[This is sufficient to produce fatal apinva, a silk thread having produced serious obstruction. In performing tra cheotomy after intubation, it is impor tant to remember that, unless the cricoid cartilage be cut, it is impossible to pull tube downward. It must be pushed up ward with small forceps or by lateral external pressure. JosErn O'DwvEn, Assoc. Ed., Annual, '961 Death a few minutes after intubation in ease treated with antitoxin. Supposed to be due to bulbar reflex. Duran (Amer. Jour. Med. Sciences, June, '95).
[Convulsions are usually due to partial asphyxia from prolonged attempts to in- • tnbate, and to uraemia. Illustrative case, in which high temperature (107° F.) was found to be cause of convulsions. JosErn OHNvvrm, Assoc. Ed., Annual, '90.] Accidental swallowing of tube in 4 cases out of 122. Two of the children passed the tubes,-1 in two days, the other in three days. The other 2 died from disease; one tube found in the stomach, the other in the etecum. Variot (L'Union Med., July 13, '95).
[If properly placed and string removed, unusually large percentage of accidents. In only 2 out of almost 500 personal cases were tubes coughed out or swal lowed. JOSEPH Assoc. Ed., Annual, '90.] Prolonged intubation and consecutive ulceration of trachea and mediastinal ab scess. Mes]ay (Jour. de Med. de Bor deaux, July, '95).
O'Dwyer's tube seems occasionally to be productive of laryngeal stenosis. The majority of cases of stenosis occurred in children who had expelled the tube fre quently during the treatment of their laryngeal or other trouble. Some of these stenoses were seated below the glottis; others, and they were the gravest, were situated at the level of the cricoid cartilage, where the larynx is narrowest. Repeated expulsions of the tube are symptomatic of laryngeal ul ceration of the cricoid region of the larynx. This region should serve as the gauge for the size of the tube to be used, which would vary according to the child's age. BOkai, Heubner, Boulay, Sevestre (Twelfth Inter. Congress of Surgery; N. Y. Med. Jour., Oct. 16, '97).
Importance demonstrated on regulat ing the sire of the tube in accordance with the size, and not the age, of the child. Glover (Jour. of L., R., and 0., Mar., '98).
Case in which intubation was prolonged to one hundred and thirty-six days. The tube may be left for a long time in the larynx without harm, provided that it is of the proper size and material and that the surgeon bear in mind the delicacy of the structures upon which he is working. Ichthyol is an excellent agent as antisep tic in cases of intubation. Tanturri (Gior. Inter. delle Scienza Med., June 30, 1900).
In case there is long-continued neces sity for the use of the tube, what can be done? After removing the tube on the fourth or fifth day, if the dyspncea re turns, a smaller tube should be intro duced instead of the one removed. This
in turn should not remain longer than two days without being removed, pro viding it has not been previously ex pelled. If the dyspncea still returns, in troduce a still smaller tube. The effort should now be to use the smallest tube that will be retained. This method, to gether with the free administration of strychnine, offers the greatest hope of promptly overcoming the difficulty.
It should be a rule of practice to re move the tube within five days after the operation unless it be removed by ex pectoration betore, and then be no longer required. All cases requiring a tube for a longer period than five days should receive large doses of strychnine and constant reintubation and extuba tion daily or every second day, and progressively smaller tubes should be used. E. Rosenthal (Amer. Med., May 4, 1901).
Modifications of O'Dwyer's Instru ments.—The instruments as fully per fected by Dr. O'Dwyer have been modi fied by various operators; some of these modifications are questionable improve ments, while some undoubtedly possess advantages. The main idea, however, re mains unchanged; and, however, greatly the instruments may be altered, the fame of the great and original inventor will never be dimmed. In this connection reference will be made to only a few of these modifications.
The writer, in the early history of the operation finding the original gag (Fig. 17) inconvenient on account of its strik ing the shoulder, had one constructed (Fig. 18) to extend backward instead of downward, thus overcoming this objec [A single instrument cannot be con structed to satisfactorily serve both pur poses. If tubes are long, the curve of the introducer must be short, else the difficulty of entering the larynx is in creased; tubes cannot be removed with short-curved extractor except in very young children. JOSEPH O'DwYER, Assoc. Ed., Annual, '96.] The writer some six years ago, with the assistance and co-operation of Charles Truax & Co., of Chicago, devised a set of instruments differing in many particu lars from those of O'Dwyer, the domi nant idea, however, being the same. The aim was to insure more perfect disinfec tion. The obturator has no joint and is tion. This gag answers well all require ments. The gag has also been modified by others, notably by Henrotin (Fig. 19) and Allingham (Fig. 20). An ingenious method of overcoming the difficulty of extracting the tube was devised by Dr. Dillon Brown, of New York. It consists of a tube, with small ring attached to the head, and a thimble, with hook attached, which he used on the index finger of the right hand. Having never used this method, I cannot speak of its merits. Another modification has been devised by Ferroud, aiming to make one instru ment answer for both extractor and in troducer; his instruments have been still further modified and simplified.