OPERATIVE INTERFERENCE IN MEMBRA- 
NOUS DISEASES OF THE LARYNX. 
BY 
BENJAMIN T. SHIM WELL, M.D., 
Instructor in Minor Surgery in the Medico-Chirurgical 
College of Philadelphia. 
REPRINTED FROM 
THE MEDICAL REGISTER, 
OF PHILADELPHIA. 
1887. OPERATIVE INTERFERENCE IN MEMBRAN- 
OUS DISEASES OF THE EARYNX. 
BY BENJAMIN T. SHIMWELb, M.D., 
Instructor in Minor Surgery in the Medico-Chirurgical College of 
Philadelphia. 
THE value of operative interference in mem- 
branous diseases of the larynx and trachea has 
been discussed at considerable length by the mem- 
bers of the profession. Its advantage has been de- 
cried by some, who, while admitting the value of it in 
lessening the terminal suffering, do not consider it of 
such importance in the prognosis as to warrant its 
frequency, picked cases doing well, while the average 
case only lingers probably a while and then dies; also 
the risks incurred during the operation. The collated 
statistics of foreign operations give no more flattering 
results than are reached in this section of the world. 
English surgeons had discarded, for a time, the opera- 
tion as too unfavorable. The French surgeons gave 
more flattering conclusions, the latter giving an aver- 
age of twenty-five to thirty-three per cent, of recover- 
ies ; yet, of cures from various parts of the world, gave 
but 21.48 per cent. The time of operation has to be 
considered in the prognosis. There is no question 
that the operation is left entirely too late, in the ma- 
jority of cases it being the last resort, when the 
patient is exhausted by long suffering, the general 
vitality impoverished, and the absorption of septic 
matter having taken place; for, if the general con- 2 
dition is lowered, then absorption of such fluids takes 
place more readily. 
The operation of tracheotomy has many things to 
be considered; not only the operation itself but its 
risks ; also the after-treatment. The difficulty in get- 
ting the consent of the friends of the patient leaves it 
until no other means are available. The thought of 
an operation and the uncertainty of its results make 
people hold off from such a procedure. Then come 
the risks of fatal results during the operation, which 
will, under the best care, happen occasionally. Then 
follows a long, tiresome after-treatment: the watch- 
ing of the patient, cleansing of the tubes, the strict 
care of the thermometrical and barometrical condition 
of the surroundings, are all factors of importance. 
In the average practice this becomes almost an im- 
possibility. The insufficiency of nursing and want 
of means are not to be forgotten. The latter does not 
allow of skilled attendants. The operator must either 
impose on his medical friends or depend on the care 
of those who are more often enemies than friends. 
And in these questions lie the result of the operation, 
for, no matter how skilfully it may have been done, 
if the after-treatment is not followed out failure en- 
sues. Any one who has had any experience with 
these cases knows how much care and anxiety arise. 
Then the age, extent of membrane, presence of 
pneumonia, and general diphtheritic infection have to 
be considered as contraindications, though many 
operators discard all these conditions and advocate 
operation. Age is not the barrier it was; it has been 
done before the end of the first year with good re- 
sults. 3 
Thus have years dragged on without any change in 
the procedure, until lately a means has been devised 
which accomplishes the purpose of tracheotomy with- 
out its objectionable features, and the operation, class- 
ing all cases reported, notwithstanding the imper- 
fections of the operator, gives an average of twenty- 
eight and one-half per cent, of recoveries. In this 
operation the gravity of the interference is lessened, 
the use of the knife being dispensed with, and for 
this reason the consent of the parents or friends can 
be more readily obtained. The operation is per- 
formed quickly, with little distress to the patient. 
The relief is immediate. Then the most important 
factor is the dispensing with all complicated after- 
treatment. No extra care is needed. The sufferer 
takes food and medicine as usual, and in every respect 
is treated as an ordinary case, without regard to the 
interference. No suffering follows it, as after the use 
of the knife. If the patient recovers there is no 
wound to heal, and no risks from occlusion of the 
chink of the glottis. Shock is not present, no ether 
is required, or preliminaries to get ready; then no 
condition contraindicates its use. This method is 
that of intubation. 
The change cannot be appreciated unless seen; it 
is but a matter of a few seconds, but in that time the 
little sufferer passes from a condition of agonizing 
distress to that of comparative comfort. Respiration 
is easy, substernal breathing gives way to full-chest 
inspiration, the lungs get more air, and the blood be- 
comes oxygenated. 
The advantages of intubation over that of trache- 
otomy can be readily understood: the lessening of 4 
the severity of the operation, the facility of employ- 
ment, and immediate relief is got while the prep- 
aration for tracheotomy would hardly have been 
begun ; then the facility with which the patient can 
be fed and medicated ; and then the total absence of 
any need of worry in regard to the atmosphere sur- 
rounding the patient, for the air taken into the lungs is 
moistened while passing through the mouth and nose ; 
then, also, the ability of the patient to make known 
his or her wants, for in my experience all the cases 
were able to articulate. This is important, for many 
things without an answer from the patient can only 
be guessed at. Then the ease of introduction makes 
it applicable to all cases, for if it were possible to 
meet a case in which, after the introduction of the 
tube, aggravation of symptoms were to arise, it can 
be readily removed, and the patient is then no worse 
than before, but if tracheotomy has been done there 
is no return : the patient must take the consequences. 
