Some Practical Hints in con- 
nection with Intubation 
of the Larynx, 
And a Resume of 206 Cases operated on 
from 1886 to 1888. 
BY 
J. MOUNT BLEYEB, M.D. 
REPRINTED FROM 
arije Neh) York 
for February 2, 1889. Reprinted from the New York Medical Journal 
for February 2, 1889. 
SOME PRACTICAL HINTS IN CONNECTION WITH 
INTUBATION OF THE LARYNX, 
AND A RESUME OF 206 CASES OPERATED ON 
FROM 1886 TO 1888. 
By J. MOUNT BLEYER, M. D. 
Through the recent publications of our journals, par- 
ticularly in New York, Chicago, and Philadelphia, we have 
been able to obtain by experience positive data upon which 
to base an estimate of the merits of intubation of the larynx. 
Every new therapeutical measure must be judged by its 
results, and if on extended use it can not produce better re- 
sults than some older and tried remedy it deserves to fall 
into oblivion. According to these and the following sta- 
tistics published up to the present time, we find that Dr. 
J. O'Dwyer's method compares more than favorably with 
tracheotomy as regards the saving of life, while certainly, 
to consider it from an aesthetic point of view, it is much to 
be preferred, and no doubt will prove itself a valuable 
addition to the medical discoveries and advances of the 
age. 
I have long taken great interest in the subject which 
deals with the medical and surgical aspects of diphtheria. 
All difficult subjects are interesting, and this, one of the 2 
SOME PRACTICAL HINTS IN CONNECTION WITH 
most difficult, is therefore one of the most interesting that 
we are called upon to deal with. At present we know little 
or nothing of the essence of diphtheria, although it is being 
studied closely; until we do, I take it that our treatment 
will have to be directed against the effects rather than 
against the disease itself. 
I have found it to be of special importance to make a 
laryngeal examination in all children that are presented to 
me for intubation. Few having the experience of the laryn- 
goscope will decry the practical lessons taught by its reve- 
lations, or its certainty as a means of differential diagnosis, 
but still it seems that this method has not yet been fully 
appreciated in all its aspects by the general physician and 
surgeon. The importance of such procedure is neither to 
be underrated nor neglected. 
Why Laryngoscopy should be practiced before and after 
Intubation.-It should be urged upon operators practicing 
intubation to examine, by means of forced or normal laryn- 
goscopy, every case which is presented. I have made this 
a cardinal rule previous to intubing. 
With such means at my disposal, I see the position 
which the membranes occupy and the general conditions 
present, so that if membranes are in the way of the operat- 
ing field they may be removed, and not pushed before the 
tube downward into the trachea. Forcing down the mem- 
branes before the tube, which is so much practiced, is the 
rule and not the exception. 
The differentiation and diagnostication of other laryn- 
geal diseases may be made out at the same time, and the 
extent of the diphtheritic or croupous lesion seen. 
Suggestions as to how Forced Laryngoscopy is made.- 
Forced laryngoscopy is performed by means of my tongue 
tractor, gag, and a mirror. This tractor and gag have 
been described fully in the " Archives of Paediatrics " INTUBATION OF THE LARYNX 
3 
for October, 1888. An illustration of the tractor is seen 
below. 
In children under five years of age it will be found most 
convenient, without losing any time, to envelop the child's 
body and arms with a strong towel, pinned closely about 
them, and then place it upon an assistant's lap, who takes 
the legs of the patient between his knees and holds the 
body well and firmly down upon his lap with the left arm 
and hand, while with the other over the child's forehead 
its head is pressed backward against the chest, and thus its 
attempts to turn it from one side to the other are resisted. 
The mouth is now opened by means of the gag, which has 
a wedge attached to the gagger for forcing its way in be- 
tween the teeth and into the mouth. The alveolar rest has 
soft-rubber paddings to prevent the breaking of the teeth, 
or injuring the gums in those where no teeth are present; 
at this stage of the operation a five-per-cent, solution of 
cocaine is employed, with which the pharyngeal and laryn- 
geal surfaces are sprayed, or without the use of cocaine, as 
I often do when the examination is of a short duration, as 
in the ordinary cases for inspection purposes. The operator 
passes the tractor down, guided upon the forefinger of his 4 
SOME PRACTICAL HINTS IN CONNECTION WITH 
left hand, and secures the base of the tongue, which, being 
drawn upon, favors partial elevation of the larynx. The trac- 
tor is to be drawn upward, outward, and downward. The 
downward motion depresses the tongue. 
