C7T I L<- IH.^.J Ok ------------------------------- Compliments of the jguthor. ABSTRACT OF THE Report of the Special Committee on Croup ,OF THE Illinois State Medical Society, WITH A List of Eighty-three Cases of Tracheotomy, for Croup and Diphtheria, Performed in the State of Illinois. '<■ :■! :.,0-' By H. Z. GILlL* A. M., M. D., Jerseyville, III., Late Brevet Lt, Col., Surgeon U. S. Vols, &J T.i CHICAGO : H. Willsom & Co., Printers. 1 TO Clark Street, 1878. ^Ttf'f ■■V/i<>*H*'. this term from its original sense, as definitely set forth by the author. He believed he had made a real dis- covery, and, as a consequence, the treatment was di- CJ<- REPORT ON DISEASES OF CHILDREN. 11 rected largely against the local manifestation with the greatest hopes; and in the same line of reasoning he was led to prac- tice tracheotomy, of which Caron had previously been such an ardent advocate. Bretonneau, so firm in the correctness of his conclusions, drawn from such an extensive experience, proceeded to put into practice his theory, and performed tracheotomy five times, "with but sad partial success." Finally, in the case of the daughter of a friend (the child, Elizabeth de Puysdgur), rec- ognizing the commencement of asphyxia by the signs given by Aretseus more than seventeen centuries before, he operated and saved the child "from certain death." To this great man, it seems to me, must be accorded the distinguished honor of having established tracheotomy in the treatment of croup, popularizing it, and creating the fire at which his followers, such as Trousseau and others, have lighted their torches. The views of Millar and Weichman were again brought for- ward, Bretonneau calling all the cases of laryngitis suffocantis, of either inflammatory or nervous character, laryngitis stridu- losa, in which was found no trace of false membrane; and Guersant gave the name of pseudo-croup, or false croup, to the same affection, which he was careful to separate from true croup in the article on this subject in the Dictionnaire de Medicine (1835). From this time on, the details of the dis- ease, and the treatment, received special attention from men of the highest standing in the profession. Many new points were brought up, and diphtheria being generally recognized and admitted, the distinction between croup and false croup, the simple, primitive, and secondary pseudo-membranous mani- festations, were entered in all the medical works as accepted truths, if not as demonstrated facts. Some of the questions may be merely mentioned here, viz: nervous affections during the disease, and after convalescence ; the examination of the false membranes, both chemical and microscopical; the dis- covery of albumin in the urine (1857). But what attracted most attention from medical men was the treatment, medical and surgical, of this tearful disease. The first thing was the 12 ILLINOIS STATE MEDICAL SOCIETY. general abandonment of blood-letting; the second, the rejec- tion of all so-called specifics; thirdly, the adoption of the sus- taining treatment; and lastly, tracheotomy. Tracheotomy, after having been opposed by the most bitter opposition, denounced by some and ridiculed by others, was sustained by the test of experience, came out of the contest victorious, and "remains mistress of the fieM."—{Simon.) The period for the operation, formerly left till the last extrem- ity, was placed beyond all controversy by those having most experience, at the much more favorable time, viz., at the commencement of asphyxia. But notwithstanding the con- stant reports and the undeniably favorable results in France, still in parts of Germany, in England, and in many parts of our own country the operation has been regarded and acted upon too much in the light ot a "last resort." UNITY OR DUALITY OF CROUP AND DIPHTHERIA. On the question of the unity or duality (complexity) of the cause or causes of croup and of diphtheria, the profession is divided, even respecting the true membranous form of croup. The majority of practitioners of the present day believe in the identity of croup and diphtheria (Cohen), and I believe the number is increasing. Of the unitists we may mention the following names : Sir Thomas Watson, Hellier, Bristow, Sir Win. Jenner (recently converted), the long list of distinguished Frenchmen, Meigs and Pepper, S. Bard, Jacobi, Pilcher, our own II. A. Johnson, R. G. Bogue, and many of the members of this Society, including, I believe, parti}7, our worthy Pres- ident. Of the dualists there are the names ot Charles West, Aitken, the Germans generally (though tearfully confused), Wood, Flint, J. Lewis Smith, Barker (though he believes in the croup of diphtheria), Cohen, and many of the members of this So- ciety so profess. This is a question very difficult to settle by the exact methods ; and it is no less important than difficult, for as a man's theory is, so may his practice be inclined almost inevi- REPORT ON DISEASES OF CHILDREN. 13 tably, though not necessarily, provided clinical observations demonstrate a given course of treatment to be generall}7, or even largely, successful. But this question cannot be settled by "the count of heads, or the clack of tongues." I might fill pages with illogical inferences and irrelevant statements on this point, from the writings of distinguished men. We must, however, hold firmly to the facts in this case, as in all others, if we would arrive at safe conclusions. The impossibility of discovering a difference, either macroscopically, microscop- ically, or chemically, between the false membranes formed in the different cases, is equally admitted by both sides—Smith, Steiner, Cohen (quoting Virchow also), and Simon, Jacobi, Meigs and Pepper. Again, there is no symptom or anatomi- cal fact observed at the bedside which will enable the physi- cian to say that the case is croup and not diphtheria.—{Smith.) E. Wagner has shown, by numerous and searching investiga- tions, that there is no sharp dividing line between diphtheria and croup, an opinion with which Steiner is compelled to agree. The same writer affirms that true croup, as well as true diphtheria, may occur on the gums and throat as well as in the large air passages, but further says that most frequently the two diseases seem to shade into each other; that is, the affection appears on the gums and throat as diphtheria, in the upper part of the larynx as diphtheritic croup, and in the lower part of the larynx, in the trachea and bronchi, as croup. In speaking of the starting point of the exudation, Steiner uses the following language, strange for a dualist: The exudation occurs sometimes in the form of true croup, and some- times in a diphtheritic form, but the wretched confusion ;.nd uncertainty which till prevail among physicians in regard to the theory and nomen- clature of these two processes would mike it difficult to co lect statistics showing their relative frequency ; moreover, it must be frankly confessed that it is not always easy during life to make a clea. diagnosis. And there is no essential difference in the false membranes as they form in the different parts of the respiratory tube, ex- cept that as a rule they become less fibrous and more corpus- cular or purulent as we descend towards the lungs, until the 14 ILLINOIS STATE MEDICAL SOCIETY. croupous bronchitis has changed into a purulent or muco-puru- lent one. J. Lewis Smith, in his report on this subject, made to the International Medical Congress, 1876, discussed the question under three heads :* I. Croup a local malady; diphtheritic laryngitis the expression or manifestation of a general disease. II. Anatomical characters identical in kind, as regards the state of the larynx, but differing in degree or intensity. III. Clinical facts which indicate the duality of these tw>. diseases. At the close of Dr. Smith's paper a discussion followed in the medical section of the Congress, participated in by quite a number of the members, and the result was the adoption of the following resolution: In view of the wide diversity of opinion existing in regard to the rela- tionship of diphtheria and croup, the section prefers to recommend the paper of Dr. J. L. Smith for publi ation, with an expression of their opinion of its hieh va ue as an important contribution to the literature of the subject, but without a definite expression of opinion upon the point at issue. In Composition, the false membrane is made up of (1) amorphous material, (2) molecules, (3) cells, (4) fibrillse. In locality, it is found mostly on the naso-pharyngeal and the respiratory mucous mem cranes, but exceptionally it may be found on any of the mucous membranes, or on denuded sur- faces of the skin anywhere. MICROSCOPICAL EXAMINATION. (1) The amorphous material, which is the basis or cement, so to speak, is more or less transparent and viscid, holding together the morphological elements. (2) The molecules are of various forms and sizes, from a mere point to quite an appreciable size and regular form. They include >1) the elements of decomposition and disinte- gration of a purely chemical character, but not fat; \2) vibri- ones, bacteria, monads, micrococci or coccobacteria, as they have been variously termed ; \S) vegetable germs and my- *See my full report. REPORT ON DISEASES OF CHILDREN. 