ld be made of sterling silver. German
silver plated with pure silver is good enough for temporary use, but
the plating soon wears off under the galvanic action set up between
the two metals. Aluminum becomes roughened by boiling and contact with
secretions, and causes the formation of granulations which in time
lead to stenosis. Hard rubber tubes cannot be boiled, the walls are so
thick as to leave too little lumen, and the rubber is irritating to
the tissues. All tracheotomy tubes should be fitted with pilots. Many
of the tubes furnished to patients have no pilots to facilitate the
introduction, and the tubes are inserted with somewhat the effect of a
cheese tester, and with great pain and suffering on the part of the
patient. Most of the the tubes in the shops are too short to allow for
the swelling of the tissues of the neck following the operation. They
may reach the trachea at the time of the operation, but as soon as the
reactionary swelling occurs, the end of the tube is pulled out (Fig.
103) of the tracheal incision; the air hissing along the tube is
considered by the attendant to indicate that the tube is still in
place, and the increasing dyspnea and accelerated respiratory rate are
attributed to supposed pneumonia or edema of the lungs, under which
erroneous diagnosis the patient is buried. In all cases in which it is
reported that in spite of tracheotomy the dyspnea was only temporarily
relieved, the fault is the lack of a "plumber." That is, an attendant
who will make sure that there is at all times a clear airway all the
way down to the lungs. With a bronchoscope and aspirator he will see
that the airway is clear. To begin with, a proper sized cannula must
be selected. The series of different sized, full curved tubes, one of
which is illustrated in Fig. 104, will under all conditions reach the
trachea. If the tube seems to be too long in any given case, it will
usually be found that the tracheotomy has been done too high, and a
lower one should be done at once. If the operation has not been done
too high, and the cannula is too long, a pad of gauze under the shield
will take up the surplus length. In cases of tracheal compression from
new growth, thymus or other such cases, in which the ordinary tube
will not pass the obstruction, the author's long cane-shaped cannula
(see Fig. 104) can be inserted past the obstruction, and if necessary
into either bronchus. The fenestrum placed in the cannula in many of
th