fracture is but little in the majority of cases, it will be more in the minority; and it is not uncommon, when the displacement is not detected in the outer table, that the inner will be comminuted and the fragments lodged in the subcranial tissues, with blood extravasation.

4. In the majority of examples of this fracture the symptoms of the cerebral pressure are plainly marked; if not early they appear only a little later, and yet so early as to prove that they are the immediate result of the injury, rather than from the inflammatory products which appear later.

5. When the fracture involves the lower part of the parietal bone and the temporal with its petrous portion, if compound, or only contusion of the part receiving the blow or force with marked symptoms of this fracture, an incision made at or over the site of the bruised scalp will aid in detecting the extent of the injury.

6. If fragments of bone or blood can be reached, remove them; and if there be slight or greater displacement, with positive symptoms of pressure which cannot be removed, then apply the trephine, elevate the depressed bone, and if there should be blood, remove it.

7. In this fracture, when caused by the application of direct force, as may be in the frontal sinus and in the proximity of the base of either fossa, with positive symp toms of brain pressure, the hopeless condition of the case left to the expectant treatment, if there be no opening through the soft covering of the bone at the point receiving the injury, warrants making an incision for exploration that its cause may be better defined, and if it cannot be removed without, then use the trephine.

8. In all cases if the operation of trephining is to be done, it should, as in vault structures, be done at once after the receipt of the injury, to shorten the time of pressure upon vital structures and before inflammation has occurred.

SURGERY OF THE GENITO-URINARY ORGANS IN CHILDHOOD.-Dr. De Forest Willard continues his admirable paper on the above subject in the July Arch. of Pediatrics. The topics considered are phimosis, hypospadias, and epispadias.

Under phimosis W. says that an adherent and contracted prepuce is a normal state at birth, but this is usually relieved by the boy's own manipulations before he reaches the age of ten.

The long narrow foreskin of a child at first gives the appearance of contraction, but if the skin be gently and patiently pressed backward for a few moments the opening, almost pin-hole at first, will be seen.

As the prepuce recedes upon the stiffened member, the meatus will appear. Often the adhesion will be found to commence just behind this orifice, but no instrument other than the operator's thumb will be required.

The force requisite to peel off the rind of an orange

will speedily strip the prepuce from the glans and carry it behind the corona, when the smegma can be removed and an emollient ointment applied. Restoration of the prepuce to its original position should be accomplished before turgidity of the glans occurs. In cases of delay or difficulty, a couple of probes or hair-pins answer admirably for sliding the skin back into position.

Slight edema, and painful micturition will follow this operation for a few days, but emollients are sufficient for relief. A hot hip-bath will greatly facilitate the passage of urine. Retraction and cleansing should be persistently employed thereafter. Later the patient should be taught to wash the penis just as he washes his face and hands for cleanliness sake.

In larger boys and in adults all the circumstances are different, and dilatation is rarely beneficial without removal of the foreskin; but in infants and in boys from two to eight one need rarely ask for better results than are secured by thumbs alone.

Cold water used daily is more helpful than circumcision in the prevention of disease.

M.

PREHISTORIC DENTISTRY.-Dr. Marter, of Rome, has for some time past been devoting considerable time to examining the skulls in the various museums in Italy, and in Etruscan and Roman tombs, and he has given an account of his investigations in the Independent Pra titioner.

In the ruins of one of the Etruscan tombs, about the date 500 B. C., he found a partial denture. It was an arrangement for holding in position three upper artificial teeth, by banding them to the adjoining natural teeth. These teeth were carved out of some large animal's tooth.

Another denture found in an old Roman tomb consists of two natural teeth fastened by means of soft gold bands to the contiguous teeth. The most recently opened and oldest Etruscan tomb yet discovered in Italy was lately excavated at Capa di Monti; this tomb belongs to the sixth century B. C., and among several articles of jewelry a denture, very similar to the above described, was found. Dr. Marter was unable to discover any stopped teeth, although many cases of caries and other dental diseases presented themselves.

It is certain that dentistry must have been extensively practiced in the early history of the world, and that gold must have been used largely; otherwise the early Greek and Roman legislators would not have mentioned the matter in the celebrated laws of the twelve tables.

