Ernest Watson Cushing.

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tem, being subject at times to looseness of the bowels with the pas-
sage of considerable mucus. He was breast-fed for six months
after which cow's milk diluted with lime-water and barley-water
was used with such success that when I first saw him he was well-
nourished, not rachitic in any way, but rather pale from an ill-
ness which had begun eight days before, following a rather pro-
longed airing. The onset was so sudden that the mother said she
felt his temperature rising in a very short time while holding him
on her lap. The physician who was called prescribed a laxative
and a fever-mixture, the latter being taken for several days, un-
til the physician left town for some time, when Dr. Starr was
called in, who referred the case to me on the following day. At
his visit the tonsils were seen to have a few follicles distended,
there was a catarrhal condition of the naso-pharynx, the glands
at the angles of the jaw were swollen, more so on the left, there
was a marked cough with a few loose rales in the chest, and the
bowels were moving four times a day, the movements being wat-
ery, greenish and slimy. When I saw him the next day, his con-

♦Read before the Philadelphia Pediatric Society, October 11, 1898.

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dition was unchanged except for a marked improvement in the
tonsillar condition, the yellow plugs having entirely disappeared.
The temperature, which had been 103.° 8 F. the previous even-
ing, had fallen, without any perceived perspiration, to 99° in the
morning, and continued to follow this course for nine days longer,
or fifteen days from the onset, falling to about 99.° 5 in the morn-
ing and rising to about 104° in the evening. The cervical glands





P k O atUpkia, J. B. tApjnmcotl Gmpat^.

remained swollen, the catarrh of the pharynx persisted, while the
rales in the chest were heard in the smaller bronchi and in a few
areas were so fine as to be considered pneumonic, but the extent
was hardly enough to account fo'^ the marked febrile movement.
Five days after I first saw him, three varicellar blebs appeared and
slowly dried up. The spleen was at no time enlarged, the ab-
domen could always be freely palpated and the intestinal catarrh

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Steadily improved. The appetite was fair and he took his milk
and other feedings well, the stomach being retentive. The case
was of such a nature that a thorough physical examination was
imperative at each visit, and after a few days close watch was kept
for two conditions especially, empyema and retropharyngeal ab-
scess. The first condition was thought of because of the similari-
ty of the symptoms to those presented by a case later developing
empyema, described by Dr. Pepper in a conversation. The sec-
ond condition was rendered more probable by the striking sinoii-
larity to a case reported by the writer in the Archives of Pedia-
tries, July, 1895. There was no dysphagia, the breathing and the
voice were not altered and there was no wry-neck. The pharynx
was palpated several times, but no swelling could be detected un-
til 13 days after the onset, when the left side of the posterior
pharyngeal wall began to bulge. For several days following this,
a curious phenomenon was observed; after taking a feeding and
without any apparent pain in the stomach, the child would retch,
wilfully as the nurse thought, until the curdled milk would be re-
gurgitated. (It would seem that the swelling gave rise to a sensa-
tion as of something in the pharynx to be swallowed, which not be-
ing accomplished, an attempt would be set up reflexly to discharge
it through the mouth.) Fluctuation could not be felt in the swell-
ing, which increased so slowly in size that not until after three
days was it deemed advisable to incise it. The amount of pus
liberated by the incision could not be estimated, as the* greater
part was swallowed before the child could be inverted. There
was extensive induration in the al^cess-wall which subsided
very gradually, a little thickening still remaining 10 days
later when the child was taken to the seashore. As seen by the
temperature-chart, the incision of the abscess put an end to the
high evening-temperature, the curve then assuming the inverted
type. On the third evening the drop was sudden, the tempera-
ture falling in two hours from normal to 96 2-5°, with a cold
perspiration and a weak pulse. The usual treatment established
reaction in a few hours, but there was a tendency on several suc-
cessive evenings to a fall in the temperature, which had to be
combatted vigorously. From this time on, conyalescence was
steady and uninterrupted.

