[FIG. 103.--Schema showing thick pad of gauze dressing, filling the space, A, and used to hold out the author's full-curved cannula when too long, prior to reactionary swelling, and after subsidence of the latter. At the right is shown the manner in which the ordinary cannula of the shops permits a patient to asphyxiate, though some air is heard passing through the tracheal opening, H, after the cannula has been partially withdrawn by swelling of the tissues, T.] [FIG. 104.--The author's tracheotomic cannulae. A, shows cane-shaped cannula for use in intrathoracic compressive or other stenoses. B, shows full curved cannula for regular use. Pilots are made to fit the outer cannula; the inner cannula not being inserted until after withdrawal of the pilot.] _Anesthesia_.--No dyspneic patient should be given a general anesthetic; because any patient dyspneic enough to need a tracheotomy for dyspnea is depending largely upon the action of the accessory respiratory muscles. When this action is stopped by beginning unconsciousness, respiration ceases. If the trachea is not immediately opened, artificial respiration instituted, and oxygen insufflated, the patient dies on the table. Skin infiltration along the line of incision with a very weak cocaine solution (1/10 of 1 per cent), apothesine (2 per cent), novocaine, Schleich's fluid or other local anesthetic, suffices to render the operation painless. The deeper structures have little sensation and do not require infiltration. It has been advocated that an interannular injection of cocaine solution with a hypodermic syringe be done just prior to incision of the trachea for the purpose of preventing cough after the incision of the trachea and the insertion of the cannula. It would seem, however, that this introduces the risk of aspiration pneumonia and pulmonary abscess, by permitting the aspiration and clotting of blood in small bronchi, followed by subsequent breaking down of the 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.