Law 5th, de Jure Sacrorum, is as follows: "Quoi auro dentes vincti sicut in cum ollo sepelire, se fraude esto."-Medical News, Aug. 7, 1886.

M.

KOLPOHYSTERECTOMY FOR CANCER. Dr. S. E. Post concludes from a compilation of the statistics on this subject that:

2. The total number of operations reported is approximately 341, with a total mortality of 27 per cent.; 222 cases were treated with the open peritoneal wound, with a mortality of 22 per cent.; of that number in 93 the supra-vaginal wound was covered by peritoneum, with a mortality of 18 per cent.; and of that 93, 50 were operated upon during the preceding three years with a mortality of 10 per cent.

3. Of 97 cases which survived operations done previous to 1883, 18 or 20 per cent. are known to have been well at the end of 18 months or two years.

4. The latest results of kolpohysterectomy for cancer contrast not unfavorably with those of the total extirpation of other organs for malignant disease.

5. The tendency of medical literature is to regard kolpohysterectomy for cancer as a legitimate operation, subject only to the restriction common to other extirpations for malignant disease.-Am. Jour. Med. Sciences, January, 1886.

M.

OBSERVATIONS ON THE OPERATION OF FIXING FLOATING KIDNEY.-Douning concludes that:

2.

I. The kidney has a normal range of motion. The operation for fixing a floating kidney should comprehend and permit, so far as possible, this normal range of motion.

3. The capsule should be left unbroken, and, if possible, free from adhesions.

4. Stitching the capsule ignores the fact stated in the first conclusion and prevents the realization of the desideratum mentioned in the second, and from its very nature precludes the accomplishment of the second named desired result.

5. Suturing the fatty envelope recognizes the truth of the first conclusion, and fulfils the indications of the second and third conclusions; hence it is the method greatly to be preferred.—Jour. Am. Med. Asso., December 9, 1885.

M.

ANTISEPTICS IN SURGERY.-Mr. John Wood, in his recent Bradshaw Lecture (British Med. Jour., December 12, 1885), says:

"Chief among the measures of surgical hygiene, I would place the more intimate agent, strict and absolute personal cleanliness; and in this term I include not only clean linen, towels and sponges, and cleanliness of the patient's person, but pure hands in the dressers and nurses, as well as in the surgeon himself, pure instruments, and last, but not the least, pure water. *

*

The care and foresight required to obviate these lurking dangers (infective matters) are so great, and the precautions required to prevent them so minute, that the use of other antiseptic applications are, in my opinion, imperative, to defend effectually every unguarded avenue

M.

ON EXTRA-GENITAL INITIAL LESIONS IN SYPHILIS. -Dr. Baum has collected from the clinic of Professor Pick, in Prague, eighteen cases of syphilis in which the initial lesion was situated elsewhere than on the genital organs (Viertelj. für Darm. und Syph., London Med. Record), namely, on the lower lip in six cases, on the upper lip in two cases, at the inner angle of the left eye in one case, on the cheek in one case, on the chin in two cases, on one breast in three cases, on both nipples in two cases, and on the mons veneris in one case. The author reports the cases in full, and concludes with some remarks on the origin, symptoms and diagnosis or syphil's when the initial lesion occurs in an unusual position.

TREATMENT OF GONORRHOEAL EPIDIDYMITIS.-The method of treatment advocated by M. Stockquart (Annales de Derm. et de Syph. No. 1, 1885, Lond. Med. Record) and described by him as both "easy and rapid,” consists in the application of mercurial plaster over the affected testis. Over the plaster a layer of cotton wool is placed and outside of this a suspender of a size sufficient to exercise as much pressure as can be borne. Short notes of six cases thus treated are given. The author states that confinement to bed was exceptional, and that, as a rule, the patients were soon able to resume their occupation, sometimes even to continue it all through.

THE ELECTRIC TREATMENT OF URETHRAL STRICTURE. -The special advantages of this method are claimed by Anderson (St. Louis Med. and Surg. Jour., Oct., 1885) to be:

A METHOD OF INTRODUCING A CATHETER WITHOUT PAIN.-Dr. J. A. Stamp, in the Med. and Surg. Reporter, explains his method of doing this as follows: He fills an ordinary male urethral syringe with hot water and attaches it to a soft rubber catheter. He introduces the catheter slowly, and at the same time slowly injects the hot water. This distends the urethra as well as relaxing the spasm, and allows the catheter to enter the bladder.

