64 TRACHEOTOMY. 



orrhage, separate the two sterno-thyro-hyoideus muscles by 

 means of tenacula along the median line in the white strip 

 of connective tissue. The opening into the trachea may be 

 made in a variety of ways. The quickest and most crude 

 method is to slit it from above downwards through three or 

 four tracheal rings, and pressing the severed ends apart 

 insert the tube through the opening. Since the tracheal 

 rings are incomplete, being open on their dorsal surfaces, 

 cutting through the ventral portion divides each ring into 

 two separate parts and their being pushed apart, distorts 

 them and tends to the causation of chondritis and collapse 

 of the trachea, a danger which increases with the duration 

 of time that the tube is maintained in position. It is there- 

 fore most suitable for hurried operation in impending 

 suffocation where the tube will probably be needed for a 

 short time only. 



A second method of operation, illus|:rated in Fig. 2, con- 

 sists in making a transverse incision through the inter-annu- 

 lar ligament between the two last exposed tracheal rings the 

 length of the diameter of the tube to be inserted. Make 

 a perpendicular incision upward from each end of this at a 

 point I to 1.5 cm. from the median line through one or two 

 tracheal rings, according to the size of the tube. With 

 forceps or tenaculum grasp the segments of partially de- 

 tached cartilage and remove them by cutting through the 

 inter- annular ligament. 



A third and to us preferable method is to insert a narrow 

 bladed scalpel transversely at about the lower third of the 

 lowermost bared tracheal ring and cutting outwards and 

 upwards in a curved line, pa.ss through the first inter-annu- 

 lar ligament and continue into the succeeding segment until 

 near its superior border, when the incision is curved down- 

 ward to eventually reach the starting point, the isolated 

 section of the trachea being securely grasped with a pair of 

 forceps before its excision is completed. By this method 

 no tracheal ring is severed. 



