PRESENT VIEWS ON INTUBATION 
OF THE LARYNX, 
-BY- 
S. W. KELLEY, M. D., 
CLEVELAND. OHIO. 
PROFESSOR OF DISEASES OF CHILDREN IN THE MEDICAL DEPART- 
MENT OF THE UNIVERSITY OF WOOSTER. 
Reprinted from *'• The Cleveland Medical Gazette,” 
November, 1893. 
PRHSS OF 
Buf.l & Hubbell, 110 Sheriff Street, 
Cleveland, Ohio. PRESENT VIEWS ON INTUBATION OF THE LARYNX, 
1IY S. \V. KELLEY, M. D., CLEVELAND, O., PROF. OF DISEASES OF 
CHILDREN IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY 
OF WOOSTER ; CONSULTING PHYSICIAN TO CITY HOSPITAL, ETC. 
When what some have been pleased to call “the present revival of 
intubation” began to spread in the profession, it was taken up with 
American enthusiasm and treated to an unprecedented “boom.” 
The journals teemed with articles upon the subject, hundreds of 
cases of instruments were sold. It was called “the operation for 
the general practitioner,” “every man his own intubator,” was the 
cry. Men unskillful at any kind of operation commenced on intu- 
bation because it was bloodless and said by some to be easy. The 
operation was done almost indiscriminately and statistics manufac- 
tured galleys long. 
This could not last a great while without a reaction. Articles 
appeared declaring intubation “inferior to tracheotomy,” ineffi- 
cient, “unsurgical and useless,” denouncing it as “brutal.” It 
was objected to on account of its difficulty, because of the liability 
of pushing membrane before it, thus choking the patient ; because 
of the difficulty in administering food, or worse yet, drink ; because 
of “food pneumonia,” liability of the tube to slip down into tra- 
chea or of being coughed up and swallowed, ulceration of larynx 
f 
or trachea from pressure, irritation as of a foreign body occasioned 
by the presence of the tube in the larynx, retention of mucous or 
pus below the tube, the air continuing to pass through septic chan- 
nels, laceration of larynx in efforts at introduction of the tube, or 
more likely in efforts at its extraction ; last, not least, criminal de- 
lay about resorting to tracheotomy by fooling away time on intu- 4 
Kelley : Intubation of the Larynx. 
bation. The boom began to decline somewhat. Intubating sets 
could be bought cheap at second hand. 
Not that all the early opinions were laudatory and all the recent 
ones condemnatory. The subject was warmly handled both pro 
and con. As a rule the early effusions held more of praise, the 
next period showing a majority of writers in dispraise, while in the 
present period the operation is likely to be fairly considered and 
receive the final judgment of the profession. 
Upon closer inquiry many of the opinions and objections against 
intubation are found to possess little weight, while others may be 
justly balanced off with equally weighty difficulties in the alter- 
native operation tracheotomy. 
Having saved many lives by its use, no one can convince me 
that intubation is inefficient. In fairness it can no more be con- 
sidered unsurgical than would the reduction of an intussusception by 
injection of warm water before resorting to cceliotomy. Any oper- 
ation may be “brutal” if done by a brutal operator, but when done 
by a kind and careful operator, intubation is of itself certainly less 
harsh or revolting than tracheotomy. This is evidenced by the 
fact that parents will stand by and willingly see a child intubated, 
at the same time forbidding any cutting to be done. On the score 
of its difficulty no man equally familiar with both operations will 
pronounce intubation the more difficult. This objection was usu- 
ally urged by operators more or less familiar with tracheotomy but 
who had had only a comparatively short experience in the newer 
operation. Its difficulties only make the rule that it should be 
done by those who have by practice acquired skill. There is a 
possibility of pushing membrane before the tube and suffocating 
the patient, but this has also occurred in introducing a tracheotomy 
tube, while it seems to me the chances are much less of causing 
sudden death by this accident than they are by either shock or haem- 
orrhage in tracheotomy. The difficulty of administering food and 
drink has disappeared since the practice of placing the patient on 
an inclined plane head downward has been used. The simplicity 
and ease of this manoeuvre make feeding as nothing for the nurse Kelley : Intubation of the Larynx. 
5 
to do, compared with the constant attention required by a trache- 
otomized patient. If a tube of proper size is chosen it does not 
slip down into the trachea. This accident need not happen 
oftener than for a brush or a pledget of cotton to be lost into an 
opened trachea. The dropping of an intubation tube into the 
trachea, or into the esophagus, oftenest occurs through the care- 
lessness of introducing the tube without the thread attached. If a 
tube were to be coughed up and swallowed it would generally be 
passed without trouble. Ulceration from pressure of tube is not 
more liable to occur in intubation than in tracheotomy. Nor does 
the O’Dwyer tube cause irritation as of a foreign body more than 
is caused by the presence of a tracheotomy tube. Mucus and pus 
are not more apt to collect below the tube in intubation cases than 
they would below a tracheotomy tube if it were not removed occa- 
sionally. The intubation tube itself is not as apt to become 
clogged as is the tracheotomy tube, while the former, if it fits 
properly, not too tightly, and should become occluded by a piece 
of false membrane, will be coughed out. Not so a tracheotomy 
tube when, as usual, tied in. It must be instantly removed by a 
vigilant and dextrous nurse to prevent suffocation. 
It is said that in intubation the air continues to pass through sep- 
tic channels, that is, over the diseased surfaces. Who can tell how 
much of the blood poisoning is caused by the air that has passed 
over diseased'surfaces as compared with the amount caused by di- 
rect absorption beneath those surfaces? and how small is that 
amount of poison compared with that likely to occur in a tracheot- 
omy wound? Moreover, that air current can be loaded with anti- 
septic vapors and thus applied directly to those diseased surfaces. 
