A CASE OF CROUP Reported
by
:
TRACHEOTOMY
:
DEATH.
G. C. Roy, M. D., F. R. C. S.
In one of the houses in the town reeking with damp, and in one of those days in August when there was a continuous of 2\ years was taken ill with downpour of rain, a child slight sore-throat and noisy breathing. The latter symptom aggravation of its natural condition, being, as I was told, anwith any distress in breathing, was and being unattended child himself amused his parents lightly thought of, and the with the remark that there was music in his throat. The the worse the next day, and the anxsymptoms changed for ious appearance, the brassy cough and the louder stridor with the respiration left no doubt as to the onset of the serious malady. When I was called in, I gave at once an emetic of Ipecac and a mixture of Vin ipecac, and Pot. Bicarb., to alternate every 2 hours with a powder of Calomel gr. a, ipecac, gr. lj. Emesis was produced and gr i and Sodse bicarb, the breath the child was so well at night that the noise in But it returned the next day, and had all but the child was no to me it seemed, in my next visit, that abnormal The throat was examined but nothing better of the tonsils. As was found beyond a slight enlargement and there was a slight fever the day before, quinine, ipecac, Tr. iodine application over the soda were prescribed, strong In the inhalation. evening it larynx and hot water vapour was no return of fever and the was reported that there easier. The next morning there was breathing was somewhat the worse. The respiration was again a decided change for voice completely suppressed, louder, the nails and lips livid, and along with each inspiration the chest sank, producing sternal region. The child was very a deep hollow in the restless and lay on his chest. It was evident that this state could not last very long, and the failing strength of indicated an impending crisis. I prescribed of the a mixture of ammonia and senega and left the patient with the proposal of tracheotomy as the last resource if the consent to the operation. The parents would give their till 12 A. M. on the contrary the symptoms did not mend and in fits of suffocation threw child was more restless, himself about and attempted to bite the attendants. Consent for the operation having been obtained, it was at once I performed. I cannot easily forget the difficulty the expetube. rienced in opening the windpipe and introducing For whilst every moment threatened immediate stoppage of breath and vitality, I had to work within a very narrow comof a tube a little bigger than a goose pass after the search by the Thymus gland and traverquill, deeply seated, covered sed at its lower part by a plexus of superficial veins which still more hampered the operation. The attempt to transfix the tube and draw it upwards caused its flattening and complete closure of the passage. However the trachea was ultimately opened in situ and the tube, which was the only
disappeared.
things
?pulse
?
280
-4
THE INDIAN MEDICAL GAZETTE.
size we possessed introduced. "With dashing of cold water the respiration was re-established. The lividity disappeared after a few inspiratory whiffs, and the child, when he came to his senses, looked brighter and continued breathing through the tube without difficulty. The change was most striking. He called for milk and water, and everything looked hopeful when the distressing symptoms were completely relieved. This went on for 24 hours, after the lapse of which the former difficulty of breathing returned, attended with sinking in of the chest. The tube was removed with a view to examine whether it had got clogged up with mucus and was reintroduced. The difficulty however continued unabated. It seemed as if something had obstructed the passage lower down as if a membrane had partially separated, and was vibrating and flapping with the passage of air. The loop of a curved wire was passed through the tube down to the bifurcation for clearing the passage, but to no purpose. The lividity began to increase and the child slowly died of apnoea at 4 p. M. The object of publishing this case is to discuss the advisability of tracheotomy in a child of tender age. It is said that of all the cases under 2 years not one survived the operation. I have not seen one case of recovery of croup It is presumptuous to or diphtheria after tracheotomy. question the utility of an operation after it has been established by long experience and us'age, but the fact cannot be gainsaid that the remedy is only a palliative one, and the palliation is obtained at the risk of adding a fresh focus of inflammation to the seat of mischief not to include the other inflammatory lesions of the lung attendant on such operations. Yet who can calmly stand by and witness the suffering without offering the relief which he knows he has in his power to afford however temporary be its effect. If to relieve suffering and prolong life be the main object of treatment, surely these conditions are attained in the last stage of croup by the operation of tracheotomy. In the case under review the change in the symptoms was most striking. Taking into consideration the danger and difficulty of the operation in a child under 2 years the intolerance of a small trachea to bear a metallic tube, I would perhaps forbear from any interference in children of tender age, but the utility of the operation in grown up children is established beyond doubt and cavil. A CASE OP OBSTRUCTION OP THE BOWELS?COLOPUNCTUKE. Allied in nature to the preceding is the operation of gastrotomyin obstructed bowels. Before the introduction of antiseptic surgery such a heroic procedure was seldom thought of, and even now however well the operation may sound in theory, in practice there are serious objections to its