15 celia—zygodesmus fucus (Letzerich ; see also St. Louis Med. and Surg. Journal, 1872, p. 214.); (±) fat globules, round, of various size, and soluble in ether and oil of turpentine. (3) The cells are of the pavement epithelium or of the cylindrical and cilliary variety ^dependent upon the part from which the pseudo-membrane is taken,jgranulated corpuscles, blood and pus corpuscles. (4) The fibrillated portion consists of very fine striations, sometimes sufficiently parallel to give the specimen an ap- pearance almost fibrous, at others they are crossing or reticu- lated in every direction. CHEMICAL EXAMINATION. Chemical examination of the false membranes seems to prove conclusively that the exudate is of a fibrinous character, though it is often spoken of as a fibro-albuminate. It is insol- uble in hot and in cold water; it is contracted and condensed by acids, and dissolved by alkalies. Of the latter, the chlorate of soda has been shown by numerous experiments to possess a solvent power twice as active and more prompt than any other agent of this class.—{E. Barthez.) Lime water is also known to possess considerable solvent power, for which pur- pose Kiichenmeister has recently brought it into therapeutical application. The little red spots on the under surface of the false mem- branes, as well as on the denuded surface of the mucous mem- brane, are not the produces of vascularization, but spots of bloody points caused by rupture of minute vessels. They had been regarded as the organization of vessels in the false mem- branes. The microscope, however, has shown that to be in- correct. They are minute coagula of blood, adhering closely to the separated surfaces. The epithelium is generally re- moved from the mucous membrane, and in exceptional cases there is ulceration. HISTOLOGY OF CROUP. The manner in which the false membrane is formed has been explained in two ways : 16 ILLINOIS STATE MEDICAL SOCIETY. 1. The endogenous cell action by which the epithelial cells become enlarged and their contents multiplied, and thus form the molecular and morphological elements of the false mem- brane, while at the same time these epithelial cells send out projections or offshoots which by coalescence form the matrix or network of fibrilse among which the other elements become entangled. 2. The extravasation or transudation of amorphous and of morphological elements from the vessels of the mucous membrane, the amorphous, albuminous or fibrinous portion becoming coagulated, stratified and striated, and thus forming a basis and network tor the morphological elements. In my opinion, both these theories are partly true. But I have no doubt the extravasation has the preponderence. And the coagulation is dependent upon the essential cause of the disease—as much so as the peculiar products of variola or measles are dependent upon a peculiar poison. LARYNGOSCOPY APPEARANCES. On account of the impossibility, in most cases, ot making use of the laryngoscope in small children, from a want of co- operation on the part ot the patient, the report of Munch, as given by Steiner, is of decided interest in several respects. The patient was a boy ten years old : ( The mucous membrane was much reddened ; a marked membranous deposit covered the ary-epiglottidean ligaments, and still more copiously the vocal cords ; the glottis was narrowed, partly by the deposit upon the vocal cords, a d partly by he paresis of the dilator muscl s, the posterior crico-aryteno d. Later the whole larynx appeared to be covered w th membrane ; at the same time it was noticed that the edges of the vocal cords were apparently agglutinated to each other at various poin s by a lnyer of fluid exudation. Subsequently the d posit di appeared under the continued use of caustics, but was renewed daily until finally only a thin, gauzy layer of membrane was noticed, which returned iigain and again wi h great obstinacy, especially upon the vocal cords. The vocal cords ultimately resumed their function, and manifested considerable vibratility, even while some if the membrane remained. By the sixteenth or seventeenth day the normal white color of the vocal cords was restoied, «nd here and there a rid .ish streak was all that could be noticed." REPORT ON DISEASES OF CHILDREN. 17 Ziemssen has also noticed the exudation, the swelling of the vocal cords, and their immobility. See also Niemeyer, French transl., Vol. I. p. 26. Course.—It may be added here that croup is an acute dis- ease, of rapid progress, increasing in severity to the acme or to the fatal termination, with sudden and transient remissions^ depending upon the expulsion of false membranes or other temporary causes. The duration is short—from three to four days; some cases, however, may die sooner, and some continue for several days, or even, exceptionally, run into weeks, as I have seen. The duration is influenced by the age, the strength of the patient, previous condition, and the genius epidemicus. Before we accept the opinion of any writer on the termina- tion of croup, we must know what, precisely, he means by the term croup. Every writer of distinction testifies to the high mortality of this disease as we have defined it. "It is, under all circumstances," says Steiner, "a deadly disease, and the prognosis is in general doubtful. * * The proportion of recoveries is stated by all writers of honesty and diagnostic skill as lamentably small." The termination of croup is most fre- quently death.—Simon. In the majority of cases croup ends fatally. — Churchill. Two-thirds die.—Marley. Vieusseux says one-half died (in his early practice, 1775). Two out of three die.—Michaelis and Bard. In membranous croup re- covery rarely takes place.—Pilcher. The great fatality of croup is admitted by all.—Barker. At Hospital Sainte-Eugenie, ot 160 cases treated medically, 58 recovered and 102 died. As with the duration, so with the final result; the attendant conditions—age, previous condition, epidemic influence, hygienic advantages, treatment and com- plications will have much to do with determining the results. The Manner of Terminating.—As the case approaches the fatal termination the suffocative attacks are less intense, on ac- count ot diminishing ability of the part and of the system to rec- ognize and to resist them; drowsiness becomes increased, the 18 ILLINOIS STATE MEDICAL SOCIETY. dyspnoea continues and increases, the pulse becomes small, weak, thread-like and very frequent, and death is ushered in under one of two forms: (1), either by asphyxia from the local obstruction to]respiration, with accompanying symptoms, viz.: cyanosis and more or less of convulsive movements ; or (2) by general prostration, as exhibited by the general indifference, pallid, waxy countenence, loss of expression, and death result- ing from carbonic acid and diphtheritic poisoning. If, however, the case should have a favorable termination, the characteristic symptoms become ameliorated, the dyspnoea is less embarrassing, the cough more moist, thess}rffoea£ive at- tacks are farther separated, the countenence i=» more natural, and the pulse slower. In the convalescence the physician must bear in mind the fact that dangerous symptoms of various kinds may arise, such as the nasal twang, aphonia, difficulty of swallowing, restrained respiration, which may be caused by paralysis of the different parts to which these symptoms point; and in- deed the nervous lesion may extend to almost the entire body. Paralysis Following Diphtheria.—From statistical docu- ments carefully compiled, the proportion of cases of paralysis following diphtheria is about one-sixth. But it must be re membered that many of the recovered cases are not seen long enough to know whether paralysis follows or not, and many die before the supervention of this accident; hence, Roger es- timates the proportion affected as from one-fourth to one-third ot those who do not die in the first part of the disease proper. DIAGNOSIS. Under the head of " Symptoms" the capital points in the course of croup were set forth sufficiently in detail. It will only be necessary to point out some symptoms and circum- stances by which croup may be distinguished from some other diseases with which it has been confounded. The disease most nearly simulating croup is catarrhal laryngitis, larnygitis stridulosa, or false croup. REPORT ON DISEASES OF CHILDREN. 