Haemorrhage, however, is the chief difficulty, and is sometimes unavoidable; it may be arterial or venous. The arteries of this region are generally small, being branches of the superior or inferior thyreoids, and this accounts for the fact that severe arterial bleeding is rare. Nevertheless, the smaller vessels may at times be very troublesome: for instance, the crico-thyreoid artery or one of its branches may be divided, in which case the cut ends will retract and will be difficult to seize; and if the trachea has been opened, blood may continue to enter in sufficient quant.i.ty to cause troublesome coughing. Abnormal arteries, such as the thyreoidea ima, are not of great practical importance.

Venous haemorrhage is far more common, and, taking into account the anatomical relations of the veins, and their great size (increased by cyanosis) in children, it seems remarkable that bleeding is so seldom fatal; in desperate cases a very small amount of blood is sufficient to cause suffocation. Venous bleeding will stop only when respiration becomes free, and this is not possible so long as blood is being sucked into the air-pa.s.sages. Every effort should be made, therefore, to prevent blood from pa.s.sing into the trachea, either by hanging the head over the end of the table as soon as the dilators have been introduced, or by introducing a canula against which the walls of the trachea can be compressed.

Failure to breathe, after an opening has been made, is due to either obstruction or collapse and requires rapid treatment. The trachea must be widely dilated, and forceps used to remove any membrane which presents itself in the wound; the a.s.sistant must then slowly compress the ribs two or three times to empty the chest and encourage respiration. If consciousness returns, the patient begins to cough and mucus or membrane is expelled from the air-pa.s.sages. On the other hand, it is useless to continue artificial respiration if the obstruction is not relieved; aspiration must be employed if special instruments are at hand. The fact that a number of surgeons have lost their lives as the result of sucking through a catheter in the attempt to save the child is sufficient to condemn this practice; but good results have been obtained by pa.s.sing a catheter low down into the trachea and blowing through it with a syringe or even with the mouth. As soon as the trachea has been emptied by one of these methods, artificial respiration should be continued, and collapse treated by injections of strychnine, brandy, or ether. No attempt should be made to introduce a canula until the breathing is restored. As Turner remarks: 'Heart failure during operation generally recovers with artificial respiration, and twelve hours later the condition is indistinguishable from that of a case who has not so closely approached death. The real remedy against such an accident is never to postpone operation until the heart is exhausted.'

=After-treatment.= Although this is a subject which has produced a great deal of discussion, there is a widespread impression among the younger members of the profession that it is of little importance. Much has been said about the dangers of interference, and any suggestion put forward has been criticized by those who have had large experience, with the result that confusion is prevalent. As a matter of fact, the subject is one of the greatest importance, for there is no operation in surgery in which the after-treatment can be neglected. Care should be exercised in choosing a nurse who has special knowledge of children and of the after-treatment of tracheotomy. Great discretion is required in the management of such cases, and there is little doubt that harm may result where too much attention is shown. At many of the hospitals a special nurse is appointed for attendance on the more desperate cases only. The main duty of the nurse is to watch the child, for any difficulty in breathing requires immediate attention. It is necessary that she should understand the proper management of the tube; she must see that the inner tube never becomes clogged, and if the tube slips out of the trachea it must be reintroduced or a dilator inserted; she must also be responsible for the feeding of the child. The difficulties that arise during the first few days after operation call for much tact and experience.

It is unnecessary to enter here into the discussion about food, stimulants, or general treatment, except to point out that swallowing may be very difficult. The food must be nourishing, fluid being in most cases preferred; occasional sips of water should be administered to find out whether coughing is produced, in which case nasal feeding can be advised without hesitation. A short rubber catheter should be pa.s.sed through the nose at regular intervals according to the nature of the case. As a general rule a small quant.i.ty of nourishment should be given every two hours, studying, as far as possible, the likes and dislikes of the patient. By the observance of these principles the child soon becomes tolerant, and proper nourishment can be administered, thus removing one of the great difficulties of after-treatment.

