32 The Hyothyroid Membrane (membrana hyothyreoidea; thyrohyoid membrane) is a broad, fibro-elastic layer, attached below to the upper border of the thyroid cartilage and to the front of its superior cornu, and above to the upper margin of the posterior surface of the body and greater cornua of the hyoid bone, thus passing behind the posterior surface of the body of the hyoid, and being separated from it by a mucous bursa, which facilitates the upward movement of the larynx during deglutition. Its middle thicker part is termed the middle hyothyroid ligament (ligamentum hyothyreoideum medium; middle thyrohyoid ligament), its lateral thinner portions are pierced by the superior laryngeal vessels and the internal branch of the superior laryngeal nerve. Its anterior surface is in relation with the Thyreohyoideus, Sternohyoideus, and Omohyoideus, and with the body of the hyoid bone. 33 The Lateral Hyothyroid Ligament (ligamentum hyothyreoideum laterale; lateral thyrohyoid ligament) is a round elastic cord, which forms the posterior border of the hyothyroid membrane and passes between the tip of the superior cornu of the thyroid cartilage and the extremity of the greater cornu of the hyoid bone. A small cartilaginous nodule (cartilago triticea), sometimes bony, is frequently found in it. 34
FIG. 952– Ligaments of the larynx. Posterior view. (Picture From the Classic Gray's Anatomy) The Epiglottis is connected with the hyoid bone by an elastic band, the hyoepiglottic ligament (ligamentum hyoepiglotticum), which extends from the anterior surface of the epiglottis to the upper border of the body of the hyoid bone. The glossoepiglottic folds of mucous membrane (page 1075) may also be considered as extrinsic ligaments of the epiglottis. 35 The Cricotracheal Ligament (ligamentum cricotracheale) connects the cricoid cartilage with the first ring of the trachea. It resembles the fibrous membrane which connects the cartilaginous rings of the trachea to each other. 36 Intrinsic Ligaments—Beneath the mucous membrane of the larynx is a broad sheet of fibrous tissue containing many elastic fibers, and termed the elastic membrane of the larynx It is subdivided on either side by the interval between the ventricular and vocal ligaments, the upper portion extends between the arytenoid cartilage and the epiglottis and is often poorly defined; the lower part is a well-marked membrane forming, with its fellow of the opposite side, the conus elasticus which connects the thyroid, cricoid, and arytenoid cartilages to one another. In addition the joints between the individual cartilages are provided with ligaments. 37 The Conus Elasticus (cricothyroid membrane) is composed mainly of yellow elastic tissue. It consists of an anterior and two lateral portions. The anterior part or middle cricothyroid ligament (ligamentum cricothyreoideum medium; central part of cricothyroid membrane) is thick and strong, narrow above and broad below. It connects together the front parts of the contiguous margins of the thyroid and cricoid cartilages. It is overlapped on either side by the Cricothyreoideus, but between these is subcutaneous; it is crossed horizontally by a small anastomotic arterial arch, formed by the junction of the two cricothyroid arteries, branches of which pierce it. The lateral portions are thinner and lie close under the mucous membrane of the larynx; they extend from the superior border of the cricoid cartilage to the inferior margin of the vocal ligaments, with which they are continuous. These ligaments may therefore be regarded as the free borders of the lateral portions of the conus elasticus, and extend from the vocal processes of the arytenoid cartilages to the angle of the thyroid cartilage about midway between its upper and lower borders. 38 An articular capsule strengthened posteriorly by a well-marked fibrous band, encloses the articulation of the inferior cornu of the thyroid with the cricoid cartilage on either side. 39 Each arytenoid cartilage is connected to the cricoid by a capsule and a posterior cricoarytenoid ligament. The capsule (capsula articularis cricoarytenoidea) is thin and loose, and is attached to the margins of the articular surfaces. The posterior cricoarytenoid ligament (ligamentum cricoarytenoideum posterius) extends from the cricoid to the medial and back part of the base of the arytenoid. 