use, and instances of recorded recovery from it are few and far between. In the June number of the Glasgow Medical Journal for the year 1880 there is a case recorded of Colopuncture. The rationale of the operation consists in giving exit to the pent up gas in the bowels which, by the very distension it causes, increases the morbid condition of volvulus or lymph band that generally give rise to the obstruction and obstinate constipation. When the gas is let out the bowels collapse, and either the twist is unravelled or the opening of the canal which was almost obliterated by the tension of its wall is rendered permeable to the downward passage of faeces. The danger lies however in fecal extravasation and subsequent fatal peritonitis. Against this it was argued that a small opening in the bowel has a tendency to close itself by the eversion of its mucous membrane. I am sorry to record that the operation is not so harmless in its nature as its advocates would seem to think, as will be seen in the history of the following case treated in the Sooree Charitable Dispen-
sary. A young man, of about 35, applied for relief for obstinate constipation of IB days' duration during which he was treated in another dispensary with purgatives, injections &c>, without The upper part of the abdomen was distended a,nd success. the coils of the intestines could be distinctly felt. The long suffering had somewhat prostrated the patient, but he had Extract Belladonna none of the symptoms of strangulation. % grain every 4 hours was prescribed with injection per anum by long tube and stimulant mixture. The injection was immediately returned without any colouring, and in subsequent attempts at defascation he passed only a few drops of mucus. The symptoms still being not urgent, the same treatment was continued the next day, but on the 15th day
[October 1,
1881.
A long he felt very uneasy, and begged to be relieved. trocar and canula from the aspirator case about the size of a small hydrocele trocar was introduced at the lower part of right hypochondriac region over one of the distended coils The gas escaped with a loud hiss and the of intestine. abdomen collapsed. Just a drop of fecal matter spurted out of the canula with the air. The canula was removed and a pad and bandage was tied over,?precaution being taken during removal that the outward opening of canula was closed and pressure kept up to keep the wall in contact with The patient felt great relief after operation, the bowels. and no pain was complained of. An injection was given in the evening with the long tube and opium during the day. Next day, 16th day, no relief was obtained, but on removing the sticking plaster from the seat of puncture a drop of fecal matter was found collected underneath and the immediate surrounding with a radius of 1 inch was somewhat tender to the touch. The abdomen filled out the next day, 17th day, and the coils of intestines stood out in relief, but the tenderness did not spread. The patient however was in spite of all remonvery uneasy, and was pacing the ward strance. On the 18th day he bathed in the morning, and whilst walking suddenly felt a burning pain in the abdomen starting from the seat of puncture and spreading to the epigastric region, but all confined above the line of umbilicus. The pain was most intense, to relieve which morphia gr. \ was given. But the relatives grew alarmed at his condition, and removed him that day from the hospital. Up to the last his bowels were not moved. The fecal discharge was noticed for one day only after the operation. In the absence of post-mortem examination, the nature of obstruction will remain a matter of conjecture. But what we are interested in, is the novelty of the operation performed and its result. There does not seem to be any doubt that the patency of the puncture permitted the fecal discharge found in the dressing the next day, though it was in very minute quantity. The long continuance of the obstruction might have set up subacute peritonitis agglutinated the intestines and made them adherent to the parieties which warded off at the time the fatal effect of extravasation of feces. The next day the opening was closed but the continuance of the distension caused ultimate soften-^ ing of the bowels at the seat of puncture and extravasation took place to a larger extent than before, though its effect was not so widespread on account of the matting of the of faeces. intestines which localised the
permeation
by
:
TRACHEOTOMY
:
DEATH.