Often a very common difficulty is met with in the posi- 
tion of the epiglottis, as it is more or less depressed, over- 
hanging the larynx, or compressed and rolled together at its 
sides. By forcing and steadying the epiglottis against the 
base of the tongue, this difficulty is nearly obviated, and 
the larynx and neighboring parts may be viewed and 
treated. 
Examinations of the larynx can be made at any time 
during the wearing of the tube, in order to see the same, or 
to guard against any sudden or unforeseen circumstances, 
and thereby gain an immediate diagnostic point. 
For purposes of illumination, where gas can not be ob- 
tained, any lamp which gives a bright, steady light will 
suffice, and one practiced may obtain a good image even 
with a candle in a bull's-eye lantern, or with a carriage 
lamp. Several useful portable lamps can be procured for 
such work. In the absence of a condensing lens, a piece of 
white paper placed behind a lamp or candle will add con- 
siderably to the brilliancy of the light. If the patient lives in 
rooms where the sunlight is available, I prefer it for this use. 
The degree of success will depend upon the skill and 
management of the laryngoscope by the operator. Small 
laryngeal mirrors-the No. 2 and No. 3-are the proper 
sizes. 
The Daily Extraction of the Tube.-In my last fifty cases 
1 have extracted the tube daily. This was done for the 
purpose of removing the accumulation of loose membranes, 
tenacious mucus, pus, etc., which might block up the tube 
or the pharyngeal and laryngeal surfaces. Often the child 
has not the power left, from repeated attempts, to expec- INTUBATION OF THE LARYNX. 
5 
torate or cough up these materials. After the employment 
of this measure it was found that the little patient was 
helped to rid itself of a large amount of blocking poisonous 
debris. When the tube has been extracted, irrigate the 
posterior nares, pharynx, larynx, and entire surface with a 
mild solution of bicarbonate of sodium, and half an ounce to 
fourteen ounces of lukewarm water. Half an hour later food 
is offered. I have then seen them take it ravenously. If I 
found any difficulty at this stage, the stomach-tube was at 
once applied. 
Reintroduction of the Tube.-After the food has been 
given, the tube is reintroduced, and I have found, it advisa- 
ble in some cases, where the stenosis is not so urgent, to 
wait for some hours before the reintroduction of the tube 
is again tried. In a large number of cases it was seen that 
the tube had done its service on the second or third day, 
and with but few exceptions it was not reintroduced again. 
The Diferentiation between the Tube being in the Larynx 
or (Esophagus.-After the tube has been introduced, remove 
the gag at once and wait a few seconds; now, if your tube 
has been passed into the larynx, you will immediately ob- 
serve the difference in the breathing; the cyanosis disap- 
pears; a characteristic hollow-sounding cough, which, if once 
recognized or heard, you will be able to distinguish from 
all other coughs ; this is then followed by a second sudden 
spasmodic cough, with a large amount of expectoration of 
muco-pus and membranes; if water is now given to drink, 
it will still increase this spasmodic cough, followed by still 
more mucous discharge from the tube. 
The signs which present themselves if the tube has been 
passed into the oesophagus are different. Cyanosis increases, 
breathing is not relieved, the stenosis increases, the charac- 
teristic cough is absent, and the thread of eighteen inches 
long which is attached to the tube begins to disappear by 6 
SOME PRACTICAL HINTS IN CONNECTION WITH 
the gravity of the tube drawing it toward the stomach. 
Cough may also be present, due to irritation at an attempt 
of introduction, but without that special described cough. 
If there is any doubt in your mind about the presenting 
signs, then, before the removal of the thread from its at- 
tachment to the tube, you had better replace the gag, pass 
your finger down upon the head of the tube, and feel for 
the surrounding anatomical parts. But the most certain 
way is to make a forced laryngoscopic examination, which 
will distinctly show you the tube in the larynx and relieve 
you from all further anxiety. 
One should make himself thoroughly familiar with the 
anatomy of the larynx and all surrounding parts before he 
attempts to practice intubation. 