While the condition which subsequently developed in the
course of the illness was anticipated for several days before it ap-

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peared, the descriptions of retro-pharyngeal abscess in the stand-
ard text-books did. not resemble, in any of the major points, the
course of either of the two cases I have seen. The course is de-
scribed as being short, with symptoms of dysphagia, disturbances
of speech and respiration and wry-neck. In both of these cases
the illness lasted for nearly two weeks before the abscesses de-
veloped, and in neither of them was there disturbance of swallow-
ing, speaking or breathing, further than a slight noise, hardly
a snore, but such as is produced by a nasal catarrh. It is possible
that the symptoms described in the books occur in cases that are
allowed to go on until the abscess would almost empty itself, but
the diagnosis can easily be made before such a condition develops.
With a fluctuating temperature and enlargement of the glands
at the angle of the jaw, no other lesion being found to account for
the temperature, suppuration may be looked for in the lymphatic
structures adjacent, either back of the pharynx, or in the external
cervical glands themselves, as occurred in an infant seen with Dr.
Stout of Wenonah.

211 South Seventeenth Street, Philadelphia.


M. Paul Gaston has made a careful study of a form of cough fa^
miliar to us all and often treated as he says, sans rdsuHat. This cough
is peculiar in that it is spasmodic, suggesting whooping cough, often
causes vomiting and occurs almost exclusively at night. Dr. Gaston
attributes it to a posterior coryza. The child is too young to cough
and spit, and hence the discharge from the mucous surfaces, runs back
and at night when the child is lying down, drops through the pharynx
and into the larynx. A reflex in the region of the aretynoids and
vocal cords is excited, and spasm of the glottis ensues. Following this
explanation, he suggests treatment by introducing through the nostrils
long, narrow plugs of absorbent cotton dipped in borated vaseline, to
which may be added tannin, alum, etc., if desired. The child vnll
sneeze at first, but soon becomes accustomed and the coryza is rapidly
cured. — (Journal de clin. et de thorap. enfant.)

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Reported by F. W. Sawyer, M.D., Superintendent of Boston Floating




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Services of Drs. Robert W. Hastings and William E. Fay. C. M.
Age 9 months. Diagnosis : Cholera infantum. Admitted July 29,
1898. History : Vomiting and diarrhoea for two days; very numer-
ous green watery dejections. Has been fed on barley water since
taken sick. Child collapsed when brought on board in hospital.
Bectal temperature 104. °4 F. ; extremities blue and cold. Ex-
tremely restless and tos^^es about all the time. Weight 16 lbs., 12 oz.

Diet: Albumen water or wine whey, q.s.

Child was brought in in a very bad state and was at once given
stimulants and external heat applied. Became more quiet and
extremities got warm. Temperature ran up to 105° F., and was
given a sponge bath. This gave him some relief and he slept for a
few hours.

July 30. — Same food given today:

5. Whiskey, m.x every hour.
^ . Calomel, gr. 1-10 to ten doses.

Had five light-green watery dejections. Vomited twice dur-
ing the night. Temperature ran high, but limbs were so cold that
sponge baths were not given until temperature was 106.° 8 F.;
then after bath the pulse was weak and limbs very cold and blue.

July 31. — This morning, child had temperature of 107° F.,
and was in a state of collapse. Was given bowel irrigation with
normal saline solutions, temperature 60°, which reduced the
axillary temperature 3°, but left him in a worse state than before
and caused him to vomit. Eyes were rolled back in the head and
pupils widely dilated and crossed. Taking up the theory of Dr.
Fitz that the cause of cholera infantum was really hyperthermia,
it was suggested that the efi^ect of cold applied to the nervous
system as nearly as possible should be tried to see if by stimulat-
ing the great nerve centres the control of the heat production in
the body might be regained.

A thick compress was applied over the head, and a narrow but
thick one down the spine from the occiput to the sacrum.

At first they were saturated with cool water; then the tempera-
ture of the water was reduced until it was ice-cold. Brandy m.xv
was given every fifteen minutes all day, and wine whey Jss every
hour. Under this treatment the temperature came down slowly
and at 3 p. m. was 103.°2 F., and the child went to sleep. Four
dejections were recorded during the day, yellowish brown in

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266 F. W. SAWYER.

August 3. — Diet same. Has had a quiet night with one de-
jection, yellowish green in color. Temperature remained about
100° F. Slept well. Has had two dejections today of same
character as last night. Did not seem very well in the morning,
but picked up in the afternoon. Weight, 15 pounds, 10 ounc^.
August 4, — Diet same. Had a quiet night. One dejection,
yellowish green in color, with some mucus in it. Cried con-
siderable. Still doing well but fussed much during the day. Did
not have on compresses all day. Had three dejections, yellowish
green in color.

