mitted October 17, 1895. Breathing stridulous; loud croupy cough; sucking in of lower part of chest and of lower part of neck; tonsils slightly enlarged; no exudation visible; glands at angle of jaw rather large; very little air entering the chest ; temperature 98-2°; pulse 98; respiration 60; no albumen in urine. The breathing increasing in difficulty, tracheotomy was performed, which gave much relief, although no membrane was seen during the operation. On the following day the temperature rose to 103°, the pulse to 158, but in other respects the child seemed comfortable. On the 19th small pieces of mem

FOR DIPHTHERIA

brane were expectorated; urine contained a trace of albumen. During the night of the 20th breathing became laboured and pulse almost imperceptible; expectoration slightly tinged with blood; cough frequent and severe. Membrane stained with Loeffler's stain showed diphtheritic bacilli. On the 21st tube left out all day; pulse irregular and intermittent. From this time the child convalesced rapidly, although the pulse remained intermittent until November 12.

The success of the operation of tracheotomy is to a large extent dependent upon the nurse, and it is therefore most necessary for the child to be under the care of a nurse who has had experience in similar cases, and who is ready to deal with any emergency that may arise. The need of a tent and of a bronchitis kettle after tracheotomy has already been mentioned. Some recommend the employment of various sprays in the after-treatment of cases in which tracheotomy has been performed; hand sprays or steam sprays have been used, and various solutions have in this way been applied to the larynx; for example,

peroxide of hydrogen, carbonate of sodium, or dilute carbolic acid. In our practice at the Evelina, since the introduction of antitoxin we have entirely discarded local applications. The membrane appears to detach so speedily and easily after the use of antitoxin that local treatment is unnecessary, and as it causes disturbance of the patient it is unwise. The direct application of various solutions through the tube by means of a feather we have also entirely given up. These seem to irritate the trachea and to possess no compensating advantage. It is essential to use a double canula, so that the inner tube can be freely removed for the purpose of cleansing. This removal of the inner tube is requisite every hour or so for the first twentyfour hours; and the inner tube after being thoroughly cleansed should always be replaced speedily, otherwise the outer tube is liable to become blocked or uneven from an accumulation of mucus, and the return of the inner tube can only be effected with difficulty. If portions of membrane are seen in the interior of the inner tube they may be removed with a feather, or with a small pair of forceps, but as a rule the less the trachea is interfered with the better. Prior to the introduction of antitoxin the final removal of the tube was frequently a matter of difficulty. It was recommended that it should be removed on the third or fourth day and replaced by a fresh one, which should be left in situ for two or three days more. There can be no doubt, however, that the date of the permanent removal of the tracheotomy tube has been considerably advanced since the introduction of the antitoxin serum. Dr. Wharton states that he has seen tubes removed permanently as early as the third and as late as the sixtieth day, and he thinks that usually the tube can be removed permanently from the eighth to the fifteenth day. In most of our cases at the Evelina, since employing antitoxin we have been able

to remove the tube at the end of the second day; although previous to this I have had one case in which the tube could only be dispensed with on the fifty-fifth day.

With regard to feeding after tracheotomy, the same precautions are necessary as when intubation has been performed, and it is essential that the most nutritious diet, together with alcohol, should be administered. Should regurgitation of fluids through the wound occur, it will be necessary to feed with the nasal or œsophageal tube; and in most cases it is I think better to feed in this way than to excite the child by constant movements.

Of the complications likely to arise after tracheotomy, the most alarming is perhaps diphtheritic infection of the wound, but this must not be mistaken for the sloughing which is sometimes seen in badly-nourished children. Edema of the neck sometimes occurs and involves the tissues in the neighbourhood of the wound, while erysipelas is also an occasional sequel. Surgical emphysema in the neighbourhood of the wound is somewhat common, and unless it becomes extreme, the air is usually quickly absorbed. A trouble sometimes arises from the formation of granulations about the tracheal wound, and these necessitate the application of some form of caustic. If the tube is left in for an unduly lengthened period, some tracheitis or ulceration of the trachea may arise, especially if the tube is one which does not fit properly.

Tracheotomy followed by secretion of much tenacious mucus, and by pneumonia.-Charles H—, aged four years and nine months. Admitted October 26, 1893, died November 2, 1893. Taken ill five days before admission with sore throat, and mother thought he was going to have scarlet fever. Brought to hospital with statement that on previous night he had wakened with croup. On admission rather cyanosed; rachitic head; chest well shaped, air entered very badly; much retraction of lower intercostal spaces and epigastric angle; on inspiration all vesicular murmur masked

97°

98°

99°

100°

101°

102°

by the loud laryngeal sounds. Considerable swelling of fauces; tonsils enlarged, the right almost covered by diphtheritic membrane, the left had less on the surface: a little membrane could be seen at the base of the uvula. The child was restless, and knee jerks were absent. The cyanosis increasing, tracheotomy was performed on the 27th. Fairly good night; pulse weak at times; no membrane coughed up; short, moist cough very troublesome. On the 28th small pieces of membrane were coughed up and much thick yellow mucus, which readily blocked

103°

the inner tube. On the 30th edges of wound very ragged, but no sign of any membrane or cellulitis; small patch of membrane still on right tonsil; child seemed fairly comfortable, but frequent cough disturbed him and prevented sleep. On November 2

I

had a convulsion, due apparently to non-oxidation. There was no obstruction in the larynx to be made out. The pulse gradually failed as the respiration became more shallow, apparently in consequence of the child's inability to clear his air passages from the thick tenacious mucus secreted in large quantities. Pulse varied from 120 to 152, consecutive three-hourly records being often from 20 to 30 beats apart. General range of temperature under 101°; only once 103° (see chart). Urine contained albumen from October 30 to the time of death.

Post mortem.-Vocal cords much thickened, ædematous; no membrane; mucous membrane and trachea very red, this redness extending down to the medium-size bronchi; small granularlooking patches of membrane which could be readily separated as far as the first division of the bronchi; one small patch below the tracheotomy wound, where there was a definite loss of substance, possibly produced by pressure from the tube; bronchial glands swollen, one at the lower end of the trachea had suppurated.

Tracheotomy; recovery. Thomas C. B, aged four and a half. Admitted February 11, 1889. Dry cough four days; pain in chest; harsh voice; increasing difficulty in breathing. On admission patches of membrane were visible on both tonsils; much cyanosis; breathing distressed; considerable sucking-in of chest wall; temperature 101°. Tracheotomy was performed at once; temperature fell to 99° in six hours; much membrane brought up through tube; occasional profuse general perspiration; breathing mostly easy, although rather distressed at times. On the 14th slightly sick twice; tube taken out on the 17th. On the 18th breathing very croupy. On the 19th small piece of membrane on the wound; knee jerks present. No albumen throughout. Discharged well February 25, 1889.

While laying much stress upon the advisability of the early performance of tracheotomy in cases with signs of laryngeal obstruction it may be well to indicate once more that the introduction of antitoxin has rendered it possible to obtain good results in a large number of such cases by the much milder operation of intubation. I would repeat that if antitoxin has been employed, it is better to try the effect of intubation before resorting to the more formidable operation of tracheotomy.