Intubation of the Larynx. 
BY 
E. FLETCHEE INGALS, M.D., 
CHICAGO. 
REPRINTED PROM 
Elje 'Neto Yorft J&etiicalJournal 
for July 2 and 9, 18S7. Reprinted from the New York Medical Journal 
for July 2 and 9, 1887. 
INTUBATION OF THE LARYNX.* 
By E. FLETCHER INGALS, M. D., 
CHICAGO. 
In 1858 an attempt was made by M. Bouchut, of Paris, 
to treat stenosis of the larynx by intubation. As the result 
of his experiments he reported seven cases to the Academy 
of Medicine, of which live were fatal and but two ended in 
recovery after the subsequent performance of tracheotomy. 
Although these results were unsatisfactory, had M, Bouchut 
displayed the perseverance, patience, and moderation which 
have characterized the author of more recent experiments, 
he might then have demonstrated the practical utility of the 
method; but, in his zeal for the new operation, he unfortu- 
nately attacked tracheotomy and brought upon himself and 
his method the severe criticisms of those who had seen much 
good accomplished by opening the trachea. Trousseau, as 
secretary of the commission appointed to investigate the 
new operation, reported : 
1. Tubage of the larynx in certain cases of acute laryn- 
gitis can, by retarding asphyxia, prove of curative value. 
2. In certain chronic diseases of the larynx it may allow 
* Read before the American Laryngological Association at its ninth 
annual congress. 2 
INTUBATION OF THE LARYNX. 
one to delay tracheotomy, and may sometimes relieve or cure 
the patient. 
3. In the treatment of croup it delays asphyxia and 
allows an easier introduction of air, and the administra- 
tion of agents capable of modifying the diphtheritic inflam- 
mation. 
4, It can only very rarely supplant tracheotomy, which 
is the principal means of opposing croup when medical 
measures fail. 
The last declaration proved the text for a discussion 
which was “ an extinguishment of M. Bouchut’s views and 
methods,” and intubation of the larynx was condemned as 
an impracticable procedure. 
In M. Bouchut’s experiments a tube was used from 18 
to 24 millimetres long, and from 6 to 8 millimetres wide, nar- 
rowed at one end. This was pressed into the larynx on the 
end of a hollow sound, a thread having first been attached to 
it to prevent its passage into the trachea, and to facilitate its 
removal. This thread was brought out through the mouth, 
and seems to have been the cause of much irritation ; but 
the larynx was tolerant of the tube. Previous to Bouchut’s 
experiments and since that date, catheters have been fre- 
quently used to prevent suffocation from closure of the glot- 
tis. As early as 1801 Desault accidentally learned of the 
tolerance of the larynx and trachea for a foreign body of 
this sort by passing a tube through the nose into the trachea, 
instead of into the oesophagus, as he had intended. The tube 
remained in that position for several hours, and he only be- 
came aware of its situation upon attempting to introduce 
food. 
This accident suggested the possibility of treating laryn- 
geal stenosis similarly. He experimented and reported two 
cases. The first patient was relieved temporarily, but died 
the same day the catheter was introduced. His second, who INTUBATION OF THE LARYNX. 
3 
had oedema of the glottis, recovered, the catheter having- 
been retained in the trachea for a day and a half. 
Within the last few years Schroetter has successfully 
treated chronic stenosis of the larynx by the use of hollow 
three-sided bougies. 
In 1880 Dr. William McLean, of Glasgow, reported three 
cases in which he had used a catheter in the larynx, one end 
of which protruded from the mouth. In one case the cathe- 
ter was used during a surgical operation to prevent blood 
from flowing into the trachea. In the second case a No. 12 
catheter was retained thirty hours, and in the third thirty- 
six hours. 
Numerous other physicians have practiced catheteriza- 
tion of the larynx, but with no great success. 
Dr. Joseph O’Dwyer, of New York, in 1880 began a 
series of experiments with intubation, which have resulted 
in giving to the profession one of the most useful operations 
of modern times. He first tried a bivalve elliptical tube 
with narrow transverse diameter, and having a head to pre- 
vent it from slipping into the trachea. But the membrane 
soon protruded between the blades, and there was a conse- 
quent return of dyspnoea. Retaining the head, he next 
made plain tubes about an inch in length. These were 
employed in three cases which he reported: The first 
was that of an infant, aged two months and twenty-four 
days, suffering from suffocative diphtheritic croup; relief 
was promptly obtained, but the child died in seventeen 
hours. The second case was that of a girl aged three 
years and a half, who was suffering from urgent dysp- 
noea. She made a rapid recovery. The third case was 
that of a boy aged four years; he died in twenty-four 
hours. At the autopsy the lower end of the cannula was 
found obstructed by a thick deposit of membrane. This 
showed the necessity for longer tubes. They were made 4 
INTUBATION OF THE LARYNX. 
and tried, but in a large proportion of the cases they were 
soon coughed out. A tube was then tried having a wedge- 
shaped piece of metal on either side to make it self-retain- 
ing, but it was held so firmly in the larynx that it could only 
be removed with great difficulty. Dr. O’Dwyer then con- 
ceived the idea of fusiform tubes which, with slight modifi- 
cations, were like those in use at the present time. His 
present set of instruments consists of a gag, five laryngeal 
tubes, an applicator, an extractor, and a gauge. The tubes 
vary in length from an inch and a half to two inches and a 
half, the caliber of the largest being about one eighth by one 
quarter inch, that of the smallest about one half that size. 