19 The symptoms in this latter disease are of milder degree generally. The attack comes on suddenly, in the night, fre- quently without any warning. The voice is seldom entirely obliterated, though it may be hoarse and rough. False croup is not preceded by membranous angina, though croup is not always ushered in by this angina. False croup partakes in its manifestations very much of the nature of acute laryngitis. The suffocative attacks are early in the disease, and frequently in the beginning, and soon oc- cur at longer intervals, and are of less intensity; while the opposite is«tke course with croup, the symptoms progressing instead of diminishing. There is no expulsion of false mem- brane in false croup; neither does asphyxia appear, though temporary suffocation may occur. At the beginning, when there is a moderate degree even of dyspnoea and aphonia, it is not always safe to pronounce posi- tively what the future may develop. The whole history will develop the true character of the case, but prophesying is sel- dom profitable before data are presented. Acute, grave cases of laryngitis have many of the same symptoms as croup. But the former often follows some other acute disease, such as small-pox, or measles, or scarlatina, and then may be regarded as secondary. In some cases making an accurate diagnosis will require very careful observation, and even then a positive opinion may not be based upon sufficient evidence. The presence of false membrane on the mucous surfaces, or expectorated, is regarded as pathogno- monic of croup'. PROGNOSIS. To what I have said under " Termination" may here be added that the prognosis is always doubtful, and should be given with great reserve. Simon reports, from 1826 to 1840, 3,845 cases, of which onfy 961 recovered, and 2,884 died, that is, one recovered out four cases. From 1841 to 1858 the numbers rose to 6,876 cases, of which 20 ILLINOIS STATE MEDICAL SOCIETY. 1,146 recovered, and 5,730 died, viz: one out of six cases. Tracheotomy has added greatly to the favorable issue. Under prognosis Steiner says : Out of quite a large number of cases occurring in my practice, before I had adopted the practice of tracheotomy, I saw but three recoveries. Since 1863, however, this discouraging rate has been so much improved by the employment of tracheotomy that the mortality has at different times amounted only to sixty, sixty-five and seventy per cent. Bricheteau states it at sixty-nine, Franque at sixty-eight, Trousseau at fifty, and Greve, in Sweden, at twenty-three per cent. I will return to this feature of the case under "Tracheotomy." "Finally," says Simon, "as a general rule, we should never lose hope of saving our patient." THE TREATMENT Very naturally divides itself into Medical and Surgical. MEDICAL TREATMENT. The study of the therapeutics of croup during the last fifty years, or even from the beginning of the present century, jus- tifies us in abandoning the claim of any agent as a specific in the treatment of this disease, whether local or general. Blood-letting, mercurials and alkalies, as having a de- cidedly beneficial effect, have also fallen into disfavor with the profession. Bromine, syrup of copaiba, and cubebs, and especially sulphate of copper, have their advocates. The latter has been recommended by numerous authors of distinction, and it still holds considerable reputation in this country, through the writings of the late Niemeyer. Samter, who studied its action carefully, comes to the following con- clusion : When eniesis still follows its administration, he doubts not the propriety of this treatment for croup; but when this action is no longer produced, paralysis is superven- ing, and it is proper to operate. Its depressing effect, added to that of the disease, will not be a favoring condition for the success of tracheotomy, while nothing has been gained beyond what would have been acconi- REPORT ON DISEASES OF CHILDREN. 21 plished by less exhaustive agents. It is given in from one- fourth to one grain doses, repeated frequently. The syrup of copaiba and cubebs has been given with report- ed success by Trideau, and was recommended by a physician in Washington City, in the transactions of a medical body of that city. It has not met the expectations of its advocates, at least yet, though it seemed to promise well in the cases attack- ing the larynx first. Tincture of the chloride of iron (tinct. ferri perchloride) has been in use since 1858. It was brought to the notice of the profession about the same time by Heslop, of England, by Gigot, Aubrun, and Jodin, of France, and by Crichton, of Scot- land, and its application in croup and diphtheria was probably suggested by its previous use in the treatment of erysipelas. It has been used locally and generally, singly and in combina- tion, and it has to-day the confidence of the profession above any other single remedy for the membranous diseases, and ap- proaches nearer to the rank of a specific. Emetics.—English, French, Germans and Americans are in accord as to the great value of emetics in some form. Tartar emetic, formerly much used, has been replaced by less depres- sing agents, especially in the case of young children. It is still given in combination by a respectable number of prac- titioners. I must here add that if it should be chosen, its effect must be carefully watched, otherwise irreparable damage will be done by it. I prefer other means, for it must be ad- mitted that the principal effect of an emetic in this disease is mechanical; hence, that which produces the most prompt and efficient action, with the least depression or other objectionable effects, is the one to be chosen. Simon prefers the syrup of ipecac, with five or ten grains of the powder added to each dose when a decided effect is desired. Steiner prefers ipecac in combination with tartar emetic, "a 22 ILLINOIS STATE MEDICAL SOCIETY. powder containing two grains of ipecac and one-sixth of a grain of tartar emetic, and five grains of sugar, to be taken every ten minutes " till it operates. " If diarrhoea be present, or if it follow the administration of this prescription, I select the sulphate of copper." This is very significant language, and carries with it the intimation of the danger which I have men- tioned. Ipecacuanha is perhaps the most generally approved emetic by the four nationalities referred to. Within the last ten years, through the recommendations and published reports of Prof. Fordyce Barker, the turpeth mineral (hyd. sulphas flav.J has grown rapidly in favor with the profession of this country. It acts promptly, efficiently and kindly. I have been so well pleased with its action as to prefer it to all others. It is given in three to five grain doses, according to the age of the child, and repeated in fifteen twenty minutes if the first dose does not operate. It is not deemed well to repeat it more than once in the twenty-four hours, or even at a longer inter- val. Through the teaching of the late Prof. C. D. Meigs, alum in powder has been much used, both by the profession and in domestic practice. I have seen it. more than once en- tirely fail to produce the desired effects. It is given in tea- spoonful doses, mixed with syrup or honey, to be repeated in a quarter or half an hour if it does not produce vomiting. To increase its efficiency, powdered ipecac may be added to it. Quinine was used in the treatment of croup as early as 1848, by Puis. As an antiseptic it is altogether probable that in the early stages of the disease its action is by contact with the mor- bid products. As an antipyretic and tonic it may be used, as Dr. Fordyce Barker suggests, in combination with verat. viride very beneficially in the advanced stages. As one of the chief remedies in uncomplicated croup it is not so much relied on as it is in the febrile stages of catarrh and pneumonia. The local treatment must receive careful attention. The ex- ternal applications may be either cold or hot. If the former REPORT ON DISEASES OF CHILDREN. 23 be chosen, with a view to reduce a simple inflammation, their applicability is especially, and may I not say only, in the begin- ning and early stage of the disease. The applications should be made by means of cloths wrung out of cold water and ap- plied to the anterior part of the neck, and covered with a dry towel. They must be frequently repeated. They may be con- tinued while symptoms of active, acute inflammation continue. These conditions will frequently not be present to any marked degree, and the long continued application of cold without corresponding local reaction will have an injurious rather than a beneficial influence. This will be the case if the inflamma- tion is of a decidedly diphtheritic character. Hence, as a rule, where the larynx is involved, I prefer the hot application, made by the same method, viz., compresses wrung out of hot water and applied to the external throat; or by means of a sponge, as recommended by Dr. Lehman, of Torgau, frequently repeated until the surface is quite red. This is also applicable to the first stage. RESUME OF THE MEDICAL, TREATMENT. 