VOL. II.

[NEW SERIES.]

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

INTUBATION OF LARYNX FOR TRUE AND DIPHTHERITIC CROUP.*

BY W. CHEATHAM, M. D. Lecturer on Diseases of the Eye, Ear, Throat, and Nose, University of Louisville.

Although it has been but a short time since Dr. O'Dwyer, of New York, introduced intubation of the larynx for the relief of the above affections, the device has made a remarkable record for itself against tracheotomy. The operation is not a new one; it was tried years ago, and given up as a failure. To Dr. O'Dwyer we are indebted for the perfection to which it has been brought. In the last three weeks I have practiced intubation in four cases, which I will now report.

October 20th I was called to see a case of diphtheritic croup by Dr. J. A. Ouchterlony. The urgent symptom at this time was loss of voice, the breathing not being much interfered with. The child was four years old, and had been sick seven days. On the 22d the breathing was labored, and all the symptoms of laryngeal stenosis developed, the left lung being partly involved. Drs. Ouchterlony, Brandeis, Gilbert, and myself decided that there was but one chance to save the child's life, and that was in intubation. The case was too far gone to admit of a successful tracheotomy, and moreover, the family would not consent to the performance of, the operation. The patient was chloroformed, and the tube introduced with but little diffi

Read before the Louisville Medico-Chirurgical Society, November 5, 1886.

No. 10.

culty. Relief was instantaneous. Respiration, became quite free and easy. The child coughed

a little, and the string attached to the tube dis turbed her to some extent. After the string was removed she was comfortable.

The operation was performed October 22d, at 10:30 P. M. The patient passed a comforte able night, but there was some difficulty in swallowing fluids, as they caused cough. The voice, which could scarcely be heard before the tube was used, now, strange to say, could be heard distinctly across the room.

On the morning after the operation the involved lung was quite clear, and the patient. looked much better.

On the occasion of our afternoon visit we found her much worse; the disease, no doubt, having extended to the smaller bronchi. At 3:30 P. M. that afternoon she died suddenly, I suppose from heart failure.

The tube in this case relieved all urgent symptoms immediately, and did quite as much as under the circumstances it could be expected to do.

Case No. 2 was in the practice of Dr. Pelle, of this city. The urgent symptoms were the same as in No. 1, and relief was instant. The child died, twenty-four hours after the introduction of the tube, from extension of the dis ease below. This case had lung complication also before the tube was inserted.

While treating another case with Dr. Field, of this city, the disease developed in a twoyear-old child in the same family. Laryngeal complications began early, I think on the second day of the invasion.

physical efforts were such as to render it difficult to hold her. The tube was inserted after a few seconds, with instant relief.

On the same morning Dr. A. M. Cartledge called me to see a little patient of his, who he feared would die before we could reach it. The tube was inserted with some difficulty, as the child was only thirteen months old. The tube was twice coughed up, and once inserted, by mistake, in the esophagus. As soon as it was got in position, and the thread removed, breathing became entirely natural.

On November 3d we attempted to remove the tube, as it had been impossible for the child to take nourishment up to that time, and it was actually starving to death. In my efforts to remove it it was pushed a little farther down to the point where it should have been at first; some mucus came away from the throat, and this gave immediate relief; she nursed without difficulty.

If this child should get well it will be a marvel, since the surroundings are as bad as they can possibly be. The family cook, eat, and sleep in a room about twelve by twelve. The floor seems to be below the level of the ground outside. They are too poor to get proper food for the mother, consequently the baby is badly fed. With such surroundings, diphtheria is likely, with the best of treatment, to do its fatal work.

Physicians who have used the tube write of the difficulty of its introduction. I have given an anesthetic in but one of the four cases in which I have introduced it, and have found but little trouble in getting it into place. The discomfort from the tube is but slight, passing off in a few moments. The patients feed very well afterward; especially is this true after the first twenty-four hours. I recognize feeding as a matter of first importance in diphtheria, and realize the importance of the loss of twentyfour hours. A majority of the patients feed well in from three to six hours after the introduction of the tube.

Now let us glance at the comparative statistics of intubation and tracheotomy in diphtheritic croup.

