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J. A. (Joel Asaph) Allen.

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has been extracted. Breathing may go on easily for some minutes,
when suddenly stenosis recurs, requiring the immediate replace-
ment of the tube or death will speedily follow. In fact, the time
may be so short that it is always necessary to have a second tube
threaded ; if this has been neglected, a thread may be wound
around the upper end and immediately under the collar, and the
tube rapidly introduced. The cause of this second obstruction
occurring when the child has apparently recovered, and after three
or four days the tube removed, cannot possibly be due to reforma-
tion of pseudo membrane, as that cannot develop so quickly, but
seems to be caused by the relaxed tissue, and possibly the vocal
cords having been pressed apart for several days, suddenly collapse,
and thus shut off the air. I have had one death follow this acci-
dent. The child, four years old, had the tube removed the third
and fifth days, each time replacement became necessary within an
hour ; the seventh day, while playing about the room, and eating
bread, some crumbs probably having been drawn into the tube, it
was coughed up, and as immediate assistance could not be had, the
child died from suffocation.

We have a habit of counseling patients that in case the tube is
coughed up, not to swallow it. This seems to be a needless



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COTT : ' INTUBATION. 139

preoaution, according to O'Dwyer, as it never happens, the tube
always escaping by the mouth.

Nevertheless, a case is on record where the tube was swal-
lowed.

Occasionally, sadden cessation of respiration occurs after the
tube has been introduced, caused by false membrane occluding the
opening. In that case a small catheter may be passed through the
tabe to push the membrane out of the way, and while doing this
the child will probably die, it is far better to withdraw the tube
immediately ; the irritation attendant upon the manipulation usu-
ally causes coughing, and false membrane is expelled often in suf-
ficient quantity to relieve the stenosis.

All writers seem to agree upon the position in which the child
should be placed while introducing a tube. I do not lay much
stress upon this point. I have introduced a tube while the child
was lying in bed just as easily as when held by an assistant. Of
coarse, when the operation is done upon a child in bed, you may
depend upon it that it is so far gone it cannot resist. The object
of the upright position is only for the purpose of holding firmly
the struggling child.

What is the result of intubation as compared to tracheotomy ?
Wazam has gathered 1027 cases, of which only twenty-six per cent,
recovered. Rauchfuss reported to the Deutscher Aerztlicher
Verein in St. Petersburg thirty per cent, of recoveries in thirty-
eight cases, but adds that in eight cases tracheotomy had to be re-
sorted to. Prescott and Goldwaith report in Boston 3Iedical
Journal Z92 cases of intubation with a mortality rate of seventy-
nine per cent, and 139 cases of tracheotomy with a death-rate of
88 per cent. Altogether 2,815 cases of intubation and 23,941 cases
of tracheotomy have been collected and analyzed, showing very
little difference in the percentage of deaths in the two operations.
Although the percentage of recoveries is small, it no doubt would
be greater if left alone.

How long may a tube be borne by the larynx, is an interesting
question. The longest time I permitted a tube to remain in situ
was seven days. Dr. I. H. Lynde, of Fillmore avenue, had a
patient in which it was left four weeks, but the child finally died.
O'Dwyer left his first tubes in thirteen days on an average. In
one case it was left in a month, then extracted and re-introduced,
remaining in this time over two months without removal. Schmeige-
low, of Copenhagen, cites the case of a child six years old, in



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140 cott: intubation.