_The atmosphere of the room._ The value of steam for producing warmth and moisture is undoubted; the amount required depends on the case. The main object to be kept in view is to encourage secretion from the mucous membranes, and so to prevent the formation of crusts. When secretion is scanty a large amount of moisture is required, and _vice versa_; also, when much pus is present, extra moisture is of value to prevent it from becoming dried and to allow it to be expectorated. The value of disinfectants is doubtful, but on general principles it may be said that the more septic the secretion the greater the indication for their use: tincture of benzoin, oil of eucalyptus, and thymol act as sedatives; carbolic acid, creosote, and numerous other drugs are useful disinfectants; soda and potash, recommended by R. W. Parker, tend to liquefy the exudations. Steam, however, is more important than all these, and should be advised as being likely to encourage the quicker healing of the wound: even in catarrhal conditions improvement is more rapid when this practice is adhered to.

The most important point in the after-treatment, however, as far as the surgeon is concerned, is to prevent recurrence of the obstruction.

Obstruction is most often due to the blocking of the inner tube by secretions, a condition easy to recognize from the symptoms which are produced. The inner tube should be removed, thoroughly cleaned, and reintroduced. This usually suffices to allow the child a period of quiet breathing, and sleep may be obtained. To keep the tube free it is very necessary to repeat the removal at regular intervals. In those cases where the secretion is tenacious, the tube constantly becomes blocked, but it is better to remove it again than to allow a feather to be pa.s.sed. Nothing is gained by attempting to hurry the separation of crusts, and the pa.s.sage of a feather tends to force downward far more than can be extracted, and so to increase the danger of broncho-pneumonia. If dyspna continues after removal of the inner tube, a spray should be used, or a small amount of fluid should be dropped into the trachea to moisten the secretions.

Changing the outer tube rarely presents any difficulty because the tissues of the neck soon become matted together, a funnel being thus produced along which the canula is introduced with ease. A new tube should be prepared before removal of the old, and dilators should be at hand for use if the child is frightened, struggles, or coughs: the canula should be introduced quickly and without hesitation, sufficient force being employed to overcome any obstruction. Unless the original opening in the trachea was too small, it should be possible to introduce a tube equal in size to that which was removed. Frequent changing of the outer tube should be avoided.

_The time for removing the outer tube._ In every case of diphtheria there is a certain amount of catarrh, with swelling of the mucosa, increased secretion, and some difficulty of breathing. In addition, the habit of breathing through a canula is difficult to alter; the child shows an aversion to breathing through the natural air-pa.s.sages, and is often frightened or bad-tempered. As soon as the secretion becomes small in amount and serous rather than purulent in consistence, an attempt should be made to discard the tube: the canula should not be retained a day longer than is necessary, the usual period varying from five to fifteen days. Various methods may be adopted:--

1. If the outer tube be provided with a window, the tip of the finger can be placed on the opening to compel the child to breathe through the larynx; breathing may be difficult, but by this means an indication can be obtained as to whether it is advisable to persist.

2. If the above method be successful, the tube may be removed. A small pad of gauze is placed over the wound and the child further encouraged to breathe through the larynx. Expiration is generally easier than inspiration, and older children should be encouraged to blow out a candle or to sound a whistle, this process being continued so long as the child can endure it, but not to the stage of exhaustion. It is often possible to remove the tube at the first attempt.

3. The canula may be plugged with a cork which the nurse removes when necessary: it is often possible to replace the plug while the child is asleep without his becoming conscious of the fact, thus showing that the dyspna is largely mental.

4. In some children breathing is easy so long as the tube is simply plugged and is not removed; in such cases the canula can be replaced by a shield and a plug which does not pa.s.s into the trachea. This may completely deceive the child.

5. The silver tube can be changed for one of rubber, and this can be shortened daily until nothing remains but the shield.

If these various methods have been tried with no success it is probable that the case is abnormal, but before this can be conceded it is necessary to repeat that, in the large majority of cases, the difficulty of removing the tube is due not so much to definite stenosis of the larynx as to the bad habit acquired by the patient.

=Complications= arising after tracheotomy and preventing removal of the tube:--

1. _Wound infection._ This rarely occurs at the present time, and diphtheritic wounds are seldom seen. Some inflammation of the wound is natural under the conditions, and may be a.s.sociated with dema of the surrounding tissues; this generally yields to antiseptic treatment in a few days. In very weakly children suffering from a virulent form of disease the healing of the wound may be slow, and septic conditions are apt to arise ending in cellulitis of the neck or even typical erysipelas. Owing to the disposition of the fasciae there is a tendency for the infection to spread in a downward direction, and for mediastinal inflammation or suppuration to occur: this appears to be more common after low tracheotomy. The prognosis in such cases is not good, and every endeavour should be made to prevent the possibility of their occurrence by absolute cleanliness at the operation and by suitable after-treatment of the wounds.

