Reprinted from the New York Medical Journal 
for March, 3, 1894. 
A CASE OF INTUBATION OF THE LARYNX 
OF UNUSUAL INTEREST, 
WITH SOME REMARKS ON THE MANAGEMENT OF SUCH CASES. 
By W. M. SEWARD, M.D., 
VISITING PHYSICIAN TO THE PRESBYTERIAN HOSPITAL DISPENSARY, 
CLASS OF DISEASES OF CHILDREN. 
The case of a girl, seven years old, of healthy German par- 
ents, was referred to me by Dr. A. A. Richardson. She had 
been sick for three days before my first visit-on November 29, 
1893. The tonsils and pharynx were covered with false mem- 
brane; temperature, 100° F.; pulse, 112. 
November 30th.-Doing well; temperature, 99'5°; pulse, 
108. 
December 1st.-In the morning she had a croupy cough, 
with some dyspnoea, which increased rapidly. I called again at 
5 p. m. and found her cyanosed. The parents had called in Dr. 
George B. McCauliffe, whose residence was near by. lie had 
his tubes with him, and, at my request, intubated at 6 p. m. 
This relieved the labored breathing and the cyanosis, but the 
patient was very weak. The temperature was 101°, the pulse 
130, and the respiration 30. Steam inhalations were given, 
also calomel fumigations, twenty grains every three hours. 
2d.-The patient had not recovered her strength so rapidly 
as I have seen in such cases, but was doing fairly well. The 
temperature was IOPS0, the pulse 128, and the respiration 28. 
Copyright, 1894 by D. Appleton and Company. 2 
A CASE OF INTUBATION OF THE LARYNX 
Four drops of tincture of digitalis and a grain of ammonium 
chloride were given every three hours, with the effect of im- 
proving the pulse. 
3d.-The temperature was 99°, and the pulse 108 and of 
good quality. 
Ifth.-The patient was still improving. 
5th.-The temperature and the pulse were normal. 
6th.-I removed the tube; the patient breathed well and 
there was very little spasm. 
7th.-She was very comfortable and took food well. 
8th.-She was still improving and continued to gain until 
noon, when she took cold and was attacked with bronchitis 
and a recurrence of croup. 
13th.-There was some dyspnoea, and the use of calomel 
fumigations and steam inhalations was begun again. 
IJ^th.-Dyspnoea was decided and there was suprasternal 
and epigastric recession. 
15th.-The breathing was very labored and she was cya- 
nosed. Emetics were given, but without relief. 
16th.-Dyspnoea was increasing in the morning. Wishing 
to postpone operating the second time as long as possible, I in- 
formed the parents as to where I could be found. I called 
again at noon and found the cyanosis increasing. At 4 p. m. I 
introduced a fresh tube. The child was in a very poor condi- 
tion when it was done, and she fell asleep at once, exhausted, 
and slept all night, except when coughing for a minute at a 
time. 
17th.-The color was good, the temperature 102°, the 
pulse 138, and the respiration 34, and there were moist rales 
over both lungs. 
18th.-The tube was coughed out at 5 a. m. The patient 
was somewhat croupy, but the tube was left out. 
19th.-The croup increased again, and the parents were in- 
structed to call upon me at any hour if the breathing seemed 
dangerous. 
20th.-The patient was cyanosed again, and intubation 
was performed at 10 a. m., with perfect relief. 
21st.-She was very comfortable and took food well. She OF UNUSUAL INTEREST. 
3 
continued to improve until the 30th, when, at 3.40 p. m., I re- 
moved the tube for the third time. The patient breathed well 
for only an hour; then the croup returned and increased 
steadily. 
31st.-In the morning the breathing was quite hard, and in 
the afternoon the patient was somewhat cyanosed. As she had 
gained some strength, I thought it safe to leave the tube out a 
while longer. 
January 1st.- At 12.10 a. m. the father called for me and 
said that the child bad been breathing harder since my evening 
visit, so he feared she would live but a short time. Twenty 
minutes later I intubated for the fourth time and none too soon. 
