MEDICAL JOURNAL

A Journal of Medicine and Surgery

Vol. XLVIII No. 4

BALTIMORE, APRIL, 1905

INTUBATION EXPERIENCES.

By Wm. T. Watson, M.D.

Whole No. 1043

READ BEFORE THE SECTION ON LARYNGOLOGY AND RHINOLOGY, MEDICAL AND CHIRURGICAL FACULTY OF MARYLAND, FEBRUARY 24, 1905.

THE first of my patients to be intubated was operated upon by Dr. W. D. Booker October 9, 1894. The tube was removed on the fourth day. The child breathed well for an hour or so and then rapidly closed up. By the time I secured Dr. Booker-some five hours after the tube's removal-the child was fighting hard for breath.

Ten months later Dr. J. W. Chambers was called by me in the morning to intubate a two-year-old child, but was unable to operate before 5 P. M. The physician and parents had several anxious hours, and the child's life was greatly imperiled.

These experiences determined me to do my own intubating. I read up on intubation, and resolved to get a set of instruments.

On October 1, 1895, I was called to a case of laryngeal stenosis in an infant of 10 months. It had been treated by a physician for pneumonia. A neighbor, seeing the resemblance of symptoms to those in a case in her own house, diagnosed it as "chronic croup." The physician accepted her diagnosis and also her suggestion to send for me, as she thought I knew how to intubate.

I tried to get someone to intubate, but without success. Dr. Chambers was occupied, but kindly offered to lend me his set of instruments and encouraged me to try to use them. I, however, procured a set for myself, and succeeded very well. I passed the tube into the esophagus two or three times, and finally landed it in the larnyx. A large quantity of mucus was coughed up. Much to my dismay, the tube became obstructed and I had to remove it and intubate again. Dyspnea was relieved, but the child died 15 hours later. Antitoxin was not administered until three hours before death. I had advised its use at the time of intubation.

This was the beginning of the most satisfactory work I have done in my professional career. Provided it is within a reasonable radius from home. I hail with delight every call for laryngeal diphtheria. At a distance these cases are exceedingly troublesome. In the past nine years I have intubated 109 children, or an average of one a month--just about enough to keep me in practice. Antitoxin came into use in the spring of 1895-just 10 years

ago-so that all my intubations have been performed in the anti

toxin era.

ANTITOXIN CASES.

One hundred of my cases received antitoxin. In most of the cases the diagnosis of diphtheria was confirmed by culture, by membrane in the nose or throat or which came up during operation, or by the presence of the disease in other members of the household.

Of these 100 cases 78 recovered and 22 died.

Of the 22 fatal cases 13 were almost beyond hope when I saw them.

On several occasions I have been called to operate, but found the children dead upon my arrival. In several other cases I arrived just in time to get them into my statistics, but too late to be of any service save to make easier the mode of death. The neglect has sometimes been on the part of the parent, but more often upon that of the physician.

Eighty-one of these cases occurred in the practice of other physicians, and I had but little control of the time of intubation or of the amount or time of administration of the antitoxin.

Of these 81 cases 19 died, or a mortality of 23.5 per cent. Nineteen of these cases were in my own practice. There were three deaths, or a mortality of 15.8 per cent.

These percentages compare very favorably with those reported by other operators.

In the pre-antitoxin days these figures would have been reversed -about 22 per cent. of recoveries and 78 per cent. of deaths.

The mortality was greatly influenced by the age of the patients. But one-fourth of my cases were under the age of two years. Yet 60 per cent. of the deaths occurred in this fourth. The younger the patients the less able are they to battle for breath and to withstand the diphtheria poison.

NON-SERUM CASES.

In the nine cases receiving no antitoxin the stenosis was due to the following causes:

One to measles (recovered).

Two to catarrhal laryngitis (recovered).

Three to diphtheria (two died).

One to papilloma of larynx (recovered).

One to a post-diphtheritic contraction (temporarily in my care). One to tuberculous lymph glands.

Of the three diphtheritic cases, one died a few minutes after intubation and before antitoxin could be administered. One died three and one-half days after operation. I advised the use of antitoxin, but, because the only culture made was negative, the attending physician would not use it.

The third case got well without antitoxin. It was in the early days of the serum, and the child's physician did not then believe in it.

AGES.

The ages of my patients have ranged from six months to

12 years.

