TRACHEOTOMY IN DIPHTHERITIC CROUP. 
-BY- 
H. R. WHARTON, M. E>., 
Surgeon to the Children's Hospital, Demonstrator of Clinical Surgery in the 
University of Pennsylvania, Assistant Surgeon to the Hospital 
of the University of Pennsylvania. 
[from the Proceedings oj the Philadelphia County Medical Society.] TRACHEOTOMY IN DIPHTHERITIC CROUP. 
-BY- 
H. R. WHARTON, M. D., 
Surgeon to the Children's Hospital, Demonstrator of Clinical Surgery in the 
University of Pennsylvania, Assistant Surgeon to the Hospital 
of the University of Pennsylvania. [Reprinted from the Proceedings of the Philadelphia County Medical Society.} 
TRACHEOTOMY IN DIPHTHERITIC CROUP. 
Read January 21, 1885. 
BY H. R. WHARTON, M. D. 
Surgeon to the Children's Hospital, Demonstrator of Clinieal Surgery in the University 
of Pennsylvania, Assistant Surgeon to the Hospital of the University of Pennsylvania. 
IN the following paper I desire to record briefly the histories of 
five cases of tracheotomy, performed for the relief of respir- 
atory obstruction consequent upon diphtheria, and to make some 
remarks upon the operation in this affection:- 
Case I. -On April 15, 1882, I was called to see James D , aged 
years, an inmate of the Southern Home for Destitute Children, who at the 
time was under the care of Dr. Samuel F. Hazlehurst. The patient was 
convalescing from an attack of measles, when he suddenly developed 
marked croupous symptoms. When I saw the case, the symptoms of 
laryngeal obstruction be'ng very urgent, it was decided to perform trache- 
otomy at once. Ether was administered, and the trachea was opened 
below the isthmus of the thyroid gland, and a ti acheotomy tube introduced 
without difficulty ; the child experienced immediate relief from his extreme 
dyspnoea, the respiratory movements becoming quiet and natural. The 
day after the operation, the case was doing well, but it was ol served that 
the lymphatic glands below the jaw were much enlarged, and that an exu- 
dation had appeared upon the surface of the w ound in the neighborhood of 
the tube. On the third day, symptoms of respiratory obstruction again 
appeared, the tube was withdrawn, and attempts were made to remove the 
exudation from the trachea without success ; the tuhe was then replaced, 
but the child grew gradually worse and died some hours later, with symp- 
toms of increasing dyspnoea. Cask II.-On April 30, I was called to see Ella M , aged 5 years, an 
inmate of the same institution, under the care of Dr. Hazlehurst. The 
history of this child, prior to the operation, closely resembled that of the 
preceding case. When I saw her, she presented marked symptoms of laryn- 
geal obstruction, but, unfortunately, in this case much delay was experienced 
in procuring a tracheotomy tube, and when this was finally obtained the 
child was markedly cyanosed, very restless, and presented all the symptoms 
of dyspnoea in a most aggravated form. 
She was put upon the table, and a small amount of ether was adminis- 
tered, and the incision was made, but before the trachea could be exposed, 
the respiration suddenly ceased, and the pulse failed. The trachea was 
then hurriedly opened, and in doing this some of the thyroid veins were 
wounded and bled profusely; the tube was introduced and artificial respi- 
ration was practiced for some minutes, but the respiratory action could not 
be re-established. 
In this case I think I ei red in two respects ; first, in not performing the 
operation sooner-I should have opened the trachea, and depended upon 
keeping it patulous by means of retractors or sutures introduced through 
the edges of the trachea, until I could have obtained a tracheotomy tube ; 
and secondly, in administering ether where the respiratory action was 
already so much embarrassed. 
Cask III.-On May 12, 1882, I was called to see Eddie M , aged 2 
years, an inmate of the same institution, who was, a few days before I saw 
him, attacked with diphtheria, which was followed by symptoms of laryn- 
geal obstruction. When I saw this case, the respiratory obstruction was 
very maiked, and the condition of the lungs seemed to indicate an involve- 
ment of the parts below the seat of the proposed operation. 