August 5. — Diet: Cream, 3^ added to whey feeding. Amount
of each feeding increased ,^8S. Dejections dark green, two in

August 6. — Diet: One and oue-half ounces of ilodified Milk,
with the formula :

Fat, 1.00

Sugar, 5 00

Proteids, 0.75

Alkalinity, 5 per cent

Brandy continued.

Coughed some last night and during the day. Two move-
ments, green with curds. Modified milk cut off for the night
and whey given in its place. Temperature 101° F. Slept well
all night.

August 8. — Diet continued same. Has two to four dejections
a day, green with some mucus. Coughs more.- Weight, 15
pounds, 8 ounces.

Physical Examination. — A few dry rales heard beneath the
angle of the left scapula. Percussion note normal.

August 10. — Brandy cut down one-half. Temperature ran
up to 102° F.

Diet: Two ounces of Modified Milk, with the same formula as
above, alternating with one ounce and a half of plain whey, and
Brandy, m.x.

Has large yellow dejections. Sleeps well and looks very
bright. Temperature 100° F.

August 11. — Diet: Two and one-half ounces of Modified Milk,
with the formula:

Fat, 2.00

Sugar, 6.00

Proteids^ 1.00

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Brandy, m.x every two hours, this increasing materially the
amount of food. Weight, 15 pounds, ^ ounce.
August 12. — Diet:

Cream, 3f

Barley Water, ^i

Water, ^i

Lime Water, 3i

Milk Sugar, 3ss

Had a bad time t^day, looks very badly and temperature is up
to 104.^ F. Hands and feet cold and child very restless. Has
vomited three times today and the order for the food was changed
to the above.

August 13. — Grew worse until late in the evening and was
collapsed badly.

External heat warmed the extremities, and ice-cold compresses
applied to the head and spine brought the temperature down and
brought on sleep in a few minutes. Was given Whiskey, m.xv
every fifteen minutes for a time. Slept for some time and took
stimulants without waking. Cold compresses were taken off for
an hour and temperature went up from 100.° 2 to 103° F. Came
down under treatment to 101.° 2 F., and he went to sleep again.
Vomited three times during the night and had one yellow dejec-
tion. Temperature has been about 102° F. today until tonight,
when it dropped to 100.°4 F. at 6 p. m. Has had Whiskey, m.xv
every half hour all day.
. August 16. — Diet:

Barley Water, '^i

Water, ,^ss

Lime Water, 3ii

Alternating with:

Plain Whey, ,^i

Albumen Water, Jss

Whiskey, m.xv every two hours.

Weight, 14 pounds, 6 ounces.

August 16. — Has not taken his food very well, but dejections
are yellow and well digested, two or three a day.

August 18. — Diet same. Calomel, gr. 1-20 to five doses. Has
had some green dejections with bad odor. Vomited once yes-
terday. Temperature went up to 102° F., and ice caps were aph

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268 p. W. SAWYER.

plied to head, giving him a chance to sleep. Vomited yellow
liquid today. Stomach was well washed out with weak boric
acid solution. Took next feeding greedily and has not vomited
since. Weight, 14 pounds, 2^ ounces.

Physical Examination. — ^Limgs still show a few rales at apices
of scapulse. Breathing very clear, however.

August 20. — Diet same. Whiskey, m.xv, every two hours. Had
a bad day and temperature went up to 103.° 5 F. Cold bath and
cold compress to head reduced the temperature, and he slept well
all night. Had two green movements yesterday. Today tem-
perature has dropped to 100° F., and he is smiling and playing in
his crib tonight.

August 31. — Child has improved considerably; is taking a fair
amount of food and digesting it fairly well. Temperature 99°
F. Has not vomited for two days. Has gained a few ounces in
weight during last four days. As today is the last trip for the
season this patient will have to be sent home. If proper care is
taken he ought to be entirely well in a few days. Weight, 14
pounds, 7 ounces.

