Part 83 (1/2)
8. Its better results in children under five.
9. Recovery is quicker.
The practical _disadvantages_ are:
1. Quite unsuitable except at special hospitals, as great dexterity and constant practice are necessary.
2. Respiration is interfered with during introduction, so that celerity is indispensable, accidents are frequent, and failure is common.
3. Tube may be coughed up (28%, Goodall[39]), blocked (12%, Goodall), and does not provide good drainage for secretions.
4. Swallowing difficult.
5. Complications common: Broncho-pneumonia, ulceration, cicatrization.
6. After-treatment difficult and constant watching required.
7. Necessity for secondary tracheotomy (32.6%), which has a greater mortality (death in 46.1%, see table below).
8. Retained tube.
[39] _Edin. Med. Journ._, 1902, p. 235, 'Observations on Intubation of the Larynx.'
In considering the above it is the obvious duty of the surgeon to advise what he considers the better operation for the case, and this must depend largely upon the amount of his experience; the argument that the operation is superior because it can be previously practised on the cadaver is a bad one, and implies a failure to realize the many difficulties which will be encountered in the selection of cases, the operation itself, and its after-management.
I am strongly of opinion that the operation ought not to be tried indiscriminately by those who have no knowledge of these difficulties.
In the hands of an expert it is a justifiable method of treatment which is suitable for selected cases, and it is one which can be used early; tracheotomy, on the other hand, is naturally delayed, or used for serious cases and those which have not derived relief from intubation.
Although intubation has received extensive trial, the published results show great variations and do not prove that intubation is superior to tracheotomy, but rather the reverse.
TABLE SHOWING DETAILS OF CASES DURING 1906 AND 1907 AT THE M. A. B.
HOSPITALS WHERE INTUBATION IS FAVOURED
+-------+------------+------------+------------+------------+
_Intubation
_Both
_Tracheotomy
_Total
only._
operations._
only._
operations._
+-------+---+---+----+---+---+----+---+---+----+---+---+----+
_C
_D
_C
_D
_C
_D
_C
_D
a
e
a
e
a
e
a
e
s
a
s
a
s
a
s
a
e
t
%.
e
t
%.
e
t
%.
e
t
%.
s
h
s
h
s
h
s
h
._
s
._
s
._
s
._
s
._
._
._
._
+-------+---+---+----+---+---+----+---+---+----+---+---+----+
Eastern
78
4
5.1
44
19
43.1
30
13
43.3
152
36
23.6
Western
25
7
28.0
10
4
40.0
126
41
32.5
161
52
32.2
Park
31
3
9.7
11
7
63.6
16
11
68.7
58
21
36.2
+-------+---+---+----+---+---+----+---+---+----+---+---+----+
Total
134
14
10.4
65
30
46.1
172
65
37.7
371
109
29.3
+-------+---+---+----+---+---+----+---+---+----+---+---+----+
Certain points in the table deserve attention:
1. In cases treated by intubation only, the results are excellent, namely, death in 10.4%.
2. In cases where tracheotomy was afterwards performed the mortality is high, _i.e._ 46.1%.
3. Where tracheotomy was the original operation the mortality is also high, _i.e._ 37.7%.
4. The total operations at these hospitals taken together show a rather higher mortality than appears in the table below.
As regards the first three points, the facts are the same as in any published statistics dealing with the relative advantages of the two operations. I wish to emphasize that the results obtained by intubation depend very largely upon the selection of the cases and I agree with Turner and Cuff that, in order to arrive at any conclusion in the matter, it is necessary to compare the total results of those hospitals where intubation is favoured with those of the hospitals where tracheotomy is chiefly employed.
TABLE SHOWING COMPARATIVE RESULTS AT 'INTUBATION' AND 'TRACHEOTOMY'
HOSPITALS
+-------+------------------+--------------------+-----------------+
_Three
_Six
_Total
'Intubation'
'Tracheotomy'
Cases._
Hospitals._
Hospitals._
+-------+------+-----+-----+--------+-----+-----+-----+-----+-----+
_C