Prof. Ashhurst, who kindly saw the case with me, thought it justifiable 
to open the trachea. The operation was accordingly done and a tube intro- 
duced, and the child obtained immediate relief from the urgent symptoms 
which he had previously presented, the respiration soon becoming quiet 
and natural. The child's condition for the next few days was very favor- 
able, but at the end of a week it was noticed that fluids taken into the 
mouth escaped in part from the tracheotomy tube ; this condition gradually 
improved, and on the fifteenth day after the operation the tube was perma- 
nently removed, and a week later the wound was entirely healed. A short 
time after this date, the child began to exhibit signs of paralysis, and one 
morning, three weeks after the wound had entirely healed, in rising from 
his bed he fell suddenly backwards, and when the nurse reached his side she 
found him dead. 
Case IV.-Mary Rischer, aged 6 years, born in Germany, was admitted 
to the Children's Hospital on tbe afternoon of June 11, 1883, with symptoms 
of dyspnoea, complicating an attack of diphtheria. Her condition at the 
time of admission was not threatening, and upon consultation with Dr. 
Morris Lewis, who at the time was on duty in the medical wards of the 
hospital, we decided to await the development of more urgent symptoms 
before resorting to tracheotomy, especially as the case could be under con- 
TRACHEOTOMY IN DIPHTHERITIC CROUP. 
125 126 
PHILADELPHIA COUNTY MEDICAL SOCIETY. 
stant medical observation. During the succeeding night the symptoms of 
dyspnoea became so marked that I was summoned, and, as the child's con- 
dition had become very critical, with the assistance of Dr. Lewis and the 
resident physician, who administered a small amount of ether, I opened the 
trachea below the isthmus of the thyroid gland and intioduced a trache- 
otomy tube ; no trouble was experienced from hemorrhage, one small venous 
trunk only requiring a ligature. 
After the introduction cf the tube the child's color rapidly improved and 
the respiration soon became natural. 
The improvement in this case was rapid and continuous, and the temper- 
ature had become nor mal by the eighth day after the operation, and the 
wound had granulated as far as the sides of the tube. The tube was 
removed at intervals and the child was allowed to breathe through the 
wound and mouth. 
On the thirteenth day I removed the tube permanently, as the child 
appeared to breathe well through the natural passages. Two hour s after its 
removal, while speaking, the child was suddenly seized with symptoms of 
respiratory obstruction, and, owing to the contraction which had occurr ed 
j n the wound, some delay occurred in the re-introduction of the tube, and 
the child rapidly perished. 
Case V.-Edwin W , aged 21 years, was admitted to the Children's 
Hospital on the morning of June 13, suffering from laryngeal obstruction 
consequent upon diphtheria. This patient was sent to the hospital by Dr. 
William M. Welch, who had had the case under observation for a few days. 
The child, on admission, presented symptoms of dyspnoea in so marked a 
degree that it was decided to perform tracheotomy at once, as it seemed to 
afford the only chance of saving life. 
In this case no anaesthetic was administered, as the respiration was so 
much embarrassed. I exposed the trachea as rapidly as possible, although 
some delay was caused in displacing the numerous enlarged thyroid veins 
which presented themselves in the wound, and opened the windpipe below 
the isthmus of the thyroid gland, and introduced a tracheotomy tube. 
After the introduction of the tube the respiratory act ceased and it was 
only by the aid of artificial respiration that it was finally re-established. 
A number of fragments of membrane were removed from the tube and 
were coughed up for some hours after the operation. 
This case improved slowly after the operation, the temperature not 
reaching the normal until the nineteenth day. 
The tube was permanently removed on the twenty-fourth day after the 
operation, and the patient was discharged from the hospital, with the 
wound entirely healed and in excellent condition, on July 28, 1883. 
I have reported the preceding cases, because I think it important 
to report all cases of tracheotomy done for the relief of respira- 
tory obstruction consequent upon diphtheria, for until within a 
very recent period, in this country, the operation in this disease TRACHEOTOMY IN DIPHTHERITIC CROUP. 