2. _Septic conditions_ of the trachea are less common since the introduction of ant.i.toxin, but occur in cases where false membrane is abundant. There may be swelling of the mucosa, or copious discharge which persists for long periods.

3. _Ulceration_ may be due to sepsis or to pressure from a badly fitting tube, especially when the latter has been worn for a protracted period (Fig. 270). It may cause perforation and localized abscess either in front of the trachea or in the neighbourhood of the sophagus, and may result in a communication with the latter. In the region of the cricoid, ulcers are liable to cause necrosis. The signs of such ulceration are: continuance of purulent discharge, discoloration of the tube, bleeding from the wound, and, above all, difficulty in removing the tube.

[Ill.u.s.tration: FIG. 270. TRACHEA SHOWING ULCERATION CAUSED BY A BADLY FITTING TUBE. A, Tracheotomy opening; B, Ulcer caused by the end of the tube. (_From Specimen No. 1659a in the Museum of St. Bartholomew's Hospital._)]

At the first indication of ulceration the cause of irritation should be removed. It is advisable to discard a metal in favour of a rubber tube, or, if possible, to remove the tube altogether. Strenuous efforts must then be made to disinfect the trachea by the insufflation of antiseptics, either as powders or in solution. The healing of such ulcers is very slow, and granulations are apt to form resulting in obstruction and preventing removal of the tube. In later stages contraction of fibrous tissue causes stenosis; this is more common in the neighbourhood of the cricoid, especially when the latter has been divided at the time of the operation.

4. _Granulations._ The possible presence of granulations must always be borne in mind. I believe this condition is far less common than is generally supposed, and that in many cases the granulations are entirely limited to the neighbourhood of the wound, where they can be seen. It is doubtful whether they are responsible for the dyspna which occurs.

Great ingenuity and patience are required for the treatment of this condition. The wound must be kept scrupulously clean and all source of irritation removed. A rubber canula should be subst.i.tuted in place of a metal one; if it were possible it would be advisable to discard the tube altogether, but as yet no form of dilator has been devised which will take the place of the canula. If the granulations be large they should be removed either with a sharp spoon or with suitable forceps, the area having been anaesthetized previously by a small quant.i.ty of the novocaine and adrenalin mixture. When small, the use of silver nitrate is preferable. It may be necessary to repeat this after a few days, and as soon as seems advisable a further attempt should be made to dispense with the tube. At this stage time must be allowed for the various tissues to regain their normal condition. Should this treatment prove unsuccessful, a thorough investigation must be made under chloroform.

The wound is enlarged as far upwards as the cricoid, bleeding being arrested with the mixture just described. By throwing a strong light into the wound, the condition of the mucous membrane can be inspected and granulations removed. If there be no granulations in the trachea, a tube speculum can be pa.s.sed through the mouth to ascertain the condition of the larynx (see p. 480). Such a method of procedure is preferable to the pa.s.sage of probes, forceps, sponges, and other articles through the larynx, in the hope that any obstruction may be removed. If ulceration or necrosis of cartilage be discovered, it is impossible to relieve the condition by surgical means without prolonged treatment with tubes and the constant use of antiseptics. Under these conditions it is advisable to consider the removal of the tracheotomy tube in favour of intubation.

In the hands of many foreign authorities the use of intubation tubes covered with gelatine, in which antiseptic is introduced, has been attended with such conspicuous success that further attempts should be made in this country; there is little doubt that, as our knowledge of the treatment of such wounds improves, better results are daily attained. Whatever treatment is considered it is important first of all that the actual cause should be distinguished. This is now possible owing to the great advances made in methods of examining the larynx.

5. _Stenosis_ of the larynx or trachea occurs in old-standing cases, as the result of ulceration, after some cases of crico-tracheotomy, and especially where a tube has been worn for a very protracted period.