1. Give an emetic—turpeth mineral from three to five grains; ipecac, in syrup or powder, or the two combined ; sul- phate of copper, from a fourth to a grain every half hour or till it produces free emesis; powdered alum with syrup, either alone or combined with ipecac; compound syrup of squills, that is, tartar emetic in this form—(hive syrup), from one-third to1 a teaspoonful, repeated every half hour until vomiting is produced. The above remedies are preferred in the order in which they are stated. If the catarrhal character should be suspected, an anodyne might be given with propriety, to quiet the system until symptoms were sufficiently marked to decide the case. 2. Tincture of iron and chlorate of potassium or sodium, in solution, with glycerine : 24 ILLINOIS STATE MEDICAL SOCIETY. U Tinct„ ferri muriatis, - fl 3 iss—3 ij- Potassii vel sodii chloratis, - - 3 i. Glycerins?, - - - fl 3 i— 1 iss. Aqua? q. s. ad, Z 1]1- Dose, a teaspoonful every half hour or hour. It may be farther diluted if required. 3. Regulate fever with tincture of veratrum viride. 4. Local application to the external throat of hot applica- tions, frequently repeated (cold may be used in the beginning by those who prefer it); also counter irritation with turpentine. 5. Disinfectant or antiseptic gargles or washes to be used according to demands, for the throat or nose. Carbolic acid, from two to six grains to the ounce of water; or the above so- lution of iron, potash and glycerine; or lime-water § iij. chlo- rate of potassium 3 i, glycerine and water each § i, may be used with the spray apparatus, according to one's preference. 6. Inhalation of steam by keeping the atmosphere of the room saturated, or, in addition to this, by means of some spe- cial apparatus; breathing the steam from slacking lime, or inhaling the spray of lime-water, repeated every hour or two. 7. Sustain the patient's strength by easily digested, nutri- tious diet (preferably milk), given at suitable times and in pro- per quantities. Give cold or warm drinks as preferred by the patient, guarding the quantity so as not to disturb the stomach. 8. Treat complications according to general principles. Daily remissions may be met with antiperiodics with great ben- efit ; finally, when medical means fail, as they often will, re- sort to the ultimum refugium—tracheotomy—before it is too late. SURGICAL TREATMENT. In this branch of the subject under consideration, it will not be expected that the report shall cover more than the most im- REPORT ON DISEASES OF CHILDREN. 25 portant points in practice ; neither would it be especially pro- fitable ; yet enough must be given, it seems to me, to show the status of the operation of tracheotomy, and its recent history to its present position in practical medicine. Those of the pro- fession who have not given the subject much investigation would be somewhat surprised at much of the illogical argument offered against the operation in croup, to be found in some of our standard surgical works published only twenty-five years ago. (Velpeau's Oper. Surg., by Mott, Townsend's notes). As we might very naturally have supposed, and as history has shown, tracheotomy was known and practiced at a very early date in medical history.—Simon. AMERICAN REPORTS. In Dr. Cohen's report from various sources, published and unpublished, there were 325 operations with 84 recoveries, 25 4-5 per cent. There were over forty operators [1874]. Dr. L. S. Pilcher, of Brooklyn, reports [1877] from 36 oper- ators, himself included, 121 operations, 24 recoveries; 20 per cent. *Dr. A. Jacobi (New York) has performed the operation about 200 times; 68 operations (reported), 13 recoveries; 20 per cent. Dr. Wtn. Porter (St. Louis) 17 operations (mostly in Lon- don), 4 recoveries ; 23^ per cent. One of the 4 returned to hospital in two weeks, and died of pneumonia, perhaps a sequel. Dr John H. Packard (Philadelphia, 1878), 6 operations, 1 recovery ; 16 2-3 per cent. Prof. E. Andrews' report of his own and other cases, 21 operations, 4 recoveries ; 19 per cent. ♦New York Medical Record, February IT, 1877. Since 1868, has saved but a small per- centage of suffocating children,— Am. Jour. Obs., February, lSlB ' LIST OF CASES ON WHICH TRACHEOTOMY HAS BEEN PERFORMED IN THE STATE OF ILLINOIS, FOR CROUP OR DIPHTHERIA. to OS No NAME. AGE.| CAUSE. RESULT. RESIDENCE. OPERATOR. DATE. REMARKS. 1 Henry Kohn..... 4 yrs Croup, memb.. Im'ed'te re-lief. Recv'd Beardsto'n. Dr. J. G.Erhardt May 16, '71. Wore the canula eleven days before suflacient air would pass through the larynx. 2 3 P. McDonald.. W. Lohmann(boy 5 yrs. 2 yrs. Croup, memb.. Croup, diph. .. Im'ed'te re-lief: died of broncho-pneumonia on 5th day. Died ...... An;:. 31,'72. Dec. 8, 1872 Operated fourth day of disease. Breathed comfortably till third day after operation. Operated seventh day of disease. Too loia^ delayed; died in a few minutes. 4 Willie Schwaer. 5 yrs. Croup, meml).. Recovered. " " " Dec. 15, '72 Immediate and permanent relief; removed canula sixth day. 5 J. Friese (girl)... 5 yrs. Croup, memb.. Died...... Relief of dyspnua immediate. Died third day, of pneumonia. In all cases, laryngo-trache-otomy. Dr Erhardt has operated twice since, in St. Louis, for diphtheria, with bad results. 6 Willie Winston.. 8 yrs. Croup, diph. .. Recovered . Korreston, Ogle Co. l> L. A. Mease.. Sept. 28,'75 Had been ill with diphtheria eight or ten days. Partly chloroformed. Extreme condition. Tube removed tenth day. "Patient snatched from the jaws of death."—Dr. Winston. 7 Clyde Shonte(boy S%y. Diphtheria, fol-lowed by croup Died....... 1* U »i " T. Winston.. Oct. 11, '75. Sick two days. Survived 26 hours. Diphtheria appeared on the lips and extended into the bronchial tubes. Delicate constitution. 9J 10 11J 12 4 yrs. 5 yrs. 2y.5m Died...... Died....... Died....... Died....... Died....... Sullivan... Lovington. u " E. W. Mills.. " T. A. Collett Jan'y 1, '71. Jan'y 7, t77. Jan'y 8, '75. SesenaJDoke— [da May Bunyan. Walter Love..... Moribund. Lived twelve hours. Lived twenty-seven hours. Croup (laryngi-tis). Lived a few minutes. Moribund when opera-tion was performed. Two or three ineffect-ual efforts to breathe. 13 Willie Hostetter. 5 yrs. Croup......... Died...... " ^ .b i. April 10, '72 Died almost immediately. Complicated with whooping cough. Ho NAME. AGE. CAUSE. RESULT. RESIDENCE 14 William Noll.... 5^y's Croup, memb.. Died....... Virden ... 15 5 yrs. 4 mos Norwood . 16 Oussie Bartlett.. 1 year 9 m. Died....... 17 Frankie Baxter.. 4 yrs. Recovered. Chicago. . 18 Josie Moses(boy) 4 yrs. Croup, diph... Recovered. 19 Brice Miller, " 5 yrs. Croup, diph. Died....... 20 Emma Kerga .. 3 yrs. Croup, diph . . Died....... 21 ---Sussman.... 2Ky's Croup,diph ... Died....... 22 Larry McMullen. 6J*y'B Croup,diph.... Recovered. 23 ---Rossene. 2y 2m Croup, diph.... Died....... 24 Charley Kennedy 3J^y's Croup, diph___ 25 Maud Stanley___ 3 yrs. Croup, diph___ Recovered. 26 Willie Kerfoot... 10 yrs Croup, diph___ Died... . » OPERATOR. DATE. REMARKS. Dr.A.T. Bartlett. Feb 11, '75. Unmistakable case. A complete cast of a por- tion of the bronchial tube thrown up. Lived 48 hours. Operated on 2nd day of disease. March 5, '77 Low tracheotomy. Lived 14 hrs. Died of as- han. phyxia, the disease having continued down the trachea. " John L. White May 6 1883. Iived3hour6. Operation too long delayed. Improved for an hour. Cause of death gen-eral congestion of lungs, rather than filling up of the trachea,. Tube not suitable. Com- plaining two or three days. " R. G. Bogue .. Feb. 21, '74. Tube removed the 16th day. Chloroform was « « « Mch.27,'74. Tube retained 120 days. Had been sick about 8 weeks with diphtheria before operation. " " " Dec. 15. '74. Lived 12 hrs. Cause of death, probably syn-cope. Had been sick about one week. Child insensible during the operation. " *' " Feb. 10, '76. Lived 32 hrs. Chloroform was given. Had been sick with diphtheria over a week. Died from extension of the disease into the lungs. t, It *i Apl. 29, '76. Lived 24 hrs. Died from a commencing pneu-monia. Gave little chloroform. Sick with diphtheria several days. >l Aug. 27, '76. Tube removed the 11th day. Chloroform was given. Had been sick two or three days. " Nov. 12,'76. Lived 18 hrs. Chloroform was given. Died of lung complication. " •' " Feb. 5, '77. Died 4th day, of asthenia and accumulations in the trachea below the tube. " Ap'l 21, '77. Removed tube on 5th day, on account ef ulcei-ation. Chloroform was given. Prolonged convalescence; recovered perfectly. Had had diphtheria several days. Severe case. " " •' June 23, '77 Sick 6 days; lived 10 hours. Malignant case. No chloroform. fcO NAME. Edward Cross. Willie McCoy.. Baby Wasserman Mary Donehue... George Healy__ AGE. 7 yrs y 2m 2y 2m 3 yrs 11m. CAUSE. Mabel S.........5 yrs 33 Master Dawson 34 David E.Beaiy.jr. ;J,V 1 85 ' " " " by 3m 36 MattieCummingslioi^in 37|Martin Rohan. Croup, diph. Croup, diph. .. Croup...... Croup....... Croup, diph. RESULT, Croup. 