127 
was looked upon with marked disfavor, but 1 am glad to say that 
it is now growing in favor with the profession. 
The operation of tracheotomy, if carefully done, does not, in 
my judgment, complicate the case, but averts an immediate ten- 
dency to death, and offers a chance of recovery to a class of cases 
which, left to themselves,almost invariably terminate unfavorably. 
The results of expectant treatment in these cases, where symp- 
toms of respiratory obstruction are present, have been so unsatis- 
factory, that the operation of tracheotomy, which in the vast 
majority of cases prolongs life, and is in itself seldom a cause of 
death, seems to be most clearly indicated. 
It must also be remembered, that the operation is not generally 
proposed until full trial has been made of the various forms of 
medicinal treatment which may be considered appropriate to 
the symptoms presented. 
The statistics of this operation in diphtheritic cases are difficult 
to estimate, as in many of the collections of cases membranous 
croup and diphtheritic croup are used as synonymous terms. 
Prof. Hensch, of Berlin, reports sixty-six tracheotomies for 
diphtheritic croup with sixteen recoveries; a little over 24*3 
per cent. 
These statistics agree very closely with Prof. Cohen's observa- 
tion, that one case out of four recovers when the operation is 
performed for diphtheritic croup. Mackenzie quotes Trousseau's 
statistics' of 466 cases of tracheotomy occurring in the Children's 
Hospital of Paris, in which 126 recoveries took place, or about 
one recovery in every four cases. My own limited number of 
cases furnishes two recoveries out of five cases, though one perished 
ultimately from diphtheritic paralysis. 
To form a correct diagnosis between diphtheritic croup and 
membranous croup is at times a very difficult matter; for instance, 
in Case I, the symptoms pointed to a false croup, which occasion- 
ally complicates measles, but on the day succeeding the operation 
the glands of the neck became greatly swollen and the trache- 
otomy wound was covered with a diphtheritic deposit. 
The diagnosis in cases where the pharyngeal lesions antedate 
the symptoms of dyspncea is comparatively easy, except in the 
case of very young children, where a satisfactory examination of 
the fauces is often impossible. 
I myself am a believer in the non-identity of the membranous 128 
PHILADELPHIA COUNTY MEDICAL SOCIETY. 
and diphtheritic croup, but, as far as their surgical treatment is 
concerned, I can see that an exact diagnosis makes little differ- 
ence; the same indications exist in both diseases, namely, to 
relieve the dyspnoea which threatens life, and this is to be over- 
come by the same operative procedure. 
As regards the age of the patient, there is no doubt that the 
chances of recovery, after the operation of tracheotomy, are 
better after the age of three years, but examples of recoveries in 
the second and even the first year are not wanting, and in my 
own successful cases the patients were aged two and two and a 
half years respectively. 
The shortness of the neck, the depth of the trachea, the com- 
paratively larger extent of its surface, which is covered by the 
isthmus of the thyroid gland, the possible presence of the thymus 
body, and the danger of wounding the left innominate vein in 
very young children, are all elements which render the operation 
of tracheotomy more difficult, and cause its performance to be 
accompanied by more immediate risk than in the case of older 
children where these conditions do not obtain. 
Gr. Chaym * has collected a number of cases of tracheotomy in 
children under two years -of age, and gives the following statis- 
tics: In fifty-six cases of children one year old, the mortality 
was eighty-four per cent.; in nine hundred and twenty-one cases 
where the age was two years, the mortality was eighty-five per 
cent. Archambault,f of the Children's Hospital of Paris, presents 
some statistics bearing upon t he results of the operation at dif- 
ferent ages:- 
976 cases in children from 1-3 years gave 104 recoveries. 
