[279] CHAPTER XXXVII--TRACHEOTOMY _Indications_.--Tracheotomy is indicated in dyspnea of laryngotracheal origin. The cardinal signs of this form of dyspnea are: 1. Indrawing at the suprasternal notch. 2. Indrawing around the clavicles. 3. Indrawing of the intercostal spaces. 4. Restlessness. 5. Choking and waking as soon as the aid of the voluntary respiratory muscles ceases in falling to sleep. 6. Cyanosis is a dangerously late symptom. As a therapeutic measure in diseases of the larynx its place has been thoroughly established. Marked improvement of the laryngeal lesions has been observed to follow tracheotomy in advanced laryngeal tuberculosis, and in cancer of the larynx. It has proven, in some cases, a useful adjunct in the treatment of luetic laryngitis, though it cannot be regarded as indicated, in the absence of dyspnea. Perichondritis and other inflammations are benefited by tracheotomy. A marked therapeutic effect on multiple laryngotracheal papillomata in children has been noted by the author in hundreds of cases. _Tracheotomy for foreign body_ is no longer indicated either for the removal of the intruder, or for the insertion of the bronchoscope. Tracheotomy may be urgently indicated for foreign body dyspnea, but not for foreign body removal. _Subcutaneous rupture of the trachea_ from external trauma may produce dyspnea and generalized emphysema, both of which will be relieved by tracheotomy. [280] _Acromegalic stenosis of the larynx_ is a rare but urgent indication for tracheotomy. _Contraindications_.--There are no contraindications to tracheotomy for dyspnea. _The instruments_ required for an orderly tracheotomy are: Headlight Scalpels 2 Retractors Trousseau dilator 6 Hemostats Scissors (dissecting) Tracheal cannulae (six sizes) Curved needles Needle holder Hypodermic syringe for local anesthesia No. 1 plain catgut ligatures Linen tape Gauze sponges These are sterilized and kept in a sterile copper box ready for instant use. Beside the patient's bed following the tracheotomy the following sterile materials are placed: Sterile gloves 1 Hemostat Sterile new gauze Trousseau dilator Scissors Duplicate tracheotomy tube Silver probe Basin of Bichloride of mercury solution, 1 : 10,000