40 The thyroepiglottic ligament (ligamentum thyreoepiglotticum) is a long, slender, elastic cord which connects the stem of the epiglottis with the angle of the thyroid cartilage, immediately beneath the superior thyroid notch, above the attachment of the ventricular ligaments. 41 Movements—The articulation between the inferior cornu of the thyroid cartilage and the cricoid cartilage on either side is a diarthrodial one, and permits of rotatory and gliding movements. The rotatory movement is one in which the cricoid cartilage rotates upon the inferior cornua of the thyroid cartilage around an axis passing transversely through both joints. The gliding movement consists in a limited shifting of the cricoid on the thyroid in different directions. 42 The articulation between the arytenoid cartilages and the cricoid is also a diarthrodial one, and permits of two varieties of movement: one is a rotation of the arytenoid on a vertical axis, whereby the vocal process is moved lateralward or medialward, and the rima glottidis increased or diminished; the other is a gliding movement, and allows the arytenoid cartilages to approach or recede from each other; from the direction and slope of the articular surfaces lateral gliding is accompanied by a forward and downward movement. The two movements of gliding and rotation are associated, the medial gliding being connected with medialward rotation, and the lateral gliding with lateralward rotation. The posterior cricoarytenoid ligaments limit the forward movement of the arytenoid cartilages on the cricoid. 43 Interior of the Larynx (Figs. 953, 954)—The cavity of the larynx (cavum laryngis) extends from the laryngeal entrance to the lower border of the cricoid cartilage where it is continuous with that of the trachea. It is divided into two parts by the projection of the vocal folds, between which is a narrow triangular fissure or chink, the rima glottidis The portion of the cavity of the larynx above the vocal folds is called the vestibule it is wide and triangular in shape, its base or anterior wall presenting, however, about its center the backward projection of the tubercle of the epiglottis. It contains the ventricular folds, and between these and the vocal folds are the ventricles of the larynx The portion below the vocal folds is at first of an elliptical form, but lower down it widens out, assumes a circular form, and is continuous with the tube of the trachea. 44 The entrance of the larynx (Fig. 955) is a triangular opening, wide in front, narrow behind, and sloping obliquely downward and backward. It is bounded, in front, by the epiglottis; behind, by the apices of the arytenoid cartilages, the corniculate cartilages, and the interarytenoid notch; and on either side, by a fold of mucous membrane, enclosing ligamentous and muscular fibers, stretched between the side of the epiglottis and the apex of the arytenoid cartilage; this is the aryepiglottic fold on the posterior part of the margin of which the cuneiform cartilage forms a more or less distinct whitish prominence, the cuneiform tubercle 45
FIG. 953– Sagittal section of the larynx and upper part of the trachea. (Picture From the Classic Gray's Anatomy) The Ventricular Folds (plicœ ventriculares; superior or false vocal cords) are two thick folds of mucous membrane, each enclosing a narrow band of fibrous tissue, the ventricular ligament which is attached in front to the angle of the thyroid cartilage immediately below the attachment of the epiglottis, and behind to the antero-lateral surface of the arytenoid cartilage, a short distance above the vocal process. The lower border of this ligament, enclosed in mucous membrane, forms a free crescentic margin, which constitutes the upper boundary of the ventricle of the larynx. 46 The Vocal Folds (plicœ vocales; inferior or true vocal cords) are concerned in the production of sound, and enclose two strong bands, named the vocal ligaments (ligamenta vocales; inferior thyroarytenoid). Each ligament consists of a band of yellow elastic tissue, attached in front to the angle of the thyroid cartilage, and behind to the vocal process of the arytenoid. Its lower border is continuous with the thin lateral part of the conus elasticus. Its upper border forms the lower boundary of the ventricle of the larynx. Laterally, the Vocalis muscle lies parallel with it. It is covered medially by mucous membrane, which is extremely thin and closely adherent to its surface. 47