SUPPRESSION OF URINE IN DIPHTHERIA.-Dr. Geo. C. Kingsbury (Brit. Med. Jour.) reports a fatal case of The suppression of urine in a diphtheritic patient. little patient, aged 3 years, did very nicely until the ninth day, when suppression began, lasting three days. On the evening of the third day he died, having gone 70 hours without having passed any urine. Diaphoretics. even had no effect.

NEW SERIES, VOL. X, No. 11. WHOLE No. 248

As

Original Communications.

INTUBATION OF THE LARYNX.*

BY C. G. JENNINGS, M. D.

S YOU all know, many attempts have been made to treat croup by intubation of the larynx during the last fifty years, but not until Dr. Jos. O'Dwyer, of New York, perfected his tubes and accessory apparatus have results from it brought it prominently before the profes

sion.

The apparatus and method of use have been well described in recent journals.

My first experience well illustrates the difficulty which attends the introduction of the tubes by an unskilled operator.

The patient was 17 months old and had laryngeal diphtheria, with but slight pharyngeal implication. Expecting difficulty, I tried to introduce the tube before the dyspnoea was severe enough to really warrant interference. Although I made several attempts, I failed to lodge the tube in the larynx. On the following morning the dyspnoea was more severe, and another trial was made but with no better result. An expert laryngologist who was with me also failed. Each attempt, however, was followed by great relief of the dyspnoea, and after the second trial it never became alarming and the child slowly recovered.

Since that attempt I have introduced the tube in four cases, all of which died.

Case 1. A girl, æt. 6 years, seen in consultation with Dr. A. H. Bigg. The tube was introduced on the third day of the dyspnoea. The breathing was so difficult at the time that we were prepared for an immediate tracheotomy in case the intubation failed. This time I lodged the tube securely in the larynx in a few seconds. The tube produced no irritation and the breathing was much easier. She passed a quiet night, but the breathing was continually somewhat embarassed-the tube did not admit the air which she demanded for perfect respi

*Read before the Detroit Medical and Library Association. Profeseor of Chemistry and Diseases of Children, Detroit College of Medicine.

$2.00 a year. Single copies, 30 cents.

ration. At times when the tube partially filled with secretion, the dyspnoea was quite severe. The next morning her temperature was 1021⁄2°, pulse 120, and she showed signs of exhaustion. The breathing was quite labored and she was unable to clear the tube of secretion. Another important element in producing the exhaustion was her inability to swallow liquids. Although suffering greatly from thirst, each attempt to swallow water was attended by violent coughing and distress. It was impossible for her to prevent the fluid from trickling into

the trachea. At ten o'clock I removed the tube to let her drink. The larynx quickly began to close and we replaced it. A large piece of membrane was dislodged at this time and became firmly fixed in the tube. In her struggles the child pulled the tube and membrane out together. We quickly replaced it and she breathed easier. The patient breathed easier for an hour or two and then began to fill up again. The dyspnoea was so great that at 7:00 o'clock p. m. I performed tracheotomy, leaving the O'Dwyer tube in situ. I opened the trachea. at the lowest possible point, deeply under the sternal notch. I then removed the O'Dwyer tube and inserted the trachea tube. There was no membrane below this point and she breathed with perfect ease. With no sign of extension of membrane below the tube, she gradually sank and died from exhaustion early the next morning.

Case 2.-August 2d; child æt. 12 months, with croup secondary to a severe measles. No membrane in pharynx; diphtheria in adjoining houses I introduced the tube without difficulty, and it gave the child perfect ease. While nursing milk would pass into the trachea and produce much irritation. In a few hours his temperature ran up to 1032°, and the physical signs of pneumonia. developed over his whole left side, and the little fellow quickly succumbed. At no time, however, was there any dyspnoea from laryngeal or tracheal obstruction.

Case 3-September 24th; a girl, æt. 4 years, with diphtheritic croup, seen with Dr. S. H. Goodwin. I introduced the tube with some difficulty and the child was relieved. She was easy for about 24 hours, but had some difficulty at times in swallowing. Then the exudate began to extend below the tube, and she died the following morning from extension of the disease to the bronchi.