Breathing through a tube, if continued for a long time, interferes with the natural growth of the air-pa.s.sage above it. The child grows, but the larynx remains stationary. This condition is aggravated by the fact that some inflammation is constantly present, especially in the neighbourhood of the wound, so that the tissue become fibrous and hard. The fibrous tissue contracts and stenosis is caused. According to von Bruns, Kohl,[28] and others, constrictions of the trachea may in rare instances result from some kinking of its wall. Such conditions as a bulging of the posterior wall due to the approximation of the posterior ends of the cartilage secondary to the spreading of the anterior portions, inversion of the tracheal margins from too small an incision, overlapping of the tracheal wound, and cicatricial union between the thyreoid and cricoid, must be exceedingly rare. Here, again, a definite diagnosis can always be made by proper investigation, but treatment is more difficult.

Dilatation must be attempted by either continuous or intermittent methods. If preferred, a short piece of rubber tubing can be pa.s.sed upwards from the tracheotomy wound into the larynx and kept in place for several hours by two silk sutures, one pa.s.sing out of the tracheal wound, the other out of the mouth; or a stenosis canula can be inserted with some form of hollow plug which pa.s.ses upwards into the larynx (Fig.

272). The question whether the tracheotomy wound should be kept patent is difficult to answer. When stenosis is extreme there is no alternative, and the open wound allows of the constant pa.s.sage of graduated bougies, which is more easily accomplished from below than from above. If treatment be persistent the prospect of a good result is not unfavourable, and there is every reason to believe that in the future the number of cases which require a permanent tracheotomy tube will be reduced to a minimum.

[28] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 270.

[Ill.u.s.tration: FIG. 271. STENOSIS FOLLOWING TRACHEOTOMY. (_From Specimen No. 1659d in the Museum of St. Bartholomew's Hospital._)]

6. _Paralysis._ In the larynx there may be paralysis of the sensory or of the motor nerves. In the former case food may enter into the trachea and cause troublesome coughing and possibly 'Schluck-pneumonie'. When the motor nerves are affected, the paralysis is commonly abductor and may be unilateral or bilateral, the latter a.s.sociated with inspiratory dyspna. 'Complete paralysis of the recurrent laryngeal nerve may also occur, but is nearly always confined to one side' (C. A. Parker[29]).

Such paralyses may last from a few days to several months, and are very troublesome when a.s.sociated with the pa.s.sage of food into the trachea; when severe, nourishment should consist of fluids which can be administered by a nasal tube.

[29] _Nose and Throat_, 1906, p. 94.

[Ill.u.s.tration: FIG. 272. TUBES USED IN THE TREATMENT OF STENOSIS OF THE LARYNX. A, Lack's; B, Stork's; C, Schimmelbusch's.]

Further complications arising during the after-treatment of tracheotomy:

7. _Broncho-pneumonia._ This occurs in the worst forms, and is accompanied by high temperature with definite signs in the lungs. The absence of septic discharge, the restlessness of the patient, and the rapidity of the breathing (in many instances accompanied by 'recession'

not caused by obstruction in the tube) make the condition easy to recognize. There is no satisfactory treatment for septic broncho-pneumonia which has already developed, but it may be prevented.

Within recent years it has become less common. This is due to better technique in the operation, and to careful attention during the after-treatment. The habit of pa.s.sing feathers into the trachea has been abandoned with advantage to the patient. When possible the child should be removed from septic influences which are liable to infect the throat, for the occurrence of tonsil[l]itis as a sequel to tracheotomy is always to be feared in wards containing septic cases.

8. _Emphysema_ may occur in the neighbourhood of the wound, or in rare cases may be extensive and involve the whole of the face, neck, and chest. Champneys[30] was the first writer to call attention to this complication of tracheotomy. After a large number of observations and experiments, he was of opinion that emphysema of the anterior mediastinum occurs in a certain proportion of tracheotomies and is of frequent occurrence in cases that are fatal; that it may be a.s.sociated with pneumothorax; and that the conditions which favour its production are a low division of the deep cervical fasciae in the neighbourhood of the sternum, combined with obstruction of the air-pa.s.sages and strong inspiratory efforts; artificial respiration, especially if improperly performed; and want of skill on the part of the operator; further, that the dangerous period of the operation is between the division of the deep cervical fascia and the efficient introduction of the tube. To this may be added those cases in which the tube slips out of the trachea into the cellular tissue above the sternum and thus causes more or less obstruction to breathing. It seems probable that the air is sucked into the cellular tissues beneath the pretracheal fascia, rather from the outside than from the trachea, and that with forced expansion of the chest it finds its way beneath the fascia into the mediastinum.