Of all the tracheotomies done in Louisville, we know of but four successes. Dr. J. A. Lar

rabee reports eleven operations, with one success. In Chicago there have been acknowledged three hundred and six tracheotomies, with fifty-eight successes, or only 18.95 per cent. Would any of us undertake to guess at the many failures not reported? The ages of the patients in whom tracheotomy was performed averaged five years and one month. Dr. Waxham, of Chicago, to whom I am indebted for most of the statistical notes in this article, says he knows of one physician who has performed tracheotomy fifty times, with two recoveries; another, twenty times, with no recovery; another, fourteen times, without one recovery; another, eight times, without one recovery; and another fif teen times, with one recovery. In all, 107 cases, with but 3 recoveries.

It seems to me that this showing is bad enough to make any substitute, even if it should promise only equal success, with no mutilation, more than acceptable.

Now let us look at what intubation has done. Dr. W. P. Northrup, of New York, reports 12 cases, with 5 recoveries; Dr. C. P. Caldwell, of Chicago, 3 cases; Dr. E. F. Ingalls, of Chicago, 5; Dr. Strong, of Chicago, 7; Dr. Richardson, of Chicago, 10; Dr. Waxham, of Chicago, 58. Total, 95 cases, with 28 recover. ies, or 29.47 per cent. The age of these cases averaged three years and seven months. You remember the cases that were tracheotomized averaged five years and one month, which should have been much in their favor, yet the recoveries from tracheotomy were only 18.95 per cent, while intubation gives 29.47 per cent of recoveries. Dr. Waxham says, of the 58 cases operated on by himself 20 of them were actually moribund.

All of us must acknowledge that the usual average of successes of tracheotomy in diphtheritic croup given in the books is too high. Few ever save one third of the cases. One author has reported fifty per cent of his cases saved, but acknowledged at the same time that he operated very early in each case, and that many of them would no doubt have recovered if left to nature.

All the cases of intubation reported were performed late in the disease, not until it was impossible for the patient to breathe without

the measure, and some of them were performed after the patient had become pulseless.

The followers of intubation must acknowledge that tracheotomy gives one advantage, and that is, a chance to keep the trachea clear of obstruction. But the operation is attended by many disadvantages: (1) The difficulty of getting permission to perform it; (2) the mutilation; (3) the open wound with danger of septic inoculation; (4) the danger incurred by the passage of the air directly into the lungs without having obtained the proper degree of temperature and humidity; (5) the danger of obstruction to the tube from the causes given in No. 3; (6) the slow recovery from the wound; (7) the difficulty of the operation; (8) the great care needed after its performance; (9) the great irritation caused by the canula, if used; (10) if the patient dies, regret is always expressed that the operation was allowed; (11) the greatest of all, the few recoveries.

Now, as to intubation: (1) The readiness with which permission is granted to perform it; (2) no mutilation, and of course no hemorrhage; (3) the inspired air, going through the natural passages, is moist and warm; (4) the air being moist and warm the expectoration is easier; the tube is not so apt to become obstructed, and pneumonia is less liable to follow; (5) no wound to granulate and slowly heal; (6) the ease with which the operation can be performed; (7) but little attention is needed after intubation—the tube occasionally becomes closed, but this does not happen near so frequently as in tracheotomy; (8) the tube causes but little irritation; (9) if the patient dies, no regret is expressed that the operation was performed; (10) the encouraging per centage of successes.

There are no doubt objections to intubation, the chief of which, so far as I know, is the difficulty of removing the tube after recovery. In the very young, we must expect some trouble here. When the patient has recovered sufficiently to have the tube removed, if it is necessary, ether can be given, which will simplify matters very much. In some cases simple inversion of patient is all that is necessary. In others inversion with a sharp blow on the

back will be successful. Again, gagging the patient by introducing a finger or some foreign substance into the mouth, and touching the soft palate or pharynx while the patient is inverted will succeed. A special instrument for the removal of the tube, when the above fails, is with each set of instruments. Again, the tube may be coughed up when the doctor is not convenient, or, as has occurred occasionally, it may become occluded by mucus or membrane when the physician is not on hand.

