INTUBATION OF THE LARYNX, -BY- CARL H. VON. KLEIN, A. M., M., I)., Cleveland, Ohio. Reprinted from " The Cleveland Medical Gazette, " August, 1891. press OF Buel, Mather & Hubbell, 110 Sheriff St., Cleveland, Ohio. INTUBATION OF THE LARYNX.* CARL H. VON KLEIN, A. M., M. D., CLEVELAND, OHIO. The duties to which physicians are assigned, are not simply to practice medicine by a method which is laid down in text- books, or demonstrated by colleges, professors or eminent authors. Nay, it is also his duty to investigate every issue of the past as well as of the present, and try to improve on their methods to suit each individual case, regardless of fear of friends and patient. The most peculiar thing in the practice of medicine, which 1 regret to mention, is that it has modes and styles; they come and go, and it is not confined to the uneducated, but many of our best cultured physicians are victims thereto. Intubation of the larynx is not a new method which many sup- pose it to be, though it is said to have been practiced centuries back, yet we have no later history on this subject than thus given by Dessault in 1801. It was again revived in 1854 by Dr. Horace Greene of New York, but neither of those men have explained intelligently enough to be followed, especially the later being doubted for various reasons in professional conduct. In 1858 M. Bouchut of Paris, a man of high culture and standing, appeared before the Academy of Medicine and exhibited his various cylindrical tubes to be placed in the larynx and advocated against tracheotomy. The opposition and stand made against him by Trousseau, the leading laryngologist of the world at that time, in such an antagonistic manner, that the committee appointed by the Academy to investi- gate the utility of Bouchut's procedure, reported it to be imprac- ticable and worthless. *Delivered before the Union Medical Association of North-eastern Ohio, at Canton, Aug. 11 1891. 2 Von Klein : Intubation of the Larynx. The matter laid dormant from 1858 to 1880, a period of twenty- two years, when Dr. O'Dwyer, with his non-pretentive ingenious dexterity, knowing nothing of the prior devices and methods of Dessault, Greene and Bouchut, proposed to intubate in the Foundling Asylum of New York, which he did with a recovery of one patient. His experiments, however, were done with a long catheter, introduced through the nostril, which gave relief to the little sufferer, but the difficulty was that the patient could reach it with his hand and would pull it out. To overcome this he suggested a short one with a swell shoulder at the head of the tube so as to allow the shoulder to rest on the venticular bands and the glot- tis to close over the opening of the tube. By his various experiments with different lengths and shaped tubes, swells, etc., he made his tube so perfect that it leaves but tittle space for improvement. Dr. Waxham of Chicago, who probably has made more intuba- tions than O'Dwyer himself, has long experimented upon a new tube with a covered top so as to make a false glottis in order to cover the tube during the time when food or drink is taken. This, however, he accomplished satisfactorily to himself but unfortunately without utility to myself and to many operators of my personal acquaintance. I have tried it in three different cases but regret that I was compelled to fall back on O'Dwyer's tube, but whatever tube there has been or may be devised, it has attested that intubation proved to relieve membranous stenosis of the larynx promptly and effectually. At first the operation was very discour- aging. Dr. Brush, who first brought to notice before the profession O'Dwyer's method, reported eight cases and all fatal. Then came Dr. O'Dwyer reporting one hundred and thirty-four intubations with only twenty-six recoveries ; Dr. Waxham with one hundred cases and twenty-six recoveries. Again Dr. Waxham reported one- hundred and fifty cases with one hundred cases of O'Dwyer's, a total of two hundred and fifty cases with sixty-eight recoveries, making the per cent, of recovery 27.20; and the 1,072 cases of Von Klein : Intubation of the Larynx. 3 intubation collected by Dr. Waxham in various parts of the United States showed two hundred and eighty-seven recoveries, or 26.77 per cent., thus making but very little difference in the per cent, of recovery between intubation and tracheotomy according to the reports of Dr. Stern at the International Congress at Washington. His report was taken from Bourdillat, which gave the recovery in tracheotomy 26.40 per cent. Until 1888 intubation shows but very little life-saving in preference to tracheotomy. In Dr. Waxham again reported sixty cases with twenty- eight recoveries, or 46.66 per cent. In one year the operation made such progress and became so well known, and the profession so well educated to early tubage, that Waxham's recoveries were 75 per cent, greater than in his previous report. Since 1889 various additional reports have been published (from one to ten cases) in the Medical Journals, reporting many total recoveries. Some had intubated two and three cases, all recovered; some as high as 90 per cent., and some as low as 10 per cent.; others totally fatal ; adding all together shows about 36 per cent. From 1888 until now I have noted 2,204 cases (including one hundred and thirty-one of my own) with seven hundred and twelve recoveries, or 32.30 per cent. In the one hundred and thirty-one cases of intubation that I performed, I have the pleasure to report sixty-three recoveries, or 48.9 per cent. This shows the largest per cent, of recovery in the United States by one person with more than ten cases. I will admit that I have performed twenty-three intubations which I think that the patients in all probabilities would have re- covered without the operation, yet I have performed on twenty- nine cases where tracheotomy would have answered a better purpose, but owing to the usual objection raised by the parents to tracheot- omy I was compelled to perform intubation, or allow the little sufferer to die without aim of relief. In thirty-eight cases of membranous croup I have intubated? I had but one death. This 4 Von Klein : Intubation of the Larynx. ought not to have occurred, but as the operation was performed at a distance and the attending physician entirely inexperienced with intubation, he allowed the case to strangulate with loose membrane packing itself in the tube. He even had not sufficient judgment to notify me of the condition, which could have been changed and the life of the child saved had the tube been removed and allowed the larynx to throw off the membrane after it has loosened itself on the fourth day; accordingly, it died from strangulation the fifth