SURGERY.
Tracheotomy in a Case of Croup Successful. By William Craig,
Esq.—The subject of the following case was Master William A., aged
7. He is of a delicate and somewhat irritable constitution, and has had
enlarged tonsils since he was three years of age. The enlargement of
the tonsils has not been uniform, but liable to variations in size, from
occasional exposures to cold. The frequent application of a weak solu-
tion of nit. argent, had only a partially beneficial effect, as the tonsils
always continued less or more swollen.
To invigorate his constitution, and improve the affection of the throat,
he was brought from Glasgow to the coast, to obtain the benefit of the
sea air. I saw the little patient for the first time on the 23d of
March. I then found the tonsils more than usually red, and pretty much
swollen, and, on the most projecting part, they were partially ulcerated.
I touched the ulcerated portion of the tonsils lightly with nit. argent.,
and recommended counter-irritation around the neck.
On entering his room on the following day, the first sound that met
my ear was the well-known ringing cough of croup. My little patient
was immediately subjected to the most rigid antiphlogistic treatment.
Emetics and purgatives were freely administered, warm salt placed
round the throat, and leeches applied during the first day of these
croupy symptoms. On the second day, no improvements being apparent,
the emetics were given in more decided doses; but their effects were
more depressing than emetic. Besides antimony, ipecacuanha and sul-
phate of zinc were perseveringly administered by anxious and trustworthy
attendants-. Calomel was also given in repeated doses, accompanied by
mercurial frictions, but without any specific or beneficial effect. A
blister was also applied to the side of the neck. Notwithstanding all
these measures, the disease progressed to the full developed stage. On
the fourth day of the disease, the emetics and other measures were con-
tinued, without the slightest melioration of the symptoms, as every
repeated paroxysm returned with aggravated violence, and threatened
immediate suffocation. I had had a dread from the first that the case
might come to this extremity, and had resolved—and had the concur-
rence of Dr. Paterson, from Glasgow, in the propriety of my resolution—
to give my patient the benefit of tracheotomy as a cZermer resort. Dr.
Whiteside, of this town, was also of opinion that my patient should
have the chance of the operation; and he assisted me in the performance
of it. The boy was seated on the knee of an assistant. A free incision
of fully two inches in length was then made, without losing a drachm of
blood; and every drop was removed before opening the trachea. It was
opened to the extent of an inch fully, and the incision was at the same
time carried through the false membrane. Immediately on the opening
being made, the membrane was seen vibrating in the trachea, and a
violent expiratory effort caused a large portion of it to be forced out;
and the patient was immediately and completely relieved. The larger
portion of the membrane thus ejected was about two inches in length
and, at its greatest breadth, was fully an inch and a quarter. There
were two small fragments thrown out at the same time, which, when
added to the largest piece, made it of a uniform length and width. It
was fully a line in thickness, and, in tenacity, it somewhat resembled
that of an orange skin.
For a number of hours after the operation, there was little cough and
no expectoration; but there was a considerable discharge for some time
after this, without any bronchial or other pulmonary irritation which
cbuld be discovered to account for it. The discharge might, in my
opinion, be supplied for the most part by the solution of that portion of
the membrane which lined the trachea between the glottis and the
opening. On the third day after the operation, the tube was found
more than usually obstructed; and, on removing it, a portion of thin,
membranous matter was flapping in the wound. Part of this was forced
out by the expiratory efforts; and another portion adhered so firmly, that
some force was necessary to separate it from the attachment it had with
the inner surface of the trachea above the wound. This was evidently
that portion of the false membrane which filled the trachea between the
glottis and the upper part of the wound. A portion of it had a distinct
tubular form; but it was remarkably attenuated, having rapidly dis-
solved after the opening through the trachea had been effected. In the
course of eight days after the operation, the natural air passage had
become so clear, that the tube was removed, and the respiration was
established in its natural course. There was a partial return of the
croupy cough on the 2k2d of April; but it became speedily better, and
he has since continued to progress most satisfactorily, and is now nearly
well, and the wound in the neck is now cicatrised. There was some
suspicion that this attack was connected with scarlatina, as a younger
sister of our little patient died at the same house from a severe attack of
fever, accompanied by the species of sore throat peculiar to this affection.
What, in addition, gave countenance to this apprehension, was the
desquamation, to some extent, of the cuticle, from the anterior part of
the chest; but this might have depended exclusively on an erysipelatous
condition of the skin around the incision, and extending down the an-
terior part of the chest a few days after the operation. The age of the
patient, and the uncomplicated condition of the complaint—there was
no pulmonary affection—were very encouraging circumstances in this
case. Another circumstance which, in my opinion, promoted a favorable
result, was the free opening in the trachea, as a strong expiratory current
was permitted, which forced out the whole of the false membrane which
was situated below the incision. The false membrane reached about an
inch below the lowest point of the incision, very near the bronchial
bifurcation. Some authors mention, that there is no prospect of success
if the membrane extend below the point chosen for incision.
I do not consider that the question of tracheotomy should be delayed
till the leaden hue of the countenance and purpled color of the lips
evince to what extent the vitiation of the circulating fluid has advanced.
The hopelessness of the case can be easily prognosed before the affection
has advanced so far; and if an earlier period were generally chosen, there
would, in all probability, be less chance of the extension of the false
membrane into the bronchial tubes. It would have been hopeless to
have expected the expulsion of the false membrane through the glottis,
when, even in the attenuated condition in which the last portion came
away, it required considerable traction with forceps to separate, or,
rather, tear it from its adhesion to the inner surface of the trachea.
Though the membrane had been loose in the trachea, such a mass
coming up through the glottis with diminished expiratory efforts to
force it through would inevitably have produced suffocation. Although
the lower edge of the membrane was unattached to the walls of the
trachea, it was firmly connected with the upper part, as was evinced by
the strong adhesion of the attenuated portion that came last away.
The greatest number of authors who write on this disease consider
tracheotomy as a hopeless expedient to save patients laboring under this
formidable malady. If one can be saved out of ten, or even a much
smaller exceptional proportion, I see no good grounds to withhold from
a little sufferer the only chance which he has of being snatched from
the jaws of death.—Med. Times and Gaz.