The middle cast is from a girl of eight years; other casts from a brother and sister intubated 36 hours apart These casts, and others, were obtained by pulling out the tube by means of the string during an expiratory effort. This maneuver has so far obviated the use of tracheotomy in my cases. A writer in the February (1905) Laryngoscope found it necessary to do 25 tracheotomies in 108 cases. W. T. W. tube, but without success. I gave the child a rest, and then tried again with the one-year tube, but could not introduce it. The manipulations had increased the dyspnea. I then prepared to do a tracheotomy. When all was ready I gave the child a very little chloroform. I made one more attempt at intubation, and was successful in introducing the three-year size by using just a little more force than usual. The child revived greatly, coughed up a large quantity of the imprisoned mucus and then went to sleep. The next day it had a temperature of 101 and respiration about 40, color good and no dyspnea. The temperature record was not kept regularly. The respirations when taken were never below 40. The child died four days after intubation. Autopsy showed tracheitis, bronchitis, and a consolidated lobe in one lung. Death was caused by pneumonia. My especial interest was in the larynx, and here the cause of my difficulty in intubation was readily apparent. The anterior wall of the larynx in the cricoid region was the seat of an ulcerative process which had destroyed the soft tissues and allowed a film of free cartilage to loop backward into the lumen of the larynx. Dr. MacCallum has kindly studied this for me, and regards it as an old process, and not due to a tube worn but four days. I have here a vertical section of the anterior portion of the larynx, showing the ulceration, and the free loop of cartilage in cross section. This finding fits in with the previous history of the case, which was that its respiration was always noisy since a few weeks after birth. It had a chronic cough, for which it had been taken to the Johns Hopkins dispensary on several occasions. At one time the cough was evidently regarded as due to some syphilitic lesion, as the infant was treated by mercurial inunctions. At another time it was thought to be due to an enlarged thymus. The thymus was not unduly large, and neither were the bronchial lymph nodes. It seems probable that the cough was due to this chronic ulcerative process in the larynx. No membrane was seen. No cultures were made. No diphtheria bacilli were found in smears from trachea and bronchi. Rapid Return of Stenosis.-In some cases almost complete stenosis returns immediately upon the removal of the tube, and it is in this class of cases where previous experience in intubation. will make the difference between life and death to the patient. I have never lost a patient from this cause, but have come so near it that for several years I have not removed the tube without having another ready for immediate insertion. In one of my prolonged cases, when the tube was coughed out, dyspnea was so urgent that I had to have two assistants dressed and ready to fly to their positions at a moment's notice day or night. A duplicate tube was always at hand. I was compelled to live in the house of the patient for five weeks. In one case, in the suburbs, the tube was coughed up and the child suffocated before I could be gotten. Where the stenosis occurs immediately after the removal of the tube it is probably due to swollen tissues above the glottis which fall together and prevent inspiration. The gradual return of stenosis is probably due to edema below the glottis. This, fortunately, is the usual form of returning stenosis. Retained Tubes.-This is the greatest bugbear of the intubationist. O'Dwyer used this term to designate "the necessity of continuing intubation long after the disappearance of the original disease (diphtheria)." After the use of antitoxin, the evidences of diptheria rarely persist over a week, yet occasionally a tube which has been inserted during an attack of diphtheria has to be retained for weeks or months. I have had six cases which come under this heading: One of 17 days' duration, 4 intubations. One of 22 days' duration, 5 intubations. All have made perfect recoveries. In two there was no mem- . brane seen and cultures were negative. In one no membrane was seen, but cultures were positive. In one meinbrane came up during operation. In two no membrane was seen and no cultures made. O'Dwyer believed that the cause of persistent stenosis following intubation in laryngeal diphtheria was almost solely due to traumatism; more often to improperly-fitting tubes, less often to laceration produced by inexperienced operators. John Rogers, Jr., believes that retained tubes are due to a chronically-inflamed and hyperthropic condition of the subglottic tissues, which is a sequel of the original diphtheria inflammation, and not in any way the result of operative treatment. To this rule he finds but few exceptions. With this view I am inclined to agree. AFTER-CARE. Feeding is in most cases almost our sole concern after intubation and antitoxin. Children at the breast usually nurse very well. In children who take the bottle the Casselberry method should be employed. One infant a year old, whenever hungry, would throw his head back into the Casselberry position. In a recent case a child of four years still drank milk from a bottle. Twentyfour hours after intubation his physician telephoned that he could. take no nourishment and was coughing incessantly. I traveled 20 miles by sleigh on a winter night just to stand the boy on his head. He drank a pint of milk immediately, and the cough was greatly ameliorated by the drainage of the mucus from the trachea into the pharynx. To older children I give almost any food suitable for a sick child. In only one case have I found food to enter the tube. In that instance it was partially obstructed by what appeared to be bread. In two cases I had to resort to nasal feeding. It was easily done and exceedingly satisfactory. Obstruction of Tubes.