Monday, April 4, 2016

1874: Solis Cohen recommends tracheotomies for croup

While physicians of the 18th and 19th century were frequently afraid to perform the procedure of tracheotomy, a few physicians, such as Dr. Armand Trousseau, Dr. J. Soles Cohen, and Dr. Morrel Mackenzie strongly recommended that every physicians become adept at the practice, as it is sometimes the only means of saving the life of a child who is suffocating daue to croup.

Mackenzie, a nose and throat specialist , said the first person to recommend the operation of tracheotomy for croup was Francis Home, who published a book on the subject in 1765 called "An Inquiry into the nature, cause and cure of croup." (1, pages 134, 523)

He said various other physicians followed suit, including doctors Crawford, Chaussier, Schwilgue, and others.  (1, page 523)

Trousseau (1801-1867) was an ardent supporter of the procedure, and his thoughts on the subject were often referenced by Cohen as he attempted, in his 1874 book "Croup, in its relations to tracheotomy," to convince his colleagues the procedure was sometimes necessary, and that every physician should become adept in performing the operation.

The procedure had been performed many times in the ancient world, although with great difficulty and risk.  Cohen said it wasn't until 1782 that the first successful tracheotomy for croup was performed, and this way by John Landree in London, and later by Chevalier in London in 1814.  (2, page 7-8)

He said Bretonneau also performed a successful tracheotomy for croup in 1825, yet that was only after two unsuccessful attempts in 1818 and 1820. Professor Stolz succeeded in 1825, and Armand Trousseau in 1833. (2, page 7-8)

Trousseau, Cohen said, "remained the most zealous advocate of the operation during his entire life." (2, page 7-8)

Cohen also explained that successful tracheotomies were rare prior to the 1850s, and the main reason for a rise in success rates was improved care during the procedure, which was mainly due to a new idea called the germ theory of disease.
Post operative deaths declined slightly due to increased attention paid to these patients following the operation.  (2, page 8)

Cohen went on to note statistics comprised by various studies performed that resulted in increased confidence in performing the procedure. (2, pages 8-26)

It should be noted, however, that during this time in our history it was rare for a patient to visit a physician in a controlled setting.  In most instances, when a person was sick, a physician was sent for, and he rode in on his horse and buggy to take care of his patient.

So it was very rare for the operation of tracheotomy, or any operation for that matter, to take place in a controlled setting.  If efforts to control infection were made, it was solely the responsibility of the physician.  One could imagine that, upon observing a young child who was suffocating due to a swollen throat, that a physician would have little time to consider aseptic procedure.

Despite this fact, Cohen said a patient would be more likely to survive such an operation at home than in a hospital.  Cohen said that...
...hospital cases in themselves, as a rule, offer less chance of recovery than cases in private practice, though the operation is frequently performed better, and the after-treatment is much more assiduous." (2, page 8)
A common cause of distress among children, and a common cause for the airway to become swollen and cause suffocation, was croup.  By this age there was a lot known about this disease, particularly that it was inflammation of the throat that can occur as a result of diseases like diptheria.  (2, page 27)

Cohen recommended, that upon visualizing a child, or adult, with croup, that an immediate assessment be made, and the decision to perform a tracheotomy should only be made "whenever it is apparent that death from suffocation cannot be averted by any other means."  (2, page 27)

In other words: tracheotomy should only be used as a last resort to save a life.

The procedure involved the physicians cutting the throat with a blade.  It would have been distressing for all involved, and very painful for the child.  It would have required the parents, and anyone else in the room, holding the child still. It would not have been a pretty site to behold.

When the child was screaming, writhing and turning during the procedure, this increased the risk that the physician would make an incision in the wrong spot. This could cause extreme agony, although it could also increase the risk of death.

For this reason, when the procedure was performed in Great Britain, Germany and the United States, chloroform was would be used as an anaesthetic.  The physician would be well versed in how to obtain it, how to store it, and how to provide it to a patient.  In the case of a screaming child, he would use it liberally, although never in an amount that would risk the child dying as a result of the poison.  (2, page 34)

If you lived in France, however, and you were the poor child suffering, your physician would not provide you with an anaesthetic.  Surely the drug was good for calming a child down, but if given in too high amounts this would cause breathing to become so shallow that asphyxia sometimes occurred, resulting in brain injuries and death.  (2, page 34)

This was especially a concern because there were no standard doses, and it was particularly difficult for a physician to accurately dose a small child.  When not enough was given, the child would continue to fight.  However, when too much was given, the risks were too severe for French physicians to recommend the poison.  (2, page 34)