This was one of the most interesting cases during the season.
The exceeding high temperature of 107° F., the two severe condi-
tions of collapse, the heroic treatment which brought about the
relief, with such a prolonged continuation of the symptoms, make
it a case worth while mentioning. Much credit is due the assist-
ant physician for his untiring efforts. Also a just amount of
credit must be given one of the nurses who took entire care of the
case, remaining on duty without being relieved, for thirty-six

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tubation, rarely occurs. As for myself, even in my first intuba-
tions, I made such arrangements in my hospital practice that
tracheotomy could be performed at any time in the diphtheria
pavilion. Furthermore, whenever intubation is called for in my
private practice, I carr^^ with me all the instruments necessary
for tracheotomy, and shall not neglect to take that precaution in
the future.

As intubators have never denied the possil
down the membrane during intubation, or of t
occluded, the question can only be, how often c
tion arise, and of what importance is it? Does i
so frequently and is it of so dangerous a natur
in the two operations, belongs by right to tracht

O'Dwyer,^ Fr. Huber,^ Dillon Brown,^ Waxl
Ganghofner,^ Baer'' andMcXaughton,* allemph
only exceptionally in their experience, has the
pseudo-membranes taken place. Occlusion of tl
membranes is also but rarely reported by intuba
the pioneer of intubation in Germany, makes tl
ment: "When the tube is introduced, we n
suddenly confronted with danger of suffocation
our obsen^ations in ifunich, this complication
countered. The experience of American pi
roborates this fact."

Practice, therefore, has failed to substantial
on theory; indeed experience has undoubtedl;
complications under discussion are only encouni
And why is the pushing down of pseudo-meml
introduction of O'Dwyer's tube, of so rare oc(
looked upon from a purely theoretical standp
supposed to be a frequent complication?

1. Because the edges of the lower end of the
and when the latter, rightly mounted with thi

(1) The Medical Record, 1887.

(2) Ibid.

(3) Ibid.

(4) The Journal of the American Medical Asso

(5) Verhandlugen der Gesellschaft ffir Einde
"bergr. 1889.

(6) Ibid.

(7) Deutsche Zeitschrift f. Chimrgrie, 1892.

(8) The Brooklyn Medical Journal, 1893.

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Such cases happened in the practice of the following observers:

1887: Ferguson,^ New York 1 case.

1888: Thiersch,* Leipzig of 31 observations, 1 case.

1888: Graser,' Miinchen of 4 observations, 2 cases.

1889: Guyer,* Ziirich of 27 observations, 1 case.

1889: Ganghofner,^ Prag of 41 observations, 6 cases.

1889: Ranke,^ Miinchen of 65 observations, 2 cases.

1890: Widerhofer,*^ Wien of 142 observations, 1 case.

1892: V.Muralt and Baer,*Zurich.of 74 observations, lease.

1892: MaNaughton,^ iNew York, .of 143 observations, 1 case.
1893: Schweiger and Hiittenbren-

ner,^^ Wien of 70 observations, 2 cases.

of 498 observations, 18 cases.

Of 498 intubation cases, therefore, an immediate tracheotomy
became necessary in 3 J per cent.* Tracheotomy failed to relieve
the asphyxia in only two of these cases to my knowledge — and
these patients died from the pushing down of pseudo-membranes.
One of these cases occurred in the practice of Dr. Von Muralt,
the other, in that of McNaughton. In Von Muralt's case (re-
ported by Baer) intubation was performed in the death agony.
Post-mortem examination showed, besides the detachment of
pseudo-membranes, bronchitis croupoea and extensive pneu-
monia. That a tracheotomy, moreover, in spite of the forcing
down of thick pseudo-membranes, does not appear to be absolute-
ly necessary in all cases, is sufficiently proved by the extensive
casuistry published by intubators. Immediate extubation leads,
in most cases, to the result that the loosened pseudo-membrane is
ejected by violent coughing, either simultaneously with the tube

(1) New York Med. Journal, 1887.

(2) Verhandl. der deutschen GeseUschaft f. Chirurgie, 1888.

(3) Miinchener Med. Wochenschrift, 1888.

(4) Correspondenzblatt f. Schweizer Aerzte, 1889.

(5) Verhandl. d. GeseUschaft f. Kinderheilkunde, Heidelberg, 1889.

(6) 1. c.

(7) Padiatrische Arbeiten, Henoch-Festschrift.

