There are signals of danger and dis tress which should never be passed un heeded and which, once recognized, ren der the operation imperative. When the voice becomes toneless, and whispering and the cough suppressed; when, in ad dition, the dyspncea becomes urgent, and the loud stridor of croup is heard both during inspiration and expiration; when there is marked recession at the base of the sternum and above the clavicles; and when all these symptoms cannot be re lieved by emetics, it is certainly time to operate.
While we are not justified in waiting longer after these symptoms have ap peared, it is even better when possible to operate earlier. When the diagnosis of diphtheritic or membranous laryngitis is clear and positive, as indicated by the voice and cough, beginning dyspncea, the bacteriological examination, and the gradually increasing distress, in spite of treatment, I believe we should not wait until the condition becomes alarming.
Again, in infants, and in young and feeble subjects, the dyspncea, while not sufficient to give rise to marked cyanosis or alarming symptoms of suffocation, may, nevertheless, be sufficient to cause dangerous or even fatal exhaustion. In these cases it is our plain duty to operate earlier than when the patients are older, more rugged, and better able to stand the exhaustion caused by difficult respiration.
In all cases of intended intubation the surgeon should have instruments ready at hand for tracheotomy, and should not only have the consent of the parents for intubation, but for tracheotomy, also, if the latter should become necessary. Bays (Lancet, Sept. 20, '90).
Intubation should be practiced in all cases presenting any one of the follow ing symptoms prominently: Deep epi gastric recession with each inspiration, labored and prolonged expiration, ex treme restlessness, spasmodic attacks coining on at intervals, or persistent cyanosis. In cases seen late it might be wiser to intubate and administer anti toxin rather than administer antitoxin and wait for its effects before intubation. II. M. McClanahan (Brit. Med. Jour., July 9, 'M.
The indications of successful introduc tion of the tube are relief of dyspnit, and violent, straining cough. It is im portant that this cough should be pres ent, as it causes expulsion of loose mem brane. If it be absent a drink of whisky should be given to excite it. Bernard Wolff' (Laryngoscope, Nov., '98).
Serum-therapy has greatly diminished the percentage of operations in laryngeal, diphtheria, as antitoxin causes the most serious symptoms of stenosis to rapidly disappear; the main use of intubation now is to assist in tiding the patient over momentary danger. Collective investiga tion to ascertain the extent to which in tubation has been employed in private practice, and the results obtained. An swers received from S4 European and American physicians, 55 of whom have altogether performed 546S intubations in private, with an average of recoveries of 35.6 per cent., before seropathy was adopted and of 81.98 per cent. since. Ac cidents after intubation shown to be by no means so common as believed, and as might be theoretically expected. Trumpp (Miinchener med. Woch., No. 44, '99).
Technique.—PRELIMINARY PRACTICE.
—Preliminary practice upon the adult cadaver is of but little help in acquiring the operative technique for children. The adult larynx, in the cadaver, is al most beyond the reach of the finger; the epiglottis is prominent, while the cavity of the larynx is large and easily deter mined. In young children, however, the epiglottis is small; while the rims glot tidis feels to the touch as a mere slit or depression. By referring to Fig. 9 it will be seen that if the epiglottis is drawn for ward with the finger and the tube is passed in the median line with its point hugging the anterior wall, it must neces sarily pass into the larynx. It is impor tant to follow preceisely the median line and to hug the anterior wall with the point of the tube.
Many operators prefer to perform the operation in the adult by the aid of the laryngeal mina. The patient holds the tongue (with a napkin or soft towel be tween the thumb and forefinger of the right hand) well drawn out, while the operator, sitting in front and aided by reflected light from a mirror on the fore head and by the laryngeal mirror, guides the tube over the epiglottis and engages its point in the cavity of the larynx. Quickly dropping the laryngeal mirror from the left hand he then passes the forefinger down upon the head of the tube and crowds it into position. One accustomed to laryngeal work will per form the operation in this manner very readily, but the procedure is practically impossible for one not familiar with laryngeal instruments and their use.