[30] _Trans. Med. Chirurg. Soc._, vol. lxv, p. 85; vol. lxvii, p. 102.

[Ill.u.s.tration: FIG. 273. TRACHEA SHOWING ULCERATION INTO THE INNOMINATE ARTERY AFTER TRACHEOTOMY. (_From Specimen No. 1622a in the Museum of St.

Bartholomew's Hospital._) A, Aorta; B, Ulcer; C, Right subclavian; _D_, Right common carotid; E, Left common carotid; F, Left subclavian.]

9. _Haemorrhage_ may occur as the result of slipping of a ligature during an attack of vomiting or struggling after the operation; it is usually venous and requires nothing but pa.s.sing notice. Secondary haemorrhage may result from ulceration into one of the larger arteries or veins.

Kocher[31] states that 'the number of cases recorded is now about eighty-seven, of which fifty-six are a.s.sociated with the innominate artery. Unfortunately it is not known how often in these cases inferior tracheotomy had been performed. Low tracheotomy was performed in my case because an excision of the larynx for cancer had been undertaken.

Doubtless the danger of these fatal complications is much greater with inferior tracheotomy owing to the pressure of the canula.' Von Bruns[32]

also agrees that 'the vast majority of fatal haemorrhages were in cases of inferior tracheotomy. Of thirty-six cases in which the source of haemorrhage was given, twenty-eight were traced to the innominate vein, two to the right carotid, and one each to the superior thyreoid, the left innominate, the right jugular and the left jugular.' Bleeding is also recorded in cases of aneurism of the aorta, in which tracheotomy has been performed, as the result of erosion of the tracheal wall and the bursting of the sac. Further, troublesome oozing may take place from the mucous membrane of the trachea when this is inflamed, or when granulations are present, or when there is much sloughing of tissues, and especially after a metal tube has been worn for a considerable period. Haemorrhage from an enlarged thyreoid isthmus is also described.

When due consideration is given to the septic condition of the wounds and the close relation of large vessels, it is surprising to find that haemorrhage proves so seldom fatal.

[31] _Chirurg. Operat._, 1907, p. 631.

[32] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 265.

[Ill.u.s.tration: FIG. 274. ANEURISM OF THE AORTA PERFORATING THE TRACHEA.

(_From Specimen No. 1500 in the Museum of St. Bartholomew's Hospital._) A, Aorta; B, Left subclavian; C, Left common carotid; D, Ulcer in sac of the aneurism.]

10. _Cardiac paralysis_ may also complicate tracheotomy. When supervening in the acute stages of the disease, the patient becomes prostrate and vomiting is persistent, while the heart gradually fails.

In other cases death occurs suddenly and unexpectedly, in mild as well as in severe disease; this may happen at any period, during the first days or later, during convalescence. Heart failure is more common in diphtheria than in any other infectious disease which is met with in this country.

=Prognosis.= It may be said that all cases of laryngitis caused by diphtheria are of a serious nature, and especially those which require tracheotomy (see Table, p. 517). The mortality amongst tracheotomized patients during five years was 31.5%, and the variations in each separate year were slight. Such results are far from satisfactory, but it must be remembered that in pre-ant.i.toxin days less than 30% recovered after tracheotomy (Goodall[33]). The use of ant.i.toxin, first suggested by Behring, is undoubtedly responsible for this remarkable decrease in the mortality. The sooner the serum is injected the better the prognosis with tracheotomy. A large dose should be given, 8,000 to 18,000 units, irrespective of age, and the dose may be repeated on the second day if required. Improvement generally commences between twelve and twenty-four hours after injection; the swelling of the mucosa subsides, and secretion is diminished; false membrane is not so copious, and rarely extends to the trachea and bronchi; crusts become less adherent, and are expelled by the patient. In this manner the whole area of the disease becomes clean, and there is less absorption of toxins. It is now generally agreed that serum should be used in all suspicious cases, and some authorities inject at once not only the patient, but also other children living in the same house. It is hoped by early injection to avoid the necessity for tracheotomy.

[33] _Brit. Med. Journ._, 1899, vol. i, p. 199, 'On the Value of the Treatment of Diphtheria by Ant.i.toxin.'

The age of the patient is very important, as the following table shows: