Intubation is indicated in every in stance in which dyspncea is caused by laryngeal obstruction, except when due to lodgment of a foreign body in such a manner that the introduction of a tube is mechanically impossible. Bernard Wolff (Laryngoscope, Nov., '9S).
When we are called to a case of suffo cation, before hastily resorting to intuba tion we should make a correct diagnosis and exclude the cases in which this oper ation is clearly indicated. This matter of differential diagnosis is most impor tant, and a patient's life may depend quite as much upon the diagnostic skill of the physician as upon his ability to do the operation when indicated. The special field and usefulness of intubation is in cases of diphtheritic or membranous obstruction of the larynx; the presence of growths in children, as papilloma; and cicatricial stenosis in the adult.
Intubation recommended in certain cases of laryngeal stenosis from chronic inflammation or from accidental or sur gical conditions. Thomas Annandale (Brit. Med. Jou•., Mar. 2, 'SO).
Intubation in syphilitic stenosis af fords, in a large proportion of cases, the simplest and most practical means de vised of quickly and efficiently relieving the dyspncea of acute laryngeal stenosis, and for dilating chronic cicatricial strict ure with speed and certainty. Lefferts (Med. Record, Oct. 4, '90).
[In cicatricial stricture of the larynx, after thorough dilatation has been ac complished, intermittent intnbation, ex tending over a considerable period of time, will be required in order to effect a cure. First personal case was of this nature, and required. occasional dilata tion for three years to accomplish a permanent cure. The intervals between the intubation were at first one week, which was finally extended to two months, the tube being left in position from one to three days on each occasion.
The significance attached to the results obtained in a small number of cases of chronic stenosis of the larynx treated by intubation is very different from that to be derived from an equal number of cases of croup, because in the former there are none of the complications that exist in the latter. It matters not how badly the patients swallow, no pulmo nary complications ever occur, or, at least, ever have occurred in my experi ence. JosErn O'DwyEn. Assoc. Ed., Annual, '92.] All cases of chronic stenosis requiring intubation are divided into two classes: (1) those in which the operation is prac ticed for the double purpose of relieving existing dyspncea and at the same time producing gradual dilatation of the stricture; (2) those in which it 'is re sorted to in order to get rid of retained tracheal cannul. O'Dwyer (Jour. of
Laryng., Oct., '94).
Case of laryngeal stenosis in which tracheotomy was first performed; strict ure then dilated with sounds from below until small tube could be introduced from above. Tracheal wound allowed to close and large tubes introduced into larynx. Cholmeley (Birmingham Med. Rev., May, '95).
[This procedure recommended in former editions of Annual. Very slight enlargement of tracheal wound only necessary. From above, the tube may enter one of the ventricles and create false passage. JOSEPII O'DWYER, Assoc. Ed., Annual, '96.] lntubation in infant in whom nut-shell had entered larynx. Complete relief. Bonain (Revue Mens. des Mal. de l'En fance, July, '95).
It is unnecessary in this connection to review the literature of intubation in cases of papilloma in children or of cica tricial stenosis in the adult. It is a legiti mate and often successful procedure in both conditions.
Intubation in Diphtheria.— In the great majority of cases the operation will be called for to relieve the impending suffocation in diphtheritic or so-called membranous croup.
In "cases of diphtheritic or mem branous stenosis of the larynx, which conditions I believe to be identical with perhaps a very few exceptions, it often becomes a nice question of judgment as to when we should interfere surgically. Shall we operate early with the first symptoms of laryngeal invasion or wait until it is evident the patient must die unless given relief? I would say that if we operate early we will do so in many, in these days of antitoxin, that would re cover without operation; on the other hand, if we operate late, after the patient has become comatose, and unconscious, we will lose cases that would recover otherwise. It does not often happen that the operation is done early, as it is gen erally performed by the specialist, who is only called in as a last resort. I believe it can be safely said that the operation is more frequently performed too late to give the best chances of recovery than too early. Inasmuch as, properly carried out, the operation in no wise com promises the case or adds to its danger, but gives comfort, relieves suffering, and prevents exhaustion, there seems to be no valid reason why the operation should be postponed after certain well-marked symptoms have occurred.