Then, besides, in intubation the air is warmed and moistened by 
passing through natural channels, and we all know that in some 
environments it would be impossible to get proper attention paid 
to warmth and moisture of air for a tracheotomy case. 
To object to intubation because lacerations of the larynx have 
occurred in efforts of operators to introduce or to extract the tube 
would be like objecting to tracheotomy because it has occurred that 6 
Keli.ey : Intubation of the Larynx. 
an operator has missed the trachea altogether, dissecting down to 
one or other side of it, or lias punctured not only into the trachea 
but through the trachea into the esophagus, and at least in one 
recorded instance into the vertebra, or has pushed the tracheotomy 
tube down in front of the trachea instead of into the trachea, or 
has been so unfortunate as to have air enter a severed vein, or air 
to dissect its way between the fasci® of the neck or into the medi- 
astinum. Accidents may occur during any operation, but care and 
skill make them rare. 
Delay in resorting to tracheotomy would indeed be criminal if 
tracheotomy was indicated. But there is no need of dangerously 
delaying tracheotomy if required because intubation has been first 
performed. That is a great advantage in intubation, that it does 
not prevent nor prejudice the chances of subsequent tracheotomy. 
It seems to me that a careful comparison must convince any fair- 
minded observer that the operation has merits, has its place, which 
can be determined by the good judgment in a given case. There 
can be no doubt that intubation was injudiciously used both by in- 
experienced operators which led to bad results, and on the other 
hand by enthusiasts, who, for the purpose of making money and 
statistics, would intubate a well man on the street, if permitted. 
As to the value of statistics in general in determining a subject of 
this kind I hold to the opinion of Furneux Jordon, the famous sur- 
geon of Birmingham. He expresses himself as follows (Surgical 
Enquiries, p. 167): “Statistical enquiry in the inexact sciences 
has misled as often as it has led. There are more avenues for 
errors to creep into statistics than there are avenues for errors to 
creep into the opinions of trained observers. If six competent 
surgeons tell me one thing and the statistics of 600 hospitals tell 
me another, I believe the six surgeons.” 
As illustrating the difficulty of comparing the merits of tracheot- 
omy and intubation by mere numbers, I may mention an instance 
where two children in one family were intubated and both died, a 
third child in the same family was taken sick and the same intu- 
bator declined to operate, pronouncing the case necessarily fatal. Kelley : Intubation of the Larynx. 
7 
The family physician performed tracheotomy and the child recov- 
ered. It might have if intubated, or the others might have if trache- 
otomi/.ed. I will cite a case from my own practice. Being called 
by the attending physician to intubate, I declined because the ob- 
struction was on the epiglottis where the tube could do no good; it 
grew worse. Other counsel was called and it was decided that 
tracheotomy must be done. I was called in to do the tracheotomy, 
but declined for the reason that I did not think the dyspnoea so 
great but that the chances were better without operation than with 
it. The child recovered. It might have recovered if either intu- 
bated or tracheotomized, and counted one on my list of cases in 
favor of whichever operation had been done. Each case must 
be judged by itself. 
Intubation has come to stay. There is no fair comparison of 
the “present revival ’’ with any previous attempt >n the same line. 
Bouchut’s tubes in 1858 were like mere open end thimbles and 
their method of use correspondingly imperfect. He had the crude 
idea right but could not execute it. It was left for O’Dwyer’s me- 
chanical gepius to work out perfection in the tubes, and so near 
perfection in the accessory instruments and methods of their use 
that, notwithstanding many attempts, very little if any improve- 
ment has been effected by newer modifications. Casselberry’s plan 
of lowering the head of patient to feed is as good a thing as has been 
added to the original plan. Waxham has a gag with a different 
catch, and so on. Some operators wear a ring on the fore finger, some 
a piece of adhesive plaster across the back of the finger, but these 
differences are of no moment. Some children will hold the mouth 
open voluntarily, others will if the assistant who stands behind to 
steady the head will press his thumbs firmly against the cheeks, 
I have never found any advantage in up-your-sleeve sleight-of-hand 
trickery in handling instruments. Nor is it often if ever necessary, 
as recommended by Ashby and Wright, to anaesthetize the patient in 
order to remove the tube. Otherwise the teaching upon this sub- 
ject in their excellent text book on the diseases of children gives 
the most liberal recognition afforded intubation by any European 8 
Kelley : Intubation of thr Larynx. 
book. The fact that an anaesthetic is seldom required is a point in 
favor of intubation. Thorough cleanliness and antiseptic princi- 
ples should be carefully observed in the practice of intubation. 
The use of the same tubes and other throat instruments indiscrim- 
inately in diphtheritic or syphilitic and in non-contagious cases is 
especially reprehensible. Another abuse is the cessation of medi- 
cal treatment when the tube is placed in the throat. Because the 
mechanical obstruction to respiration has been mechanically re- 
lieved for the time being, is no reason why we should cease ad- 
ministering drugs directed against the pathological condition. One 
should continue the treatment by way of the stomach, by local 
applications, by lime steam. Sometimes too much reliance is 
placed upon the operative aid, and the disease, baffled temporarily, 
renews the attack in another quarter and the patient finally suc- 
cumbs. 
In conclusion, I reiterate my belief that intubation has come to 
stay. It will be permanently recognized by the profession as one 
of the standard life saving operations. The more one studies it 
and practices it the more he must admire the ingenuity, the pa- 
tience and the thoroughness with which O’Dwyer worked it out. 
It will not supplant tracheotomy. Each operation has its field 
of usefulness; each its rational and recognizable indications.