| Three ‘Intubation’ Hospitals. | Six ‘Tracheotomy’ Hospitals. | Total Cases. | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Cases. | Deaths. | Mortality per cent. | Cases. | Deaths. | Mortality per cent. | Cases. | Deaths. | Mortality per cent. | |
| 1902 | 076 | 023 | 30.2 | 0222 | 071 | 32.0 | 0298 | 094 | 31.5 |
| 1903 1 | |||||||||
| 1904 | 156 | 047 | 30.1 | 0173 | 047 | 27.1 | 0329 | 094 | 28.5 |
| 1905 | 157 | 046 | 29.3 | 0184 | 040 | 21.7 | 0341 | 086 | 25.2 |
| 1906 | 166 | 058 | 34.9 | 0188 | 051 | 27.1 | 0354 | 109 | 31.5 |
| 1907 | 205 | 051 | 24.8 | 0289 | 086 | 29.7 | 0494 | 137 | 27.8 |
| Total | 0760 2 | 225 | 29.6 | 01,056 3 | 295 | 27.9 | 1,816 | 520 | 28.7 |
1 No return.
2 Of these more than 400 were intubations.
3 Of these 23 or more were intubations.
From these figures it will be seen that the total result for five years is a mortality of 27.9% as against 29.6%, in favour of tracheotomy. This serves, in my opinion, to strengthen the position of those hospitals which rely upon tracheotomy. Upon a comparison of this sort it would certainly appear that the results of intubation, at any rate in England, are not so good as has been stated. I am aware that this opinion is not shared by many authorities and that Stack[40] writes, ‘taking everything into consideration, my impression is that under the most favourable conditions of operating, nursing, &c., the mortality is almost halved by doing intubation as a routine instead of tracheotomy.’
It has been claimed that intubation gives better results in children under five. This question has been worked out by H. W. L. Barlow,[41] who concludes that ‘the younger the child, the longer will it require the tube, and the more frequently, therefore, has the latter to be inserted’, and ‘from the mortality alone, there is no indication that one operation is better suited for certain age periods than another, but since secondary tracheotomy appears to be rarest at three years old and the intubation fatality is least between four and six years, it follows that children from three to six are best adapted for intubation’.
Conclusions. Intubation is justifiable for diphtheria of a mild type if sufficient experience can be obtained and if the after-treatment can be personally carried out. The success of the operation depends largely upon a proper selection of the cases; in other words, it is not suitable for the worst types of this disease. It should never be performed upon a patient in whose case the question of tracheotomy does not arise.
In my opinion it is not a good operation for those general hospitals where there is constant change among the resident officers; it seems probable that it will remain the treatment of a small number of physicians who have frequent opportunities of practising their art.
Indications. (i) In diphtheria, intubation is justifiable when the disease is of a mild type without great toxæmia, where early diagnosis has been made, and antitoxin has been administered. It is not recommended when there is great pharyngeal inflammation, or in cases with bronchitis or pneumonia, or when the patient is prostrate, nor for severe obstruction caused by excessive swelling or false membrane in the larynx or trachea. In the last-mentioned condition intubation is difficult to perform, and the patient may be choked by false membrane which has been pushed down: intubation should be abandoned in favour of tracheotomy when immediate relief is not obtained.
(ii) In other forms of septic laryngitis, there is evidence to show that with intubation the mortality is higher than with tracheotomy; in œdematous laryngitis, such as follows the inhalation of steam, every effort should be made to prevent laryngeal obstruction by other forms of treatment, for intubation is difficult to perform owing to the swollen condition of the tissues; moreover, injuries are common, and there is a danger that the upper opening of the tube will become obstructed. Again, the tube may be expelled by coughing, and the child suffocated without relief.