(i) Diphtheria. The extent to which diphtheritic obstruction has to be taken into account is shown by the following table:—
Table showing the Number of Cases admitted to the Fever Hospitals of London (M.A.B.) during the Years 1902–7, inclusive[25]
| Year | All forms of Diphtheria. | Laryngeal Cases. | Tracheotomy Cases. | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Cases. | Deaths. | Mortality per cent. | Cases. | Deaths. | Mortality per cent. | Cases. | Deaths. | Mortality per cent. | |
| 1902 | 06,839 | 0741 | 10.8 | 0639 | 134 | 20.9 | 0264 | 086 | 32.5 |
| 1903 | 05,422 | 0504 | 09.3 | 0560 | 102 | 18.2 | 0223 | 067 | 30.0 |
| 1904 | 04,639 | 0464 | 10.0 | 0659 | 116 | 17.6 | 0247 | 079 | 32.0 |
| 1905 | 04,224 | 0346 | 08.2 | 0706 | 116 | 16.4 | 0255 | 072 | 28.2 |
| 1906 | 04,937 | 0444 | 09.0 | 0702 | 127 | 18.1 | 0275 | 101 | 36.7 |
| 1907 | 05,674 | 0544 | 09.6 | 0981 | 169 | 17.2 | 0432 | 129 | 29.9 |
| 31,735 | 3,043 | 09.6 | 4,247 | 764 | 17.9 | 1,696 | 534 | 31.5 | |
An examination of the above figures shows that in recent epidemics 13% of the cases developed symptoms of laryngeal affection; that about 40% of these laryngeal cases were treated by tracheotomy (in some cases preceded by intubation); and that the mortality in all the cases of tracheotomy was 31.5%. Tracheotomy in diphtheria, therefore, must still be regarded as a serious operation.
Fig. 267. Skiagram showing an Angular Tracheotomy Tube in the Trachea. H, Body of hyoid; PH, Pharynx; CR, Posterior plate of cricoid; L, Larynx; OE, Œsophagus; T, Trachea.
The operation is required chiefly during the early years of life, namely, from one to six (see table on [p. 543]). Although the larynx cannot be inspected in children, it is easy to determine whether mechanical obstruction is present; for inspiration is noisy and accompanied by stridor, the voice is lost or reduced to a whisper, and attempts to cough are frequent. The alæ nasi are dilated, the extra muscles of respiration are called into action, and laryngeal excursion is seen. On examining the chest, recession is evident; and during inspiration the supraclavicular fossæ, the intercostal spaces, and the epigastrium are all indrawn. The amount of recession depends more upon the muscles of the chest than upon dyspnœa, and is marked in weakly children. When dyspnœa becomes urgent the restlessness increases, and this is an important indication that an operation is required. In very serious cases the face is drawn, livid, or extremely pale; respiration is deficient, and the chest expansion feeble. An examination of the lungs shows the air entry to be imperfect; the bases are dull to percussion, and all sounds absent. The action of the heart is feeble, rapid, or intermittent; no nourishment can be swallowed. It is always difficult to determine how much of this collapse is due to toxin; but by relieving the obstruction the most distressing feature of the disease is removed, better aeration of the blood is obtained, and the heart is relieved from strain. The operation also drains the trachea, and the amount of poison absorbed is thus diminished. There is abundant evidence to show that the best results are obtained by early operation, especially in young children, in whom the larynx is comparatively small. It should be remembered that dyspnœa is often worse at night, and that at any moment there may be spasm.
(ii) Infectious diseases, such as (a) secondary diphtheria, by no means uncommon in the fever hospitals of London: in the five years 1902 to 1906, thirty cases are recorded, with sixteen deaths (53%), a very high mortality; (b) scarlet fever or measles, which provided 118 cases in which tracheotomy was performed, with eighty-seven deaths (74.3% mortality); (c) erysipelas, small-pox, typhoid fever, influenza and whooping-cough, which occasionally cause dyspnœa, calling for tracheotomy.
(iii) Acute laryngitis (other forms) in which œdema supervenes as the result of septic infection, or of the inhalation of steam, boiling water, or irritating chemicals, or as the result of trauma with or without fracture of the cartilages, or in the course of renal or heart disease. Brandy in excess, and certain drugs such as iodide of potassium, may also cause œdema of the larynx, and two cases are recorded by Fournier where death occurred before tracheotomy could be performed, as the result of taking iodides.