TKACHEOTOMY. 485 



tlie dissection of the cellular tissue which confines them, and drawn 

 apart by means of two blunt tenaculums, leaving a gaping wound 

 through which to reach the trachea, which is thus exposed, and 

 in readiness for the second step of the process. 



Second Step. — In the second step portions of the two cartilages 

 which have been selected, are held by the pointed tenactdum, passed 

 through the connecting ligament, are excised, and a circular open- 

 ing established by the removal of a semilunar segment from each 

 ring. It is necessary at this point to be certain that the isolated 

 valve is securely held, to guard against the force of suction, by 

 which it may be liable to be drawn into the trachea as the new 

 breathing place is suddenly opened. 



lliird Step. — This consists in the insertion of the tube into 

 the apertiu'e prepared for it, and is the simplest and easiest part 

 of the procedure. The only difficulty likely to occur is from the 

 neglect or error of the operator in measuring the dimensions of 

 the opening, and securing a perfect coaptation between that and 

 the tube. If the opening proves to be too narrow, it must, of 

 coui'se, be enlarged, with the caution before mentioned against 

 losing any detached portions by the suction of the trachea. The 

 bull-dog forceps is of value here. If the tube is of the self-hold- 

 ing kind, its introduction completes the operation ; but if the or- 

 dinary tube before described is used, the t}Txig over the neck of 

 the tapes attached to the flat plate becomes the final manipulation. 

 If no tube is at hand, the wound must be held apart with tapes 

 applied upon its edges, and tied over the neck. 



Immediate Operation by Longitudinal Incision. — This is 

 done with the sharp straight bistoury, passing it at once through 

 all the tissues, penetrating the trachea between two cartilages, 

 and making a vertical incision of two or three rings. This mode, 

 as we have said, is principally justifiable in case of emergency 

 when suffocation is imminent, and no time can be lost in proour- 

 ing the instruments necessary for the classical operation. 



There is still another mode of operating, credited to Kris- 

 haber, which, from the location where it is performed, is better 

 known as sub-cricoidean tracheotomy, and which consists in mak- 

 ing the opening through the crico-tracheal ligament, which unites 

 the cricoid cartilage to the first tracheal ring. It includes three 

 steps, comprising the incision of the skin and dissection of the 

 underl^dng muscles, the incision of the ligament, and the inser 