which intubation was performed three months after tracheotomy ;
the child finally recovered after having intubation kept up for a
whole year. Another case, a child four years old, intubated eight
days after tracheotomy, tube removed after a month, cure. A
most interesting case is recorded by Dillon Brown, New York. A
little girl, aged three and a quarter years, had intubation done seven
days after the first appearance of laryngeal symptoms ; twelve days
afterward, marked dyspnea was present during the course of an
attack of diphtheria ; dyspnea was immediately relieved, and a
piece of pseudo membrane was coughed up. At the end of seven
and a half days, the tube was removed, but was returned within
fifteen minutes because of urgent dyspnea. Four different
attempts were made to remove the tube, but it had to be returned
each time after intervals ranging from four hours to thirteen days ;
it being impossible to insert a full-sized O'Dwyer tube, and the
smaller one not relieving dyspnea, tracheotomy was performed.
There was marked stenosis of the trachea, not, however, extending
along its whole length. At the time of operation, the inner tube
only of the canula could be pushed into the trachea, fitting
very tightly, but next day the parts being stretched, a regular
tube was inserted. A month later, the tracheotomy tube was
removed, and after dilating from below with sounds, a three-year-old
O^D wyer tube was inserted. An attack of pneumonia subsequently
followed. The tube was removed every month or two, but always
had to be inserted within an hour. Digital exploration proved the
larynx to be occupied with granulating tissue overlapping the
edge of the tube ; a larger tube was inserted to press upon the
granulations, subsequently this could be removed, and there
was no return of the dyspnea. The patient is now perfectly well
and has a good, though at times rather harsh, voice. Intubation
in this case was continued for nine months.

From the foregoing it appears a tube may be retained any
length of time, but it is well to remember that enough irritation
may be set up to cause erosion and, finally, granulations which
occlude the tube, when removal becomes necessary, probably
the larynx dilated, and a larger tube inserted, which will
press on the granulations and cause their absorption. In acute
stenosis from edema or pseudo membrane, the tube is not left in
long enough to produce such an effect. I make it a rule, if the
child's condition permits, to remove the tube the third or fourth
day and re-insert it if necessary.



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COTT : INTUBATION. 141

The shortest time on record, I think, occarred in one of my
cases. I introduced a twelve-year-old tube into the larynx of a
ten-year-old girl ; it was immediately coughed up, followed by a
piece of false membrane two inches long. The child breathed
easily afterwards and I declined to replace it that evening. After
twenty-four hours, however, I was again cabled to insert the tube ;
I removed it the next day, because the girl could take no nourish-
ment. It was not necessary to replace it. This patient was strong
and apparently little affected by the disease, but I gave an unfavor-
able prognosis based upon the frequency of respiration, showing
diphtheritic toxemia present. I find whenever respiratory move-
ments reach thirty-five per minute, the case invariably terminates
fatally.

All writers agree that it is more difficult to remove a tube than
to insert one, and it seems the older the child the more difficult
the operation. I found in the girl above quoted, that every effortof
inspiration drew the larynx away from my index finger, and it re-
quired several attempts before I could locate the opening in the
tube. At any rate, it is exceedingly difficult to extract at the first
attempt.

In the past year I have intubated seventeen times, in
twelve children, with four recoveries. The operation was per-
formed in two children on one morning, and each tube removed
the third day, both recovered ; ages three and four years. Another
case, four years old, tube removed fourth day; recovery. The
fourth case, a Fitch patient, tube removed the third day ; stenosis
still very marked, reinsertion refused ; a week later I learned the
child had recovered. Of the eight cases that died, five had the
tube removed several days before death. Dyspnea 4i<i not return,
death being caused by diphtheritic toxemia. Whether or not
all twelve cases were diphtheria, I cannot say, as but two occurred
in my own practice, no pseudo membrane being visible and both
recovered. The ten other cases occurred in the practice of other
physicians ; their diagnoses I do not presume to criticize, as all of
them had seen a large number of cases, and, I judge, are competent
to make a diagnosis, since our best authorities agree to disagree
on the question.

My percentage of recoveries is a little higher than the average ;
those of Dr. Mynter (not including his hospital cases), reach as
high as eighty per cent., I am told, in five cases ; Dr. Niemand
had, of seventeen cases, about forty per cent, of recoveries ; Dr.



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142 COTT : INTUBATION.

Park, twenty-five per cent, out of thirty-five cases ; Dr. Myers,
assistant to Dr. Park, had thirty per cent, out of seventeen cases ;
Dr. Bergtold obtained thirty per cent. Dr. Renner had thirty-
five per cent. So that Buffalo has as good a record as any
individual city in the world.

