should practise the operation on the cadaver. Its modus operandi cannot be learned from reading. Colleagues with a short and thick index finger have some difficulty in learning to tube properly.

How to Operate.-Remove the child's clothes, except the undershirt, and wrap the child securely in a towel from the shoulder down, secured by safety pins. Place the child upright, facing the operator, in the lap of the nurse, who sits upright in a common straight backed chair. The arms of the patient are to be firmly held below the elbow; the child's legs are clasped between the knees of the nurse. The assistant stands behind the chair, holds the child's head firmly between the palms of his hands, and when the gag is inserted includes it within his firm grasp. The position of the child should be as though it hung from the top of its head. The operator now inserts his index finger, hooks up the epiglottis, and inserts the tube

in the funnel-shaped entrance to the larynx by elevating the handle of the introducer. The tube is then gently pushed home. While loosening and withdrawing the obturator, the head of the tube is held in place by the tip of the index finger in the throat, and a gentle push may be given to place the tube well into the larynx. The introducer must be kept in the middle line, and the child must not be allowed to slip down in the nurse's lap.

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The gag must be properly adjusted and firmly held. Any carelessness in carrying out these details will result in failure to introduce the tube.

It may be in place to dwell briefly upon some important points as regards feeding and medication, duration of wearing the tube, intermittent intubation, the management of cases where the tubes have been coughed up, secondary stenosis from cicatrix, granulations, or adema, the select on of special

tubes for ædema of the epiglottis and venticular bands, retained tubes, etc. Α new tube should be used for each case. If the operator is in doubt as to the proper size, the smaller size should be chosen. The tube may be disinfected immediately before using, and a minute quantity of iodoform ointment may be used as a lubricant. When the tube is in the larynx, and not blocked by detached membranes, a characteristic moist rattle will be heard. as the air is forced in and out in respiration. Before removing the gag, the left index finger is rapidly passed to the head of the tube to determine positively that the tube is in its proper place, then the string and finally the gag are removed. It is best not to use a string which is too strong to be broken, for in case it should become wedged in its eyelet, the string may be broken away with the index finger at the head of the tube to prevent dislodgement. If a detached membrane has been forced down, the child will become more cyanotic, whereupon the tube should be pulled out by its string and reintroduced after the detached membrane has been expelled by coughing. If a tube is coughed up after having been in the larynx a day or two, a reintroduction is not necessary until urgent symptoms

demand it, and if a child has great difficulty in swallowing food, the tube may, in exceptional cases, be taken out once a day for the purpose of proper feeding.

FEEDING. Some children will swallow liquids without difficulty, others will swallow semisolids best, such as custard, scraped meat, ice cream, sponge cake soaked in milk, hard yolk of egg, farina with egg, somatose, matzoon, or ice. Most children will swallow well in the dorsal-horizontal posture. Forced feeding by means of a tube (gavage) may become

necessary, the tube being introduced through the nose or mouth. (See Gavage.)

MEDICATION.- Stimulants, heart tonics, and antipyretics can be given with the food or subcutaneously or per rectum. Tubes may be removed after two, four, or six days. Antitoxine has shortened this period very much. When it is noticed that a greenish mucopus is coughed up through the tube, it is time to remove it. To avoid pressure necrosis, a tube should not remain longer than six days. A moderate secondary stenosis after the removal of a tube may be relieved by a few five-grain doses of antipyrine.

HOW TO REMOVE THE TUBE. -Place the child in the position for intubation, as described above. Thrust the left index finger past the epiglottis, hook it up, and with the tip of the finger as a guide introduce the extractor tip into the tube lumen and get a firm hold on the tube by depressing the handle. The tube is raised sufficiently to get the tip of the index finger under its head, and by this combined manipulation the tube is lifted out of the larynx and out of the mouth. In introducing, stand before the patient; in extracting, sit before the patient. After removing a tube, it is desirable to be within easy call for some time, as some cases need re-intubation even after twelve to twenty-four hours. If re-intubation is not necessary within one hour, the operator may leave the patient, but be within easy call.

RETAINED INTUBATION TUBES.-Apart from ordinary "prolonged tube cases," a stenosis which occasionally persists in intubation cases is usually the result of traumatism, i. e., laceration during attempts at intubation, and pressure necrosis from badly constructed tubes that have been too long in the larynx and become roughened by calcareous deposit. Cica

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tricial stenosis or granulations will be found at the entrance of the larynx at the base of the epiglottis. Such cases require expert management, and each case will need its own treatment. Hard rubber tubes for long wear and built up tubes with extra large heads and large retaining swell are called for. Accessible granulations may be removed, and superficial granulations may be attacked by coating the tubes with gelatin and alum or tannin, as suggested by O'Dwyer. In some cases, but rarely, tracheotomy must be done, with subsequent local treatment and dilatation. Specially built up tubes are also used when swollen tissue overrides the head of the ordinary tubes in primary intubation. As a dernier resort resection of the constricted portion of the larynx or trachea has been performed.

Secondary stenosis, after intubation, due to abductor paralysis, has been reported, but lacks confirmation. Secondary stenosis or persistent hoarseness with moderate stenosis may be due to ankylosis of the crico-arytenoid articulation, which may follow any local inflammatory process. Vibratory massage would be applicable to such conditions. Antitoxine and intubation combined have given such brilliant results in croup that primary tracheotomy is now rarely performed in this country for diphtheritic stenosis. A rapid tracheotomy may become necessary if, in the act of tubing, the stenosis should suddenly become complete. This accident has happened

FIG. 77.-INTUBATION STATISTICS OF BUDAPEST STEPHANIE CHILDREN'S HOSPITAL. Serum period represented by thick line

Mortality represented by the interspace

between two lines. (Prof. Bokay.)

to the writer in tubing an adult for stenosis of several weeks' standing and of unknown origin. The tube struck a subglottic vascular new growth, which bled freely into the bronchi. A rapid tracheotomy was performed and the hæmorrhage fortunately arrested, the patient making a complete recovery. Intubation in the adult is a difficult and rather unsatisfactory procedure. In diphtheria cases with great swelling of the tonsils, of the uvula, and at the entrance to the larynx, tracheotomy would probably be the most satisfactory operation.

Tracheotomy is not a difficult operation, but is, as a rule, an unpleasant one in private practice. In performing the operation the surgeon is usually fortunate if one trustworthy assistant is at hand, who is expected to

administer the anesthetic and assist at the wound as well. Now, if the patient is in any way troublesome, as is frequently the case, the operator may not be able to proceed with the necessary ease and facility. In such a case he author's automatic retractor will be of service; it will keep the edges of the wound well apart, it may be hooked into the fascia as the several layers are divided, it will hold aside such blood vessels as are in the way of the knife, and may finally be hooked into the edges of the tracheal wound, the trachea

FIG. 78.-LARYNX OF CHILD TWO AND A HALF YEARS OLD. Showing ulceration caused by too large a tube. The ulceration at a involves the whole thickness of the cartilage. Those at b and c are mere abrasions. (Dr. M. Nicoll, Jr.)

may be examined at lei ure, and there need be no haste in getting the tube into its place.

The instrument, devised many years ago, consists of a rubber band to each end of which is attached a curved double hook of nickel plated steel. It can be used as a general retractor in operations requiring careful dissection in different parts of the body; but it is especially applicable to the neck.

The instrument can be disinfected and the rubber must be renewed occasionally.

With a bottle, wrapped up in toweling to act as an appropriate support at the nape of the neck, and the child under chloroform, an incision is made about two inches long, from the superior border of the thyreoid cartilage