At the upper end of the tube is a diamond-shaped head, 
with rounded angles, which rests upon the ventricular bands 
and prevents the tube from slipping into the trachea. The 
anterior aspect of the head is beveled off where it rests 
against the base of the epiglottis, and at its anterior part is a 
small eye through which a double thread is passed during 
its introduction. About the middle of the tube is a fusi- 
form enlargement, designed to make it self-retaining. Joint- 
ed obturators accompany each tube, the distal end of which 
is rounded and of a size to close the caliber of the tube. At 
the proximal end also the obturator is enlarged to accurate- 
ly fit the tube, and in its base is a small hole into which the 
end of the applicator is screwed when the tube is to be in- 
troduced. The stem of the applicator is covered by a slid- 
ing tube, which may be crowded forward by a thumb-piece 
to release the obturator from the laryngeal tube when the 
latter is in position in the glottis. The extractor is con- 
structed on the principle of a dilator. When in use the 
closed blades are passed into the end of the laryngeal tube; 
a lever on the handle is then pressed down to open the 
blades, which impinge against the inner aspect of the tube 
and hold it firmly so that it may be withdrawn. The gauge INTUBATION OF THE LARYNX. 
5 
is used in determining the size of tube necessary for a child 
of any given age. 
You will find no difficulty in doing intubation ; but those 
not familiar with laryngology will find it profitable to prac- 
tice on the cadaver before attempting it on the living subject. 
The Operation.—The child should be wrapped in a shawl 
and held in the nurse’s lap, with the head thrown slightly 
backward against her left shoulder. The gag is then placed 
between the jaws on the left side of the patient’s mouth, 
and intrusted to a competent assistant, who should hold it 
carefully in position.* 
With the gag in position, the index finger of the left 
hand is carried over the base of the tongue behind the epi- 
glottis to the opening of the larynx. At this point great 
difficulty is sometimes experienced in recognizing the epi- 
glottis, which in young children is so soft that it can hardly 
be felt, though in patients over three years of age there is 
usually no difficulty. In very young patients the larynx is 
so small and soft that its outlines are indistinct to the tac- 
tile sense. To me it feels much like the end of ray ring 
finger. I avoid trouble with the epiglottis by carrying my 
finger first behind the arytenoids and then slightly forward. 
With the finger resting on the larynx, the tube is glided 
quickly along the palmar surface until its end is lodged in 
the larynx; it is then gently forced through the glottis 
until its head rests upon the ventricular bands, where it is 
held by the index finger of the left hand while the ap- 
plicator with the obturator is disengaged and withdrawn. 
* The gag which goes with this set is too small, and, unless very 
carefully watched, is liable to become displaced, so that the operator 
may be bitten. A friend of mine lost his life the past winter from 
diphtheria caused by a bite which occurred in this way. 
I have used latterly Goodwillie’s gag, which is easily retained in 
position; but, as an additional precaution, I usually use a broad steel 
band on the first finger. 6 
INTUBATION OF THE LARYNX. 
If any difficulty is experienced in introducing the tube, 
the instrument should be withdrawn after a few seconds 
to allow the child to catch its breath ; then the attempt 
may be repeated. The double thread attached to the tube 
before its introduction is allowed to remain for a few 
minutes until the child has partially cleared the trachea, 
and respiration has become fairly easj*. Then the index 
linger of the left hand is again introduced for a moment 
upon the head of the tube, and the thread is cut and with- 
drawn. The whole time occupied after the gag is in posi- 
tion until the tube is safety lodged in the larynx is seldom 
more than a minute. Within five or ten minutes more the 
patient is usually breathing with perfect ease, and falls into 
a quiet sleep. No anaesthetic is used, and little if any pain 
is complained of by the patient. Subsequently the child 
requires no more than the ordinary care for a patient with 
the same malady who had not required surgical interfer- 
ence, excepting as to nourishment. 
The patients should be fed on soft solids, and I believe 
that fluids must be absolutely forbidden, excepting by ene- 
mata. Most of these patients might swallow half a drachm 
of liquid without harm, if at the time they were always care- 
ful to bend the head well forward and a little to one side, 
with the chin pressed firmly against the neck. Some will 
swallow without any difficulty even without this precaution, 
and others will swallow readily a part of the time ; however, 
the entrance of a small amount of fluid into the trachea may 
be sufficient to excite a fatal bronchitis or pneumonia. The 
best plan is to forbid the use of fluids entirety, for the child 
on the second day will beg so for water that the attendants 
are nearly sure to give it unless they have been told that it 
will kill the patient. After the second day the thirst seems 
to be much less troublesome. At the time, this direction 
seems almost cruel, but there is some reason to believe that INTUBATION OF THE LARYNX. 
7 
withholding fluids has a decided effect in limiting the 
amount of diphtheritic deposit in the air-passages, as well 
as preventing the excitation of bronchitis or pneumonia. 
At most, the suffering of the patient can not be long, and, 
in view of the evils to be avoided, I hope those who use 
intubation will bear in mind the danger from the ingestion 
of fluids. 
The tube in the larynx is cleared by the ordinary re- 
spiratory efforts, or, if it becomes clogged, it will usually be 
coughed out. Not infrequently it will be coughed out during 
the course of the treatment; but this does not occur in more 
than one fourth of the cases, and then it is not apt to be 
more than once. The largest tube that can be used is most 
likely to be retained. After from four to six days in many 
favorable cases, the swelling and false membrane will have 
so much diminished that the tube may be coughed out 
finally, and need not be reintroduced. If not expelled, it is 
removed with the instrument designed for the purpose. In 
removing the tube, the gag should be inserted, and the ex- 
tractor guided into the tube by the finger of the left hand, 
when, by opening its blades, the tube is caught and may be 
extracted. If at the same time the trachea is grasped just be- 
low the cricoid cartilage and crowded slightly upward and 
backward, the liability of forcing the tube into the trachea 
is diminished. Dr. F. E. Waxharn, of Chicago, who, I 
think, first after O’Dwyer to adopt this method of re- 
lieving the dyspnoea of pseudo-membranous laryngitis, has, 
I think, done more than any one else, excepting the origi- 
nator, to popularize this operation. He has experimented 
quite extensively with tubes of various forms. Recently he 
had constructed tubes with a very small head, and a rubber 
collar, fitted with an artificial rubber epiglottis, designed to 
prevent the entrance of foreign substances into the air- 
passages during deglutition. He has used these with fair 8 
INTUBATION OF THE LARYNX. 
success, but has not yet overcome this objection to intuba- 
tion. 