The present O'Dwyer gag, or any other, has given more
trouble than is convenient, constantly slipping, and even breaking,
under the enormous pressure exerted by the jaws of the child. If
a gag could be constructed which would move with the child's
head, there would be no danger of slipping and being bitten by
the sharp teeth, which occurred to me several times, although just
short of penetrating the skin. Such a gag, to be successful, must
be self-retaining. In order to run less risk, I had a ring made to
fit upon the index finger, between the second and third joints, the
most exposed part ; it is broad above, and narrow below. The
dorsal surface of the finger, being rather thin, is easily penetrated,
while the palmar surface being thick, is not affected. Mobility is
not lessened by its use, as is the case with other protectors found
in the shops.

In conclusion, let me insist on early intubation, not in prefer-
ence to tracheotomy (for the American people do not take kindly
to that operation), but to give the child a very fair chance to
recover, if that be possible, for certainly a small proportion die
for want of air, and that is always obviated by the tube. The
principal objective symptom, among others, which always means
obstruction somewhere in the air passage above the bronchi, is a
very marked recession at the pit of the stomach at every inspira-
tory effort, and cannot be overlooked. I make this statement,
since surgeons have often been called upon to operate because the
patient was breathing thirty or forty times per minute, which,
however, had nothing at all to do with the obstruction.

In passing, I may say that intubation is just as efficient in the
adult as in the child, and I would never hesitate to use a twelve-
year O'Dwyer tube in edema, or any other obstruction of the
larynx in the adult, if I had no larger one at hand. I would,
however, allow the thread to remain attached to the tube, to
prevent slipping. I think it preferable to tracheotomy in such
cases, especially when obstruction would not last long anyway ;
moreover, no scar will be left, as in tracheotomy. Still, in chronic
stenosis, it seems to be more serviceable than the tracheotomy
tube.



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JUDSON : TREATMENT OF POTT's DISEASE OF THE SPINE. 143

Schmeigelow has performed intubation in six chronic cases
He says *< Intubation is indicated in all cases of chronic stenosis,
and ought, or might, be performed in every case of acute stenosis
from diphtheria."

660 Michigan Street.



THE TREATMENT OF POTT'S DISEASE OF THE SPINE.

By a. B. JUDSON, M. D.,
Orthopedic Surgeon to the Out-Patient Department of the New York Hospital.

While caries of any part of the vertebral column cannot be con-
sidered an unimportant affection, it is well to recognize the fact
that much depends on the region of the spine involved. In the
middle dorsal region it is, perhaps, the most serious trouble,
excepting malignant disease that can attack the bones of the grow-
ing child. In this part of the spinal column the destruction is
often extreme and .the deformity great, evidently because the
affected bones are at the greatest disadvantage mechanically.
Lower down, the vertebral bodies are so large that they do not
lose their relation of mutual support until the loss of substance
is very extensive ; and above, the vertebral bodies, though small,
have less weight to sustain. But, in the intermediate portion, not
only do the bones feel the incessant movements of respiration, but
they are also more widely moved in flexion and extension, and in
lateral curving with rotation, than in other parts of the column ;
and, furthermore, they are exposed in a peculiar manner to the
risk of over-strain, from their position in the middle of the col-
umn. I think it is in the experience of all of us that in this mid-
dle and upper dorsal region Pott's disease continues longest before
consolidation takes place.

Here we have a most striking illustration of the fact that the
recovery from articular osteitis is postponed by unfavorable
mechanical environment. As joints in the upper extremity, free
from the mechanical stress attending locomotion, recover easily,
while those which, in the lower extremity, bear the heat and
burden of the day, recover only after prolonged and extensive
destruction, so articular osteitis, in the cervical region of the
spine, is easily curable, while in the upper and middle dorsal
region, relief and repair come only after desperate and prolonged
risk.



1. Presented at the Pan-American Medical Congress, at Washington, September, 1898.



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144 JUDSON : TRBATMENT OF POTl's DISEASE OF THE SPINE.

