Tracheotomy may be required in the absence of a surgeon, and every physician should be familiar with the steps of the operation, since he may find himself in an emergency responsible for the life of a patient gasping from a remediable obstruction of the larynx. The operation known as " high " tracheotomy or crico-tracheotomy is always selected.
Chloroform anaesthesia of mild degree will be necessary unless the patient be asphyxiated completely; in adults local anesthesia is often quite sufficient. The head being extended by placing a small hard pillow or bolster at the back of the neck, a median incision is made from the lower margin of the cricoid cartilage downwards for about s to 2 inches,dividing the septum between the sterno-hyoid muscles, any bleeding veins being clamped, and the thyroid isthmus being drawn down or divided the trachea is exposed. By fixing a sharp hook into the tissues at the lower edge of the cricoid the larynx is steadied for the scalpel, which is thrust into the lumen of the trachea with its cutting edge upwards, and the two uppermost rings of the trachea are then divided; usually in small patients it is advisable to sever the cricoid cartilage as well.
The trachea dilator is introduced between the lips of the slit in the tube and any membrane present gently removed by forceps, after which a proper-sized tracheotomy tube is inserted, the outer sheath or canula of which is to be fixed by tapes passed round the neck, the inner tube being kept free for frequent removal and cleansing. The skin wound is to he treated on ordinary surgical principles—viz., by dusting with Iodol and covering its margins by antiseptic gauze lightly inserted under the collar of the canula.
The after-treatment will consist in the keeping of the inner tube clear and free from obstruction; the temperature of the sick-room should never he allowed to fall below F. and the steam always be kept going; a further dose of antitoxin should be administered after the operation unless one had been administered a short time before, and all feeding should be by the spoon.
Intubation requires no anesthesia and can be rapidly performed. O'Dwyer's or preferably the shorter Bayeux's instrument should be used. The operation may be performed most readily when the patient is placed upon his back ; the tube with its obturator or pilot on the end of the intro ducer is passed into the orifice of the larynx guided by the left forefinger of the surgeon introduced through the gagged mouth beyond the base of the tongue, and the finger must be kept in this position to steady the tube before the pilot and introducer are withdrawn.
After either operation the tubes should be removed as soon as the ,symptoms abate to the extent of restoring the free passage of air through the normal channel; if the O'Dwyer's tube he kept in beyond a few days there is danger of a permanent stenosis of the larynx following. After intubation the child should he fed by the nasal tube to prevent the food entering the lungs through the patent larynx. O'Dwyer's tube can be removed by pressure over the trachea and sudden flexure of the extended head with the mouth wide open, hut when this fails it must be removed by the introducer.
In great emergency where the necessary instruments are not at hand an attempt may be made to prevent suffocation by passing into the trachea a large-eyed, gum elastic catheter or a small stomach-pump tube, of the same material having a terminal aperture.
Tracheal or Tracheobronchial Diphtheria is a grave affection, owing to the almost certainty of pulmonary obstruction and collapse. Lynah effects mechanical removal of the membrane by the use of a suction tube introduced through the larynx and connected with a vacuum and spraying pump. After sucking up the obstructive membranes the interior of the trachea and bronchi are sprayed freely with Antitoxin and a long tube is left in situ for 3 days.
Nasal Diphtheria is rarely an isolated condition, and is easily treated on the same lines as the faucial, by antitoxin injections and the free use of the carbolic spray.
The treatment of Diphtheria of the Conjunctiva is described under Conjunctivitis.
In the convalescent stage, even in mild cases of diphtheria, rest in the horizontal position must be maintained as long as there is any symptom of cardiac weakness; the pulse should be frequently investigated, and the temperature of the extremities watched carefully in infants; the patient's clothing must be warm, and generous feeding at short intervals should he strictly enforced even by the nasal tube should paralysis of the throat prevent swallowing. Iron tonics with Quinine or Strychnine should be administered as a routine till perfect health is restored.
The complications and sequelx of diphtheria are to be treated upon general principles, always remembering that the main reliance is to be placed upon early large, and repeated smaller doses of the specific anti toxin. Broncho-pneumonia and bronchitis must he treated by appro priate remedies, but tartar emetic and nauseating expectorants must be sparingly used, if at all, in a disease characterised by debility and cardiac weakness. Ammonia is the safest agent in such cases; stimulants- brandy or whiskey in the milk, or wine whey—will be generally freely indi cated. Cardiac failure, as already stated, should be promptly met by Strychnine hypodermically and prolonged rest. Albuminuria in the early stage requires no interference, that following later must be treated upon the principles laid down for guidance in Acute Bright's Disease.
Symptoms of Acidosis must be met by the prompt use of Alkaline serum intravenously or subcutaneously.
Scarlatina' Diphtheria, contrary to what might be expected, is usually controlled by the antitoxin treatment, and as a prophylactic measure when a case of diphtheria appears amongst the inmates of the scarlatina wards an antitoxin injection of 2,00o units should be administered to each patient within the zone of infection. In the treatment of diphtheria with profuse fetid discharge from the nose and throat in scarlatinal patients the injection of the antitoxin should be accompanied by a dose of so c.c. of a Polyvalent Antistreptococcic Serum. The same treatment is clearly indicated in all diphtherial cases occurring independent of scarlatina when the purulent nasal or throat discharge is profuse and fetid.
For the treatment of the paralysis which follows diphtheria, see under Paralysis.