Dr. A. E. Hoadley, also of Chicago, by accident intro- 
duced one of O’Dwyer’s tubes wrong end foremost, and the 
patient did well for a time. Subsequently he and others em- 
ployed this method of seating the tube. It was maintained 
that, instead of resting with its head on the ventricular 
bands, it could thus be crowded down so that it rested on 
the true cords, where it did not so much interfere with 
closure of the epiglottis, and therefore deglutition was more 
easily accomplished. Cases treated in this way did just 
about as well as those treated by O’Dwyer’s method, I 
think, neither better nor worse. 
Dr. Hoadley has had tubes constructed much shorter 
than O’Dwyer’s, and with somewhat modified heads, de- 
signed to rest on the true cords. He thinks they will be 
more satisfactory than the longer tubes, but he has not 
used them. None of these are very different from some of 
O’Dwyer’s patterns. Dr. J. Tascher, an eclectic physician 
of Chicago, has recently been experimenting with a short 
tube quite different from O’Dwyer’s, with which he has had 
good success, having treated six patients, of whom three re- 
covered, though in one of these the lower end of the tube 
became filled with false membrane, and the child nearly suf- 
focated before it could be removed. It will be remembered 
that it was the liability to this accident which caused Dr. 
O’Dwyer to adopt the long tube. Dr. Tascher’s tubes are 
made of German silver and are very light, with a compara- 
tively large caliber. There are six in a set, varying in 
length from fto inch. They are of uniform size from 
the slight collar which forms the head to the lower end, 
and have no bulging upon the side to secure more perfect 
retention, which he maintains is unnecessary, on account of 
the position which the head occupies below the ventricular INTUBATION OF THE LARYNX. 
9 
bands. These tubes are flattened at the sides and have an 
oval aperture measuring- from by \ inch to \by f inch. 
The collar which forms the head is only about y of an inch 
in width. The outer edge of its lower surface, which is de- 
signed to rest directly upon the vocal cords, projects a trifle 
below its attached border to prevent it from slipping off the 
cords. 
On a wet preparation of a child’s larynx it has been 
demonstrated that this collar catches so firmly on the vocal 
cords that the tube can not be forced into the trachea even 
by using considerable force. 
While this is true with this particular larynx, and al- 
though the doctor states that there is no danger whatever 
that the tube will be crowded into the trachea, there re- 
mains a fear that this accident may occur at times, and this 
fear becomes the more real from a knowledge of the fact 
that, at least in one case,* even O’Dvvyer’s tube, with its 
large head, has been crowded down into the trachea and 
caused death. With the small tubes of Dr. Tascher’s it 
would seem that, even if they were crowded into the trachea, 
they would not greatly obstruct it and might be easily re- 
moved by tracheotomy, or possibly with a long tracheal for- 
ceps. The advantages of these small tubes, if they were only 
longer, are at once apparent, if it is a fact that there is no 
danger of their passing into the trachea. They are small 
and light, and may be so deeply seated that they do not 
greatly interfere with deglutition ; but it remains to be seen 
whether they are more likely to cause ulceration of the 
vocal cords, and whether subsequent cases will average 
* It is hardly necessary to state that this case has not been reported. 
The knowledge of it came to me through a physician for whom I had 
performed intubation. He told me that the child had recovered from 
diphtheria, and that, on attempting to remove the tube, the accident 
occurred with the result stated. 10 
INTUBATION OF THE LARYNX. 
better than those treated hy O’Dwyer’s tubes. These, like 
the other modifications of the laryngeal tube, are introduced 
and removed with Dr, O’Dwyer’s instruments. 
I have treated twelve cases of diphtheritic laryngitis 
by intubation, none of which occurred in my own practice. 
In only three of these cases had I the subsequent care of 
the patient, and by a strange coincidence these were the 
only ones that recovered ; however, one other lived for 
eight days and then died suddenly, an hour after the tube 
had been removed, either of paralysis or of spasm ; and an- 
other lived eight days, but then died of pneumonia said to 
have resulted from exposure after the tube had been re- 
moved. 
Of these cases, Nos. I to Y, inclusive, have been reported 
elsewhere, but, as two of them illustrate what I wish to say 
of treatment, I shall be obliged to give abstracts of them 
here. 
Case I.—Consultation with Dr. A. M. Stout. A little girl 
two years of age. Diphtheritic laryngitis, with great lividity, 
dyspnoea, and stridor. Intubation; immediate relief. Death 
from constitutional results of diphtheria forty hours later. 
Cask ll.—Consultation with Dr. J. F, Todd. A strong boy 
five years of age. This was termed membranous croup. There 
was considerable lividity of the lips, wfith recession of the chest- 
walls during inspiration. Intubation; complete relief of dysp- 
noea. The patient did well for about twenty hours. Bronchitis 
then developed, and the child died about thirty-nine hours after 
the operation. 
Case HI.—Consultation with Dr. 0. J. Creighton. A girl 
five and a half years of age. Diphtheritic laryngitis, with great 
dyspnoea. Intubation; complete relief, but death from bron- 
chitis in thirty-six hours. 