Case 4-Katie M., æt. 5 years, diphtheritic crou p

Case seen in consultation with Dr. Chittick. At the time of intubation there was no membrane in the pharynx, but a few days after a moderately severe pharyngealdiphtheria developed. The child was moribund when the tube was introduced. She quickly rallied after its introduction and breathed with perfect ease. She did very well for four or five days and there seemed to be every prospect of her recovery. Still there was the same difficulty in swallowing. Every attempt to drink was followed by distressing cough, but the plucky child persisted and got a fair amount of nourishment. She would not take solid or semi-solid food. On the fifth day she commenced to show signs of exhaustion. On the sixth day she commenced to breath with some effort. The signs of exhaustion were increasing. We removed the tube and a membranous cast of the trachea about two inches in length followed it. She breathed fairly well for a time, but we were compelled to replace it in about six hours. The breathing soon again became embarrassed from extension below the tube, and she died the next day-the seventh day after intubation.

My experience with these cases has taught me some of the difficulties, dangers, and possibilities of the operation of intubation.

Let us now compare the results of intubation with the medical treatment of croup and with tracheotomy.

We all know the terrible fatality which attends croup when left to medical treatment alone. Cases now and then recover under the most diversified forms of medication, the dyspnoea never reaching a degree of severity sufficient to warrant surgical interference, and still more rarely, cases recover when apparently in the most hopeless condition. In quite a large experience I have never seen a case recover after I thought tracheotomy necessary.

The results of intubation are encouraging. Dr. F. E. Waxham,* of Chicago, has reported 83 cases with 23 recoveries a percentage of 27.7. Dr. O'Dwyer has reported 25 cases with 6 recoveries, or about 25 per cent. This covers most of the cases reported up to this time, and as the operators are skilled, it probably fairly represents the possibilities of the operation. How long this percentage will keep up when the operation passes from the hands of these experts, who have until now alone practiced it, to the general practitioner, it is impossible

to say..

Now what does tracheotomy offer? From a study of 11,000 cases, Agnew † fixes the percentage of recoveries at about 30. The statistics were collected from all sources, and include the records of operators good and bad. The possibilities of tracheotomy may be shown by a glance at the results attained by some of our most successful operators. I have selected a few operators whose records I have at hand.

*Medical Age, vol. 4, p. 313.

+ Practice of Surgery, vol. 3, p. 36.

These figures show over 50 per cent. of recoveries. My own experience covers about the average run of cases of croup. I have operated on children from eighteen months to ten years of age (four patients being under two years), and presenting all degrees of diphtheritic toxæmia. From these observations I think that about fifty per cent. is as high a proportion of recoveries as can be expected, as there are so many unavoidable and necessarily fatal complications liable to arise. Still I can look back and recall at least three of my cases that might possibly have been saved by more judicious treat

ment.

It will thus be seen that while the results of intubation about correspond to the general results of tracheotomy, they do not compare with the possibilities of the more severe operation, as shown by the records of the most successful operators.

Enthusiastic advocates of intubation have proposed it as a general substitute for tracheotomy, but although I believe it to be of value, I do not think it can or should entirely replace tracheotomy.

Let us examine in detail the advantages which it has over tracheotomy and some of its faults, and try to give it its proper place among the methods of treatment of croup.

Intubation is an operation which will readily receive the sanction of the patient's friends. It is not a cutting operation, is performed quickly, without the alarming attendance of chloroform, knives, etc. This is without a doubt a very great advantage as it brings within the reach of treatment hundreds of children whose parents would allow them to die rather than consent to tracheotomy.

Then again, it will be popular with physicians. Comparatively few physicians will attempt a tracheotomy. Although I think the dangers and difficulties of the operation are somewhat exaggerated, still it will occasionally require a swift and masterly operation to save the patient from dying on the table. Any physician with ordinary manual dexterity can readily learn to introduce the internal tubes, and as but little immediate danger attends the operation, he will not hesitate from timidity.

Croup.

Intubation has been remarkably successful in the *Reference Handbook of the Medical Sciences, article on

+ Ibid.

Archives of Pediatrics, vol. 1, p. 10. § Medical Age, vol. 4, p. 317.

treatment of croup in very young and weakly infants who have always been considered the worst possible subjects for tracheotomy, although my own opinion is that age alone has but little influence upon the prognosis. Quite a number of the reported recoveries were in young, puny foundlings. The simple and easily performed intubation may save many such children in the future.

