On the Early Performance of Tracheotomy in Croup. By G. M. JONES, Esq,. Surgeon to the Jersey Hospital. The successful result of an operation leads us naturally to recommend its adoption in other cases in which identity of character exists. To propose an operation is one thing, but to induce others to follow in our footsteps requires something more; we must be able to show its utility, probably its absolute necessity, and that the well-being, oftentimes the very existence, of our patient depends on its performance. To hear some speak of tracheotomy in croup would almost lead us to imagine that the operation is a new one, a mere experiment and the offspring of some enthusiastic innovator. It would be foreign to my purpose to prove the contrary, my present object being to endeavor to persuade its contemners that they may be in error, and to show that if resorted to in time, it may be the means, the only means left us to preserve the life of a fellow-creature, the greatest and the most heartfelt wish a medical man can experience. It is not the favorable result just given the history of, † which leads me to speak highly of the operation. I have long been impressed with its propriety, and only waited an opportunity to judge for myself but even had my views at any time been different, or had my case terminated fatally, the success which has attended M. Trosseau's endeavors, and which deservedly entitle him to be looked upon as the first French authority on this subject, and the unwearied exertions of my friend Mr. Henry Smith, of London, which place him on the same level as his Parisian competitor, would certainly have shaken, or altered altogether my views, even had they before been opposed to operative interference. It may reasonably be asked-Why is tracheotomy in croup so little resorted to in England? Why, to make use of a homely phrase, is it at such a discount? The reason is easily explainedwe have the prejudices of parents to overcome--the opinion of *Although croup, as a distinct disease, and tracheotomy, as one of the means employed for its cure, have only been brought conspicuously into notice within the last years, both are undoubtedly of ancient date. The quinsy described by Hyppoerates as existing "without any evident tumor iu the neck or fauces, but attended with violent strangulation or difficult respiration, and which proves fatal either on the first or third day," and the cynanche of the Greeks, stated to be "a contraction of the orifice of the asperia arteria, by which not only the voice is suppressed, but respiration is performed with difficulty, and sometimes wholly stopped, often in so short a time as to kill the patient in twenty-four hours, or the third day," is the same affection which we now designate as croup;" and the following passage, also to be met with in one of the earlier writers, unquestionably proves that tracheotomy was then one of the established methods of cure in cases of "cynanche trachealis." But if, in a quinsy, after the use of proper medicines and repeated evacuations of blood from different veins, there is still a necessity for making an incision in the trachea, in order to prevent suffocation, the operation may be performed in three different manners," etc. + Vide Medical Times and Gazette, Oct. 4. some of the highest authorities to oppose and the ill success which has almost invariably attended its performance to account for in such a manner, as to show that death has possibly arisen, more from neglect or inattention to other important points, than to the operation itself, or to any effect it may have produced on the human economy. It is by no means surprising, that parents, particularly in the low grades of life, object to submit their child to an operation, the nature of which they will naturally make inquiries about, and which when explained, conveys a degree of horror to their minds, only surpassed by the reply given to their second question-its probable result in the present instance, and the amount of success which has attended it in others. The conscientious Surgeon can not promise a certain cure, a circumstance not to be overcome by the ignorant-precious time is lost, till at last a tardy acquiescence, at times an earnest entreaty to do any thing which may offer a chance of saving the sufferer is given; but then the last stage of the disease has already set in, the operation is performed, and is almost immediately, or in a few hours, followed by death. As a natural consequence the operator has all the odium, and the dis ease for which it was performed, and which Dr. West very justly says, "is unquestionably one of the most dangerous to which childhood is liable," is forgotten. But if we have this to contend. with among the lower orders, the surgeon has equal difficulties, equally unfavorable chances of success among the superior classes of society; he has "the opinion of some of the highest authorities to oppose;" and if called in by them, or by those who adhere to their views, he comes as the "forlorn hope," oftentimes as the "last witness to expiring life;" this brings me to the most import ant point of my subject, "the endeavor to persuade its contemners that they may be in error." Many authors of indisputably high reputation, whose works are constantly consulted, and whose views and treatment respecting the nature and cure of disease are the beacons by which thousands are guided in their line of practice, speak of tracheotomy in croup in a manner which, to say the least, offers but little encouragement to its performance. I shall quote the words of a few of the most eminent on the subject: "When signs of approaching death have come on, lividity of the lips, coldness of the skin, and a tendency to stupor, the question will obtrude itself, whether there may not still be a chance of saving the patient by tracheotomy. In the first place, the operation is much more difficult to execute upon children, than upon adults, and is attended with more per plexing hemorrhage; but a greater objection is the existence of the preternatural membrane, which precludes air being admitted into the lungs. Tracheotomy has again and again been practised in this complaint to no purpose, and I should be inclined to look upon it as absolutely hopeless, but for two instances recorded in the Medico-Chirurgical Transactions."* "Whenever tracheotomy is performed, it should be after every other remedy has failed, and not before any other has been attempted, as the exudation extends through the ramifications of the trachea, and probably through the lungs, there is but little hope, after all, of any benefit from such an operation." "There does not appear to be a chance of success from this operation in any case wherein the treatment developed above has failed. I perfectly agree with Goelis, Cheyne and many others, in concluding that it should seldom or never be attempted in this disease." "In England the result of almost every instance of the performance of tracheotomy in croup has been so unfavorable that the operation is scarcely looked upon as a justifiable proceeding." Such, then, are the opinions propounded by some of the most weighty of English authorities. * * * Under such circumstances, can it be a matter of astonishment that few general practitioners are willing to attempt an operation, the result of which is likely to bring discredit on themselves? Now let me ask, from what cause or causes combined is this operation so generally followed by fatal consequences? I have no hesitation in stating that a contrary result might, in all probability, ensue, if the trachea were opened, not "when signs of approaching death have come on," nor "when every other remedy had failed," but at a much earlier stage of the disease--in a word, before all hope of the efficacy of medicine had ceased altogether. Better to expunge the operation of tracheotomy in cynanche trachealis from all works on practical surgery, than perform it under circumstances which, from the weakened and exhausted state of the patient, must render an operation much less formidable than this one-an accelerator of death, and not the means by which death may be averted. Why are the statistical returns in cases of strangulated hernia more favorable now than formerly?