Case IY.—Consultation with Dr. E. Garrott. Girl four 
years of age. Diphtheritic laryngitis, but no membrane in the 
fauces. Great difficulty in respiration, with recession of chest- INTUBATION OF THE LARYNX. 
11 
walls. Intubation. Very soon after the tube was introduced 
the child coughed up a large piece of false membrane, after 
which dyspnoea was entirely relieved. Prescribed the mild 
chloride of mercury, gr. -J- to gr. j, every two or three hours. 
Directed that soft solids be given, but fluids withheld as far as 
possible. Ice was allowed freely. A little water and milk 
were given this patient, but she soon learned to swallow half a 
teaspoonful at a time, when lying on the side, without cough, 
which would have occurred if it had entered the trachea. 
However, before this, fluids had been frequently taken which 
had caused paroxysm of cough. Bronchitis developed, and the 
second or third day after the intubation there was high fever 
with numerous mucous rales over the entire chest. The mild 
chloride was continued during this time, and in addition tinc- 
ture of nux vomica and carbonate of ammonium, with syrup of 
ipecac, were given. The fourth day the patient was better. 
During the latter part of this day the patient managed to get 
the tube out without cough, but it was not necessary to rein- 
sert it. She made a rapid and complete recovery. 
Case Y.—Dr. Lilly’s patient, a girl, aged four years and eight 
months. Diphtheritic laryngitis, Avidity, great dyspnoea, and 
recession of chest-walls. Intubation, with immediate relief. I 
directed that the child should be fed on soft solids and allowed 
to suck bits of ice, but that very little fluid be given, and this 
never in greater quantities than half a teaspoonful. Unfortu- 
nately, these directions were not carried out thoroughly, but 
considerable fluid was given, each draught of which caused 
severe cough, showing that more or less of it went into the 
trachea. Twenty hours after the tube was introduced 1 found 
the temperature 104-B°, patient extremely restless, face becom- 
ing livid, pulse irregular, rapid, and feeble, urine scanty, and 
respiration sighing and imperfect. All over the chest were 
numerous sonorous and sibilant rales; indeed, the patient pre- 
sented all the symptoms of the last stage of diphtheritic bron- 
chitis. Such symptoms I have often seen, but have never before 
seen the patient survive more than two or three hours. "When 
the child was first seen I had ordered hydrarg. chlor. mite in 
doses of two grains every two hours, which was still continued; 12 
INTUBATION OF THE LARYNX. 
but at this time I ordered tinct. nucis vom., ni j ; amm. carb., 
gr. j; syr. ipecac, ni xij; and potass, acetat., gr. iv, in syrup of 
licorice, to be given every two boars alternately with the mild 
chloride. The following morning the patient had slightly im- 
proved, the temperature being only 104°. I then discontinued 
the mild chloride and ordered the above-mentioned remedies to 
be given every hour. The relief was most marked, and I have 
no doubt that the comparatively large and frequently repeated 
doses of the cardiac and respiratory stimulants saved the child’s 
life. The tube was coughed out and reinserted on the second 
day, and was again coughed out on the fourth day, but was not 
needed subsequently. The child recovered slowly, and it was 
three or four weeks before the signs of laryngitis and bronchitis 
had entirely disappeared. 
Case YI.—Seen in consultation with Dr, B. A little 
girl, two and a half years of age, suffering with diphtheritic 
laryngitis: serious dyspnoea, with recession of chest-walls dur- 
ing each inspiration. Introduction of the laryngeal tube gave 
immediate relief, but she died about twenty-four hours later 
with symptoms of diphtheritic bronchitis. 
Case Vll.—Consultation with Dr. R. J. Price. Girl, two 
and a half years of age, suffering from diphtheritic laryngitis, 
there being no membrane in the fauces. There was great dysp- 
noea, which must have terminated fatally in a few hour's but 
for the operation. Intubation ; perfect relief. Patient did well 
for six days. Seventh day, peevish and irritable, and looking 
poorly. The eighth day, better. The attending physician re- 
moved the tube, and after half an hour, during which time 
respiration had been natural, he left the patient. He was called 
back in about half an hour, and found the child dying, but 
could not determine the cause. However, he opened the 
trachea, but without avail. 
The cause of death in this case was inexplicable, but it 
seemed to have been much the same as that in two cases 
reported to me by Dr. O’Shea, and one of which I had 
verbal reports from Dr. Waxham. At the time I thought 
it to have been heart failure. Dr. O’Shea attributed the INTUBATION OF THE LARYNX. 
13 
death in his cases to spasm. Dr. Waxham could not account 
for the one of which he told me, hut thought it must have 
been from occlusion of the glottis by partially loosened 
membrane. It is probable that laryngeal paralysis or spasm 
was the cause of the fatal termination of these cases, for it 
is not likely that cardiac failure would have happened to 
occur at that particular time—half an hour to an hour after 
removal of the tube—when there had been no evidence of 
it immediately before. 
Case Ylll.—Consultation with Dr. G. Y. Bachelle. A girl 
seven years of age had been suffering from diphtheritic croup 
for five days, and at the time of operation was livid and labor- 
ing for breath, with marked recession of the chest-walls. In- 
tubation ; complete relief; did well for six days, when the tube 
was removed. The parents were very careless, and allowed 
the child to expose herself shortly afterward, whereby she con- 
tracted a pneumonia from which she died three days later. 
This case I have not counted among the recoveries, 
though, so far as the operation was concerned, it was entirely 
successful. 
OasE IX.—Consultation with Dr. F. A. Lilly. Boy aged 
four years and four months. Diphtheritic laryngitis of severe 
form, severe dyspnoea, the child having already passed into that 
listless stage which precedes a fatal termination. Intubation; 
great relief, but the child was so low as to be unable to cough 
up the mucus from the trachea. Death in twenty hours. 