How can we best assist Nature to cure this disease in this
difficult part of the skeleton ? The saine general rules apply here
as in the treatment of articular osteitis in the lower extremities.
We cannot cut short the disease by an operation, or by any
procedure whatever, but can expect, with confidence, and must
promote by our best endeavors, the arrest of destruction and the
beginning of repair. What then can we do to put the affected
vertebrsB in their best attitude, and to raise the defensive and
reparative powers of the system to their highest efficiency ? As in
articular osteitis, occurring elsewhere, we desire (1) to relieve
the bone of the duty of supporting weight and concussion;
and (2) to prevent the affected joint from motion, believing that
the arrest of these two functions, weight-bearing and motion,
are essential to good treatment. It does not seem wise to keep
the patient recumbent for the long period necessary. In th^
management of hipdisease, we put the affected limb to bed, so to
speak, while the patient is up and about. But a similar resort in
Pott's disease is impossible. Since the patient must be up, and^
to a certain extent, active in locomotion, our best resort, in my
opinion, is to take what benefit can be had from the application
of a lever making pressure from behind forwards, in the neighbor-
hood of the posterior projection, and counter-pressure from before
backwards at two points, one above and the other below the level
of the seat of the disease. In a limited sense, this application
relieves the diseased joints from the weight of the body while
the patient is up and about, because antero-posterior pressure,
thus applied, transfers a part of the weight and concussion
incident to standing and walking, from the diseased bodies of the
vertebrsB to the processes, which remain sound. Having thus
(1) removed, so far as is practicable, injurious pressure from the
diseased structures, it is obvious that we have also applied the
most effective kind of retentive splint for (2) the arrest of motion
in the affected joints.

It does not take much practical experience to convince one
that efficient pressure, applied in this manner, is productive of
good. It may not at once arrest morbid action and induce cica-
trization of the carious bone. For these events we must wait for
the natural reaction, but it is not difficult to believe that Nature
will the more promptly intervene with reparative efforts if our
mechanical applications relieve distress and substitute a feeling of
strength for weakness and apprehension. A well-applied support



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JUD80N : TREATMENT OF POTT's DISEASE OB' THE SPINE. 145

at once gives a degree of relief, which finds plain expression in
the face and attitude of the patient. As a matter 6f fact, a feel-
ing of security and comfort is afforded by the use of a corset made
from any of the materials in ordinary use. I will not indicate
the defects of apparatus of this kind. The inexpensiveness of
jackets, and the ease with which they can be obtained and applied,
make them of the greatest service to a vast number of patients
who otherwise would have no mechanical support whatever. But,
when and where it can be done, it is necessary to give the patient
the benefit of accurately adjusted antero-posterior pressure.

At the best, antero-posterior pressure, no matter how carefully
applied, fails to give all the support which is desirable. This is
because the leverage is deficient. In the vertebral column there is
found no long bony lever, such as is at hand in making a mechani-
cal application for fixing the knee. There is, rather, a succession
of irregular bones, movable upon each other, which, from the
nature of the case, impair the success of any attempt to arrest
motion or support the column by pressure from behind forwards
and counter-pressure from before backwards, because the pressure
from before backwards will, a part of it at least, be expended in
bending backward portions of the vertebral column above and
below the projection. The force thus employed is, however, by
no means wasted, as it secures an ultimate improvement in the
shape of the trunk, which is often characteristic of patients who
have been thus treated.

The apparatus needed is essentially simple, consisting of two
parallel uprights united below by a pelvic band, and diverging at
their upper ends at the base of the neck, and curving over the tops
of the shoulders. Pressure from behind forward is made by two
pads attached to the uprights at the level of the projection, and
applied a short distance from the median line on each side. Coun-
ter-pressure from before backward is made below by a strap pass-
ing from one end of the pelvic band to the other in front of the
pelvis, and above by straps, one on each side, passing from the
upper end of the upright through the axilla, to be buckled to the
upright. The most important feature of a brace constructed to
carry out these views is the use of mild steel for all the metal
parts. The use of this material puts in the hand of the surgeon
the power to modify the degree and direction of pressure to the
changing shape, and to meet the increasing tolerance of the skin
to pressure. The reaction of the skin should receive special and



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146 milliken: radical cure of inguinal hernia.

constant attention, and gentle and gradaally increasing pressure
should be made till the limit of comfortable tolerance iu reached.
By patient attention to details, apparatus thus designed may
with certainty be made comfortable and efficient. The diffused
support furnished by a jacket is often secured by the addition to
the simple lever, described above, of aprons and other pieces,
which add to the feeling of stability and security without inter-
fering with the chief function of the apparatus, which is to make
antero-posterior pressure. One hardly knows where to begin and
where to end in the consideration of the details which demand
attention in practice of this kind. I will close by saying that
cheapness and cleanliness may be promoted by leaving the steel
parts of this brace unpolished, and covering them with a single
layer of adhesive plaster, and then with strips of canton flannel,
or silk, cut bias, and renewed without much trouble as often as
may be desired.