822 " " " " 3-4 " " 175 
736 " " " " 4-5 " ' " 174 " 
497 " " " " 5-6 " " 148 " 
547 " " " over 6 years " 198 " 
The time at which the operation should be performed is a matter 
of the greatest importance; if we wait until cyanosis, coldness 
of the extremities, and extreme dyspnoea are present, it is 
often too late, so that I think it is generally conceded that it is 
advisable to operate when the local signs of laryngeal stenosis 
are well marked and are increasing, as will be shown by continuous 
* Med. News, Aug. 2, 1884, p. 125. 
t Archives of Pediatrics, June 18, 1884, p. 415. TRACHEOTOMY IN DIPHTHERITIC CROUP. 
129 
stridor in the breathing and retraction of the supra-sternal fossa 
and the lower ribs. 
But upon this latter point there is a wide scope for the exercise 
of individual judgment, some surgeons recommending the opera- 
tion where others would consider it hopeless; even the presence 
of pneumonia is not considered by some authorities as a contra- 
indication to operative measures. 
The steps of the operation are too well known to require any 
detailed consideration ; the question of the point at which the 
trachea should be opened, whether above or below the isthmus of 
the thyroid gland, is one which the surgeon should decide for 
himself, and, I think, depends somewhat on the size of the isthmus 
of the thyroid, and the ease with which it can be displaced 
upwards or downwards. The opening of the trachea *'bove the 
isthmus of the thyroid gland is generally accomplished with more 
ease, as the trachea is more superficial at this point, and there is 
less risk of wounding important vessels, especially in young 
children. 
In some cases where it is impossible to displace the isthmus of 
the thyroid gland, either from the extent of the trachea which it 
covers, or its immobility, it may become necessary to ligature it 
on cither side of the trachea, and expose the latter by an incision 
between the ligatures which can then be accomplished without 
fear of dangerous hemorrhage. 
The size of the tracheotomy tube to be introduced, is a matter 
of some importance, and I think it is considered an advantage to 
use as large a tube as possible, that is one which closely tits the 
calibre of the trachea , this not only furnishes as much breathing 
space as possible, but has less tendency to cause ulceration of the 
trachea, such as is occasionally seen after the use of loosely-fitting 
tubes. 
The tracheotomy tube most commonly used is a double oner 
constructed of silver, and the outer tube contains a fenestrum 
which is intended to communicate with the cavity of the trachea 
when the inner tube is removed, but in my experience it is gener- 
ally useless as regards this object, for the fenestrum is placed so 
far from the end of the tube that it is outside of the tracheal 
wound. For this reason the non-fenestrated tube recommended 
by Prof. Litble,* which is constructed of aluminium, which has the 
* London Lancet, August, 1883. 130 
PHILADELPHIA COUNTY MEDICAL SOCIETY. 
advantage also of great lightness, seems to possess advantages 
over those in general use. 
With the modification of the operation which has at various 
times been suggested of dispensing entirely with the tracheotomy 
tube, by removing a portion of the trachea, or by holding the 
wound open by sutures introduced through the edges of the 
tracheal wound, I have had no personal experience, but as a 
temporary procedure 1 should think it might, under some circum- 
stances, be adopted with advantage. 
In very young children, when the trachea is very soft and 
pliable, and presents very much the characteristics of a mem- 
branous tube, the use of the tracheotomy tube seems to me to be 
almost imperative, for I can recall one case of the operation in a 
young child in which I assisted Prof. Ashhurst, in whom, as soon 
as the trachea was exposed and opened, inspiratory efforts caused 
a flattening of the trachea, so that no air could enter, and it was 
only after the introduction of the tracheal canula that respira- 
tory action was satisfactorily established. 
The use of an anaesthetic in tracheotomy is recommended by 
many surgeons, among whom is Erichsen, who always administers 
chloroform, thinking that it relieves the spasmodic condition, 
which is a factor in the dyspnoea; other operators prefer ether; 
for myself, I must say that I am opposed to the use of any anaes- 
thetic, unless it be in the very early stage of the operation, and 
in cases which are not extremely urgent. 