Case X,—Consultation with Dr. 0. J. Creighton. Boy aged 
four years and three months. Child in almost exactly the same 
condition as that in the preceding case. Intubation; complete 
relief from dyspnoea, but the child died in about twenty-one 
hours. 
Case XT.—Consultation with Dr. B. Girl aged three and a 
half years. Diphtheritic laryngitis, urgent dyspnoea, and im- 
pending death. Intubation; perfect relief. In this case the 
child ceased to breathe before the tube was inserted, but it was 14 
INTUBATION OF THE LARYNX. 
introduced quickly and artificial respiration was instituted, 
whereby the patient was resuscitated. Here I had urged the 
necessity of withholding all fluids, but about fifteen hours after 
the tube had been inserted I was told that the child had learned 
to swallow easily, though how long it had been practicing with 
fluids was not stated. lat once mentally affixed to its record 
the word dead. The patient died at the end of about twenty- 
four hours of diphtheritic bronchitis. 
Case Xll.—Consultation with Dr. P. Matthei. Boy aged 
four years. Had been sick five days. Diphtheritic laryngitis, 
with labored respiration and recession of the chest-walls. In- 
tubation ; perfect relief of dyspnoea, and the child, as usual in 
such oases, soon fell into a quiet sleep. Directed that soft solids 
be given and ice to quench thirst, but forbade a drop of fluid in 
any other way. Ordered hydrarg. chlor. mite, gr. j, every hour. 
The next morning (twenty-four hours later) pulse 132, tempera- 
ture 100°, a little cough, and easy expectoration, but no signs 
of bronchitis. The child was now begging for water, hut I im- 
pressed the friends with the danger, and water was still forbid- 
den excepting by enemata. The child was very restless during 
the day, apparently on account of thirst, and begged piteously 
for water, milk, wine, beer, or anything that it might drink. 
The friends thought he was becoming delirious for want of 
water. Fearing they would yield, I told them that they would 
kill the child if they gave it anything to drink. Even the 
physician, kind-hearted man that he is, interceded in behalf of 
the child, but I was so strongly impx-essed with the necessity 
for the measure that I still firmly refused; and, as the family 
had just lost one little one from diphtheritic laryngitis after 
tracheotomy, they were sufficiently frightened to follow my 
orders, excepting that they gave fluids per rectum but once. 
The second day the pulse was 130, respiration 28, temperature 
99*5°. The child had rested quietly through the night and 
asked very little for water. The mild chloride was now given 
less frequently—only once in four hours—and alternately with 
it a grain of quinine. No rales over the chest. The morning of 
the third day pulse 186, respiration 24, temperature 98°. The 
patient had rested well, but had eaten little since the operation, INTUBATION OF THE LARYNX. 
15 
and had had only two nutritive enemata during the whole time, 
instead of three or four daily, as had been ordered. A very few 
bronchial rales could be beard at this time. The child bad 
ceased to ask for water. Early the following morning (fourth 
day), with a slight cough the tube was expelled. Breathing re- 
mained easy, so that it was not necessary to reintroduce the 
tube. Pulse 132, temperature 96-2°. After the tube had been 
removed milk was given, but some of it found its way into the 
trachea and excited cough. However, very little trouble was 
subsequently experienced from this source, and the child made 
a complete recovery. 
Of these cases, those numbered IY, Y, and XII indicate 
the course of treatment which I believe to be most efficient 
after intubation for diphtheritic laryngitis: 1. Prohibit all 
fluids excepting by enemata, and insist upon this so forcibly 
that your orders will be obeyed. 2. As another safeguard, 
give some preparation of mercury in comparatively large 
and in frequent doses. 3. In case of the development of 
bronchitis or pneumonia, give respiratory and cardiac stimu- 
lants freely but judiciously. 
In Case IV ray directions were followed very well, 
but I allowed water or milk to be given in small quantities, 
hence the bronchitis. 
In Case Y fluids were given far too freely, hence the 
bare escape from death. 
In Case XII I told the friends they would kill the 
child if they gave a teaspoonful of fluid, hence the recovery 
with but little bronchitis. There may be too small ground 
for these conclusions, but I am fully convinced of the neces- 
sity of withholding fluids excepting when given in such 
manner that they can not possibly enter the larynx. 
There is an old and, it is said, very efficient treatment 
for acute laryngo-tracheitis and bronchitis, which consists of 
simply withholding all fluids for forty-eight hours. This 
gives color to the hypothesis that, after intubation for diph- 16 
INTUBATION OF THE LARYNX. 
theritic cases, tin's method not only avoids the danger of ex- 
citing inflammation, but actually aids in curing that which 
already exists. 
Most valuable and interesting articles on this subject 
have been written by Dr. O’Dwyer, Dr. Waxharn, Dr. North- 
rup, Dr. Hance, Dr. Caille, and others. From these and 
from personal letters which these gentlemen have kindly 
furnished me, I have obtained reports of over five hundred 
cases. Briefly, these reports are as follows : 
Dr. S. A. McWilliams, of Chicago, reports three cases, one 
of them in a child under three years of age—all of diphtheritic 
croup. The tube was worn in them from one half to forty-eight 
hours. There were no recoveries. The immediate effect of 
intubation was excellent. In two cases the tube was coughed 
out, and the parents refused to have it reintroduced. 
Dr. William Cheatham, of Louisville, Ky., writes me that he 
has had fifteen cases of intubation, ten of them in patients under 
three years of age. Tubes were worn from eighteen hours to four 
days. There was immediate relief, except in one case. This 
latter patient was found pulseless; when seen, the tube was in- 
troduced, brandy was injected hypodermically, artificial respira- 
tion was resorted to, and in half an hour the child was breathing 
well again. It died in twenty-four hours from heart-failure. 