day. If there exists specific treatment in any branch of medical science, I believe tubage in croup is one; but in laryngeal diph- theria I believe many lives have been and will be lost on account of waiting too long and then resorting to intubation where tracheot- omy ought to be performed. Again, I believe that the small per cent, of recovery reported by O'Dwyer, Waxham and others until 1888, is due to the cases being allowed to go on until too late for intubation and it being performed when tracheotomy would have saved a larger per cent. I wish it to be understood that the fault lies not with the opera- tor, but with the attending physician. In 1886, when I first began to perform intubation, I had no better result than O'Dwyer, Waxham and others until 1888. I soon learned that intubation is only a remedy in milder and early cases of dyspnoea, and not to wait until the pseudomembrane becomes too low extended, and too large to pass through the opening of the tube. In such cases intubation is useless and tracheotomy is the only remedy; therefore the low per cent, of recovery in intubation is due to the late introduction of the tube, or in other words, intu- bation is uselessly performed where tracheotomy may be effectually performed. In such cases tracheotomy will show a recovery according to Drs. Bourdillat, Jacobi and others 26.40 per cent. I attribute my large per cent, of recovery to the courtesy of the high-cultured and broad-minded physicians of Southern Ohio, my former home, whom I have tried and succeeded in educating to early intubation. In many cases I have been summoned to consult Von Klein : Intubation oj the Larynx. 5 where intubation was never performed, but symptoms have induced their diligence to have me on hand for early intubation in case it was necessary. I believe that many more cases could be performed and many more lives could be saved, if all the humbug and delusion attached to the operation would be done away with; that is, the useless exhi- bition of instruments to patients, parents and bystanders; to do away with the savage-looking and unnecessary gag; to dispense with the thread, which is absolutely unnecessary. The index finger will guide the tube to its proper channel. I experienced various difficulties in many operations before tubage was allowed. I have had many cases where the attending physician expostulated for quite a time before he was permitted to summon me to perform the operation. Many have backed out after my arrival, at the preparing and viewing the instruments. Others even at the moment when the gag was placed in the mouth and the tube to be inserted, declared they would rather see it die than tortured. I have since learned to dispense with the exhibition of instru- ments and preparing them in the presence of patients and bystanders, and to do away with the gag, with the thread and with all other unnecessary paraphernalia which makes it appear as though it was a critical and capital operation, shocking the feelings of all those present who imagine that in all probabilities the patient will die before the operator is through with it, while in reality they are not hurt, but will be relieved from strangulation and breath gasping in a few seconds, even though it be but temporary. My mode of operation is this : After placing the patient in prop- er position, ( which should never be done by parents if it can be avoided,) I place the introducer with the tube already attached in the sleeve of my right arm. My instruments are always ready and in an aseptic condition. As I decide on the size of the tube, I turn to some corner or into an adjoining apartment, screw the tube onto the carrier and place it in my sleeve ; then I beg the little patient 6 Von Klein : Intubation of the Larynx. with kindness to open its mouth or to show me its tongue, patting it with my left hand on the right cheek and having my left index finger in readiness to introduce just as soon as it consents to my FIGURE I. request. I hurriedly introduce my left index finger, having upon it an intubating thimble of my own design which acts as a gag. I perform with the finger two functions; the thimble on the first joint from the metacarpus as a gag, and with the two other joints to elevate the glottis and guide the tube as shown in figure 2. The thimble is made of coin silver, or it may be made of other material, such as aluminum, etc., and heavy enough to prevent bending it together with the teeth. When the tube is inserted FIGURE 2. in the larynx, I pull the finger out and leave the thimble between the teeth, which the patient soon lets fall. Gentlemen, if you will permit me, I will call your attention to another matter which stands in the way of early intubation and which retards many a parent's consent to the operation and induces them to believe it to be of a capital nature ; that is, the exorbitant fees for tubage. Von Klein : Intubation of the Larynx. 7 Parents of ordinary circumstances are very apt to be backward in consenting to place themselves under heavy expenditure unless they see the child critical, and when it is critical and parents are willing to give up all their possessions in order to save their little ones, it is then too late. I wish to impress on you that I claim intubation is an operation, if an operation I may call it, no more than the fitting of a uterine pessary. Experience must teach you the size of the tube. The knowledge of the anatomy of the larynx is a matter of course; if one knows not that much he deserves not the name physician, and ought not to practice medicine in any of its branches; he is a dangerous man in a community. I coincide with Waxham when he says that the operation requires a certain amount of dexterity in order to become an expert in that particular branch, and that the operation should be performed by one or two persons in a certain locality or in a radius of so many miles; but I do not believe in the indolent writings that intubation is one of the great capital operations of the world. I am surprised that men like O'Dwyer, Waxham and their like make such asser- tions. Intubation is no more surgery than the proper fitting of an umbilical truss. It is laughable that those who claim to be specialists in surgery make a claim on intubation as part of their specialty. Nay, they make that claim from a dishonest motive only. The large and uncalled-for remuneration is the height of their ambitious surgery. If it belongs to a specialty at all it belongs to a laryngol- ogist, who has dexterity and rapidity in handling throat instruments. The hand which is trained to perform the slow operation of laper- otomy or divide the sphincter ani has not the dexterity and rapidity that is necessary to intubate.