FIG. 954– Coronal section of larynx and upper part of trachea. (Picture From the Classic Gray's Anatomy) The Ventricle of the Larynx (ventriculus laryngis [Morgagnii]; laryngeal sinus) is a fusiform fossa, situated between the ventricular and vocal folds on either side, and extending nearly their entire length. The fossa is bounded, above by the free crescentic edge of the ventricular fold; below by the straight margin of the vocal fold; laterally by the mucous membrane covering the corresponding Thyreoarytænoideus. The anterior part of the ventricle leads up by a narrow opening into a cecal pouch of mucous membrane of variable size called the appendix 48 The appendix of the laryngeal ventricle (appendix ventriculi laryngis; laryngeal saccule) is a membranous sac, placed between the ventricular fold and the inner surface of the thyroid cartilage, occasionally extending as far as its upper border or even higher; it is conical in form, and curved slightly backward. On the surface of its mucous membrane are the openings of sixty or seventy mucous glands, which are lodged in the submucous areolar tissue. This sac is enclosed in a fibrous capsule, continuous below with the ventricular ligament. Its medial surface is covered by a few delicate muscular fasciculi, which arise from the apex of the arytenoid cartilage and become lost in the aryepiglottic fold of mucous membrane; laterally it is separated from the thyroid cartilage by the Thyreoepiglotticus. These muscles compress the sac, and express the secretion it contains upon the vocal folds to lubricate their surfaces. 49
FIG. 955– The entrance to the larynx, viewed from behind. (Picture From the Classic Gray's Anatomy) The Rima Glottidis (Fig. 956) is the elongated fissure or chink between the vocal folds in front, and the bases and vocal processes of the arytenoid cartilages behind. It is therefore subdivided into a larger anterior intramembranous part (glottis vocalis), which measures about three-fifths of the length of the entire aperture, and a posterior intercartilaginous part (glottis respiratoria). Posteriorly it is limited by the mucous membrane passing between the arytenoid cartilages. The rima glottidis is the narrowest part of the cavity of the larynx, and its level corresponds with the bases of the arytenoid cartilages. Its length, in the male, is about 23 mm.; in the female from 17 to 18 mm. The width and shape of the rima glottidis vary with the movements of the vocal folds and arytenoid cartilages during respiration and phonation. In the condition of rest, i. e when these structures are uninfluenced by muscular action, as in quiet respiration, the intramembranous part is triangular, with its apex in front and its base behind—the latter being represented by a line, about 8 mm. long, connecting the anterior ends of the vocal processes, while the medial surfaces of the arytenoids are parallel to each other, and hence the intercartilaginous part is rectangular. During extreme adduction of the vocal folds, as in the emission of a high note, the intramembranous part is reduced to a linear slit by the apposition of the vocal folds, while the intercartilaginous part is triangular, its apex corresponding to the anterior ends of the vocal processes of the arytenoids, which are approximated by the medial rotation of the cartilages. Conversely in extreme abduction of the vocal folds, as in forced inspiration, the arytenoids and their vocal processes are rotated lateralward, and the intercartilaginous part is triangular in shape but with its apex directed backward. In this condition the entire glottis is somewhat lozenge-shaped, the sides of the intramembranous part diverging from before backward, those of the intercartilaginous part diverging from behind forward—the widest part of the aperture corresponding with the attachments of the vocal folds to the vocal processes. 50
FIG. 956– Laryngoscopic view of interior of larynx. (Picture From the Classic Gray's Anatomy) ]] Muscles—The muscles of the larynx are extrinsic passing between the larynx and parts around—these have been described in the section on Myology; and intrinsic confined entirely to the larynx. 51 The intrinsic muscles are: 52 Cricothyreoideus.
