TRACHEOTOMY IN CROUP.*

BY PROF. STEINER, Prague.

Translated by JOHN C. JAY, Jr., M. D., N. Y.

HAVING already, in 1863, published six cases of tra cheotomy in croup among children (Jahr Buchder Kinder heilkunde, 6 Jahrgaug 2 Heft) I again return to the same subject with a more recent and extended experience. These remarks are the result of four years' continued practice in the Franz Joseph Children's Hospital in Prague, and in conjunction with the observations of other physicians, may not be without value. I only present facts, which have been collected and confirmed, partly at the bedside and partly in the dead house, with the avowed intention of candidly pleading for an operation which is still so generally feared, or so often discarded as worthless.

I.

Tracheotomy was performed upon fifty-two children, i. e., thirty-three boys and nineteen girls. Their ages were as follows:

* From "Jarbuch fur Kinderheilkunde," 1 Jar. 1 H.

Of these, eighteen were saved by the operation : eleven boys and seven girls, consequently 34.6%. In the fifty-two cases operated upon the disease was idiopathic in forty-eight, twice secondary to scarlatina, in one a complication of measles, and once it supervened to an attack of tussis convulsiva. If we turn first to the large number of those cases in which the operation failed, we find that these thirtyfour children were of the following ages:

If we seek for the cause of failure we meet with one fact, the importance of which I dwelt upon in my former treatise, namely, the condition of the rest of the respiratory apparatus. As a result of post mortem examination, I find the most frequent lesion to be a co-existive affection of the tracheal and bronchial mucous membrane. In twenty-five of the thirty-four children who died after tracheotomy, there was found not only in the larynx but also in the mucous membrane of the trachea and bronchi of the first, second, and third dimensions, a more or less abundant croupous exudation, with tumefaction and congestion of the mucous membrane to such a degree that the respiratory surfaces seemed very considerably diminished. Some of the croupous exudations presented the appearance of tubules which filled, like a cast, the cavity of the bronchial tubes, while others were membranous shreds, and others again were mere isolated

membranous patches. Frequently, and especially in children who had not died until eight or ten days after the operation, a large portion of these croupous formations had undergone purulent degeneration. In one case, a boy four and a half years old, in which croup was a complication of scarlet fever, and in which death occurred eight days subsequent to tracheotomy, the trachea and bronchi were filled with a purulent, highly offensive secretion, while in the larynx the croupous exudation might be seen in its membranous form. I also found Bronchiectasis with a grey mem. branous deposit upon the mucous membrane of the bronchi in a boy five years old, who died forty-nine days after tracheotomy.

A second equally frequent lesion was found to be Emphysema of the lungs. This was most marked in their anterior portions, and was more or less extensive in proportion to the intensity of the croupous attack, the duration of the disease, and the age of the child. Croupous pneumonia of the diffuse lobar variety was only met with five times in all the cases, and then, three times on the left side, once on the right, and once on both sides.

Croupous lobular pneumonia was found six times, and co-existing with gangrene of the lung in one, a girl five years old, who died eight days after the operation. Pleuritic adhesions were present in six cases, and always upon that side in which there was concomitant affection of the lung, but were for the most part of a delicate nature and easily broken down. Ecchemoses of the visceral pleura were found in two cases, a boy of three and a half and one five and a half years of age. If this strikingly small number of pneumonias

in the course of the croupous process be considered, we must admit the fallacy of the objection made to tracheotomy, that it favors pneumonia. In repeated cases the posterior and inferior portions of the lungs were gorged with blood, and presented more or less numerous atalectases. In almost every case the brain was congested, the vessels of meninges, even to the most minute capillaries, were strongly injected, sections of the brain were bountifully studded with large and small vascular points from which blood oozed, and the membrane lining the ventricles was very vascular; in three cases there was also a considerable serous effusion into the cavities of the brain, and in one very marked oedema of the brain.

A constant lesion in all fatal cases of croup whether they have been operated upon or not, consists in a very considerable tumefaction of the sohturg glands of the intestinal canal, and particularly those of the small intestines. This lesion has been described by Professor Reed, Maier. (Archiv. du Heilkunde, 6 Jahr, 1865, Leipsig.) Whether this tumefaction has any connection with the croupous process itself, or is possibly induced by the emetics which as a rule are administered, especially the tartarus stibiatus, or finally, whether they are the expression of the suddenly induced inanition of the child, I am not yet able to say.

If we consider the above described lesions, we are convinced that in all the twenty-five children, the chief cause of death was the croupous process and its consequences. The active agents of the fatal result are, on the one hand, the very considerable diminution of the respiratory surfaces, the consequent imperfect res

piration, the constantly increasing "besoin de respirer," and paralysis of the lung cells; on the other hand the imperfect oxydation of the blood, and the qualitative and quantitative reaction of the same upon the central nervous system. It is evident that the fatal issue must be surer and earlier in those few cases in which, besides croup of the air passages, penumonia is present. We may therefore deduce from these twentyfive cases the following assertion, that in cases in which the croupous process has extended into the bronchial tubes of the second and third dimensions, tracheotomy is, for the most part, useless. I say for the most part, because this rule also has its exceptions. For instance, I have seen cases in which, after the operation, croupous formations, two, three, and four inches long, have been expelled, and that too three to four weeks subsequent to the performance of tracheotomy. However, it is an undeniable fact that, from the physical symptoms of laryngeal croup, we are not able to diagnosticate a simultaneous similar affection of the trachea and bronchi; hence, notwithstanding the rule above cited, croupous tracheo-bronchitis should be no certain contra-indication for tracheotomy. In the nine other fatal cases the cause of death was of another nature. In three cases, in which before death the symptoms of a serious blood-poisoning were very marked, namely, intense exhaustion, a yellow sallow discoloration of the skin, with lowering of the temperature and a thin thready pulse, (diphtheritic septicemia) the post mortem examination showed, besides a more or less abun dant exudation in the larynx and throat, no appreciable results, so that death could only be explained by a