-is it not from operative measures being resorted to before symptoms of approaching dissolution manifest themselves? and in what light would the advice of a surgeon be looked on now, were he to recommend us to wait till repeated vomiting of fæcal matter took place before subjecting his patient to herniotomy? Whatever theories may have been broached-whatever views medical menmay have taken of the causes and other circumstances connected with croup, there exists, I believe, among the most experienced, almost, if not altogether, unanimity of opinion that blood-letting, antimony, calomel and warm baths, are the means we are called upon, first of all, to employ in this dangerous disease. I have too often had recourse to them, and others as their adjuncts, not to add my humble testimony to their efficacy; and, happily, many * Dr. Watson's Lectures on the Practice of Physic. Dr. Copland's Dictionary of Practical Medicine. cases will yield to their judicious employment, but that all the remedies recommended are to be carried out seriatim, and some tried a second and even a third time, as a matter of course, before resorting to tracheotomy, appears to me the point which high au thorities ought to employ their pen in condemning, rather than dwell on the fatality of an operation, possibly occasioned, in very many instances, from too systematically following out the plan recommended by writers. Are there not diseases in which we can safely pronounce our patients better, although the symptoms continue stationary for a time? This is exemplified in several forms of fever; and, on the other hand, we meet with complaints in which a stationary state must be regarded as most unfavorable, and croup can be brought forward as an illustration. For instance, we are called on at an early hour to attend a child laboring under a severe form of this disease; in the evening we find our patient possibly not worse, but in no respect better. Are we, then, to rest satisfied in imagining that, although we have not gained, still we have not lost ground? If we think so, we deceive ourselves; for a whole day we have been unwearied in our exertions, we have exhausted all the means medical science has placed at our disposal, and with no better result than having been able to keep symptoms stationary, and that in an affection which not unfrequently runs its fatal course in eighteen, twenty-four, or thirty-six hours. Can a repetition of already tried remedies bring on an improved condition? I do not mean to state this can never happen, but I feel confident practical men will bear me out when I say that, in a vast majority of cases, the absence of any improvement after steadily pursuing for twelve or sixteen hours the medical course most approved of, leaves but very slender hopes that a continuation in a similar line of practice will be crowned with success. pro I have already spoken of the improved statistical returns in cases of strangulated hernia, and the probable reason why they are so satisfactory. Those who have attentively watched the gress of surgery, must admit that it yearly makes rapid strides towards perfection; and it appears to me that there is, in many respects, a striking resemblance between hernia and croup, not only as far as regards symptoms, but also with respect to the indications of cure. In hernia, we have strangulation of the bowels to overcome; in croup, obstruction to the passage of air to remove; both diseases may come on suddenly, and without premonitory symptoms; in each the most prompt and energetic treatment is required; both are fraught with the greatest danger to life; each runs its course rapidly; the same delay which may prove fatal in one case becomes equally so in the other, and the discriminating judgment which tells the surgeon when it might be hazardous to delay operative interference, guides, or ought to guide, the physician in recommending surgical means to super sede, for a time, those he has zealously, though unsuccessfully, employed. Is the operation a dangerous one? This is a question not easily solved some authorities say that it is, others are of a contrary opinion, and when this is the case, I know of no better rule to follow than this: not allow ourselves to operate solely under the latter impression, or be intimidated by the former; to hope the one, and be at the same time fully prepared for any casualty which may supervene. But that which must ever make tracheotomy in eroup dangerous, is, the performing it when symptoms of dissolution are at hand. Blood lost then is assuredly "life's blood," and if this operation is at any time attended with "perplexing hemor rhage," what effect must even the loss of the most trifling quantity produce on the dying; almost as well may we operate on the dead subject in the hope of seeing returning life, as on the expiring, with the expectation of witnessing recovery. In recommending an earlier performance of tracheotomy in eroup than is practised in England or advocated by British writers, I am far from advising it to supersede other measures (compatible with existing symptoms). It is said that in France there are many instances in which this operation has been performed on patients whose discase would probably have been amenable to other treatment, and cases are mentioned in which none of any description had been tried before. This practice is not advisable, for there is no operation, however trivial it may appear, which ean be positively pronounced as free of ulterior danger, and consequently none ought ever to be performed unless really necessary; thus it appears that in France, surgeons often operate earlier than is required, while in England they almost invariably do so too late. The observations I have made are intended to induce practitioners to adopt a middle course, that is to be neither too hasty nor tardy, but to be guided in a case of eroup as they would in a case of strangulated hernia. The success this operation has been attended with, in France, is most encouraging; but there is another reason, besides operating earlier than we do, which undoubtedly gives our continental brethren an immense vantage ground over us. There croup presents a different character to that which it exhibits in England; with us it is certainly a much more dangerous complaint. This difference arises, in a great measure, if not altogether, from the parts more materially implicated. "In France, croupal symptoms are induced, in the majority of cases, by the extension to the larynx of false membrane, originally deposited on the fauces and left palate, while the wind-pipe itself is comparatively seldom in a state of active in * Casserius pronounces, "those men unskilful, cowardly, and even cruel, who foolishly neglect this operation, which is often safe in itself, and attended with the most speedy and salutary effects, and who suffer their patients to die for want of this proper and seasonable assistance." |