2 yrs. Croup Emma Hauschilrl ---Lancaster. Fred Launsbury Croup, diph. . Recovered Died...... Died...... Recovered. Died ..... Died. RESIDENCE. Chicage... OPERATOR. Dr. R.G. Bogue. Died...... Kecovered 17 m 3 yrs. 13 m Paralysis mus |Recovered, cles of glottis Memb. croup. .|l)ied...... Died...... 0 yrs (Edematous laryngitis Diphtheria..... Croup, memb. Croup, memb. Died. Died....... Recovered. Grafton, Jersey Co Freeport .. Jerseyville. BunkerHill Madison Co Macoupin" Cairo..... E. L. Herriott DATE. Aug. 27, '77 Oct. 10, '77 Oct. 12, '77 Oct. 22, '77 Dec. 5, 1877 Oct. 15, '76 •L. A. Mease ..,Mch. 13, '7 H.Z.Gill. Fer'd Brother II. Warduer Met). 22,'77 May 11, Nov. 8, Jan. 31, "73 Feb'y 5, '78 l<\'by 27, '(IS REMARKS. oo Sick for ten days previously. Tube worn 44 days. Chloroform was given. Granulations in the wound gave some trouble. Died on 16th day, of pueumonia, and 10th day after tube was removed. Gave chloroform. Gave little ether. Lived 24 hours. Died of broncho pneumonia. Had been ill 36 hours. Ill 24 hours. Gave chloroform. Tube retained 21 days. Lived one day. Gave chloroform. Died from accumulation of membrane and mucous in the trochea and bronchi. Had been ill of diphtheria several days. Had been sick about six days. Gave chloro- form. Lived five hours. Died from the fill ing of the trochea with ( xudations. Tube a piece of No. 12 gum catheter. Ill 10 or 12 days. Gave little chloroform. Mor ibund. Died in 15 minutes. Had been complaining 4 or 5 days. Gave no chloroform. Removed the tube on 6th . ay. May 11,1877 Difficult inspiration for about a week, c-ave chloroform. Wore the tube for — mouths.* '71jHad been ill 40 hours. Lived 6 hours. diate cause of death prostration. Had been ill 18 hours. Lived 45 hours. Cause ot death, bronchitis. Had been ill 72 hours. Lived 1 hour. Cause of death, collapse, possiMy hastened bv hemorrhage. Had been ill about 8 days Lived 12 hours. j Died of exhaustion. No ana-sthetics. Dec. 15, '68|Had been ill 11 days. Wore the tube 128 days. Muffled voice remained. No anesthetic. A little tumor of granulations would drop into ___^__ I the fenestra, and at times prevent breathing. ♦Tube still remaining in, Sept., 1868. Imme- Ho NAME. — - Harman..... Nellie Gobble... Mary Walter.... Minnie Fish..... Mary Voigt...... Albert Bremwall AGE. 4 yrs. 3 yrs. 5 yrs. 4K y. 13 yrs 3 yrs. Bertha Bremwall ...... E. Stapp (.girl).. 12 m Nannie Keegan . 3 vr 10m John Phalon .. 51 Clara Nolan. 4 yrs. 7 yrs. 52 Matthew Currau. 4 yrs. 531 Eddie Nolan___4 yrs. 54JElice Turcell ...3^ y. 55!.Vlich,l O'Kourke'dy 2m CAUSE. Croup, memb. Croup,memb.. Croup, diph... Croup, memb. Croup, diph... Croup,memb.. Diphtheria as a complication of scarlatina. Diphtheria, lar- yngeal compli- cation. Diphtheria___ Diphtheria___ Memb.croup[?] Memb. croup. Mem. croup [?] Mem. croup [?] Memb. croup.. RESULT. Died...... Recovered Died...... Died...... Recovered Recovered Died...... Died...... Died...... Died...... Recovered Died...... Died...... Died...... Recovered RESIDENCE. OPERATOR. Cairo. Girard, 111. Peoria.. Chicago. Wa shinj ton Co. Chicago. Dr. II. Wardner. Dry. R. S. Cowan and It. J.Mitchell Dr. R. S. Cowan " F. Brendel... " H. A.Johnson "C. W. Earle.. " Jas. Phillips.. " E. W. Lee.... DATE. Mch.12,'73 Jan'y 8, '74 Dec. 15, '77 Jan. 15. '78 Dec. 3,1865 — , 1873 ----, 1876 ---, 1861? Aug. 29, ' Oct. 18, '77 Oct. 22, '77 Nov. 17, '77 Nov. 23/77 Dec. 7, '77 Mch. 18, '78 REMARKS. Had been ill about 8 days. Lived 36 hours. Death caused by pseudo-membranous bron- chitis. No anaesthetic. Lived three days. Cause of death, bronchitis. Lived four days. Cause of death, bronchitis. Had been ill several days. Last visit Dec. 23. Case reported by Dr. R. Roskoten. Ill several days. Insensible from asphyxia. No anaesthetic. Had malignant scarlatina four years after, without unpleasant effect from the operation, and recovered. Immediate relief of dyspnoea. Died in two hours, of exhaustion from general disease. ill several days. Was in articulo mortis. Res- piration was entirely relieved. Lived 12 hours. Death from pneumonia. No anaes- thetics. Sick three days. hours. Used chloroform. Lived 30 Asphyxia imminent. Gave Lived zy2 days. Died by as- Sick 10 days. chloroform. phyxia. Two weeks complaining. Chloroform. Arti- ficial respiration necessary after the opera- tion. Removed lube sixth day. Sick 36 hours. Lived 2% days. Died by ex- haustion. Chloroform. Sick five days. Chloroform. Lived 12 hours. Died of exhaustion. Sick four days. Lived four days. Died from asphyxia. Chloroform. Sick 2 days. Removed tube 4th day. Chlorof'm Ho 56 NAME. Bertha Nelson. AGE 4 yrs. 6 yrs 4 yrs yrs Richardson (boy)j5yrs. 67:l.einhardtKoot. 9 vrs. CAUSE. Diphtheria ... Memb. croup. Memb. croup. Memb. croup. Four of croup. not epidemic; Sof diphtheria epidemic. Diphth. croup. Memb. croup. Croup and diph theria. RESULT. Recovered Died. Died. Died. Died RESIDENCE Chicago. Mendota.. Died.. . Jacksonv'e Clinton, De Witt Co. Recovered 4 rec( vered E 12 died. Freeburg, St.ClairCo Chicago. OPERATOR. Dr. C. T. Parkes. E. P. Cook. David Prince, John Wright. F. Koeberlin H. A. Johnson July 4, 1877 Spring.1854 DATE. Nov. 20, '77 Nov. 17, '77 REMARKS. 00 o The disease showed itself the day following the operation.fe Wore the tube 4 months. Retention of tube caused by "exuberant granulations," destroyed by nit. arg. solid. Chloroform. Lived 54 hrs. Chloroform. " Dernier resort." Chloroform. Chloroform. First four fatal from subsequent pulmonary engorgement. Last two fatal from apparent extension of the disease to the bronchial subdivisions. Three days sick. Died on table. Another, younger,child died of diphtheria in the same family, 3 days later; was a favorable case had it been done early instead of moribund. Anaesthetic, ether. Three days ill. "Patient with blue lips and staring eyes." Removed canula 6th day. On 4th day after operation the aphonia disap- peared. Pulse 140 half an hour after opera- tion. Second day afier, in evening, temper- ature roge to 108°. It is possible that No. 4fi is included in thece 16. Taking the whole number as eighty-three (83), and the recoveries as twenty-three (23), the percent, of recoveries is twenty-seven and seven tenths (27.7), a very fair result considering the desperate nature of many of the cases. The most successiul operators, in consider .hie numbers of cases, are : Dr. li. G. Bogue, 15 cases with 6 recov- eries—^ per cent. ; Dr. II. A. Johnson, 10 cases, with 4 recoveries—25 per cent.; Dr. E. W. Lee, 7 eases, with 2 recoveries—28.5 per cent. H t> H d c > o Q 4 REPORT ON DISEASES OF CHILDREN. 31 TWO OPERATIONS OF TRACHEOTOMY IN THE SAME PATIENT, WITH AN INTERVAL OF FIFTY-ONE DAYS. Case 1. David E. Beaty, Jr., aged three years and one month, of certainly medium constitution, and decidedly bright mentally. Was called to see him March 20, A. M., 1877. Previous to this date, as early as the 14th, he had a little fever, and in the evening had a chill, for which on the 15th some quinine was given. On the 16th was hoarse, but did not com- plain of sore throat. On 17th and 18th the hoarseness con- tinued, but the child seemed not to be affected so as to attract special attention or create alarm in the minds of the parents, they having gone to church on the 18th. On the 19th, hive syrup was given by home prescription. He had some appetite, but diminishing for two or three days before I saw him. I found tiim entirely aphoueous, having an extremely dry, ring- ing cough ; respiration not much embarrassed, fever slight, thirst marked, submaxillary glands somewhat enlarged [said to be so usually]. On examination of the throat, found some small spots on the tonsils, and on the posterior wall of the pha- rynx a patch about half the size of the finger nail; tonsils a little red. I at once expressed a decided opinion of the gra- vity of the case; gave an emetic of turpeth mineral, which acted promptly and well ; left a solution of muriated tinct. of iron and chlorate of potash to be used as a frequent drink, and a solution containing quinine grs. x.,tinct. opii. gtt. viii, with aromat. sulp. acid q. s., aq. § i, a teaspoonful every two hours. I also left tinct. veratrum viride to be given in case there should be perceptible fever. The father, coming home after I left, began to realize the serious nature of the case, and Dr. J. L. White, their former family physician, being in Jerseyville, was requested to see the case in consultation. On examination of the case in the afternoon, the patches were not visible. Other symptoms were no better. Voice completely obliterated ; wheezing audible at quite a distance. 