After-treatment. Although this is a subject which has produced a great deal of discussion, there is a widespread impression among the younger members of the profession that it is of little importance. Much has been said about the dangers of interference, and any suggestion put forward has been criticized by those who have had large experience, with the result that confusion is prevalent. As a matter of fact, the subject is one of the greatest importance, for there is no operation in surgery in which the after-treatment can be neglected. Care should be exercised in choosing a nurse who has special knowledge of children and of the after-treatment of tracheotomy. Great discretion is required in the management of such cases, and there is little doubt that harm may result where too much attention is shown. At many of the hospitals a special nurse is appointed for attendance on the more desperate cases only. The main duty of the nurse is to watch the child, for any difficulty in breathing requires immediate attention. It is necessary that she should understand the proper management of the tube; she must see that the inner tube never becomes clogged, and if the tube slips out of the trachea it must be reintroduced or a dilator inserted; she must also be responsible for the feeding of the child. The difficulties that arise during the first few days after operation call for much tact and experience.
It is unnecessary to enter here into the discussion about food, stimulants, or general treatment, except to point out that swallowing may be very difficult. The food must be nourishing, fluid being in most cases preferred; occasional sips of water should be administered to find out whether coughing is produced, in which case nasal feeding can be advised without hesitation. A short rubber catheter should be passed through the nose at regular intervals according to the nature of the case. As a general rule a small quantity of nourishment should be given every two hours, studying, as far as possible, the likes and dislikes of the patient. By the observance of these principles the child soon becomes tolerant, and proper nourishment can be administered, thus removing one of the great difficulties of after-treatment.
The atmosphere of the room. The value of steam for producing warmth and moisture is undoubted; the amount required depends on the case. The main object to be kept in view is to encourage secretion from the mucous membranes, and so to prevent the formation of crusts. When secretion is scanty a large amount of moisture is required, and vice versa; also, when much pus is present, extra moisture is of value to prevent it from becoming dried and to allow it to be expectorated. The value of disinfectants is doubtful, but on general principles it may be said that the more septic the secretion the greater the indication for their use: tincture of benzoin, oil of eucalyptus, and thymol act as sedatives; carbolic acid, creosote, and numerous other drugs are useful disinfectants; soda and potash, recommended by R. W. Parker, tend to liquefy the exudations. Steam, however, is more important than all these, and should be advised as being likely to encourage the quicker healing of the wound: even in catarrhal conditions improvement is more rapid when this practice is adhered to.
The most important point in the after-treatment, however, as far as the surgeon is concerned, is to prevent recurrence of the obstruction. Obstruction is most often due to the blocking of the inner tube by secretions, a condition easy to recognize from the symptoms which are produced. The inner tube should be removed, thoroughly cleaned, and reintroduced. This usually suffices to allow the child a period of quiet breathing, and sleep may be obtained. To keep the tube free it is very necessary to repeat the removal at regular intervals. In those cases where the secretion is tenacious, the tube constantly becomes blocked, but it is better to remove it again than to allow a feather to be passed. Nothing is gained by attempting to hurry the separation of crusts, and the passage of a feather tends to force downward far more than can be extracted, and so to increase the danger of broncho-pneumonia. If dyspnœa continues after removal of the inner tube, a spray should be used, or a small amount of fluid should be dropped into the trachea to moisten the secretions.
Changing the outer tube rarely presents any difficulty because the tissues of the neck soon become matted together, a funnel being thus produced along which the canula is introduced with ease. A new tube should be prepared before removal of the old, and dilators should be at hand for use if the child is frightened, struggles, or coughs: the canula should be introduced quickly and without hesitation, sufficient force being employed to overcome any obstruction. Unless the original opening in the trachea was too small, it should be possible to introduce a tube equal in size to that which was removed. Frequent changing of the outer tube should be avoided.
The time for removing the outer tube. In every case of diphtheria there is a certain amount of catarrh, with swelling of the mucosa, increased secretion, and some difficulty of breathing. In addition, the habit of breathing through a canula is difficult to alter; the child shows an aversion to breathing through the natural air-passages, and is often frightened or bad-tempered. As soon as the secretion becomes small in amount and serous rather than purulent in consistence, an attempt should be made to discard the tube: the canula should not be retained a day longer than is necessary, the usual period varying from five to fifteen days. Various methods may be adopted:—
1. If the outer tube be provided with a window, the tip of the finger can be placed on the opening to compel the child to breathe through the larynx; breathing may be difficult, but by this means an indication can be obtained as to whether it is advisable to persist.
2. If the above method be successful, the tube may be removed. A small pad of gauze is placed over the wound and the child further encouraged to breathe through the larynx. Expiration is generally easier than inspiration, and older children should be encouraged to blow out a candle or to sound a whistle, this process being continued so long as the child can endure it, but not to the stage of exhaustion. It is often possible to remove the tube at the first attempt.
3. The canula may be plugged with a cork which the nurse removes when necessary: it is often possible to replace the plug while the child is asleep without his becoming conscious of the fact, thus showing that the dyspnœa is largely mental.
4. In some children breathing is easy so long as the tube is simply plugged and is not removed; in such cases the canula can be replaced by a shield and a plug which does not pass into the trachea. This may completely deceive the child.