There was one recovery among his cases. The doctor says he 
will never do another tracheotomy for croup, and believes 
intubation is far better. A majority of his patients died from 
extension of the membrane, others from heart-failure and 
asthenia. 
Dr. George W. Mason, of Bloomington, 111., reports three 
cases, all in patients over three years of age. One case he terms 
diphtheritic croup, and the others membranous croup. There 
was relief to respiration in all. The tubes were worn from one 
to one hundred and twenty hours. There was one recovery. 
The third patient died from complication of whooping-cough 
and pneumonia. 
Dr. Horner 0. Bates, of Chicago, reports six cases, two of INTUBATION OF THE LARYNX. 
17 
them in children under three years of age. All suffered from 
diphtheritic croup. The tube was worn from one hour in one 
case to four days and four hours in another. The relief was 
immediate. There were three recoveries. Dr. Bates believes 
intubation a valuable means of relief, and in proper cases the 
best treatment, but that it can not supplant tracheotomy in all 
cases. The youngest patient that recovered was eight and a 
half months old. This patient came near dying from diphthe- 
ritic bronchitis, but was finally relieved by the same prescrip- 
tion that I had given in one of my successful cases (No. 5), 
Dr. F. Henrotin, of Chicago, reports nine cases, two of them 
in children under three years of age. These patients were suf- 
ering from croup, all but two showing more or less diphtheritic 
membrane in the fauces. The tube was worn from three to six 
days. In two cases no relief was given by the operation ;in one 
only partial relief, and in the others there was complete relief 
from stenosis, and disappearance of its symptoms. He had three 
recoveries. 
Dr. J. L. Mulfinger, of Chicago, reports two cases, one pa- 
tient being eight, the other five years old, both suffering from 
diphtheria. One had relief almost at once, and recovered. The 
other had very little relief, even temporarily, and died in about 
twelve hours. In the one that recovered there was complete 
loss of voice for seven days after the tube was removed, and 
more or less aphonia continued for two months. 
Dr. Hopkins, of Buffalo, reported six cases in which impend- 
ing death was overcome, and life saved by intubation. 
Dr. Hailes, of Albany, N. Y., reported two cases in which 
intubation was successfully practiced. 
Dr. John B. Wheeler, of Burlington, Yt., reports the case of 
a child three and a half years old. There was improvement at 
once, but the tube became plugged with a large piece of mem- 
brane, and the child choked and died in about two minutes. 
The tube was retained about fourteen hours. 
Dr. E. D. Ferguson, of Troy, N. Y., reports one case, in a 
child three years old, suffering from diphtheria. When the ob- 
turator was withdrawn, respiration was stopped completely, and 
tracheotomy became necessary. The child died in about thirty 18 
INTUBATION OF THE LARYNX 
hours. False membrane had probably occluded the lower end 
of the tube. 
Dr. Charles Denison, of Denver, Col,, reports one case of 
diphtheritic laryngitis in a child six years old. On introduction, 
the tube displaced some membrane, and the tube and membrane 
were immediately ejected, and it was not necessary to reintro- 
duce it. The child was laboring for breath, with its lips purple 
and its face suffused before the intubation. 
Dr. F. Tipton, of Selma, Ala., reports one case in a child four 
years old suffering from diphtheria. The tube remained in 
position fourteen days. There was immediate relief, and the 
child recovered. The same physician reports that one tube 
went into the stomach, but was passed in ten days without ill 
effects. 
Dr. L. H. Dunning, of South Bend, Ind., reports seven cases, 
four of them in children under three years of age. Two of them 
were for diphtheritic croup, five for pseudo membranous croup. 
The tube was worn from twelve to one hundred and twelve 
hours. In five cases there was almost immediate relief. In one 
case thex*e was relief after reintroduction of the tube. In an- 
other case the patient had a violent struggle after the tube was 
placed, and finally, when death seemed imminent, a pseudo- 
membranous cast of the larynx and trachea, one inch and a half 
long, was forcibly ejected from the mouth. This patient made 
a speedy recovery. The doctor is enthusiastically in favor of 
the operation, which he thinks simpler than catheterization of 
the bladder. 
Dr. Irwin H. Hance, of New York, informs me that he has 
had six cases of intubation, all in children under three years of 
age, four cases of diphtheria, one of which was complicated with 
scarlet fever, one case of diphtheritic laryngitis, one case of ca- 
tarrhal croup with extensive bronchitis. The tube was worn 
from six hours to five days and a quarter. This latter patient 
recovered; the remaining five died. In five cases there was 
immediate relief; in one case no relief until after laryngotomy 
had been performed. In this last-named case there was no re- 
lief while the tube was in place. It was placed in the larynx 
five times, and remained once for twenty-five minutes, without INTUBATION OF THE LARYNX. 
19 
diminution of the seventy of the dyspnoea, which was more 
severe while the tube was in situ. 
Dr. Montgomery, of Philadelphia, reports thirteen cases. In 
no case did death occur in less than twenty-four hours, and the 
relief from dyspnoea was prompt in every case. Six of his pa- 
tients recovered. The youngest child, eighteen months old, 
died on the fifth day in convulsions. The youngest child to re- 
cover was two years old. In one case the tube was coughed up 
and swallowed. It was passed per anum two days later with 
no ill effects. 
Dr. A. E. Hoadley, of Chicago, reports nine cases, two of 
them in children under three years of age. All had diphtheria. 
The tube was worn from twelve hours to four days. The opera- 
tion afforded complete relief from the difficult breathing, but 
there were no recoveries. One of the patients died from pneu- 
monia, one from extension of the membrane into the finer tubes, 
and seven from the constitutional effects of the disease. lie 
prefers the deep position of the tube. 