Yet I cannot imagine a case in which relief will not 
follow intubation. 
I have seen cyanosis to a marked degree, and res- 
piration entirely substernal, and every breath one of 
agony ; and this changed to full-chest respiration, the 
cyanosis disappear, and the patient be in a comfort- 
able sleep in five minutes after the tube was intro- 
duced. What better result than this can be imagined ? 
The breathing gives rise to no peculiarities that 
would ever call the attention of any one to its pres- 
ence. Food and medicine are taken with ease, though 
at times a slight quantity of fluid may trickle into 
the larynx and give rise to coughing, but yet this is 
not very distressing. 5 
The great advantage of this instrument lies in the 
fact that, as no knife has to be used, its early applica- 
bility is possible, and by this means a case that is apt 
to run to the bad is anticipated, and in any case diffi- 
cult respiration is overcome, and the patient is ren- 
dered comfortable. We must admit that in a certain 
percentage of cases recovery occurs, and in cases of 
tracheotomy and intubation this self-limitation must 
be considered. All cases of recovery by either mode 
are not entirely due to the interference, so what the 
ratio would be no one is able to judge ; but the un- 
certainty of the prognosis should put one on the 
alert, and I think that the' operation cannot be 
done too early. I would not be understood to mean 
that all cases should be intubated at the first symp- 
toms, but yet the practice of waiting until sub- 
sternal breathing takes place I think is rather long, 
for, if sufficient air is not taken into the lungs 
to aerate the blood, impoverishment of tissue takes 
place immediately, lowered vitality is shown at once, 
and as force is not easily created is it not advisable to 
save all we can ? The proper time of introduction 
should be when internal remedies show no response 
and the breathing becomes markedly sonorous. The 
time is not limitable : cases vary; some will reach 
the suffocative point within a few hours while others 
may run into days. 
When substernal breathing is present, or has been 
present for any length of time, few cases escape a cer- 
tain amount of blood-poisoning ; and as the causes of 
death are suffocation, exhaustion, and blood-poison- 
ing they should be averted. Then, if suffocation is 
overcome, or if it has not reached this stage, the les- 6 
Sening of the muscular effort in breathing, caused by 
the narrowed glotta, causes less exhaustion ; and as 
less expenditure of muscular force requires less vital- 
ity, we then husband what strength we have, for our 
treatment does not keep the system at normal but 
only tries to prevent as much waste as we can; 
if the strength is saved we have then a possibility 
that the glandular system may be sufficiently able to 
overcome the flooding of the system with septic 
poisons. 
To illustrate this method I will give the notes of a 
case in which I introduced the tube. I was called 
into the case by a friend on January 7th. The pa- 
tient, a boy eight years old, had every evidence of a 
case of membranous croup. He had expectorated por- 
tions of tubular membrane. The pharynx was free 
from any deposit; it was inflamed, yet not much tume- 
fied. The boy had been sick from the 3d inst., and, 
steadily growing worse, the doctor in attendance had 
suggested the advisability of the tube the day pre- 
ceding the introduction, but for certain reasons his 
opinion had been set aside; but the difficulty in 
breathing was steadily getting worse and entirely 
substemal, the chest action being suspended and the 
alae of the nose were showing the violent effort that 
was being made to get air into the chest; cyanosis 
was becoming marked. The respiration was sonor- 
ous and could be heard in the adjoining rooms. The 
boy was wrapped in a blanket to prevent struggling. 
He was held in the arms of one person while another 
steadied the head and the gag was placed in the 
mouth. On the introduction of the finger into the 
pharynx the glottis was found very oedematous, and 7 
there was difficulty in passing the finger between its 
posterior wall and the posterior wall of the oesophagus. 
After securing the larynx the tube was rapidly in- 
serted. There was immediate cessation of the harsh 
breathing ; the gag was removed ; the breathing then 
became soft and easy, so much so as not to be heard 
unless the ear was placed close to the mouth. Chest 
action set in immediately, becoming full and ex- 
panded with every respiration; the cyanosis disap- 
peared very rapidly. The boy complained of no dis- 
tress from the tube : the only remark he made was 
that ' ' it felt funny. ' ' He was put into bed and in- 
side of five minutes was dozing comfortably. His 
respiration had been 64 to the minute and tempera- 
ture 102.10; pulse was not taken. The respiration 
fell immediately to 38 a minute. 
I saw the boy two hours after the introduction. The 
respiration was 36 and temperature ioi°. The face 
had a perfect flush ; not the flush of hectic irritation 
but one due to the oxygenation of the blood from free 
lung expansion, and then the blood being decarbon- 
ized was thrown more freely into the capillary system, 
and the part being previously deprived of its stimu- 
lus had set in with renewed action and dilatation of 
the vessels had occurred. The fact of lowered tem- 
perature is against it possibly being due to hectic 
causes. The breathing still continued soft and easy. 
