Tracheotomy 133 



again, and the engorgement of the tributaries of the innominate veins 

 subsides. 



In the high operation the surgeon opens the trachea above the 

 isthmus of the thyroid gland. A great deal is discussed about the 

 misfortune of wounding the isthmus ; for my own part, I never give 

 it a thought, but clear all the tissues from the front of the top rings 

 of the trachea by using a director and pair of dissecting-forceps. If 

 the isthmus happen to be across this track, and not easily displaced; 

 it must be sacrificed. But, if the surgeon proceed to open the trachea 

 below the isthmus, not only will he find it deeply placed, but he will 

 also be traversing the region of the important inferior thyroid veins 

 which descend from the isthmus to the innominate veins. Moreover, 

 should the left common carotid come from the innominate, should 

 there be a thyroidea ima, or should the left innominate vein cross 

 above the level of the episternal notch, as sometimes happens, the 

 complications might be extremely grave. He may even surprise 

 himself by coming against the apex of the thymus, which in young 

 children ascends well into the neck, as is shown by the figure on 

 pp. 132 and 155. 



The metal tube should not be too much curved, lest its sharp end 

 impinge against the front of the trachea and set up an ulceration, 

 which may eventually implicate the left innominate vein, or the 

 innominate or common carotid artery, and entail a fatal haemo- 

 ptysis. 



Fallacies in the operation. 1 ' The skin wound may be too low 

 and too short ; the trachea may have been dragged aside, or not 

 sufficiently incised, so that the tube . . . does not enter, but slips down 

 in front of it. The trachea may be altogether missed if the dissection 

 be not kept in the absolute middle line. If the wound in the trachea 

 be made with a dull scalpel, and without the little plunge, the mucous 

 lining may escape transfixion, the tube passing down between it and 

 the tracheal wall. If air do not pass through the tube, either naturally 

 or on compressing the chest, the chances are that the tube has not 

 been passed into the trachea. . . . The tube may be blocked with mucus, 

 or its aperture obstructed by false membrane. If the tracheal wound 

 be open, search should be made for a membranous cast of the trachea, 

 which might be drawn out by forceps. For thorough exploration, the 

 tracheal wound should be enlarged slightly upwards, and a pair of 

 forceps introduced. . . . Much more likely is it that the tube has 

 been passed down amongst the ribbon muscles at the front of the 

 trachea than that its end is blocked by a membranous cast of the 

 trachea. 



* I know of a case in which, from the windpipe having been twisted 

 from its position, the tube was found post mortem to have been 

 introduced into the trachea through the cesophagtis ; and of another 



1 From The Surgical Diseases of Children^ Cassell & Co., 1889. 