Dr. J. Tascher, of Chicago, reports eleven cases, three of 
them in children under three years of age. The tube was worn 
from eight to seventy-two hours. He says there was immediate 
relief in every case. He had four recoveries. Four of the deaths 
were from broncho-pneumonia, one from occlusion of the tube 
by a large piece of membrane, two from blood poisoning. On 
six of the patients he used the short tube with small head, 
already described, and of these three recovered. He states 
that none of these six patients had much difficulty in swal- 
lowing. 
Dr. D. O’Shea, of Chicago, reports thirty-seven cases, eight 
of them in children under three years of age. These patients 
had diphtheritic laryngitis. The tube was worn for periods 
varying from six hours to eleven days. He reports fourteen 
recoveries. In two cases patients had spasmodic action of the 
larynx after the tube was coughed out, and died in a few 
minutes. 
Dr. A. B. Strong, of Chicago, reports thirty-one cases, eight 
in children under three years of age. All these had membranous 
obstruction of the larynx. The tube was worn from a few 20 
INTUBATION OF THE LARYNX. 
hoars to seven days. The patients had immediate relief in 
every instance. There was one recovery. The remainder died 
the second or third day, usually from bronchitis. lie objects 
to the operation for the reason that patients can not eat -with 
the tube in position. 
Dr. F. 0. Schaefer, of Chicago, reports four cases. Two of 
the patients were under three years of age. The tube was worn 
from one hour to two days. All had diphtheria. There was 
great relief in all cases except the last one, in which a short 
tube was used. This child had pneumonia at the time, and 
there was hut slight relief. He had no recoveries. In one case 
tracheotomy was performed twenty-four hours after intubation, 
and the child lived thirty hours after the operation. 
Dr. A. Oaille, of New York, writes me that he has operated 
in twelve cases, seven of them in children under three years of 
age. Seven of these had pharyngeal diphtheria with laryngeal 
stenosis, four had true membranous laryngitis, and one had 
urgent stenosis of live days’ standing. The tube was worn from 
four hours to fourteen days. The result was very satisfactory in 
every case. He had five recovexdes. The doctor says he finds 
that solid food chopped tine and moistened is swallowed fairly 
well. In addition he gives ice. and stimulates per rectum. He 
gives mercury through the cutis by means of lanolin. He has 
done tracheotomy twenty-one times with only five recoveries, 
and says that in the majority of cases he shall intubate. In cer- 
tain cases of septic diphtheria with stenosis, where proper and 
sufficient nourishment and stimulation were a sine qua non, he 
might prefer tracheotomy. Recently he has been in the habit 
of removing the tube after twelve, twenty-four, or thirty-six 
hours, if the patient does not get enough nourishment, and then, 
after giving food, medicine, or stimulants by the mouth, he re- 
introduces it if necessary, repeating this process several times 
as needed. He gives finely divided solid food moistened with 
water and no liquids, and says his results have been better since 
he has followed this plan. 
Dr. 0. E. Denhard, of New York, writes me that he has op- 
erated on twenty-four patients with diphtheria, seventeen of 
them under three years of age. The tube was worn from two INTUBATION OF THE LARYNX. 
21 
to eleven days. In every instance there was immediate relief. 
There were ten recoveries. He says that out of thirty-four 
cases of tracheotomy he had fifteen recoveries. All who recov- 
ered were over thx*ee years of age, excepting two, aged two and 
two and a half respectively. 
Dr. W. P. Northrop, of New York, writes me that he has 
operated on thirty patients with six recoveries. Twelve of his 
patients were under three years of age. The tube was worn 
from two hours to seven days. In every case Imt one there was 
effectual prompt relief. In that exceptional case the patient 
died two hours after the intubation from extension of the diph- 
theritic process. AH the patients had albuminuria and diphthe- 
ria of the pharynx. Two died from heart failure while appa- 
rently doing well. He has never had the slightest accident 
attributable to the tube, but has found, in the course of his 
autopsies at the asylum, two ulcers at the lower end of the tube 
where it rubbed against the anterior surface of the trachea; but 
he is uncertain whether or not there were defects in the tube to 
account for the irritation. 
Dr. Northrup says his predecessor put a tube into the stom- 
ach by mistake. It passed in fifty-twm hours unaided and with- 
out symptoms. 
Dr. Joseph O’Dwyer informs me by letter that he has oper- 
ated in one hundred and thirty-seven cases of croup since the 
beginning of his experiments in 1880. Of these he reports 
twenty-seven recoveries; but he adds that a large number of 
them were experimental cases before the instruments had been 
perfected. The average time during which the tube was worn 
in eighteen cases of recovery was four days and twenty-two 
hours. 
Dr. F. E. Waxham, of Chicago, in addition to the eighty- 
three cases already reported with twenty-three recoveries, tells 
me that he has had forty eight additional cases with eleven re- 
coveries, making one hundred and thirty-one cases with thirty- 
four recoveries. The youngest child to recover was nine months 
of age, the oldest nine years. He believes the percentage of 
recoveries under three years better than after tracheotomy, but 
for patients over three years the percentage after tracheotomy 22 
INTUBATION OF THE LARYNX. 
seems a little better than after intubation. He adds that all the 
cases operated on were desperate, many of the patients being 
moribund at the time, and that in no case was the tube intro- 
duced until the dyspnoea had become urgent. 