He had taken both nourishment and medicine with- 
out any interference from the tube. The voice was 
not interfered with except in volume. At 12 p.m., 
same day, the temperature was 102. i°; pulse, 144; 
respiration, 30. He made no complaints from the 
tube, was resting comfortably, breathing still full and 8 
easy, and taking nourishment without difficulty. 
The next morning, 8th inst., at 6 a.m., pulse became 
intermittent and heart failure was marked, but under 
stimulation he rallied and at 10.30 A.m. pulse was 
120 and steady; temperature, 100.30 ; respiration, 36, 
and easy ; tube still giving no annoyance except oc- 
casionally coughing spells. At 11 p.m., same day, 
pulse, 136; temperature, 1020 ; respiration, 32; he 
was still resting comfortably. On the 9th inst.-, 7 
p.m., pulse, 120; temperature, 1010 ; respiration, 36 ; 
he had been comfortable, tube giving no annoyance ; 
no difficulty in nourishing or medicating him. At 
11.30 p.m., same day, pulse, 136; temperature, 
ioi.i0; respiration, 36. On the 10th inst., 10.30 
a.m., pulse, 132; temperature, 102.2°; respiration, 33. 
There was no discomfort in breathing; the lungs were 
beginning to exudate and rales were just notice- 
able. The boy complained of no distress or incon- 
venience. As the boy's breathing and general con- 
dition were such as to warrant the removal of the 
tube at 11 p.m. of the same day, the gag was applied 
to the mouth and the tube removed without any diffi- 
culty or special annoyance to the boy. His tem- 
perature, when I first went into the room, was 1020; 
pulse and respiration were not different from the pre- 
vious examination. When the boy found that the 
tube was to be removed he became greatly excited 
and alarmed, and considerable shock took place as a 
result. The face became immediately pale and cyan- 
osed to a slight extent, and he told me that he was 
going to die. Whiskey was given hypodermically 
and the tube immediately removed. 
Respiration was as free as before, and as soon as he 9 
found it was removed his courage returned ; lie was 
put into bed, and inside of a half-hour the tempera- 
ture had increased 2°, making it 104.2°. This in- 
crease was not due to the effect on the lungs by the 
removal of the tube, but the reaction that followed 
from the depression at the thought of removal. 
Next morning the temperature had fallen to 1020. 
From the removal of the tube my connection with 
the case ended, but yet I have kept myself informed 
of the boy's condition. He had marked albuminuria 
that gave a great deal of annoyance. The case ran 
gradually into marked capillary bronchitis. I am in- 
clined to think the latter was due not to any exten- 
sion of inflammation into the smaller tubes, but 
rather due to the condition of the lungs produced by 
the prevention of lung expansion previous to the in- 
tubation. And there is no doubt that if the tube 
had been introduced earlier this condition could have 
been averted and the patient had better chances of 
recovery. When we come to look at the condition of 
the lung during the time in which there was so little 
chest expansion, we can readily understand how ca- 
pillary bronchitis could occur, for there were deficient 
inspiration and expiration-more markedly deficient 
inspiration-and as the latter condition is productive 
of a tendency to collapse of the lungs, and from this 
cause capillary bronchitis. And not only this con- 
dition but in combination with it is the weak and 
debilitated condition of the patient, which in itself is 
a frequent cause of both primary and secondary bron- 
chitis, and, judging by the boy's physique, there was 
not that muscular status that would give free lung 
expansion. Then the presence of albuminuria, the 10 
irritation arising from this state on the lungs, would 
help to aggravate an already existing condition. 
The case dragged on, and died after the lapse of 
twenty-two days from day of attack and fifteen days 
after the intubation. Though the termination was 
not favorable, the object for which this paper was 
written was successful. The intubation gave the 
results expected ; the boy was carried through the 
disease by this means, and, as the sequelae developed 
new factors in the case, they alone were answerable 
for the results. 
The medication of the boy when I was called to 
introduce the tube was hydrarg. chlor, mite., gr. %, 
every two hours, combined with a small amount of 
Dover's powder and tartar emetic each (the latter two 
ingredients were the suggestion of a physician that 
had been called in consultation), quinine, iron and 
chlorate of potash. The Dover's powder and tartar 
emetic were stopped and the calomel continued. 
Quinine was given by suppositories, about 18 grains 
a day; whiskey according to condition. The calo- 
mel was stopped on the 10th instant. He was then 
continued on stimulants, quinine and carbonate of 
ammonia. Digitalis was given for heart debility and 
to increase its tension. Anaemic stupor became 
marked, and active measures were called for. Pilo- 
carpine, gr. y-j, was given hypodermically when the 
excretions became marked; the heart's action lessened 
and became weak; respiration irregular, and all in- 
dications of a rapid demise ; but in time reaction set 
in, a marked relief was shown, the mind cleared, and 
diuresis was freer. From this time the case showed 
no peculiarities except length of time, and then 
gradually lapsed into death. 11 
With the information gained from the report of 
cases and my own experience in their use, it is a 
query to me, if any physician should allow a patient 
to die without the trial of intubation, would the law 
justify it ?