INTIMATION OF THE LARYNX.— Few operations in the history of medi cine have excited more wide-spread in terest than intubation of the larynx. It modifying the instruments as to make them of practical utility.
The relief of laryngeal stenosis by means of catheters introduced into the trachea through the larynx, the use of the short round tube as used by Bouchut (Fig. 1), and Dr. O'Dwyer's early experi ments and the gradual development of the instruments (Figs. 2, 3, 4, 5, 6, and 7), are all a matter of history which has been fully recorded in medical literature.
has fulfilled the expectations of its advo cates, and has fairly and surely won its way in favor, until it now outranks the older and time-honored operation of tracheotomy. We are indebted to Dr. Bouchut, of Paris, for the idea of reliev ing stenosis of the larynx by a tube intro duced by way of the mouth, but to the late Dr. Joseph O'Dwyer, of New York City, belongs the imperishable honor of reviving the operation from buried for getfulness, and by his ingenuity of so Intubation of the larynx is a difficult operation; indeed, by many it is regarded as one of the most difficult in surgery. It certainly requires the maximum amount of manual dexterity if it is to be performed with gentleness and celerity. One cannot become expert without con siderable practical experience.
Theoretical knowledge is important, but I would emphasize the necessity of a thorough and careful training by prac tice upon the cadaver. Unless the oper ation is quickly and skillfully done, it be comes one of the most repulsive and brutal in surgery. This difficult tech nique has doubtless had much to do with the opposition it has met in the past.
Indications.—In considering the sub ject of intubation, one of the first ques tions raised will be as to the diseases or conditions calling for the operation. Are all cases of alarming dyspncea to be treated by intubation? Most decidedly not. in case of foreign bodies so im bedded in the larynx as to produce diffi cult respiration the performance of in tubation would obviously be a fatal mis take. In cases of pharyngeal abscess located low down, causing more or less difficulty in breathing, or the presence of retro-cesophageal abscess, had better, for obvious reasons, be treated otherwise.
In many cases there is marked dyspncea from great enlargement of the tonsils and uvula, associated with nasal obstruc tion, with little or no involvement of the larynx. Intubation would be useless and uncalled for in these cases. (Edema of the larynx may give rise to great and even fatal dyspncea. The majority of such cases, I am convinced, are better treated by tracheotomy. In most of these cases the swelling of the arytenoid cartilages and of the epiglottis is so great that the head of the tube in the larynx is overlapped; hence little relief is ex perienced. The larynx here requires rest, which it cannot obtain with a large heavy tube in Sit/L.
[No form of acute stenosis of the larynx, when situated in or above the chink of the glottis, ever offers any very serious impediments to passage of a tube of the proper size. The infiltra tion of the mucous membrane, which is the principal cause of the obstruction in croup, is rarely, if ever, confined to these parts, but extends to the subglottic division of the larynx; and, this being small in the normal condition, any con siderable swelling of the tissues reduces the breathing space, in some cases, to a mere pin-hole. JOSEPH O'DWYER, Assoc. Ed., Annual, '92.] Two cases noted in which it was im possible to introduce the laryngeal tube, owing to smallness of the glottis, due to Ganghofner (Jahrb. f. Kinderh. n. phys. Erzie., Nov. 30, 'S9).
Intubation with permanent relief of dyspnwa in ease of subglottic oedema, using a No. 6 tube. Chiari (La MM. Mod., Nov. 14, '94).
[No. 6 tube, the largest of children's tubes, not safe in adults, even immedi ately after the age of puberty, without a strong string attached. J. O'DWYER,. Assoc. Ed., Annual, '96.] Intubation is of great service in the slighter forms of laryngeal obstruction due to catarrhal inflammations, but in the severer forms of laryngeal obstruc tion intubation is only slightly more favorable in its result than tracheotomy. 1. Jeffreys Wood (Intercolonial Med. Jour., Nov., '97).