clots. As the
author has so often said, "The cough reflex is the watch dog of the
lungs," and if not drugged asleep by local or general anesthesia can
safely be relied upon to prevent all possibility of the blood or the
pus which nearly always is present in acute or chronic conditions
calling for tracheotomy, being aspirated into the deeper air-passages.
Cocaine in any form, by any method, and in any dosage, is dangerous in
very young children.

_Technic_.--The patient should be placed in the recumbent position,
with the extended head held in the midline by an assistant. The
shoulders, not the neck, should be slightly raised with a sand bag.
The head should be somewhat lower than the feet, to lessen the danger
of aspiration of blood. A midline incision dividing the skin and
fascia is made from the thyroid notch to just above the suprasternal
notch. The cricoid is now located, and the deeper dissection is
continued from below this point. The ribbon muscles are separated with
dissecting scissors or knife, and held apart with retractors. If the
isthmus of the thyroid gland is in the way, it may be retracted
upward; if large, however, it should be divided and ligated, for it is
apt to slip over the tracheal incision afterward, and render difficult
the quick finding of the incision during after-care. This covering of
the tracheal incision by the slipping back of the drawn-aside
thyroidal isthmus is one of the most frequent avoidable causes of
mortality, because it deflects the cannula off into the tissues when
it is replaced after cleaning during the early postoperative period.
The corrugated surface of the trachea can be felt, and its exact
location can be determined by the index finger. If the tracheotomy is
proceeding in an orderly manner, all bleeding points should be caught
and tied with plain catgut (No. 1) before the trachea is opened.
Because of distension of vessels during cough, all but the tiniest
vessels should be ligated. Side-cut veins are particularly
treacherous. They should be freed of tissue, cut across and the
divided ends ligated.

The _incision in the trachea_ should be as low as possible, and should
never be made through the first ring. The incision should be through
the third, fourth and fifth rings. Only in cases of laryngoptosis will
it be necessary to incise the trachea higher than this. The incision
must be made in the midline, and in the long axis of the trachea, and
care must be exercised that