32 ILLINOIS STATE MEDICAL SOCIETY. Dr. White calls it membranous croup, but thinks not diphthe- ria, though he might " call it diphtheritic croup." Adopted the same treatment as in the case of Julia Neumeyer [a severe case treated in February], viz., hot applications to the neck, high temperature of the room, and the atmosphere saturated with moisture, the previous treatment to be continued. Dr. W. thought it as favorable a case for recovery as could be of the membranous form of the disease. The perfectly dry, ring- ing cough in conjunction with the wheezing respiration made the case to me one of much anxiety. On the 21st, at 9 A. M., found the respiration much obstruct- ed ; had had a bad night; several severe paroxysms of approach- ing suffocation were reported as having occurred during the night. The characteristic symptoms were steadily progressing, with loud, dry,wheezing respiration. Gave the turpeth mineral, which was followed by moderate emesis and some relief. Con- tinued the chlorate of potash and iron ; also the quinine, at two or three hours interval. Suggested the probability of tracheotomy becoming necessary. The reply was to do what I thought to be best. 3 P. M.—Condition no better. All the indications for trach- eotomy growing stronger. Suggested to have everything readv to operate at any time during the night. At 5 P. M., spoke to Dr. Shobe of the probable necessity for the operation during the night. Applied vapor from vine- gar and water, created by hot bricks in a bucket at foot of bed under the bed clothes. 7 P. M.—Still worse; respiration very difficult; depression of the ensiform cartilage and lower ribs very marked on inspi- ration ; evident carbonization of the blood. Dr. S. was sent for. I prepared for operating. Before the doctor arrived there was a sudden marked relief following a fit of coughing. The operation not now thought to be imperative ; indeed, not justi- fied at the moment by the symptoms. The doctor remained an hour, then returned home ; I remained all night. Temper- ature of the room maintained at 85Q, and vapor continued. report on diseases of children. 33 22nd.—Respiration most of the night tolerably easy, after the sudden relief last evening, until towards morning, when it gradually became more difficult. Left for home at 8:30 A. M., expecting to return at 11 A. M. A messenger soon came, and Dr. S. was notified. At 10 A. M. the effort at inspiration was terrible to witness. Imperfect oxidation was present, but not strongly marked, except at one time during a severe paroxysm. I regarded the operation as absolutely necessary, if any more paroxysms should occur. Dr. S. thought the operation very doubtful, regarding it now as very late. We agreed to try the vapor from slacking lime. Little or no benefit followed. The father desired, if necessary, other council from a distance, and proposed to telegraph Dr. Armstrong of Carrollton, to come on the 5 P. M. train. This was readily agreed to, con- ditionally ; that is, if necessity required the operation, we should proceed to operate at any time, and not wait; for I had no expectation the child would live till evening without sur- gical relief. We were to remain and be ready for any emer- gency. Two points were clear in my mind : (1) Progress- sive aggravation of the symptoms; and (2) imminent danger of suffocation. [See conclusions.] Towards noon the symp- toms became more alarming, but no paroxysms occurred. We concluded that if no improvement began by 1 o'clock, P. M., we would operate. By the time dinner was over, the ob- structed respiration had become still more marked, and the danger of suffocation imminent. Delay was no longer safe. I proceeded to operate, Dr. Shobe kindly assisting. The effect of the imperfect oxidation of the blood was plainly visible in the color of the fingers and face, and also in the general anaesthetic effect. Gave no anaesthetic. Some of the family and neighbors rendered efficient aid. I marked out the line of incision with dots of ink. Operated slowly and cautiously, after the first principle incision using forceps and the handle of the scalpel freely, pressing the vessels aside with blunt hooks. The inferior (median) thyroid vein was directly be- neath the inferior portion of the first incision, and distended 34 ILLINOIS STATE MEDICAL SOCIETY. to the size of a crow quill. Not a vessel required ligation. I believe there was no misstep in the operation. The hemor- rhage was somewhat embarrassing. The thyroid gland was scarcely observed, and at most not to annoy. Opening the trachea would have been, perhaps, a little easier had it been held with a tenaculum, though it was thoroughly cleared before the incision was attempted. At this point considerable self- control is needed to prevent haste in opening the trachea before the dissection is completed. The neck was quite short, and the usual amount of adipose tissue was present to obstruct the operation. The opening was dilated by means of a bent loop of wire, while I cleared the trachea of a considerable amount of thick, tenaceous mucus and lumps of false membrane, with the curved forceps. After this the tube was introduced with- out difficulty. The relief was perfect from the time the incis- ion in the trachea was dilated and cleared, the child falling asleep almost as though fully under the influence of an anaes- thetic. In fifteen minutes the respiration was 40 per minute, and in an hour down to 36. The demand for water was most urgent and persistent; and it was quite necessary to limit the supply in order to prevent disturbance of the stomach, there being an unfavorable dispo- sition to nausea. Examined the urine in a spoon, but could not say there was albumen in it. On the second day after, I found a trace of albumen, examined in the same way. The early part of the night was spent with considerable comfort by clearing away the tenaceous material as it was forced into and out of the tube, using the curved forceps to remove any obstructions, and occasionally removing and cleansing the inner tube. About 10£ P. M. there occurred a severe fit of coughing, and the tube was soon filled with mucus and membranes, and respira- tion for the time was arrested. Fortunately I was near at hand (though taking a little rest, having been up the most of the two preceding nights), and quickly removed the inner tube, also removed with forceps the additional mucus and membranes, thus relieving the obstruction to such an extent as report on diseases of children. 35 to restore the respiration. I would remark here that I found it almost necessary to leave the inner tube out after that, dur- ing the night, it then being possible to clear the outer tube fre- quently with the curved forceps when necessary. I watched him pretty closely the remainder of the night, but found the obstruction increasing towards morning, and by 7 o'clock he appeared to be sinking from some impediment to Oration, yet nothing in the tube. With the needed assistance I removed the outer tube, cleared the trachea thoroughly of all mucus and hard, tough lumps of false membrane; all of which restored the respiration and rescued the child from impending death. Prostration was decided, and the child greatly exhausted. When commencing to change the tube the father (before per- fectly courageous and apparently hopeful) said, "The child has been dying for the last twenty minutes." A profound and prolonged sleep followed, after which our patient began taking some nourishment, more than at any time before. Frequent fits of coughing, however, occurred, in which the same kind of material as before, was brought up, and sometimes quite considerable lumps, thick, deep yellow or dark yellow, were thrown out with considerable force, and at other times, brought out with the forceps; but it was evident that the material was losing its consistency and toughness. A part of the day he was quite cheerful. Towards evening the obstruction increased. I removed the nwaer tube, applied an 80-grain solution of nitrate of silver to the edges and surface of the w^und, used a spray upon it of a 40-grain solution of carbolic acid, cleared the trachea, and replaced the tube. In the early part of the night I gave a saline cathartic (Rochelle salts), there being considerable fever, and at 10 P.M. and 10.J P. M. gave one drop of tinct. verat. viride. After the second dose he vomited slightly; was very restless, tossing about con- stantly. The excessive thirst continued. About midnight the cathartic acted, and he became less restless. Towards morn- ing I began using a weak solution of salt and water, pouring a 36 ILLINOIS STATE MEDICAL SOCIETY. few drops into the tube,* which seemed to soften the material and facilitate its expulsion very much, greatly to his relief He took nourishment sufficiently. I did not replace the inner tube during the remainder of the night; the outer one seemed to transmit the air and the secretions much more freely, and the curved forceps could be used to better advantage. 