The Cricothyreoideus (Cricothyroid) (Fig. 957), triangular in form, arises from the front and lateral part of the cricoid cartilage; its fibers diverge, and are arranged in two groups. The lower fibers constitute a pars obliqua and slant backward and lateralward to the anterior border of the inferior cornu; the anterior fibers, forming a pars recta run upward, backward, and lateralward to the posterior part of the lower border of the lamina of the thyroid cartilage. 53 The medial borders of the two muscles are separated by a triangular interval, occupied by the middle cricothyroid ligament. 54 The Cricoarytænoideus posterior (posterior cricoarytenoid) (Fig. 958) arises from the broad depression on the corresponding half of the posterior surface of the lamina of the cricoid cartilage; its fibers run upward and lateralward, and converge to be inserted into the back of the muscular process of the arytenoid cartilage. The uppermost fibers are nearly horizontal, the middle oblique, and the lowest almost vertical. 55 The Cricoarytænoideus lateralis (lateral cricoarytenoid) (Fig. 959) is smaller than the preceding, and of an oblong form. It arises from the upper border of the arch of the cricoid cartilage, and, passing obliquely upward and backward, is inserted into the front of the muscular process of the arytenoid cartilage. 56
FIG. 957– Side view of the larynx, showing muscular attachments. (Picture From the Classic Gray's Anatomy)
FIG. 958– Muscles of larynx. Posterior view. (Picture From the Classic Gray's Anatomy)
FIG. 959– Muscles of larynx. Side view. Right lamina of thyroid cartilage removed. (Picture From the Classic Gray's Anatomy) The Arytænoideus (Fig. 958) is a single muscle, filling up the posterior concave surfaces of the arytenoid cartilages. It arises from the posterior surface and lateral border of one arytenoid cartilage, and is inserted into the corresponding parts of the opposite cartilage. It consists of oblique and transverse parts. The Arytænoideus obliquus the more superficial, forms two fasciculi, which pass from the base of one cartilage to the apex of the opposite one, and therefore cross each other like the limbs of the letter X; a few fibers are continued around the lateral margin of the cartilage, and are prolonged into the aryepiglottic fold; they are sometimes described as a separate muscle, the Aryepiglotticus The Arytænoideus transversus crosses transversely between the two cartilages. 57 The Thyreoarytænoideus (Thyroarytenoid) (Figs. 959, 960) is a broad, thin, muscle which lies parallel with and lateral to the vocal fold, and supports the wall of the ventricle and its appendix. It arises in front from the lower half of the angle of the thyroid cartilage, and from the middle cricothyroid ligament. Its fibers pass backward and lateralward, to be inserted into the base and anterior surface of the arytenoid cartilage. The lower and deeper fibers of the muscle can be differentiated as a triangular band which is inserted into the vocal process of the arytenoid cartilage, and into the adjacent portion of its anterior surface; it is termed the Vocalis and lies parallel with the vocal ligament, to which it is adherent. 58
FIG. 960– Muscles of the larynx, seen from above. (Enlarged.) (Picture From the Classic Gray's Anatomy) A considerable number of the fibers of the Thyreoarytænoideus are prolonged into the aryepiglottic fold, where some of them become lost, while others are continued to the margin of the epiglottis. They have received a distinctive name, Thyreoepiglotticus and are sometimes described as a separate muscle. A few fibers extend along the wall of the ventricle from the lateral wall of the arytenoid cartilage to the side of the epiglottis and constitute the Ventricularis muscle. 59 Actions—In considering the actions of the muscles of the larynx, they may be conveniently divided into two groups, vix.: 1. Those which open and close the glottis. 2. Those which regulate the degree of tension of the vocal folds. 60 The Cricoarytœnoidei posteriores separate the vocal folds, and, consequently, open the glottis, by rotating the arytenoid cartilages outward around a vertical axis passing through the cricoarytenoid joints; so that their vocal processes and the vocal folds attached to them become widely separated. 61 The Cricoarytœnoidei laterales close the glottis by rotating the arytenoid cartilages inward, so as to approximate their vocal processes. 62 The Arytœnoideus approximates the arytenoid cartilages, and thus closes the opening of the glottis, especially at its back part. 63 The Cricothyreoidei produce tension and elongation of the vocal folds by drawing up the arch of the cricoid cartilage and tilting back the upper border of its lamina; the distance between the vocal processes and the angle of the thyroid is thus increased, and the folds are consequently elongated. 