The Removal of the Thread from the Tube.-The thread 
which is attached to the tube is removed last, after you are 
positive that the tube is in its right position ; this is best 
accomplished by replacing the gag, so as to prevent the 
operator from being severely bitten ; pass the index finger 
down upon the head of the tube, add slight counter-pressure 
upon it, while with the other hand draw gently on one end 
of the thread. 
Selection of the Tube in every Case.-This depends more 
upon the judgment of the operatorthan upon the age of the 
child, as the size of the larynx differs very often at the same 
age. It will be found that a larger tube has to be inserted 
than the indication shows at the age. 1 generally pass the 
tube of correct size and, if coughed up for no other cause, 
introduce the next size larger. 
A good plan is to have more than a single set of tubes 
on hand for those who are practicing intubation, or other- 
wise, if one of the set is lost, that is generally the tube most 
required when least expected. Carry in your intubation 
bag two of each size, so that you can at any moment replace INTUBATION OF THE LARYNX. 
7 
any of the missing ones. Also it is highly necessary to have 
on hand a few with a larger lumen; these ought to accom- 
pany every intubator, as you certainly will run across a 
case which will not be relieved by the tube with the small 
lumen. 
Irrigation.-This is an admirable method of washing 
away the products of the local lesion. I use a No. 8 soft- 
rubber catheter which is attached to a fountain-bag syringe ; 
the catheter is passed into the nostrils, first the right and 
then the left. The solation which is used is made by tak- 
ing peroxide of hydrogen (Charles Marchand's), fifteen-vol- 
ume solution, chemically pure, one ounce to twelve ounces 
of water. With this solution irrigate each nostril thor- 
oughly. After this has been done, the next move is to wash 
out the mouth, pharynx, and larynx. If the child can be 
managed without forcing the mouth open, there is no need 
of the insertion of a gag ; but if not, use it. The patient 
is to be held well forward over a basin for the reception of 
the returning fluid. Make a second mixture of the perox- 
ide of hydrogen of the strength of four drachms to twelve 
ounces of water. The catheter is passed well down into the 
larynx, the surrounding parts, and thoroughly irrigated. The 
fluids are very seldom swallowed, and if this fluid mixture 
should be swallowed there is no danger of poisoning, as it is 
a perfectly harmless antiseptic. The fluid is generally im- 
mediately expelled by coughing. The mouth is to be kept 
wide open and the head well forward. By this inode of 
treatment, patches of membrane, inspissated inuco-pus, etc., 
can be washed away without difficulty and without pain. 
Mv experience with peroxide of hydrogen for the last four 
years has made me familiar with its varied use in the treat- 
ment of the diseases of the nose and throat. From a con- 
sideration of the action of peroxide of hydrogen upon the 
deposit of diphtheritic membranes, and the rapid reproduc- 8 
SOME PRACTICAL HINTS IN CONNECTION WITH 
tion of bacteria, it will at once be evident that the earlier 
the application of the remedy is adopted the better. While 
the membrane is thin and friable, the action of this agent is 
thorough, quick, and effective; the deposit melts down be- 
fore the contact of it like sugar in water, to be reproduced 
in a short time and again removed until the diseased tissue 
beneath can be plainly seen free from this characteristic cov- 
ering. In this way also the spread of the membrane is 
checked and its limits often sharply circumscribed, until 
after some days, which it seems to me is within a week, 
the germinating power of the membrane is conquered and 
the poison ceases to produce its kind, no more deposit takes 
place, and the diseased tissues heal. In view of the rapid 
reproduction of bacteria already mentioned, it is evident 
that the applications should be no longer apart than two 
hours, or even less, according to the rapid reproduction of the 
membranes. Gargling may be practiced by those who areable, 
but irrigation is preferred, as a more thorough application 
is thereby made. Irrigation is easily learned by the nurse, 
and there is absolutely no danger connected with its use. 
The peroxide of hydrogen should be kept at a tempera- 
ture below 65° F., as it begins to decompose slowly at the 
above-mentioned temperature. 
No metallic substance must come in contact with perox- 
ide of hydrogen on account of its oxidizing power. 
For internal use I give the preference to glycozone, 
which is chemically pure glycerin saturated with active 
ozone, or the formula C3IIeO3 -f- O2. It is intended to be 
used as a substitute for bichloride of mercury, carbolic acid, 
permanganate of potassium, etc. This is the most powerful 
of all organic disinfectants and bactericides. The advan- 
tages that are claimed for it in comparison with other pow- 
erful antiseptic compounds are its non-toxic properties and 
inodorousness. I give to a child over two years of age a INTUBATION OF THE LARYNX. 