24th. Patient is restless only at times; wants to drink too much water. There is an eruption on the upper part of the chest, and before noon ;it appeared on the palms of the hands also. At noon, while sleeping, the respiration was 48 per minute, having ranged from 45 to 50 during the last twenty- four hours. The discharge seems rather reddish. At 5 P. M. pulse 135, respiration 50, temperature 102°. Removed and cleansed outer tube, which could be easily done; re-applied the 80 gr. sol. of nit. silver; used the carbolic acid spray freely. There was some albumen in the urine. Having remained with the case for forty-eight hours (constantly since the operation), I now took my leave for twenty-four hours, Dr. S. remaining in my absence. 25th, 1 P. M.—The inner tube required to be removed several times during the night; there seemed also to be more fever. The secretion is reported to have been bloody. Appe- tite poor. 8 P. M.—Respiration 36 per minute, and almost inaudible ; he sleeps quietly, and more than at any time since the opera- tion. Omit now the vapor. Keep the temperature of room at 75°. 26th—Removed the tubes; cleansed the wound with soap suds. The inferior thyroid vein had become impervious to circulation, and apparently dead, and I removed it with the scissors. After severe fits of coughing there is a little hemor- rhage from the lower part of the wound. 27th-Removed the outer tube and left it out more than an h ,ur; then replaced it. On account of my not remaining at * See Gurdon Buck, New York Medical Record, 1872, p. 12. REPORT ON DISEASES OF CHILDREN. 37 the house, Dr. S. remains to-night. Keep the temperature at 75°. Gave any kind of nutritous food desired. 28th—Nothing special occurred last night; removed the tubes permanently this forenoon. Saw the child twice only, on the 29th and 30th, and once a day till April 6th, excepting the 5th, and again on the 9th, when I find the last of my notes to the following effect: "Wound nearly closed; air escapes through the wound only on coughing; speaks aloud with little effort; appetite good." From this date I was absent from home nearly two weeks. But nothing occurred to produce any anxiety until the night of May 6th. Case II.—I then saw him again for the first, and found inspiration difficult, especially so when sleeping or resting, and in the latter part of the day and night. This condition has shown itself for some days, but when he was thoroughly awake and playing, it attracted but little attention, and pro- duced but little embarrassment. On the 7th he was quite bad. Prescribed for him, but did not see him again, there being considerable relief, till May 10th. The obstruction from this time became more and more marked, and the inspiration steadily more difficult when drowsy or sleeping. Remedies seemed to produce little or no effect. This condition continued, be- coming gradually more aggravated, but without apparent paroxysm, the expiration, so far as I could judge, being little, if at all, obstructed. I remained with my patient during the nights of the 10th and of the 11th, prepared and expecting to be compelled to perform tracheotomy the latter date. At times, the child being very weary and sleepy from the long continued and laboring effort at breathing, there would be several fruit- less attempts at inspiration, and until he would arouse himself and take a deep, forced inspiration. Even this condition grew worse, and I presented strongly the only remedy which offered any hope, viz., tracheotomy. This was reluctantly received inasmuch as it seemed to appear to the parents that the other operation had not cured the child. My opinion of the nature of the case in this second attack, 38 ILLINOIS STATE MEDICAL SOCIETY. or sequel of the former, may as well be stated here : I regarded it as a paralysis oj the muscles of the glottis (the dilators par- ticularly), or at any rate, a loss of balance between the dilators and the contractors, possibly spasm of the latter. I expected immediate relief by opening the trachea, and did not intend to let the child die without the operation, unless I should be op- posed or overruled. My convictions were clear as to the course to be pursued. Dr. J. L. White was telegraphed to come in consultation, the parents thinking the child would not get well, but desired to leave nothing undone. Fortunately, the Doctor got a train immediately, and was here sooner than expected. I need scarcely say that after an examination of the case, together with the history of it, there was a perfect agiee- ment as to the course to be pursued. We proceeded to operate about 11 A. M., fifty-one days after the first operation. There was some anaesthesia already present from imperfect aeration of the blood. The Doctor, however, preferred chloroform as the , anaesthetic to be given. Patient took it slowly, of course, on account of the imperfect respiration, hence more was required to produce the desired effect, which was guarded and limited. I operated rapidly, being guided by the line of the previous incision. There was no hemorrhage to embarrass ; yet with all possible haste, the child had ceased to breathe before the tube was introduced. I quickly inserted it, had the feet ele- vated high, inflated the lungs through the tube several times, and thus restored respiration, which soon became regular. The secretion thrown out of the tube was mainly mucus. I took no notes of the case after this operation, for some weeks ; and there was nothing of special importance to require note in the recovery from this operation. Saw the patient daily for some time. Gave various forms of tonic treatment, cod liver oil, and substantial diet. Perhaps I should have re- marked that the voice was not affected in this latter difficulty or attack. In the latter part of May the respiration seemed to be entirely clear, with the tube in. June 20.—" Cannot sleep with the tube out if the opening REPORT ON DISEASES OF CHILDREN. 39 in the trachea is entirely covered and closed. The same diffi- culty as formerly exists with inspiration." July 5.—Began the local use of electricity and stimulating applications to the glottis. These were continued for some time, but with apparently not much benefit. During August and September the child was visiting in Iowa or Wisconsin. On his return I thought he seemed decidedly improved in gen- eral condition. On the way home, however, they stopped at Bloomington, and Dr. White had an opportunity of seeing him again. The Doctor suggested having a fenestra made in the tube, which I had done, with apparently some relief. This continued with little change, he being comparatively comfort- able and well otherwise, till November. At this latter date the tube was left out all night, I staying with him till after midnight. There was no special or considerable disturbance. The next day, November 3, the parents wanted the tube in again, not having expected to leave it out altogether. We found very considerable difficulty in re-introducing the tube ; indeed we found it impossible to introduce the same tube, which was of uniform diameter the entire length. I intro- duced a bit of sponge covered with a very thin piece of rubber tissue attached to a wire, and leaving that in an hour or more. I then introduced another tube, which had a gradually increas- ing diameter, the lower end being about the size of the other tube. The parents were fearful something might occur, and have kept it in, except to remove and cleanse it, until the present, September 25, 1878. OPINIONS OP THE JTJSTIFIABLENESS OF TRACHEOTOMY IN CROUP, DIPH- THERIA, OR OTHER DISEASES. Dr. Samuel D. Gross : " In diphtheria, as in croup, tracheotomy is seldom a successful operation, and still it is, in my judgment, in many cases a highly proper one. Even when it cannot save life it should often be performed to prevent impending asphyxia, and thus afford the patient a more easy mode of death." Erichsen : " It is as unpermissible for a surgeon to allow a patient to die of laryngeal asphyxia without an attempt at relief by opening the windpipe, even though life appear to be extinct, as it would be to let him 40 ILLINOIS STATE MEDICAL SOCIETY. die of hemorrhage without attempting to contract the bleeding vessel. In diphtheria, as in croup, tracheotomy may be performed