I did not use a gag, as there was no time to be lost, and I 
hardly expected the child to revive again, for she was not only 
cyanosed, but almost pulseless, and the eyes had the glassy ap- 
pearance too familiar to men who intubate and who are often 
called after children are practically dead. (In January I was 
called to intubate, and the child stopped breathing when the 
jaws were opened. The tube was introduced quickly and arti- 
ficial respiration was employed ; this started normal respiration 
again, but there was only enough strength to last for a short 
time.) The child revived, breathed easily, and fell asleep in her 
father's arms after about a minute. Twenty minutes later the 
color was better and the pulse was improved by giving 0'01 of 
a grain of strychnine in thirty minims of whisky hypodermic- 
ally. There was oedema of the lungs, as one would expect 
after a patient had been so nearly dead from inability to get 
air. 
2d.-The lungs were clearing up, and there were rales only 
in the large bronchial tubes. The color was good, the pulse 
130 and of fair quality, the temperature 101°, and the respira- 
tion 30. The child was allowed to drink only from a teaspoon 
whenever the tube was in. 
3d.-The temperature was 99°, the pulse 108, and the respi- 
ration 28. 
J^th,.-The temperature and pulse were normal. After this 
she was given whatever she wished to eat. 
8th,-She was allowed to walk about the room, and from 4 
A CASE OF INTUBATION OF THE LARYNX 
this time she sat at table with the family and ate what she 
wanted, and there was no difficulty in swallowing. She gained 
strength rapidly and spent her time in playing and doing fancy 
work. 
16th.-I removed the tube again. There was still stenosis, 
but it was not so decided as before. Dr. Joseph O'Dwyer was 
present and advised me to insert the tube again before leaving, 
as he did not think it safe to leave it out. I introduced a fresh 
tube, for the old one required to be soaked in an acid solution 
to dissolve the rough calcareous deposit that existed on its sur- 
face. It is best, in cases requiring repeated intubation, to re- 
move the tube at least once a week and insert a fresh, clean 
one if necessary. Dr. O'Dwyer advises this. 
17th.-The child was very comfortable and hearty and 
continued to increase in strength and flesh until the 24th, when 
I removed the tube for the fifth time and found that the 
breathing was better than it had been at any time before. 
Two grains of Dover's powder were given two hours before the 
tube was removed. This is very important, as it controls the 
spasm which is generally present. The tube had to be inserted 
again two hours later, as dyspnoea had gradually returned. 
At this time I inserted a tube made to order by George Ermold, 
with a greater vertical diameter of the head, to prevent the 
tube from pressing on the same tissues that the old one had 
rested on, and thus producing a tendency to the formation of 
granulation tissue or to ulceration. This tube was worn until 
February 1st, and then it was extracted, two grains of Dover's 
powder having been given two hours previously. After it was 
out the breathing was very satisfactory, except for the spasm 
after coughing, which was controlled by giving two grains of 
Dover's powder every four hours for twenty four hours. 
February 2d.-The child wras very comfortable. 
3d.-She had a severe spasm at night, and the father came 
for me to intubate, but after an additional dose of Dover's 
powder she breathed well again. 
For the last two weeks the child has been taking potassium 
iodide, from four to sixteen grains a day. It may be thought 
that tracheotomy would have been Jess troublesome in this OF UNUSUAL INTEREST. 
5 
case. I know of a case, however, in which it was done because 
the tube could not be introduced, yet months after the patient 
was finally cured by reintubations after the tracheotomy wound 
had healed. In another case, in which I saw tracheotomy done 
after the tubes had been used for a long time, the patient died 
of pneumonia. 
The chief points of interest in this case are as follows: 
1. The time that elapsed from the first introduction of 
the tube to its last extraction-sixty-one days. It was out 
fourteen days and in forty-seven. 2. After the tube had 
been worn for a week or two there was very little difficulty 
in swallowing. 3. It shows that it is important to intro- 
duce a fresh tube at least once a week. 4. The patient is 
now well, and the tube has been out since February 1st.