After a few days, when fresh membrane has ceased to be formed, we may make trial from time to time of the child's power of breathing through the glottis by closing the external wound with a finger. At first the breathing is laboured, especially in inspiration, but in most cases the glottis soon becomes accustomed to act again as an air-passage.
While the above treatment is being carried out, the strength of the child must be supported by judicious feeding. Strong meat essence, pounded meat, eggs, milk, strong meat broths thickened with arrowroot or sago, and flavoured if desired with turnip, should be given at regular intervals. Sometimes there is difficulty in persuading the child willingly to take sufficient nourishment ; and sometimes the power of swallowing is impaired from paresis of the muscles of the pharynx. Sometimes, also, there appears to be loss of sensibility of the glottis, so that articles of food taken appear at the wound in the air-pipe. If necessary, therefore, food must be conveyed to the stomach by an elastic tube passing through the nose (see Introductory Chapter, page 15). By this means the patient can be fed efficiently every three or four hours. Internal remedies, with the exception of alcohol, are better discontinued at this time. It is wiser to limit ourselves to the local measures which have been described for the relief of the local disease, and to trust to regular feeding and alcohol to support the strength of the patient and enable him to struggle successful ly against the constitutional disorder.
The tracheotomy tube should not be allowed to remain in the trachea a day longer than is necessary ; for besides that it is not well to allow the glottis to continue a long time inactive, too persistent retention of the tube may be followed by ulceration about the wound, necrosis of the rings of the trachea, and other accidents. In finally closing the wound certain dif ficulties are sometimes met with. The child having become accustomed to the use of the tube, and having a keen recollection of his sufferings before its insertion, is often nervous and apprehensive of a return of his clyspncea. This very dread may be sufficient to interfere with the normal action of the laryngeal muscles. Before removing the tube altogether many at tempts should be made, by withdrawing it temporarily and closing the opening with a pad of lint, to accustom the child to -breathe without its help. He should be also made to articulate under the same conditions (i. e. , while the opening is closed), so as to bring the muscles of his larynx again into action.
The accidents which often interfere seriously with the final withdrawal of the tube are : inflammatory hypertrophy of the vocal cords, adhesion between the cords, granulations growing from the tracheal wound or from the posterior wall of the windpipe, paralysis of the posterior crico arytasnoid muscles, spasm of the glottis, cicatricial narrowing of the trachea.
Sometimes it is only after much difficulty that the proper function of the disused larynx is restored. Such cases are, however, exceptional. Usually after a few days the child becomes accustomed to do without the help of the tube and all apprehensions of a return of his clyspncea may be laid aside.
The chief danger and common cause of death after tracheotomy in membranous croup is the occurrence of pneumonia. If this unfortunate complication arise, warm poultices must be kept constantly applied to the chest, and stimulants must be given freely.
If diphtheria of the external wound occur, it is best treated by a care ful attention to cleanliness, and by painting the wound with a solution of lactic acid (twenty-four grains to the ounce).
In the paralysis which often follows diphtheria the child should be re moved to a bracing sea-side residence, and while there should be regularly shampooed and be given baths of the sea-water. If a clip in the sea is too vigorous a shock for his weakened frame, the douche may be employed in the house after suitable preparation, as directed elsewhere (see Introductory Chapter, page 17). Quinine, iron, and strychnia are useful in these cases, and the child should pass as much time as possible out of doors. Regular faradisation is of service, especially in cases where the loss of power affects the muscles of the larynx or those employed in respiration. In cases where there is complete paralysis of the muscles of deglutition, and consequent inability to swallow, the child must be fed regularly with the stomach-tube passed through the nose. At the East London Children's Hospital many children have been saved by this means who were quite unable to take nourishment, and who without this help would certainly have died of in anition.
When a thrombus forms in the heart and gives ries to serious dyspncea, the child should be kept lying down ; hot bottles should be applied to his feet and if necessary to his sides ; and diffusible stimulants must be given internally. Dr. Richardson speaks highly of the liq. ammonim (P. B.), of which a few drops may be given with five grains of iodide of potassium every alternate holm If the heart's action appear to be failing, stimulants in large and repeated doses are indicated.