Since writing the foregoing, Case No. 4, the thirteen-months-old child has died. It lived forty-one hours after the introduction of the tube. In this case every thing was against its recovery. The cause of death is not known. Dr. Cartledge, some hours after death, enIdeaved to recover the tube.

As he was not able to reach or feel it in the larynx, he expressed some fears that it had passed into the trachea. I believe this to be impossible, because of the smallness of the glottis, and the size of the collar or head of the tube. Such an accident happened to Dr. Waxham, with one of the primitive tubes, but not with one of the latest improved form. Should this happen, there would be no immediate danger unless it became occluded. Again, the child's jaws were so stiff that the doctor had to use a piece of metal to prize them open, and could with great difficulty reach the larynx. Furthermore, the edema of the parts might have hidden the tube, or the patient might have coughed it up and swallowed it, death following the removal of the tube. We endeavored to get a postmortem in this case, but failed.

Case No. 3 has been wearing the tube since Tuesday, 8:30 A. M., or eighty-four hours.* This afternoon she breathes naturally, except after a nap, when she coughs a little. The pulse this afternoon was 126; temperature, 99°; respiration, 40. She feeds well.

There have been three cases in this family. The first, a child of six years, died from extension of the disease to the lung. She was treated with whisky and iron internally; locally, there was used a gargle of sulphur, glycerine, and sulphurous acid.

*Coughed up tube at 4:30 P. M., 6th. Discharged, cured, November 10th.

No. 2, two years old. who is now wearing the tube, was treated in the same manner, except that insufflation of sulphur, boric acid, trypsin, bicarbonate soda, and acacia was practiced. No. 3 was given from the first a one-grain calomel triturate every hour until eight were taken. The gargle was not used, but the insufflations of the above-named powder, with boric acid omitted, were used.

No. 3 was in bed but two days, not wanting to stay there longer. I found her up this morning, dressed and playing around the room. Dr. Field ordered her to bed immediately. It is wonderful with what avidity the patients I have treated drink whisky. They can hardly get enough to satisfy them. They ask for it constantly, and are never refused.

I have endeavored to present this subject to the "Fellows of this Society" in an impartial manner, and I leave it to you, gentlemen, to say whether, in future cases demanding operative interference, the measure shall be tracheotomy or intubation.

LOUISVILLE.

ON SHOULDER PRESENTATIONS.*

BY JOHN G. CECIL, M. D. Assistant to Chair of Obstetrics and Gynecology, University of Louisville.

It is not with a view of bringing up any thing new that this subject is introduced, but simply to report a case, and afterward make a few comments on the subject in general.

Mrs., white, aged twenty-six, is of English extraction, of good physique for child-bearing, and the mother of one child about two years of age. First labor normal in every respect.

Labor with the second child began about midnight. I was called to attend her at six o'clock in the morning. Found her suffering with pains of good length, strength, and frequency. Examination revealed the vulva and vagina soft and moist, the cervix dilated to the size of a silver dollar and dilatable. A small bag of waters presented. Further investigation led to the expectation of encountering a presenting breech in the left dorso-anterior position. The fetal heart sounds were distinctly heard near the median line and midway be

*Read before the Louisville Medico-Chirurgical Society.

tween the umbilicus and symphysis. The presenting part was held high on the brim of the pelvis, rendering digital exploration unsatisfactory. Inspection and palpation did not aid much in the diagnosis, for the patient being of short stature, broad pelvis, with abdominal walls tense and thickly covered with fat, the irregular shape usually noticeable in these positions was not a very suggestive feature.

The diagnosis of a breech presentation was both hasty and faulty; golden opportunities were allowed to pass unimproved. The membranes having ruptured the situation as to diagnosis quickly cleared up, but became at the same time correspondingly cloudy as to prognosis. The left hand accompanied by the cord dropped down into the vagina, no longer leaving doubt as to a shoulder presentation. The dorsal aspect of the child was to the front, the head deep in the right iliac fossa, with consequently the left shoulder and arm presenting. Efforts to alter the position of the fetus by the external method, as recommended by Wigand, were immediately begun. Failing in this, the combined methods of Hohl and Braxton Hicks were ineffectually tried.