when the pa- tient is in imminent danger of death from laryngeal obstruction.' Dr. Frank H. Hamilton : " Tracheotomy in diphtheria, under well-defined conditions, is no longer a question of doubt, but justifiable." Oertel: " Tracheotomy in diphtheria is indicated only when the local affection preponderates. " F. C. Skey: " We do not pretend to be governed by the presence of this or that form of disease, but by the pressure of symptoms, which, if imminent, demand artificial opening, to whatever class they belong or in whatever region they originate. * * With such symptoms [naming them], and with threatening suffocation, the surgeon has no alternative but that of operation [tracheotomy]." Wajwm : In the advanced stage of the disease [croup—acute lar- yngitis] medicine, I fear, can effect but little. But surgery may be more successful. * * This [tracheotomy] is one of the triumphs of the heal- ing art." " When the distinctive symptoms declare that the exudative disease [diphtheria] is present in the larynx, the question of tracheotomy is forced upon our attention. * * These two points ascertained [laryngeal exudation and advancing severity], the sooner the operation is clone the better." Aitken: " The evidence, however, is daily accumulating which shows that tracheotomy ought to be resorted to much of tener, as a remedy for croup, than it has been, and at a much earlier period of the disease; not as a last resort, when deaih from asphyxia appears imminent, and after treatment of the most depressing kind." Niemeyer: "However great the number of failures [in tracheoto- my], it is not admissible in any case not to undertake the operation if the other remedies do not give us results." Cohen: " That tracheotomy saves many croup patients from death, otherwise inevitable, and that, too, even under unfavorable circum- stances, there has long been no reason to doubt. * * The indication for the operation exists whenever it is apparent that death from suffoca- tion cannot be averted by any other means." Dr. Austin Flint.—His answer to the question is the same as his answer to the other question, "Are lives ever saved by it?" "Though the chances for success might be ever so small, the operation should not be withheld." Pilcher: " Tracheotomy is indicated in all cases of croup in which laryngeal stenosis becomes so great as to bi come an element of danger, either immediately, by rapid suffocation, or by a more gradual asphyxia." REPORT ON DISEASES OF CHILDREN. 41 Prof. H. A. Johnson: " Tracheotomy, or laryngotomy, should be performed in all cases of threatened asphyxia from causes which cannot be speedily removed by other methods, as, for instance, * * 4. Acute inflammation, simple or diphtheritic, producing so much obstruction to respiration as to materially diminish oxygenation of the blood." A. W. Barclay, St. George's Hospital: "Our chief resource for prompt relief to breathing is tracheotomy. Justifiable in diphtheria where the dyspnoea is so urgent as to throw other symptoms into the shade." Druit advises tracheotomy for threatened asphyxia from croup or diphtheria. K. G. Rogue : "Tracheotomy should be resorted to in all cases [membranous croup and diphtheritic croup the same] where death is threatened by suffocation from obstruction in the larynx, and as soon as the breathing has become insufficient to sustain the vital powers." Steiner.—Of tracheotomy he says : "No other means fulfill these indications [to establish a new provisional air-passage and assist nature in her efforts to cure] so certainly and so directly." Trousseau believes the operation should be made, no matter what degree of asphyxia has been reached. Mr. Spence : "The practitioner should not be discouraged by rea- son of repeated failures to save life by tracheotomy." Simon: "If, after using these [medical] means, the croupal affection progresses, the attacks of suffocation increase, if asphyxia commence, it is necessary to decide to perform tracheotomy. * * Tracheotomy re- mains mistress of the field for all cases of croup which the medical treat- ment cannot arrest." Fordyce Barker : "I have often found it necessary to recommend the operation in consultation, and have seen several cases of recovery after the operation." A. Jacobi: "Of its value I am convinced." E. W. Lee : "I think it ought to be done, no matter how desperate the condition." All these are among the latest and highest authorities on the subject. To multiply the number would be easy, but the sentiment would be the same. Hence, if authorities have any weight, if there is any argument in language, or evidence in facts, the justifiableness of tracheotomy in croup and the duty 42 ILLINOIS STATE MEDICAL SOCIETY. of the medical attendant to have the operation performed are demonstrated propositions in medical science to-day. For further particulars of the operation, the after-treatment, the accidents in the operation and subsequently, etc., etc., see the full report. I have given the detailed case somewhat fully because it covers most of the points in a majority of the cases, and many not in ordinary cases. CONCLUSIONS. 1. Membranous croup is not necessarily a fatal disease, ex- cept in the epidemic form. 2. Its essential nature is, in the vast majority of cases, iden- tical with that of diphtheria, though the means at our com- mand, as thus far applied, are not sufficient to demonstrate this proposition. 3. The general treatment of diptheria, so far as applicable to croup, gives better average results than when the latter is treated as simply an acute inflammation. 4. The treatment most generally approved and giving the best results is : (1) emetics having the properties of prompt- ness and efficiency, without producing depression of the sy*tem, turpeth mineral and ipecac being preferred; (2) tonics and disinfectant remedies, viz.: tinct. chloride of iron, and the chlorates of the alkalies, in full and frequent doses, and the same classes of remedies applied to any visible manifestation of the disease; (3) the local application of steam by inhala- tion, or the vapor from slacking lime, or the spray of freshly prepared lime water. Treat the fever and remissions respec- tively with veratrum and quinine. 5. Support the vital forces by an easily digested, nutritious diet. 6. Treat complications according to their general nature. 7. Tracheotomy is an established operation for all cases ol REPORT ON DISEASES OF CHILDREN. 43 " croup " not amenable to medical treatment, in which laryn- geal stenosis is the chief, or one of the chief, element^ of danger. 8. The operation should be resorted to in the latter part of the second stage, or early in the third; the earlier the opera- tion the larger will be the per cent, of recoveries. 9. The only contra-indications to the operation are, (1) generalized diphtheria, which must, then, be of severe degree, and be largely the cause of the predominant symptoms, and (2) clot in the heart. " It is never too late to operate while the child is not positively dead." (Archambault.) 10. The obligation resting on the physician to give the patient the benefit of the operation is imperative. He may not withhold it directly nor indirectly; the patient or the friends may forbid it, and thus relieve the physician. 11. The operation should be performed deliberately and carefully; exceptions, when the emergency is great, and cessa- sation of respiration about to occur, or having occurred. 12. The trachea should be thoroughly exposed before any attempt is made to open it. Exceptions as above. Opening the trachea with a stab is a dangerous procedure. The trachea should be cleared of obstructions with the tracheotomy forceps, or with the suction tube, before the introduction of the canula. 13. The ordinary silver double canula, moveable in all directions in the plate, is the best for general purposes. 14. The inner canula should be removed frequently, and both should be removed, cleaned, and the trachea cleared as 44 ILLINOIS STATE MEDICAL SOCIETY. often as, and whenever the emergency from obstruction de- mands. 15. The patient should not be left for the first forty-eight hours without an attendant competent to remove the tubes and any removable obstructions. 16. The canula should be permanently removed as soon as practicable. 17. Many patients are lost from a want, of proper after- treatment. 18. Every practising physician should be prepared to per- form the operation, or to have it done, whenever needed. 19. An anaesthetic should not be given if there exist suffi- cient asphyxia to produce appreciable anaesthesia; and when- ever given it should be done with the utmost caution. 20. A careful watch should be instituted and continued for some days or weeks, for the accidents of local or general par- alysis. • fv vi*' .'^ ^-■-•?- ,. v.- * £ ■-.. - fcv.C