64 The Thyreoarytœnoidei consisting of two parts having different attachments and different directions, are rather complicated as regards their action. Their main use is to draw the arytenoid cartilages forward toward the thyroid, and thus shorten and relax the vocal folds. But, owing to the connection of the deeper portion with the vocal fold, this part, if acting separately, is supposed to modify its elasticity and tension, while the lateral portion rotates the arytenoid cartilage inward, and thus narrows the rima glottidis by bringing the two vocal folds together. 65 The manner in which the entrance of the larynx is closed during deglutition is referred to on page 1140. 66 Mucous Membrane—The mucous membrane of the larynx is continuous above with that lining the mouth and pharynx, and is prolonged through the trachea and bronchi into the lungs. It lines the posterior surface and the upper part of the anterior surface of the epiglottis, to which it is closely adherent, and forms the aryepiglottic folds which bound the entrance of the larynx. It lines the whole of the cavity of the larynx; forms, by its reduplication, the chief part of the ventricular fold, and, from the ventricle, is continued into the ventricular appendix. It is then reflected over the vocal ligament, where it is thin, and very intimately adherent; covers the inner surface of the conus elasticus and cricoid cartilage; and is ultimately continuous with the lining membrane of the trachea. The anterior surface and the upper half of the posterior surface of the epiglottis, the upper part of the aryepiglottic folds and the vocal folds are covered by stratified squamous epithelium; all the rest of the laryngeal mucous membrane is covered by columnar ciliated cells, but patches of stratified squamous epithelium are found in the mucous membrane above the glottis. 67 Glands—The mucous membrane of the larynx is furnished with numerous mucous secreting glands, the orifices of which are found in nearly every part; they are very plentiful upon the epiglottis, being lodged in little pits in its substance; they are also found in large numbers along the margin of the aryepiglottic fold, in front of the arytenoid cartilages, where they are termed the arytenoid glands They exist also in large numbers in the ventricular appendages. None are found on the free edges of the vocal folds. 68 Vessels and Nerves—The chief arteries of the larynx are the laryngeal branches derived from the superior and inferior thyroid. The veins accompany the arteries; those accompanying the superior laryngeal artery join the superior thyroid vein which opens into the internal jugular vein; while those accompanying the inferior laryngeal artery join the inferior thyroid vein which opens into the innominate vein. The lymphatic vessels consist of two sets, superior and inferior. The former accompany the superior laryngeal artery and pierce the hyothyroid membrane, to end in the glands situated near the bifurcation of the common carotid artery. Of the latter, some pass through the middle cricothyroid ligament and open into a gland lying in front of that ligament or in front of the upper part of the trachea, while others pass to the deep cervical glands and to the glands accompanying the inferior thyroid artery. The nerves are derived from the internal and external branches of the superior laryngeal nerve, from the recurrent nerve, and from the sympathetic. The internal laryngeal branch is almost entirely sensory, but some motor filaments are said to be carried by it to the Arytænoideus. It enters the larynx by piercing the posterior part of the hyothyroid membrane above the superior laryngeal vessels, and divides into a branch which is distributed to both surfaces of the epiglottis, a second to the aryepiglottic fold, and a third, the largest, which supplies the mucous membrane over the back of the larynx and communicates with the recurrent nerve. The external laryngeal branch supplies the Cricothyreoideus. The recurrent nerve passes upward beneath the lower border of the Constrictor pharyngis inferior immediately behind the cricothyroid joint. It supplies all the muscles of the larynx except the Cricothyreoideus, and perhaps a part of the Arytænoideus. The sensory branches of the laryngeal nerves form subepithelial plexuses, from which fibers pass to end between the cells covering the mucous membrane. 69 Over the posterior surface of the epiglottis, in the aryepiglottic folds, and less regularly in some other parts, taste-buds, similar to those in the tongue, are found. 70 grays