introduction of the canula, the after-treatment of the case now becomes
the important consideration. This naturally varies in accordance with
the accident or disease which has rendered the opening of the trachea
necessary. In the instance of a foreign body lodged in either larynx or
trachea the tube may at once be removed as soon as the former is
removed or expelled. Indeed, the introduction of the tube is often
unnecessary, as the offending article flies out through the wound as
soon as the trachea is opened. The only contraindication would be to
this rule when the foreign body is of a sharp and irritating character,
and has been impacted in the larynx, especially of a child, and
consequent inflammation and swelling of the parts may confidently be
looked for. Should the operation have been called for on account of
laryngeal or tracheal obstruction due to syphilis, both constitutional
and local treatment are indicated, the latter varying with the special
conditions presented, and being fully described in the section of this
work treating of that subject. The patient not infrequently is obliged
to wear the tracheal tube permanently. In croup and diphtheria the
first efforts of the surgeon after introduction of the tube should be
directed toward the removal of such shreds of the membrane as present
through the tube or may be reached by forceps introduced through it
into the air-passage. Large quantities may thus often be gotten away,
to the manifest relief of the patient. A pseudo-membrane covering the
vocal cords and causing glottic stenosis has thus also more than once
been removed through the wound. A feather carefully passed through the
tube into the trachea, by exciting cough and through its mechanical
effects, is of assistance in promoting the expulsion of membrane lodged
in the trachea below the wound. The use of an elastic catheter and
aspirating syringe for the same purpose is advised by Roux and Hueter.
In any case, constitutional treatment as well is indicated, and other
measures--viz. the inhalation of steam, direct local applications, and
the like--such as may meet the views of the particular operator.
Granted that the operation has been performed to meet the indication in
cases of sudden and urgent dyspnoea arising from the passage of blood
into the trachea or the accumulation of serous fluids in the lower
air-passages, as well as in cases of dangerous intoxication from the
effects of poisonous gases and narcotics, aspiration of the trachea in
the former instances, followed by artificial respiration in all, and
perhaps the catheterization of the trachea in the latter, as advised by
several recent writers, will tax the surgeon's energies as the primary
consideration after his operation. The catheter may be first used for
the purpose of aspiration in the former cases, if {160} necessary, then
for the injection of air, it here taking the place of the natural upper
air-passages.
In cases of acute laryngeal oedema, certain chronic inflammatory
processes, neoplasms in the larynx or trachea, and injuries or wounds
of the air-passages, the proper treatment, aside from that of the
necessary tracheotomy, will suggest itself on ordinary surgical
principles, or is elsewhere specially treated of in this work in
connection with the subjects themselves.
Aside from these special indications for after-treatment, which must be
met as they arise, there are certain general rules for the management
of any case after the tracheotomy-tube has once been inserted: they
relate mainly to the care of the patient, the dressing of the wound,
and the care of the canula.
A variable period of intense and exhausting suffering from dyspnoea
having probably preceded the operation, the sooner the patient is
allowed to seek refreshing sleep the better; and this may be allowed if
there be no danger of hemorrhage. Nourishment of a fluid character and
stimulants, if necessary, are to be allowed in quantities and at times
dictated by good judgment. The patient's first attempts at swallowing
must be watched and directed, as the fluids frequently pass in part for
a short time into the larynx, and may appear at the tracheal wound. If
the condition persist, it may be, no other apparent cause existing,
because the tracheal tube is too long and presses on the posterior wall
of the trachea, thus interfering with deglutition. For the first day or
two at least a competent nurse must be in attendance, and the care of
the tube entrusted, after explicit directions, to her. For the first
twenty-four hours the secretions usually need to be constantly cleared
from the mouth of the inner tube as they are coughed up by the patient,
and the tube itself occasionally removed and thoroughly cleaned in
carbolized water (or water to which a little borax or potash has been
added) by means of a bristle brush, such as is used for cleaning pipes.