Tracheotomy again offers nothing in cases accompanied by grave diphtheritic toxæmia. Although I have operated on three or four such cases and have observed a number in the practice of other physicians the results have been such that I hardly think tracheotomy justifiable. It hardly ever saves life, simply because the child is about hopelessly ill before the larynx is invaded, and the relief it affords is only transient and does not counterbalance the extra suffering entailed by the operation on both the patient and friends. I heartily welcome the simple operation of intubation for the treatment of such I believe it will often temporarily relieve the dyspnoea and permit the child to die easily, which is all that tracheotomy can do.

cases.

The reports of intubation show that many serious difficulties attend it. The most serious one in my experience is in swallowing with the tube in situ. The normal closing of the larynx cannot take place and liquids readily pass into the trachea. Besides seriously. interfering with alimentation and medication, miscellaneous fluids passing into the trachea and bronchi may, and most certainly will excite bronchitis and pneumonia.

The suffering from this cause was so great in two of my cases that I became almost discouraged with the operation. Children after tracheotomy take ample nourishment and but rarely have any difficulty in swallowing. It is possible that an oesophageal tube might overcome some of the trouble, but forced feeding is not an easy thing to accomplish in children.

In several cases reported the tube was expelled by coughing. The larynx quickly fills up when this happens, and if the physician be not at hand the child may suffocate.

Then the tube is liable to be blocked by tough mucous and firm pieces of membrane, as happened to me in case 1. This child also had great difficulty in coughing the ordinary secretions through the tube. Under these circumstances the attendant is helpless owing to the location of the tube. After tracheotomy the tube and trachea are within easy reach and the nurse can give invaluable assistance in the dislodgement of obstructing masses. It is also very important to apply

local medicaments to the trachea to dissolve false membranes. This is impossible after intubation, while after tracheotomy it can be done with perfect ease.

Since my

last intubation I have performed tracheotomy on a child. four years old and it has been delightful to contrast the comfort of the child and the ease with which he could be

cared for, with the discomforts and difficulties which attend intubation.

In my first case I experienced another serious difficulty of the operation when used on old children, namely, too small calibre of the tube As now constructed they do not in some cases admit air enough for perfect respiration. Although the tube was the full size designated for children of her age, and completely filled the trachea as I could plainly see when performing tracheotomy, the child did not get the necessary amount of air and I was compelled to open the wind-pipe. I had delayed too long, however; she was exhausted. It is possible that the largest sized tube might have given relief could it have been introduced. Other operators have found this same objection.

My experience, then, is rather unfavorable and leads me to distrust the operation, particularly for children. over three or four years of age, and having mild diphtheria.

In my experience fully 75 per cent. of these cases recover after tracheotomy, and I do not think intubation offers any such chances. I think tracheotomy will save every case that intubation can and a great many more.

I firmly believe that cases 1 and 4 would have recovered with tracheotomy. Cases 2 and 3 probably would have died under any circumstances.

There is another use for the O'Dwyer tube which I have not seen mentioned by other writers, and that is, as a guide in performing tracheotomy. I left the tube in the trachea when performing tracheotomy in my first case, and was astonished at the ease and deliberation with which I could operate and how quickly I could check the bleeding from cut vessels. Anyone who has performed the operation can readily see what great advantages there must be to have the trachea filled by an obturator that will permit quiet respiration, hold the trachea firmly in place and furnish a firm back-ground against which to press a bleeding vessel. Under such circumstances tracheotomy is an easy operation. I consider, then, intubation to be not a substitute for, but a supplement to tracheotomy. As I have shown, it has some important advantages, and being a simpler and milder measure may sometimes precede tracheotomy.

It is not possible with the few cases thus far operated upon to form any but a tentative opinion of the limit of usefulness of intubation. From the present outlook the field for the operation appears to be about as follows:

(1.) It may almost always replace tracheotomy for croup in very young infants-under 15 or 16 months old; and,

(2.) In all cases in which tracheotomy has been found to be about useless, as those attended by grave diphtheritic toxæmia, or complicating the exanthemata.

(3.) In all other cases, to a moderately successful operator tracheotomy offers better results, and is, I think, to be preferred. With unsuccessful or inexperienced