TRACHEOTOMY. 479 



by the thin expansion of the cutaneous colli. In this middle third 

 of the neck, the cartilaginous rings of the trachea, with the liga- 

 ments between which unite them, are readily identified. 



The indications of tracheotomy, which are quite numerous, 

 are enumerated by Zundel, under five principal heads : 1st, when 

 an obstacle exists which interferes with the free access of air to 

 the lung, as in case of contraction or obstruction of any portion of 

 the air passages, including all the diseases of the upper part of the 

 respiratory tract, and acting directly, such as acute larj-ngitis, 

 oedema of the glottis, and polypi or paralysis of the larynx ; or to- 

 gether with those which act indirectly, as strangles, pm-ulent col- 

 lections in the guttural pouches, anasarca and pui-pura hemon-ha- 

 gica ; 2d, when foreign bodies have become lodged in the fauces or 

 the larynx, in order to facilitate their extraction, either du-ectly, by 

 means of special forceps, or indirectly, by pushing them back into 

 the mouth to enable the surgeon to grasp them with his hand ; 3d, 

 to remove tumors, polypi, cysts or cancerous growths ; 4th, in cases 

 of fractures of the bones of the face, of the cartilages of the larjTix, 

 or of the trachea ; and 5th, again, when the trachea has become 

 the seat of any specific lesions, such as tracheocele ; caries of the 

 tracheal cartilages, or of deformities, such as may result from frac- 

 tures, ossifications and contractions. 



The operation is, however, contra-indicated when the cause or 

 object which impedes respiration occupies a point so low in the 

 passage as to be beyond reach by the tracheotomy tube ; or when 

 the difficulty in breathing and the danger of suifocation are due 

 to a diseased condition, either of the lungs or of the heart. 



The instruments required for the operation are : a pair of 

 curved scissors, a convex and a pointed bistoury, a sharp-pointed 

 tenaculum, a bull-dog forceps, two blunt tenaculums and a trach 

 eotomy tube. Some special instruments for the division and am- 

 putation of the trachea have been invented, but the tracheotomes 

 as they are called, do not generally serve as good a purpose as the 

 ordinary instruments already named. 



Tracheotomy tubes are of various forms and devices. Some 

 are of very simple construction, and others are more or less com. 

 phcated. The ordinary tube consists of a bent and curved can- 

 ula, made of various diameters, more or less cylindrical, and 

 secured on a square plate, nearly flat, or with a curve in order 

 to adapt it to the convexity of the neck, and with an eyelet or 