As the case progresses, the secretions are not as profuse or annoying,
and the patient learns to assist himself, in caring for his tube and to
remove and replace the inner one. Attempts at using the voice are to be
abstained from, and a slate or pencil and paper used until, if the case
progress favorably, the third day, when he may be shown how to produce
it by closing the outer fenestrated tube (the inner being removed) with
the finger. The outer tube does not require usually to be removed,
except in diphtheria, for cleansing until the third or the fourth day,
prior to this it being done by means of a feather. The removal of the
tube should always be done by the surgeon himself, and the occasional
danger of its difficult reintroduction, caused by the swelling of the
parts, not forgotten. At the same date, the wound sutures may be cut
and removed. After its first removal the outer tube is taken out,
cleansed, and replaced at each daily dressing, which consists in the
washing of the wound with carbolized solutions, the application of
adhesive strips, if necessary, across it after the sutures have been
removed, and the insertion between the neck-plate or collar of the
tracheotomy-tube and the skin, upon which it presses, of a layer of
sheet lint covered by a little simple cerate or like dressing. The
tapes attached to the canula for fastening it about the neck need
changing, and care must be taken to regulate each day their degree of
tension about the neck in proportion to the amount of inflammatory
swelling attendant upon the wound through the soft parts overlying the
trachea.
The patient, during, especially, the first few days after the opening
into the trachea has been made, should be kept in a well-ventilated
room with a uniform temperature. There is rarely any occasion, except
in cases of croup and diphtheria, when it may be advisable, to envelop
him in steam. Some surgeons place a small wad, two or three layers of
gauze, wrung out frequently in hot water, over the mouth of the tube
for the first day or two. A {161} large, coarse sponge answers the same
purpose; and the precaution seems to me to be a good one, preventing,
as it does, air of a low temperature from entering the lungs, and
rendering it moist and free from adventitious particles. The difficulty
is in keeping it in place.
The question as to the final removal of the canula is a difficult one
to answer here, depending as it does upon the various causes for which
the operation was originally performed. In certain cases, as will be
seen from what has been said, its sojourn in the trachea will only be
from a few moments to a few hours; while, on the other hand, in cases,
for instance, of severe syphilitic disease of the larynx, with
cicatricial stenosis of its cavity, the tube, once introduced, has to
be worn during the lifetime of the patient. Between these extreme
limits the period varies greatly. As a general rule--perhaps from the
fourth or fifth day to the end of the first week--an attempt to cause
the patient to breathe through the natural passages, the outer end of
the outer fenestrated tracheal tube being closed, will partially
succeed. Each day will now make success greater; the voice in part
returns, and a period is soon reached when the outer tube may be closed
with a cork (at first during the daytime only) and respiration carried
on entirely through the larynx. The speedy removal of the tube and the
closure of the tracheal wound then follow as a matter of course. I have
never found it necessary to employ any of the various forms of
after-treatment canulas, and believe them to be unnecessary. The
original tube, preferably a fenestrated one, as heretofore described,
is to be worn until convalescence is established, then permanently
withdrawn.
The tube should be removed at the earliest safe and practicable moment.
Its lengthened sojourn is not devoid of danger, as will be shown; and
an atrophy of the laryngeal muscles, especially the abductors of the
vocal cords, may follow their prolonged disuse, or at least inactivity,
thus giving rise to a narrowing of the glottic opening perhaps
inconsistent with respiration.
The wound, covered by granulation-tissue if the tracheotomy-tube has
been worn for any length of time, quickly closes, when the latter is
removed, and needs to ensure this but a few narrow strips of adhesive
plaster to be passed across it and attached to the side of the neck, to
prevent the air being forced out through it during the first day or two
when the patient coughs or attempts to speak.
In cases where the tube has been worn for a long period, and the edges
of the opening have firmly cicatrized, their freshening by the knife or
scissors is a necessary preliminary to their being brought together by
means of a suture or two.