9 
quarter of a teaspoonful diluted well in water or milk every 
two hours, and under that age twenty drops. 
Before adopting this compound I made use of the per- 
oxide of hydrogen for internal use in diphtheria, but it was 
not tolerated by the stomach as well as this preparation. 
Fluids and Feeding.-As a general rule, fl aids are swal- 
lowed badly. This has been partially overcome by my false 
epiglottis tube. The child is placed upon the nurse's lap in 
a recumbent position and fed through a nursing bottle with 
such fluids as water and milk; shaved ice or ice-cream may 
be given in the natural way. Nevertheless, some of the 
fluids will pass into the tube unless great care is taken. 1 
supply the system with fluids and semi-solid food mostly 
by the stomach-tube. The reason why feeding by the 
stomach-tube should be adopted is to avoid irritant sub- 
stances entering the bronchi and tube. Water can be 
allowed to be taken whether it passes through or not. Tt 
is necessary that the intubated children should cough and 
expel whatever materials are lodged in the tube and air- 
passages. By feeding them without the stomach-tube you 
will certainly stop up the tube and favor Schluckpneu- 
monie, thereby complicating every case. 
The procedure of thoroughly irrigating the mouth, 
pharynx, and larynx as herein described has been found to 
act most beneficially in all cases, as then the child does not 
feel the want of fluid so much, but only has a desire to rid 
himself of the constant tenacious material which is always 
lodged in the passages during such a disease. 
A Suitable Bed.-The best means to secure pure air for 
a patient with diphtheria or croup is by surrounding the bed 
by a pair of ordinary curtains. This should be done where- 
ever it is possible; then the window can be freely opened, 
and thereby the room thoroughly ventilated. The curtains 
act as a protection to the patient from draughts; the air 10 
SOME PRACTICAL HINTS IN CONNECTION WITH 
can be kept immediately surrounding him at an equal 
temperature, and, with the assistance of the steam atomi- 
zer, the air within the inclosed bed can be medicated and 
disinfected. 
The steam atomizer is to be recommended highly, as 
there is no doubt that by keeping the interior of the 
pharynx and larynx moist by means of hot steam, it tends to 
liquefy and loosen crusts of mucus, which favors expectora- 
tion of the membranes; or otherwise, without steam, there 
may be increased laryngeal obstruction. This will always 
be found a valuable adjunct in the treatment. 
The Protection of the Operator's Eyes. - Never make 
any examination of the larynx, mouth, or pharynx of any 
suspicious nature without the eyes being protected by a pair 
of eye-glasses, for if a sudden cough or forced expectoration 
takes place and any particle of this happens to pass into 
your eyes, a great chance is run of losing the eyesight. 
The Cleansiny of Tubes and Instruments.-Before and 
after intubation a great deal of attention should be given to 
this in order that no contagion should be carried to another 
case which is to be intubated, and perhaps not suffering 
from the same degree of diphtheria or croup as the one pre- 
viously operated upon. The remedy that I suggest is that 
all tubes and instruments used should be scrubbed and 
boiled before and directly after for ten minutes in a closed 
pot of water at 212° F., and then left for ten minutes 
longer in a one-to-forty solution of carbolic acid. In con- 
clusion, I will say that I intended this paper essentially as 
a practical one, based on the experience of many cases of 
intubation of the larynx. 
The following is a table, record, and resume of my last 
206 cases of intubation of the larynx, which shows a large 
percentage of recoveries. Out of 206 cases, 67 patients re- 
covered-33 per cent, in all ages. INTUBATION OF THE LARYNX. 
11 
Table showing the Results of 206 Cases o f Intubation of the 
Larynx,. 
Total number of cases operated on, 206. 
Male, 137. Female, 69. 
Recoveries, 67 (33 per cent.). Deaths, 139. 
In the cases of recovery, the tube was: 
Removed on the 1st day in 3 cases. 
" " " 2d " 13 " 
" " " 3d " 10 " 
" " " 31 " 6 " 
" " " 4th " 12 " 
" " " 5th " 11 " 
" " " 6th " 3 " 
" " " 7th " 4 " 
" " " 9th " 2 " 
" " " 10th " 1 " 
" " " 15th " 1 " 
" " " 20th " 1 " 
UNDER THREE YEARS OF AGE. 