G. C. Roy, M. D., F. R. C. S.
In one of the houses in the town reeking with damp, and in one of those days in August when there was a continuous of 2\ years was taken ill with downpour of rain, a child slight sore-throat and noisy breathing. The latter symptom aggravation of its natural condition, being, as I was told, anwith any distress in breathing, was and being unattended child himself amused his parents lightly thought of, and the with the remark that there was music in his throat. The the worse the next day, and the anxsymptoms changed for ious appearance, the brassy cough and the louder stridor with the respiration left no doubt as to the onset of the serious malady. When I was called in, I gave at once an emetic of Ipecac and a mixture of Vin ipecac, and Pot. Bicarb., to alternate every 2 hours with a powder of Calomel gr. a, ipecac, gr. lj. Emesis was produced and gr i and Sodse bicarb, the breath the child was so well at night that the noise in But it returned the next day, and had all but the child was no to me it seemed, in my next visit, that abnormal The throat was examined but nothing better of the tonsils. As was found beyond a slight enlargement and there was a slight fever the day before, quinine, ipecac, Tr. iodine application over the soda were prescribed, strong In the inhalation. evening it larynx and hot water vapour was no return of fever and the was reported that there easier. The next morning there was breathing was somewhat the worse. The respiration was again a decided change for voice completely suppressed, louder, the nails and lips livid, and along with each inspiration the chest sank, producing sternal region. The child was very a deep hollow in the restless and lay on his chest. It was evident that this state could not last very long, and the failing strength of indicated an impending crisis. I prescribed of the a mixture of ammonia and senega and left the patient with the proposal of tracheotomy as the last resource if the consent to the operation. The parents would give their till 12 A. M. on the contrary the symptoms did not mend and in fits of suffocation threw child was more restless, himself about and attempted to bite the attendants. Consent for the operation having been obtained, it was at once I performed. I cannot easily forget the difficulty the expetube. rienced in opening the windpipe and introducing For whilst every moment threatened immediate stoppage of breath and vitality, I had to work within a very narrow comof a tube a little bigger than a goose pass after the search by the Thymus gland and traverquill, deeply seated, covered sed at its lower part by a plexus of superficial veins which still more hampered the operation. The attempt to transfix the tube and draw it upwards caused its flattening and complete closure of the passage. However the trachea was ultimately opened in situ and the tube, which was the only
disappeared.
things
?pulse
?
280
-4
THE INDIAN MEDICAL GAZETTE.
size we possessed introduced. "With dashing of cold water the respiration was re-established. The lividity disappeared after a few inspiratory whiffs, and the child, when he came to his senses, looked brighter and continued breathing through the tube without difficulty. The change was most striking. He called for milk and water, and everything looked hopeful when the distressing symptoms were completely relieved. This went on for 24 hours, after the lapse of which the former difficulty of breathing returned, attended with sinking in of the chest. The tube was removed with a view to examine whether it had got clogged up with mucus and was reintroduced. The difficulty however continued unabated. It seemed as if something had obstructed the passage lower down as if a membrane had partially separated, and was vibrating and flapping with the passage of air. The loop of a curved wire was passed through the tube down to the bifurcation for clearing the passage, but to no purpose. The lividity began to increase and the child slowly died of apnoea at 4 p. M. The object of publishing this case is to discuss the advisability of tracheotomy in a child of tender age. It is said that of all the cases under 2 years not one survived the operation. I have not seen one case of recovery of croup It is presumptuous to or diphtheria after tracheotomy. question the utility of an operation after it has been established by long experience and us'age, but the fact cannot be gainsaid that the remedy is only a palliative one, and the palliation is obtained at the risk of adding a fresh focus of inflammation to the seat of mischief not to include the other inflammatory lesions of the lung attendant on such operations. Yet who can calmly stand by and witness the suffering without offering the relief which he knows he has in his power to afford however temporary be its effect. If to relieve suffering and prolong life be the main object of treatment, surely these conditions are attained in the last stage of croup by the operation of tracheotomy. In the case under review the change in the symptoms was most striking. Taking into consideration the danger and difficulty of the operation in a child under 2 years the intolerance of a small trachea to bear a metallic tube, I would perhaps forbear from any interference in children of tender age, but the utility of the operation in grown up children is established beyond doubt and cavil. A CASE OP OBSTRUCTION OP THE BOWELS?COLOPUNCTUKE. Allied in nature to the preceding is the operation of gastrotomyin obstructed bowels. Before the introduction of antiseptic surgery such a heroic procedure was seldom thought of, and even now however well the operation may sound in theory, in practice there are serious objections to its