Finding all attempts at cephalic version futile, and fearing valuable time would be lost by further delay, I determined to perform podalic version. In the meantime labor pains followed each other in rapid succession and were very strong; the assistance at hand being unreliable, the anesthetic was not pushed to that extent desirable in operations of this character, and possibly accounted for failure in the former attempts at correction.

The right hand was introduced with ease into the uterine cavity, and after a short search the left foot was found and brought down. Traction as far as was considered safe was made on this foot, but, like the preceding endeavors, failed to dislodge the child from its position. Traction on one foot in easy versions is correct practice, but not always effectual. The left foot, funis, and left arm were now in the vagina. Search for the remaining foot was renewed; after a tedious hunt, on account of the active contractions of the womb, it was secured and brought down. The remaining steps in the operation were speedily

accomplished. After delivery of the body and shoulders the head was delivered in two or three minutes. From the rupture of the membranes to complete expulsion of the child about one hour elapsed.

The child, a female, weighing about eight pounds, was moribund at birth, and could not be resuscitated. The mother made a prompt recovery, with no bad symptoms except a rise of temperature on the third day after to 103° F., doubtless due to the combined causes of malaria and the appearance of milk.

Such in brief is the history of a case not of itself of any very great interest or unusual occurrence, but suggestive of a few thoughts on a very important subject. Trunk presentations are comparatively rare. Madame Lachapelle met with 1 in about 230 deliveries; M. P. Dubois, 1 in 169; Dr. Bland, 1 in 210; Dr. Joseph Clark, 1 in 212; Merriman, 1 in 255; Naegèle, 1 in 180; Dr. Collins, 1 in 416. Average of the above, 1 in 239. ill from large statistics arrived of 1 in 2314.

Dr. Church-
Dr. Church-

at an average

Pelvic version proves fatal to women in 1 out of 10.4 according to Reicke, and to 1 out of 11.4 according to Hüter, and according to Churchill, 1 out of 15. To children, Madame Lachapelle represents the loss of 1 child in 3.96; Churchill represents the loss of 1 child in 3. The above statistics are hardly a fair representation of the fatality either to the mother or child, in cases seen under circumstances similar to the one reported, for they doubtless include neglected and maltreated cases. In early operations, with the accoucheur present from the beginning of labor, the deathrate should not be so appalling.

Rare as this presentation is, its liability to occur in the practice of every physician should stimulate each one to so prepare himself as to be able to diagnose it before the membranes rupture, and, having so diagnosed it, set about intelligent correction of the same. "With the exception of shoulder presentations," says Cazeaux, "none of the malpositions of the child require the intervention of art, until, after waiting for a longer or shorter time subsequent to the rupture of the membranes and the complete dilatation of the cervix, it is as

certained that natural efforts are insufficient." It is true that a certain very small proportion of cases may terminate by the process of spontaneous version as described by Denman, or the spontaneous expulsion of Douglas, but these are subterfuges few are justified in taking. To quote Cazeaux, after citing a case graphically described by Velpeau, he says, “‘I may say briefly that the course of M. Velpeau was legitimized by the desire he had of testing the opinions of Denman, at that time in dispute; but young practitioners should be very cautious how they make such experiments, for although in the hands of a man like Velpeau the version at advanced period of labor would have been comparatively easy, yet it must never be forgotten that in trunk presentations the soonest possible period after the rupture of the membranes is the most favorable for artificial version."

In the case reported there were several points overlooked in making the diagnosis. A more careful and systematic auscultation of the position or fetal heart-sounds, with the fact that the presenting part was not as low down as it should have been in an ordinary breech presentation, associated with the favorable existing conditions, that progress was not as rapid as it usually is, and the absence of the head at the pelvic brim and at the fund us, should have suggested something different from a breech presentation. Introduction of the hand into the vagina would have been a valuable aid.

I am as much opposed to meddlesome midwifery as any one need be, or as the most conservative could desire. But once the necessity for obstetric interference becomes apparent, then the quicker it be done the better. An argument to establish such an assertion before this Society would be presumption. The necessity for prompt action has already been hinted at. If possible, the position and presenting part should be made out before the escape of the amniotic fluid, for there are several important resources known to obstetric art that are avail

able at this time which, if allowed to pass by unemployed, are not applicable after the escape of the waters. For example, the bipolar or combined method of podalic version of Brax