The wound in the trachea closes not by the formation of a
cartilaginous, but rather of a dense connective tissue, and the
cicatrix is so smooth and small as to be with difficulty discernible.
The cicatrix remaining externally upon the neck need be but slight and
linear, and cause no disfigurement, especially if the wound have been
properly treated and watched during the healing process.
Among the complications and accidents which may occur after a
tracheotomy successfully performed,[5] none is commoner, and none,
perhaps, is more to be feared, than the broncho-pneumonia which may
develop at any time within the first three or four days, and especially
in those cases where the operation has been rendered necessary by a
diphtheritic inflammation of the throat or air-passages. Bronchitis is
common when much blood has escaped into the trachea during the
operation. The periodical and careful auscultation of the chest is
therefore desirable, in order that the earliest physical signs of these
morbid conditions may be detected.
[Footnote 5: See Parker, "On Some Complications of Tracheotomy, with
Illustrative Cases," _Lancet_, Jan. 24, Jan. 31, and Feb. 7, 1885.]
{162} Secondary hemorrhage is rare: should it occur, the wound must be
opened, enlarged if necessary, and the bleeding vessel sought for and
secured. A slight hemorrhage may be checked by pressing the parts
firmly about the tracheal tube and the use of styptics locally.
When the pathological condition of the parts has demanded that the
canula be worn for a long time, and in cases where sufficient care has
not been taken to select one suited to the age of the patient or to the
particular form of operation that has been chosen, perhaps to the needs
of the special case, an ulceration of the anterior or posterior wall of
the trachea, the result of the pressure of the lower edge of the tube
or of its upper posterior and convex side, may occur. Usually, it
happens on the anterior wall, rarely on both, and the main trouble to
which they give rise lies in the repeated hemorrhages that proceed from
the laceration of granulation-tissue, in changing the canula, for
instance, and the descent of the blood into the trachea and lungs.
Cases of extensive ulceration, with erosion of the large vessels at the
root of the neck, and fatal hemorrhage, have been reported.
Considerable care should then be exercised in so adapting a canula to a
special case that it will lie as free as possible within the lumen of
the trachea. Ulceration of the tracheal walls, it is claimed, never
occurs with the right-angled canula of Durham. Occasional change of
form in the canula or the use of canulas with rounded extremities
(perforated with numerous slits) is often advisable when the tube is
worn for a length of time.
Another complication following the prolonged sojourn of a tracheal
tube--rare, it is true--is the development of a mass of
granulation-tissue, a veritable tumor, which may occlude the lumen of
the trachea and lead to serious disturbances of respiration. The growth
usually occurs about the inner edges of the tracheal wound, extending
thence inward and upward or downward, as the case may be, and is most
frequently met with, perhaps, after tracheotomies undertaken for
diphtheria, although it may occur as a result of the ulcerations
mentioned above, and develop even from the cicatrix in an old and
perfectly-closed tracheotomy wound. The size of the mass, its location,
and the amount and manner of its interference with the respiratory
current vary much, but the condition must ever be regarded as a
troublesome, even dangerous, one, and may always be suspected when
attempts at the removal of the canula temporarily or permanently are
followed by sudden and urgent dyspnoea.
The exuberant granulation-tissue which forms about the outer edges of
even a recent tracheotomy wound, and occasionally renders the
reintroduction of the tube difficult, as well as closing the wound
while it is out, is a much simpler matter, and is easily remedied by
cutting it away with the scissors or checking its formation by caustic
applications.
A subcutaneous emphysema not infrequently occurs as the result of poor
surgery and delay at the time of introducing the tube into the
windpipe, or may come on later when the tube fits the tracheal wound
incompletely. In either case it need excite no apprehension, and
usually quickly subsides. Cervical cellulitis is a more serious matter,
but is fortunately rare if unconnected with disease of the cartilages
of larynx or trachea. It probably depends upon injury to the tissues
and a too extensive opening up of the intermuscular strata at the time
of the operation. Should the complication arise, the tendency to the
burrowing of pus must be prevented by free drainage and, if necessary,
incisions. The other surgical indications are to be treated on general
principles.