The use of ether in eases where the respiration is much embar- 
rassed, I think adds an additional complication by increasing the 
laryngeal irritation, and I am confident that in one instance at 
least I have seen death result from this cause ; on the other hand, 
the sensibility of the parts is so much blunted that I believe little 
pain can be referred to the operation after the incision of the skin 
has been accomplished. The immediate results of the operation 
are, as a rule, mcst encouraging. The patient, who previously 
exhibited the most distressing symptoms referable to his extreme 
dyspnoea, now becomes quiet, improves in color, the respiration 
becomes slower and more natural, and he generally falls into a 
quiet and peaceful sleep; but, unfortunately, this period of comfort 
is, in many cases, in a few hours or days followed by an increased 
rapidity of the pulse and frequency of the respiration, with 
recurring dyspnoea due to an extension of the membrane into TRACHEOTOMY IN DIPHTHERITIC CROUP. 
131 
the trachea below the seat of operation, or to the development of 
a bronchitis or broncho-pneumonia. But even the occurrence of 
these complications after the operation, I take it, should not 
militate against operative interference in suitable cases, for they 
cannot be directly traced to the performance of tracheotomy, as 
they occur with corresponding frequency in cases in which 
medical treatment alone is employed. 
A favorable sign after the operation is, as remarked by Prof. 
Cohen, the occurrence of coughing and the expectoration of false 
membrane and tracheal mucus through the canula; the cases in 
which these symptoms exist are more apt to end in recovery, 
than those in which the opposite conditions obtain. 
The after-treatment of cases in which tracheotomy has been 
performed is a matter of the greatest importance, as the successful 
issue of the cases depends largely upon the care and watchful- 
ness exercised in this respect. 
The first indication requiring attention is the removal or 
escape of false membrane from the trachea, this may be coughed 
up and escape from the tube or may be removed by a camel's- 
hair brush or a feather, and to prevent the inspissation of these 
discharges a warm and moist atmosphere is generally maintained, 
this may be accomplished by the use of the ordinary steam 
atomizer in which lime-water may be used as the spray, or by 
having water boiling in open vessels in the room, or by the 
slaking of lime in large quantities. In the Children's Hospital 
of this city we have a room especially arranged for the treatment 
of these cases, which is fitted with steam apparatus by means of 
which the air of the tracheotomy room can be filled with a vapor 
of steam in a few minutes, and maintained at an even temperature. 
It is also a matter of the first importance to have the case 
under careful and continuous observation for some time after the 
operation, for at any moment the tube may become obstructed 
by mucus or detached membrane, requiring the removal of the 
inner or even the outer tube; for this reason, the presence of a 
trained assistant or a nurse skilled in the management of these 
cases, is almost indispensable. Of the medical treatment of these 
cases I will say little, as much diversity of opinion exists upon this 
point and the operation itself does not necessarily conflict with 
any form of treatment which may have previously been instituted, 
for my own part, I prefer the administration of carbonate of 132 
PHILADELPHIA COUNTY MEDICAL SOCIETY. 
ammonium, in small and repeated doses, for the first twenty-four 
hours after the operation, believing that by its use the risk of 
heart-clot is much diminished. 
The permanent remova.1 of the tube is a matter of the greatest 
importance, and sometimes I think causes more trouble and 
anxiety than its original introduction. The time at which this 
should be attempted varies considerably in individual cases: it 
has been removed permanently as early as the third or fourth 
day; in other cases it has been weeks or months or years before 
this could be executed, and in a few cases its permanent removal 
has never been successfully accomplished ; many elements may 
combine to render this an easy or difficult undertaking. 
The importance of dispensing with the tube in cases of 
tracheotomy done for temporary larnyngeal obstruction as soon 
as the cause has been removed, is generally admitted : the bron- 
chial catarrh, the danger of its displacement when competent 
assistance is not present to replace it, and the injury which it 
may inflict upon the trachea, all point to the importance of its 
early removal. 
The growth of granulations in and ulceration of the trachea 
produced by the end of the tube, in cases where it has been 
retained for some time, have both caused troublesome and dan- 
gerous complications. 