Thus, altogether, I have reports of 514 cases, in 134 of 
which, or 26yi¥ per cent., the patients have recovered. Of 
these, many were under three years of age, and a number of 
them recovered. Dr. Waxham states that of fifty-two patients 
under three years of age, 25 per cent, had recovered. This 
is certainly a remarkably good showing, for of children under 
four years in whom tracheotomy has been done for diphthe- 
ritic laryngitis, the statements of different authors, though 
varying widely, seem to prove that not more than 15 or 20 
per cent, recover. The statistics of tracheotomy in the same 
disease for all ages show that from 25 to 30 per cent, recov- 
er, but very great disparity will be noted in the results of 
individual operators. That this disparity is partially due to 
the operation itself is possibly true, though this I believe is 
the least of the factors. Much, however, does depend on 
the judgment of the operator in determining the time for 
the operation, and on his personal influence in securing the 
consent of the parents early ; much on the amount of care 
exercised by him in operating only on patients who are likely 
to recover, and on the subsequent care of the patient; but, 
most of all, the results will be modified by the epidemic in- 
fluences and immediate surroundings of the case. It has 
been found that under the same circumstances as to oper- 
ator, general surroundings, and treatment, the death-rate 
will vary greatly in different epidemics. 
The same might be said of intubation of the larynx; but 
in estimating the value of the new procedure we must not 
forget that, in probably less than 10 per cent, of the cases 
that have been treated by it, it would have been impossible 
to obtain the consent of the parents to tracheotomy, and INTUBATION OF THE LARYNX. 
23 
therefore most of those that have recovered must have per- 
ished but for the new method. 
Remembering that in the fatal cases many have died of 
bronchitis or pneumonia, which may have been caused by 
foreign substances in the air-passages, and considering the 
satisfactory results in the few cases in which fluids have 
been withheld while the tube was in the larynx, I feel con- 
fident that the percentage of recoveries from this method 
will be much greater when more care is exercised in this 
respect. 
When medicines fail to relieve pseudo-membranous lar- 
yngitis, no time should be lost in providing for the free en- 
trance of air, and for this purpose either intubation of the 
larynx or tracheotomy should be resorted to. The former 
may be done more quickly and safely and with less shock 
to the patient, and with less objection from friends; there- 
fore it should be tried first, unless there is serious obstruc- 
tion in the fauces or trachea; but the operator should always 
be prepared to open the trachea in case loosened membrane 
should be forced down by the laryngeal tube. Tracheoto- 
my should also be practiced in cases where the laryngeal 
tube from any cause fails to relieve the dyspnoea, unless we 
have sufficient reason to believe that this operation would 
also fail. In cases where the operator believes that false 
membrane is loose in the trachea, no time should be wasted 
by attempting to remove it with a forceps, for, though this 
attempt may occasionally be successful, it is much more 
likely to fail, and then a death will result which might have 
been averted by tracheotomy. If, however, it is thought 
best to introduce a forceps into the trachea, Mackenzie’s 
long laryngeal forceps opening antero-posteriorly will be 
found the best. 
While intubation can not always take the place of 
tracheotomy, it has much to recommend it in the majority INTUBATION OF THE LARYNX. 
of cases. In conclusion, I wish to state again, what has al- 
ready been said : 
1. Intubation may he quickly and easily performed, and 
with but little danger. 
2. Friends readily consent to the procedure. 
3. There is no necessity of tedious after-treatment, as 
the tube is kept clear by the respiratory efforts. 
4. The results so far are practically as good as those of 
tracheotomy at all ages, and apparently better in very young 
children. 
5. To secure the best results, great care must be taken 
to prevent the entrance of foreign substances into the 
trachea. 
6. At present, with O’Dwyer’s tubes, the most successful 
plan is to absolutely prohibit the deglutition of fluids while 
the tube remains in the larynx. Small bits of ice may be 
sucked to allay thirst; soft solids may be swallowed, and 
fluids may, if necessary, be supplied by enemata, or the 
tube may be removed to feed the patient, and then be re- 
introduced. 
7. Tubes with smaller heads, designed to rest on the 
vocal cords, have not yet been used sufficiently often to 
enable us to speak positively about them. If experience 
proves that they do not often slip into the trachea, and that 
they do not injure the vocal cords, they will be especially 
useful, for they will nearly overcome the difficulty in deglu- 
tition, and patients wearing them may eat and drink at 
pleasure, excepting when paralysis or some other result of 
the disease prevents closure of the epiglottis. 
8. Medical treatment should be carefully attended to 
after intubation, and we must spare no effort to prevent ex- 
tension of the disease to the bronchial tubes, or to relieve 
the dyspnoea which it occasions. I apprehend that success- 
ful after-treatment depends largely upon the judicious and INTUBATION OF THE LARYNX. 
25 
timely use of suitable expectorants and respiratory and car- 
diac stimulants. 
9. Though short tubes may be used with good results 
in some cases, the danger of their becoming filled with 
pseudo-membrane is so great as to render long tubes pref- 
erable. 
10. Intubation may and should be practiced early, and 
it does not preclude subsequent tracheotomy. 
11. For serious cases of spasmodic croup, and for oede- 
ma of the glottis, this will prove a most useful procedure. 
Lastly, 
12. For the treatment of chronic laryngeal stenosis this 
method will, doubtless, be of value. 
For many months this new operation received somewhat 
more of praise than it deserved, but already it is receiving 
unjust criticisms, which may possibly more than offset the 
praise; but ere long it will rind its proper place among the 
measures for relieving suffering and prolonging human life, 
and by and by a multitude of those who have been saved 
by intubation will rise to thank not only its originator, but 
also the liberal profession which keeps no secrets in the 
healing art, but freely bestows its blessings on mankind. 
Considering what has already been accomplished, we 
must acknowledge our debt of gratitude to Dr. O’Dwyer 
for perseverance in perfecting this operation, and for dem- 
onstrating its practicability, and we must thank Dr, Wax- 
ham and others for their enthusiastic employment of it, 
which has led so many physicians to test its merits. 
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