When the incision necessary for the introduction of a tracheotomy-tube
has been made through healthy tissue, necrosis of the cartilage in
contact with the tube belongs to the rarest of the complications of the
operation. The simple traumatic perichondritis set up by the operation
shows no tendency to {163} eventuate in death of the parts. Equally
rare is cicatricial contraction of the trachea as the direct result of
the operation. That it may follow the healing of the extensive defects
sometimes left by the syphilitic and other processes can readily be
understood; and the same defects, involving as they occasionally do the
loss of large amounts of tissue and destruction of important parts, may
eventuate in the formation of an aërial fistula during or after the
healing process is completed. The occurrence of such a fistulous
opening as the result of a simple and uncomplicated tracheotomy wound
could only be regarded as the evidence of unskilful surgery and
after-treatment. The various plastic operations undertaken for the
repair of such defects are described in the works on general surgery,
notably in the able monograph of Schüller. Dislodgment of the canula
out of the trachea as the result of an insufficiently long tube, or of
neglect to fasten the tapes which hold it properly about the neck, so
that it slips during coughing or the movements of the patient, is an
accident which may not for the moment attract the attention of an
inexperienced surgeon unless laryngeal dyspnoea is urgent. The patient
breathes quietly, the air passing by the sides of the tube, which
apparently is correctly placed. The simple test of ascertaining whether
air be passing through the canula or not, or of making a trial whether
the patient breathe as well when the finger closes the opening of the
outer tube, as he will do if the tube is out of the trachea, will
decide the question. Should the tube have slipped, it is of course at
once to be replaced.
The breaking off of a portion of the inner canula, and the terminal
piece falling down the trachea--several instances of which have been
reported during recent years--is more apt to happen with the
right-angled canula of Durham, the inner tube of which is necessarily
made up of segments held by small rivets: these become in time loosened
and the piece that they held detached. The outer tube of the
hard-rubber canula also has become detached from its collar and dropped
into the trachea. An occasional inspection of the condition of the tube
is therefore desirable.
{164}
DISEASES OF THE BRONCHI.
BRONCHITIS, ACUTE AND CHRONIC; CATARRHAL; MECHANICAL; CAPILLARY; AND
PSEUDO-MEMBRANOUS.
BY N. S. DAVIS, M.D., LL.D.
DEFINITION.--Inflammation of some part or of the whole of the mucous
membrane lining the bronchial tubes between the bifurcation of the
trachea and the alveoli or air-cells of the lungs. The inflammation may
vary in grade from simple hyperæmia, with increased irritability, to
the most intense engorgement, exudation, and tumefaction of the
membrane, and in activity from the most acute and rapidly-progressive
to the most chronic and protracted in duration.
SYNONYMS.--By the earlier writers the disease was called Peri-pneumonia
notha, Angina bronchialis, and sometimes Erysipelas pulmonis. More
recently it has been called Catarrhus suffocativus, Catarrhus
pituitosus, Catarrhus bronchialis, Bronchial catarrh, and Bronchitis;
_Fr._ Bronchite; _Ger._ Bronchialentzundung. Adopting the simple name
of bronchitis, acute and chronic, in the further consideration of the
subject I shall group the cases as they occur in general practice under
the heads of Catarrhal, Mechanical, Capillary, and Pseudo-membranous
Bronchitis.
HISTORY.--During all the earlier periods of medical history bronchitis
was generally confounded with inflammation of the membrane lining the
larynx and trachea on the one side, and with pneumonia and pulmonary
phthisis on the other. Among the earliest writers who gave more
accurate descriptions of bronchitis as a distinct disease were Badham,
J. P. Frank, and Broussais, in the latter part of the eighteenth
century. Full and accurate descriptions of the disease, differentiating
it from inflammation of other parts of the respiratory organs, were not
given, however, until the discovery of auscultation by Laennec, and its
practical application aided by percussion to the physical examination
of the chest. This important addition to the previous means for
studying the exact location and extent of all diseases within the
chest, and the largely increased attention given about the same time to
the study of morbid anatomy, soon led to as accurate an appreciation of
the existence and extent of disease in any part of the organs of
respiration and circulation as in any of the structures of the human
body.