Regardless of the option to use Chloroform, many physicians were slow to use it, and slow to perform the procedure of tracheotomy, because there was always the hope that other methods would work.  The dilemma of where to draw the line, and when to perform the procedure, continued to plague physicians.  Cohen said: (2, page 5)
Tracheotomy for croup is generally regarded with much disfavor in this city. Its results in Philadelphia have been less encouraging than almost anywhere else; probably because, as a rule, the operation is postponed too long; possibly because our medicinal treatment of croup cures a number of cases which, under less efficient management, would become subjects for tracheotomy; but, whatever the cause, the results, in the comparatively few instances in which the operation has been performed, have been so disheartening, that many practitioners refuse to sanction tracheotomy in croup under any circumstances. This radical feeling is wrong. Not only should our individual experience be utilized in judgment, but the recorded experience of others also. Early failures may be followed by ultimate successes. (2, page 5)
To encourage physicians to use the procedure when needed, he provided statistics. He said: :
Barthez, in a letter to Eilliet on the comparative results of the treatment of croup by tracheotomy and by medication during the years 1854-1858, stated that the first year the Hospital Sainte-Eugenie was opened, 13 croup patients were submitted to tracheotomy, of whom the first died during the operation, and 11 others in succession after the operation; the first recovery taking place in the thirteenth case. Yet Barthez had many successes afterwards; for in a letter published in 1868, he stated that in the same hospital, between the years 1861-1867, 785 cases were operated upon, with 222 recoveries. Guersant lost his first 23 cases, between 1834-1841 ; but after that saved 17 out of 82.
He also referred to statistics by  Armand Trousseau, a 19th century physician who strongly recommended the procedure.  Cohen said:
Trousseau, up to 1842, had operated 119 times, with but 25 recoveries; but at a later date (1854) he reported 222 operations with 127 recoveries. Similar examples of early want of success followed by results truly gratifying are on record. But there have been results even worse than these. Thus Trousseau, in a discussion on tracheotomy in croup, before the Academy of Medicine, in 1858, mentioned, that in the earlier days of the operation, Gosselin, Deguise, Huguier, Jarjavay, and Monod, Jr., of Paris, performed 95 operations successively without a single recovery; that Alphonse Guerin, Mtchon, Laugier, Robert, Nelaton, Lenoir, and Depaul saved but 11 cases out of 117 operations; and Velpeau, Jobert, and Desormeaux but 16 out of 84. He attributed much of this want of success to the idea then prevalent that the surgeon's duty ended when he had opened the trachea. (2, page 5-6)
Trousseau, therefore, recommended that the physician should continue to care for the patient long after the operation was performed.  If he was unable to attend the patient after the operation, it was his job to educate those would were, particularly parents, spouses, relatives, or friends who would be taking care of the patient.

Despite the risks, despite the fears of the physician, despite the anger of parents who watched as their children had their throats cut open, Trousseau recommended that the physician should not be afraid to use the procedure to save a life, and lack of skill and fear was no excuse to evade the procedure.

He strongly recommended that every physician become educated about the proper methods of performing the procedure, and to then to perform it whenever a need arose.  Since practice makes perfect, he suggested that the more a physician performed the procedure the better he would become capable of performing it. The statistics he offered in his book were used to prove it.

Cohen said:
That tracheotomy saves many croup-patients from death otherwise inevitable, and that, too, even under unfavorable circumstances, there has long been no reason to doubt: there is little doubt, either, that patients are occasionally tracheotomized unnecessarily; but the proportionately small number of such instances, whether errors of judgment or errors of prudence, is, in all probability, insignificant in comparison with the number of patients saved by the operation from certain death; life being preserved in the one instance, while it is not sacrificed in the other. (2, page 6)
Cohen reminds physicians that tracheotomy is not a cure for croup, and that it is merely a means of postponing death to allow nature, along with the physicians remedies, time to work.  He said:
Tracheotomy, in itself, does not cure croup. It affords a possibility of recovery by postponing, or insures it by averting death. The course of the disease is continued until all its attendant phenomena have undergone evolution. The surgeon's knife merely cuts a path for air to reach the bronchi in quantity sufficient for the requirements of the respiratory process, and saves the muscular force, exhausted in futile efforts at respiration through the glottis. Is it not possible that the freedom of breathing, and consequent conservation of strength, would aid the system to resist the full effects of the development of the disease, in the further production of exudation, or its plastic deposition upon the bronchial mucous membrane? Then the artificial opening affords a better means of escape for the false membrane, whether dispelled by cough or removed by instruments inserted through the wound; it enables a more efficient application of local remedies to retard the congelation of the exudation into membranes or casts; and thus facilitates the discharge of the plastic material by cough. In short, it gives the patient a chance, offered by no other means, to live and fight through the development and decline of the disease. (2, page 6-7)
A cannula was usually inserted into the stoma, and usually the one's used were double lumen. A double lumen was first used by George Martin in 1730, and was modified by Trousseau.  Cohen said it was important to insert the cannula...
...so that the inner tube projects a little beyond the terminal extremity of the outer one, so as to free the latter when the former is removed or inserted. The proximal (the part closest to the patient) extremity of the outer tube should be suspended by movable joints in a perforated plate to be fastened upon the neck by means of tapes or to adjust itself to the movements of the trachea, avoids pressure against the mucous membrane to some extent; and, thus far, prevents ulceration of the trachea; a serious complication which sometimes attends a prolonged use of the tube, though it sometimes occurs within 36 or 48 hours. The size of the tube should be as large as can be conveniently employed without touching the walls of the trachea. Trousseau thinks that the canula should be of larger calibre than the glottis. Others recommend that it should be about as large as the calibre of the cricoid cartilage, which is considerably less than that of the trachea, in some cases much less. By having a number of tubes of graduated sizes the nicety of adjustment may be attained, whatever may be the age of the child; the same sized tube employed promiscuously for all cases, as is the habit, will not always be well adapted to the case in hand. Too short a canula may be coughed outside the trachea, rendering the patient liable to become asphyxiated in a few moments by its pressure externally. Three times an accident of this kind occurred in Trousseau's practice (2, page 48)
According to Mackenzie, Soles-Cohen was among the many physicians of this era who worked to...
...modify the instruments, to improve the method of procedure, to determine the relative merits of the various operations on the air passages, or to lay down more clearly the indications for the performance of these operations." (1, page 523)
So by trial and error, various improvements were made to both the technique used in performing the operation of tracheotomy and in caring for the tracheostomy after the procedure.  The cannula and inner cannula were improved so that by the end of the 19th century the models used were recognizable to those used today.

A few more advancements would be made during the next several decades, and, finally, in the 1940s the procedure would be perfected.

References:
  1. Mackenzie, Morrell, "Diseases of the athroat and nose, Volume I, 1880, Philadelphia, Presley Blakiston
  2. Cohen, J. Solis, "Croup, in its relation to tracheotomy," 1874, Philadelphia, Lindsay and Blakiston
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