25 Madison Avenue.



A REVIEW OF THE OPERATIVE TREATMENT FOR
THE RADICAL CURE OF INGUINAL HERNIA.*

By SAMUEL E. MILLIKEN, M. D.
Lecturer on Surgery at the New York Polyclinic.

Having but recently given my views on the subject of the
Radical Cure for Inguinal Hernia, I wish to discuss only
briefly the comparative merits of three methods, viz., that of
Bassini, of Kocher, and of Halsted.

After having looked up more than one hundred cases of
recurrent hernia after various methods, which came under my
observation at the Hospital for Ruptured and Crippled, I am
convinced that the percentage is far greater than the operators
are led to suppose by the immediate apparent good results.
Hospital cases are very difficult to follow, particularly in the large
cities, because the poorer classes change their addresses so often,
without leaving behind them any tidings as to their whereabouts.

It is my opinion that we expect too much for the radical
operation anyway, owing to the fact that, with all of Nature's
devices, she has failed to let the structures of the spermatic cord

1. Read before the Pan-American Medical Congress, in Washington, D. C, September
6, 1893.



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milliken: radical cure of inguinal hernia.



147



make their exit from the abdominal wall, without leaving each
subject liable to hernia — no age being exempt. Our laparotomists
will, I think, agree that any abdominal section is likely to be
followed by hernia, whatever precautions are taken in closing the
wound ; and from our herniotomies, when the testicle is not
sacrificed, I don't see how we can but expect a larger percentage
of recurrences than they get of the ventral variety.

So long as it is not deemed advisable to sacrifice the testicle,
the best that we can hope for is to imitate Nature and reestablish
the obliquity of the canal. This is best done, in my opinion, by
the method of Bassini ; and I will endeavor to show its advan-
tages over the other two methods above mentioned.






First, the aponeurosis of the external oblique muscle is divided
over the cord structures, until the internal ring is well exposed ;
the flaps are separated from their underlying structures until the
conjoined tendon on the upper, and the shelving process of
Poupart's ligament on the lower, are brought into view. The
eord structures and the hernial sac are next lifted out of their bed



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148 MILLIKSN : BADICAL CUBE OF INGUINAL HBBNIA.

en masse, after which the sac is isolated, opened, and tied off at
the highest point.

Secondly, with the cord held out of the operation field by a
blunt hook, or the finger of an assistant, the conjoined tendon on
the upper is sutured to the shelving process of Poupart's on the
lower by means of the kangaroo tendon, or of chromatized catgut,



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^



^




Fio. 2.

but I prefer the former, as the time for absorption is longer, and
the sutures are stronger in proportion to their size. From four
to six interrupted sutures will be sufficient to make a firm
posterior wall for the cord structures, care being taken not to
constrict them at the internal ring.

Thirdly, the obliquity is rel^stablished by bringing together
the flaps of the external oblique, by a continuous suture of the
same material. The skin wound is closed with interrupted catgut
without drainage.

Kocher's method simply deals with the sac« which is dissected
out as thoroughly as possible, without slitting up the canal, and



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MILLIKBN : RADICAL CUBE OF INGUINAL HBRNIA. 149

pulled through a small opening, which he makes in the aponeu-
rosis of the external oblique, opposite the internal. He after-
wards sutures it to the aponeurosis, over the canal, but in so doing
only strengthens the outer wall.



Fio. a

Halsted's method is simply the transplantation of the cord
without any particular endeavor to rebuild the canal. After
dividing the external oblique, he lifts out the cord structures, and
ties off the sac; then sutures the respective tendons together,
posterior to them, allowing them to come out directly instead of
obliquely. Although I have never met with any recurrences from
this operation, possibly owing to its being rarely employed in



Online LibraryJ. A. (Joel Asaph) AllenBuffalo medical journal → online text (page 15 of 78)