-In older children membrane which loosens up after intubation usually causes the expulsion of the tube, the membrane following it. In these cases the tube should not fit tightly. I have had several such cases. At times the tube, instead of becoming suddenly blocked with loose membrane, becomes gradually filled with a granular deposit -probably decomposed membrane. Here the tubes must be removed and cleaned. In one case I had to remove and clean the tube three times in 17 days. I have had but one death from an obstructed tube. This was a baby of 11 months. Thirty-six hours after intubation it was apparently well, when the mother saw it suddenly begin to struggle in a few minutes it was dead. I found a tough piece of membrane wedged in the lower end of the tube. There seems to be no way of avoiding such an accident save to have a physician with assistants constantly in the room with the patient throughout the wearing of the tube. Swallowing the Tube.-No serious results are recorded from this accident. When the tube is coughed out of the larynx it almost invariably comes into the mouth and is taken out by the nurse or patient. In one of my cases tube and thread were swallowed, and passed from the bowel 36 hours later without trouble. The tube had been in place but a few minutes. I left the child in charge of an assistant while I turned to attend to something. What happened I do not know, but when I was called the thread was just disappearing in the mouth. I grasped at it, but it eluded me and went on down. After-Effects.—I have not recorded nor can I remember a case of paralysis in any of my intubated cases. In every case the voice has returned to normal. In a year-old baby which wore its tube 38 days there was an interesting psychic phenomenon. Before its illness it could say "mamma," "papa," "bye-bye" and other baby words, and could imitate the sounds of bees, and give an excellent imitation of the sounds made by a neighboring windmill. For the first few days after intubation it would attempt these sounds. Later on it abandoned all attempts. After the tube was removed it made no attempts to speak for about eight or nine months. It could laugh and cry in a perfectly normal manner, so I concluded that not the condition of the larynx, but that of the mind was responsible. Another little child became quite hysterical when it found its voice after wearing the tube five weeks. TIME OF INTUBATION. In nearly every case I have been called to there has been no room for debate as to whether or not to intubate. The dyspnea has been so marked that immediate operation was called for. cases. A good rule, whose author I have forgotten, is this: "When in doubt-intubate." Undoubtedly the early use of antitoxin will obviate the necessity for operation in a large percentage of Still we must not expect too much of it. I have within a year seen a death caused from asphyxia because the physician had delayed operation too long in the hope that antitoxin would relieve the stenosis. I believe in early intubation, wherever there are stenotic symptoms, mainly for two reasons: (1) The stenosis may became suddenly worse in the physician's absence. (2) The tendency of broncho-pneumonia may thereby be lessened. Sudden Increase of Stenosis.--It is surprising through what a small opening a child can breathe in a normal way. A year-old infant can breathe nicely through space the diameter of a matchstick. If such an infant shows signs of stenosis we know the lumen of the larynx is smaller than the diameter of a matchstick. To one who has watched in the pharynx the rapidity with which diphtheritic membrane can form it occasions no surprise to have such a larynx close up completely in an hour or two. A friend of mine, who has had a good many patients intubated, and is alert to the indications for operation, saw a child suffering with slight dyspnea. He paid a call in the suburbs, and then returned to his case of croup, only to find it moribund. I was called on one occasion to intubate a child. The symptoms were not very urgent. I did not have the tube appropriate to the age, so sent for one and returned in an hour. I found the house in confusion, and the child was said to be dying. Its pulse was feeble and fluttering. The chest heaved slightly a few times, but there was no respiration. In a few minutes the tube was in the larynx. The child made no resistance; it was like operating upon a cadaver. In a few seconds there was a slight respiration, then another, then a slight cough; then the respirations became stronger. and more frequent. In half an hour the pulse and respiration were fairly natural. It seemed almost like a resurrection from the dead. Broncho-Pneumonia. - Broncho-pneumonia exists in threefourths of fatal cases of diphtheria (Holt), and in a larger proportion of cases where there has been involvement of the larynx, trachea or bronchi. It is thought to be due to the aspiration of bacteria from above. In nearly every intubated case, whether stenosis is mild or severe, a large quantity of mucus will be released. Air can pass through a larynx for many hours after the passage of mucus has been obstructed. Sometimes many drachms of mucus are thus released. It must necessarily have filled the most of the trachea, bronchi and bronchioles. As it accumulates it must go deeper and deeper, and it seems to me must be a factor in carrying the germs which give rise to broncho-pneumonia. |