In my six-months' case the larynx was normal and there was no difficulty in introducing the one-year tube. The infant had dyspnea, which was so great that for several days it could not nurse. It made a whistling sound with each respiration. Intubation afforded no relief. We suspected pressure from tuberculous glands, as there were several enlarged glands in the neck. The dyspnea gradually subsided. Six months later, when the child was a year old, it died of tuberculosis of the lungs and pleura, and the offending glands were located at the bifurcation of the trachea. They were the seat of an old tuberculous process.

In my 12-year-old case the tube appropriate to the age could not be introduced without force, so I used the eight-nine-year size. It was retained in spite of hard coughing. At the end of three days it was coughed up and the child was well.

SOME DIFFICULTIES ENCOUNTERED IN INTUBATION.

In theory intubation is as easy as dropping a nickel in a slot. An aunt of one of my patients had this idea, for a niece having coughed up her tube, the aunt was on the point of trying to replace it when I arrived. She said: "It's just like putting a shuttle in a sewing machine and makes the same noise."

In practice it is often beset with difficulties, and I know of two instances in which the patient died during the physician's first attempt to intubate.

Improper Position.-One important source of trouble is improper position of the child, due to inefficient assistants.

Having the child properly held is essential to rapid and careful intubation. On two occasions in my experience the child was held by a drunken man. One of these men committed suicide a few days later while suffering with alcoholic mania. He really did better than some more sober but more nervous people, and took great pride in following the "perfesser's" instructions to the letter. The other fumbled and delayed the operation, which was, however, finally successful. I nearly lost one case because the mother who was holding the child fainted as I was operating.

Spasm of Laryn.r.-Spasm of the larynx proved to be a serious complication in one case. The moment my finger touched the larynx there was a complete apnea with intense cyanosis. The spasm relaxed very slowly. I tried repeatedly to intubate, but found the larynx tightly closed. I finally desisted and called in Professor Chambers, who encountered the same difficulty. He finally used more force than I dared to use, and the tube went into place.

Some degree of spasm of the larynx is frequently encountered during intubation, but it usually relaxes in a few moments.

Tube Too Large.-On several occasions I could not insert without force the tube called for by the age, but the next size smaller proved to be the proper one.

l'omiting of Food.-Vomiting of food is not apt to occur

during the first intubation, for, as a rule, the child suffering from dyspnea has taken very little food.

In a succeeding intubation it may be a source of danger. In a recent case dyspnea returned quickly after extubation. The child had just taken a bottle of milk, and I could insert the tube only after several vomiting attacks, caused by my fingers, had emptied the stomach.

In another case the baby coughed up the tube just after nursing eight ounces of milk. Necessity for reintubation was most urgent. Attempts to intubate caused vomiting. By the time the vomiting ceased the baby was almost asphyxiated. I did artificial respiration, and in one-half hour the patient was breathing normally.

Struggles of Patient.-In some cases, especially in a second or later intubation, the child knowing what is coming and being in a more vigorous condition, will clinch the jaws until almost asphyxiated. In one case I was unable to operate until the child ceased to breathe. Artificial respiration was done, and the child in an hour was as well as ever.

Effects of Anesthesia.-One intubation under anesthesia proved to be puzzling. The child had been wearing a tracheal canula, the larynx being in a peculiar contracted condition following diphtheria. Dr. Blake, whose case it was, introduced the tube under anesthesia, but found there was complete apnea. Later on, while Dr. Blake was absent from the city, I had the same experience. We supposed that the lower end of the tube must be occluded by granulation tissue caused by the wearing of the canula. On a later occasion I had the same experience, but before removing the tube I made a digital examination of the larynx and found the epiglottis tightly applied to the top of the tube. I pulled the epiglottis forward, and respiration went on in a normal manner. I held up the epiglottis until the child awakened from the anesthetic, when she was able to breathe and swallow all right. Whether this would frequently occur under anesthesia I am unable to say, but it is an experience worth keeping in mind.

Pushing Down Loose Membrane.-Every now and then, after a tube is in position, the respiration is worse than before. If the tube is removed by means of the thread the offending membrane is pretty sure to follow. The membrane is more loosely attached in the larynx and trachea than in the nose and throat, and is readily detached. The specimens which I show-three casts of the trachea, and one of trachea, bronchi and bronchioles-were brought up in this way.

In my last case, February 5, 1905, after intubation the child breathed very well for 20 minutes. I then removed the thread. As I was preparing to leave, the child began to cough, when expiration became suddenly arrested with a clicking noise. This meant loose membrane. I immediately extubated, and the tube was followed by a cast of the trachea.

Abnormality of Larynx.-In December last I encountered a peculiar and difficult case in a girl of three years. I tried a tube for a three-year child, then a two-year tube, and finally a one-year