use, and instances of recorded recovery from it are few and far between. In the June number of the Glasgow Medical Journal for the year 1880 there is a case recorded of Colopuncture. The rationale of the operation consists in giving exit to the pent up gas in the bowels which, by the very distension it causes, increases the morbid condition of volvulus or lymph band that generally give rise to the obstruction and obstinate constipation. When the gas is let out the bowels collapse, and either the twist is unravelled or the opening of the canal which was almost obliterated by the tension of its wall is rendered permeable to the downward passage of faeces. The danger lies however in fecal extravasation and subsequent fatal peritonitis. Against this it was argued that a small opening in the bowel has a tendency to close itself by the eversion of its mucous membrane. I am sorry to record that the operation is not so harmless in its nature as its advocates would seem to think, as will be seen in the history of the following case treated in the Sooree Charitable Dispen-
sary. A young man, of about 35, applied for relief for obstinate constipation of IB days' duration during which he was treated in another dispensary with purgatives, injections &c>, without The upper part of the abdomen was distended a,nd success. the coils of the intestines could be distinctly felt. The long suffering had somewhat prostrated the patient, but he had Extract Belladonna none of the symptoms of strangulation. % grain every 4 hours was prescribed with injection per anum by long tube and stimulant mixture. The injection was immediately returned without any colouring, and in subsequent attempts at defascation he passed only a few drops of mucus. The symptoms still being not urgent, the same treatment was continued the next day, but on the 15th day
[October 1,
1881.
A long he felt very uneasy, and begged to be relieved. trocar and canula from the aspirator case about the size of a small hydrocele trocar was introduced at the lower part of right hypochondriac region over one of the distended coils The gas escaped with a loud hiss and the of intestine. abdomen collapsed. Just a drop of fecal matter spurted out of the canula with the air. The canula was removed and a pad and bandage was tied over,?precaution being taken during removal that the outward opening of canula was closed and pressure kept up to keep the wall in contact with The patient felt great relief after operation, the bowels. and no pain was complained of. An injection was given in the evening with the long tube and opium during the day. Next day, 16th day, no relief was obtained, but on removing the sticking plaster from the seat of puncture a drop of fecal matter was found collected underneath and the immediate surrounding with a radius of 1 inch was somewhat tender to the touch. The abdomen filled out the next day, 17th day, and the coils of intestines stood out in relief, but the tenderness did not spread. The patient however was in spite of all remonvery uneasy, and was pacing the ward strance. On the 18th day he bathed in the morning, and whilst walking suddenly felt a burning pain in the abdomen starting from the seat of puncture and spreading to the epigastric region, but all confined above the line of umbilicus. The pain was most intense, to relieve which morphia gr. \ was given. But the relatives grew alarmed at his condition, and removed him that day from the hospital. Up to the last his bowels were not moved. The fecal discharge was noticed for one day only after the operation. In the absence of post-mortem examination, the nature of obstruction will remain a matter of conjecture. But what we are interested in, is the novelty of the operation performed and its result. There does not seem to be any doubt that the patency of the puncture permitted the fecal discharge found in the dressing the next day, though it was in very minute quantity. The long continuance of the obstruction might have set up subacute peritonitis agglutinated the intestines and made them adherent to the parieties which warded off at the time the fatal effect of extravasation of feces. The next day the opening was closed but the continuance of the distension caused ultimate soften-^ ing of the bowels at the seat of puncture and extravasation took place to a larger extent than before, though its effect was not so widespread on account of the matting of the of faeces. intestines which localised the
permeation