(8) Deutsche Feitchrift f. Chirurgie, 1892.

(9) 1. c.

(10) Jahrbuch f. Kinderheilkunde, 1893.

*In this paper, I have made use of those communications only in
which iiases of pseudo-membrane displacement were distinctly men-

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-membranes is really not pushing down, but
prolonged, that is, unskillful attempts to in-
T[ venture to state that the great majority of
)een reported as due to pushing do^vn pseudo-

> result of imskilled efforts and due either to
^ed attempts at introduction, or to asphyxia
trough a false passage." About the same may
of the tube by pseudo-membrane. It is met

but not frequently. It becomes dangerous
er sufficient control, that is, in these cases
tubation is neglected. In such cases, how-
tubation frequently takes place. The patient
iolent fit of coughing and simultaneously, the
ne. It is undoubtedly true that O'Dwyer's
ively narrow (narrower than the tracheal
limed by the most prominent intubators that
tudo-membranes can be ejected through these
cite merely from German literature — Baer
' Kinderklinik) reports several cases where
•ated large pseudo-membranes through the

bild expectorated in nine days pseudo-mem-

► centimetres in length, largely through the
ained in all eighteen days and four hours,
ms, 34; the tube was coughed out 15 times.

I four-year-old child expectorated 8 pseudo-
derable size, principally through the tube,
ms, 9. The tube was retained in all 145^

^ fact that secondary tracheotomy was not
case. Although Escherich* maintains that
tage of intubation is the excessively diflRcult
ectoration of pseudo-membranes, yet the
tances, as well as numerous cases cited by
1 the same happy result, ought to greatly di-
is assertion.

nd in the collective literature, only a single
►n of the tube by pseudo-membranes resulted
tion; it is that of Wheelerf in the year 1887.
Vochenschrift. 1891. f1, c.

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symptoms of detached membrane are undoubtedly present. Leav-
ing these tubes longer in the larynx is not to be advised, as they
might cause decubitus. In the use of these tubes, therefore, we
cannot dispense with the original O'Dwyer tubes.

I have used them, myself, only a few times, and can state mere-
ly, that their introduction is most difficult, even for very skilful

In the children's hospital under my charge, I have performed
more than 600 intubations, and among my collective patients, not
one death resulted from pushing down pseudo-membranes, al-
though this accident has happened several times. In three or
four cases, this might have resulted fatally, — as large and unusual-
ly thick membranes were detached in the trachea, — ^had not imme-
diate extubation overcome the danger of suffocation.

The following cases are cited, as instructive from a practical
point of view:

1. Katharine Sz., nine-year-old girl, admitted into the diphthe-
ria ward, February 26,^ 1892. Patient has been feverish for a
week, coughs, breathed with difficulty for one day. Medium
diphtheritic process in throat, stenotic breathing, decided symp-
toms of a stenosis of the upper air-passages. The dangerous ste-
nosis, together with pronounced cyanosis, call for prompt intuba-
tion, which is done at 11 a. m. Livid asphyxia follows intuba-
tion, on which account, patient is immediately extubated; a vio-
lent fit of coughing supervenes, during which a thick pseudo-
membrane of imposing dimensions is expectorated. The pseudo-
membrane is 13 centimetres long, a cast of the trachea,
bifurcation of the bronchi, even of the second, third and fourth
ramifications. After the expulsion of the pseudo-membrane, the
breathing is clear, the tube, however, is again inserted. On the
morning of February 27, as there is difficulty in breathing, in
spite of the tube secondary tracheotomy is performed, but with-
out success; early on February 28, symptoms of bronchitis
crouposa and pneumonia having developed, death took place.
Post-mortem examination showed: Superficial diphtheria of the
fauces, laryngo-trachitis and bronchitis fibrinosa. Pneumonia

•O'Dwyer recommends these tubes, also, when foreign bodies have
entered the upper air-passages, provided they are movable. In one
case of this kind, I have attempted to do this, without success, however.
Patient cured by tracheotomy.

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eroupoea of the upper and middle lobes of the right lung with
pleuritis fibrinosa of the same side.

It is worthy of mention, that a perfect copy of the expectorated
pseudo-membrane was found in the air-passages, which clearly
proves that in cases of so marked severity, the membranes may be
reproduced very quickly.

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