A case having a direct bearing upon this subject and presenting 
a rather unusual complication, causing death after tracheotomy, 
has recently been reported at a meeting of the Society Medicale 
des Hospitaux de Paris, by M. d'Heilly,* who showed the specimen 
taken from a case in which tracheotomy had been performed for 
diphtheria, and in which the patient died from hemorrhage on 
twelfth day after the operation. The hemorrhage in this case 
arose from ulceration of the trachea which had extended to the 
innominate artery, and was caused by the end of the tracheotomy 
tube. The reporter states that he could find only two similar 
cases which were recorded in Guy's Hospital Reports. 
As soon as the patient can breathe without the aid of the tube 
it is, of course, important to get rid of it, and to ascertain this 
fact its external opening may be plugged, or it may be removed, 
and a wet compress of lint laid over the wound in the neck; if 
under these conditions the patient breathes comfortably, showing 
* British Med. Journal, May 24, 1884, p. 1017. TRACHEOTOMY IN DIPHTHERITIC CROUP. 
133 
that the air passed freely through the trachea and larynx above 
the wound of operation, its permanent removal may at any time 
be attempted. The plan which is recommended by many author- 
ities of removing the tube each day for a few days, before its 
final withdrawal, and allowing the patient to breathe without its 
use for an increasing period of time at each removal, is on the 
whole a very good one, and one which I have generally adopted. 
That the final removal of the tube need never be entirely 
despaired of, is shown by numerous recorded cases, where, even 
after it had been worn for periods varying from three or four 
months to several years, its use had finally been dispensed with. 
The difficulty produced by the removal of a tube which has 
been worn for some time, is to be explained by several circum- 
stances, among which may be included the healing of the external 
wound as far as the presence of the tube will permit, and its 
adhesion to the trachea which causes it to assume a valvular 
action during the inspiratory acts. The growth of excessive 
granulations at the margins of the tracheal wound, or from the 
surface of the trachea impinged upon by the lower end of the 
tube, are also obstacles to the permanent removal of the tube, 
until their destruction is accomplished by appropriate treatment. 
Another clement which I think has a very important bearing 
upon this subject has been pointed out by Mr. Thomas Smith,* 
who has shown that tracheotomy, whether performed for diph- 
theria or acute laryngitis, is liable to cause undue irritability and 
disorderly action of the muscles of the glottis so as to interrupt 
their usual rhythm ; this, perhaps, is the effect of enforced cessation 
of all exercise of function in the larynx, which the operation 
entails. 
Prof. Cohen f says that the explanation of theiSe phenomena 
seems to reside in the fact that the laryngeal muscles had lost 
the habit of contracting harmoniously for the needs of respira- 
tion ; the patients being somewhat in the condition of those with 
paralysis of the vocal cords. 
In explanation of those cases where the tube can be dispensed 
with except during sleep, Smith suggests that the influence of the 
will may be necessary to regulate and secure the due action of 
these muscles, the perfection of whose movements has been im- 
* Medico-Chir. Trans., vol. xlviii, p. 227. 
f Cohen, Croup in its Relations to Tracheotomy, p. 53. 134 
PHILADELPHIA COUNTY MEDICAL SOCIETY. 
paired, and that on this account inspiration through the larynx 
during sleep is impossible. 
To restore to their normal involuntary character the impaired 
functions of the disused laryngeal muscles, he recommends 
exercise of these functions during sleep, the removal of the tube, 
the case of course being carefully watched, so that upon the 
development of dangerous symptoms it can be re-introduced. 
By this means, after repeated trials in the most obstinate cases, 
the parts have resumed their normal condition and the use of the 
tube has finally been dispensed with. 
This condition I have seen to occur after the removal of 
tracheotomy tubes and to cause the patient to exhibit the most 
alarming symptoms of dyspnoea until the tube was replaced. The 
unfortunate termination of Case IV was, I think, due to this cause ; 
here, it will be remembered, the symptoms of dyspnoea came on 
suddenly two hours after the removal of the canula, upon the 
occurrence of some excitement, and quickly terminated in death 
before the tube could be replaced. In this case, after death, I 
introduced the tube without difficulty, and could find no cause of 
obstruction in the trachea. 
1405 Locust Street.