OVER THREE YEARS OF AGE. 
AGE. 
Num- 
ber. 
Deaths. 
Recov- 
eries. 
AGE. 
Num- 
ber. 
Deaths. 
Recov- 
eries. 
6 mos 
1 
1 
3 years... 
17 
17 
9 " .... 
2 
2 
3 ' 
it 
7 
7 
9 " .... 
3 
1 
2 
34 
44 
1 
1 
10 " .... 
1 
1 
34 
44 
9 
9 
10 " .... 
1 
1 
34 
44 
4 
4 
1 year... . 
9 
9 
34 
44 
3 
3 
H " .... 
4 
3 
1 
34 
44 
9 
9 
1£ " .... 
1 
1 
4 
44 
6 
6 
U " .... 
11 
11 
44 
44 
3 
3 
H " .... 
2 
2 
4| 
a 
8 
8 
if " .... 
13 
13 
5 
4 
4 
14 " .... 
5 
5 
5 
3 
3 
2 years.. . . 
21 
21 
6 
44 
5 
5 
2| " .... 
8 
8 
: 6 
44 
3 
3 
2| " .... 
1 
1 
7 
44 
3 
3 
2| " ... 
10 
io 
7 
14 
5 
5 
2i " .... 
7 
7 
1 8 
44 
3 
3 
2 yrs. 10 m. 
1 
1 
i 9 
44 
2 
2 
24 " .... 
2 
9 
11 
44 
1 
1 
24 " .... 
4 
4 
16 
44 
1 
1 
- 
18 
44 
1 
1 
Total.... 
107 
83 
24 
31 
1 
1 
Total ... 
99 
56 
43 12 
INTUBATION OF THE LARYNX. 
Out of 107 there were 24 recoveries in children under 
three years of age, and in 99 three years and over there 
were 43 recoveries. 
Causes of Death in lift Cases. 
Sepsis 11 
Broncho-pneumonia 14 
Heart failure 6 
Pneumonia 23 
Extension membranes to bronchi, or diphtheritic bronchitis... 57 
Bronchitis 11 
Double pneumonia 1 
Asphyxia-not being notified, and tube lost in the bed mattress. 1 
Exhaustion 10 
Scarlatina 1 
Nephritis 2 
Membranous croup 1 
Haamorrhage of the nose 1 
Asphyxia due to closure of the tube by membrane 1 
83 Second Avenue. A reasons why 
PWcIms should Subscribe 
The NewYork Medical Journal, 
Edited by FRANK P. FOSTER, M.D., 
Published by D. APPLETON & CO.,' 1, 3, & 5 Bond St. 
1. BECAUSE : It is the LEADING JOURNAL of America, and 
contains more reading-matter than any other journal of its class. 
2. BECAUSE : It is the exponent of the most advanced scientific 
medical thought. 
3. BECAUSE: Its contributors are among the most learned medi- 
cal men of this country. 
4. BECAUSE: Its "Original Articles" are the results of sci- 
entific observation and research, and are of infinite practical 
value to the general practitioner. 
5. BECAUSE: The "Reports on the Progress of Medicine," 
which are published from time to time, contain the most recent 
discoveries in the various departments of medicine, and are 
written by practitioners especially qualified for the purpose. 
6. BECAUSE : The column devoted in each number to "Thera- 
peutical Notes " contains a resume of the practical application 
of the most recent therapeutic novelties. 
7. BECAUSE: The Society Proceedings, of which each number 
contains one or more, are reports of the practical experience of 
prominent physicians who thus give to the profession the results 
of certain modes of treatment in given cases. 
8. BECAUSE : The Editorial Columns are controlled only by the 
desire to promote the welfare, honor-, and advancement of the 
science of medicine, as viewed from a standpoint looking to the 
best interests of the profession. 
9. BECAUSE: Nothing is admitted to its columns that has not 
some bearing on medicine, or is not possessed of some practical 
value. 
JO. BECAUSE : It is published solely in the interests of medicine, 
and for the upholding of the elevated position occupied by the 
profession of America. 
Subscription Price, $5.00 per Annum. Volumes begin in January 
and July.