ETIOLOGY.--The causes of bronchitis, like those of all other acute
diseases, may be divided into two classes--namely, predisposing and
exciting. The first embraces all those influences that are capable of
rendering the mucous membrane of the air-passages more susceptible to
impressions, whether by direct increase of the irritability of the
structure or indirectly by altering the quality of the blood and the
tone of the smaller blood-vessels. The second embraces such influences
only as are capable of exciting a direct increase of irritability of
the lining membrane of the bronchial tubes, with congestion of {165}
blood in its capillaries. Among the most common predisposing causes may
be mentioned age, sex, occupation or modes of life, and climatic
influences. As a general rule, the several grades of bronchitis are
more prevalent during childhood and old age than during the active
period of adult life. The British Registrar-General's Report for 1868
contained 33,258 deaths attributed to bronchitis, being 1344 for every
million of inhabitants. Of the whole number, 10,550 died during the
first three years of life, and 18,485 over forty-five years of age,
leaving only 4223 to occur between the ages of three and forty-five
years. This, however, is very far from indicating correctly the
relative prevalence of the disease at the different periods of life,
for the reason that the disease is far more fatal both in early life
and in old age than in the early and middle periods of adult life.[1]
During the months of February, March, and April, 1882, in San
Francisco, there were 65 deaths reported from bronchitis, of which 37
were of children under five years of age, 25 adults over forty years,
and only 3 persons between five and forty years. During the same months
there were reported 154 deaths from bronchitis in the city of Chicago,
with about the same ratio in regard to age. In the city of
Philadelphia, during the seven years from 1862 to 1869, the deaths from
bronchitis at all periods of life aggregated 969, of which 495 were of
children under five years of age, 14 over five and under fifteen years,
and 460 of persons over fifteen years of age.[2] These and similar
mortuary statistics have led to the very general adoption of the
opinion that early childhood and old age are pre-eminently susceptible
to attacks of bronchitis. Yet my own clinical observations and records
relating to the time and number of acute and subacute cases of
bronchitis coming under my own care lead to a very different
conclusion. By reference to those records I find a larger number of
cases occurring between the ages of ten and thirty years than at any
other period of life. Thus, during the first six months of the present
year (1882) I recorded 59 cases of primary bronchitis; that is, cases
not arising secondarily as complications of other diseases. Of this
number, only 5 were children under ten years of age, 38 between ten and
thirty years, and 16 over forty. It is probable that similar results
will be obtained by all who will take the trouble to record the whole
number of cases, instead of simply the number of deaths. The statistics
of mortality in relation to this disease are deceptive, not only in
regard to relative susceptibility of the human system to attacks at the
different periods of life, but also in regard to the ratio of mortality
of the disease itself. It is generally conceded that the chief
mortality from this disease occurs during infancy or early childhood
and in old age, cases rarely terminating fatally in youth or the more
active period of adult life. Careful examination of cases will show
that this fatality at the extremes of life is owing mainly to the
greater tendency of the inflammation at those periods to extend
directly from the bronchioles into the lobules of the lungs, thereby
complicating the bronchitis with lobular pneumonia; and in more than
half the cases reported under the head of bronchitis the fatal result
was caused by the pneumonia instead of the bronchitis.
[Footnote 1: See _Reynolds's System of Medicine_, Amer. ed., vol. ii.
p. 318.]
[Footnote 2: See _A Practical Treatise on the Diseases of Children_, by
J. F. Meigs, M.D., and William Pepper, M.D., 4th ed., p. 189.]
Neither recorded facts nor my own clinical observations show any
decided difference in the susceptibility of the sexes to attacks of
bronchial inflammation.