INTUBATION 
WITH 
AN ANALYSIS OF FIFTY CASES. 
AN ESSAY 
REAP BEFORE THE ANNUAL MEETING OF THE 
Maine Medical Association, 
JXJNK 4, 1800, 
BY 
EDWARD IVI. PLUMMER, M. D., 
CHARLESTOWN, MASS., 
Aural Surgeon to the Carney Hospital; Clinical Aural Assistant to the Massachusetts Chari- 
table Eye and Ear Infirmary; Consulting Laryngologist to the Boston Dental Col- 
lege; Instructor Boston Polyclinic ; Fellow of the Massachusetts Medi- 
cal Society ; Member of the Maine Medical Association ; 
Member of the American WEftTHIl TW'SWjMTmm" 
PO RTLAIWP: 
STEPHEN BEKKY, PRINTER. 
1896. INTUBATION 
WITH 
AN ANALYSIS OF FIFTY CASES. 
AN ESSAY 
READ BEFORE THE ANNUAL MEETING OF THE 
Maine Medical Association, 
JUNE 4, 1896, 
BY 
EDWARD M. PLUMMER, M. 1 )., 
CHARLESTOWN, MASS., 
Aural Surgeon to the Carney Hospital; Clinical Aural Assistant to the Massachusetts Chari- 
table Eye and Ear Infirmary ; Consulting Laryngologist to the Boston Dental Col- 
lege ; Instructor Boston Polyclinic ; Fellow of the Massachusetts Medi- 
cal Society ; Member of the Maine Medical Ascociation : 
Member of the American Medical Association. 
PORTLAND 
STEPHEN BERRY, PRINTER 
1896. K S S A Y 
The purpose of this paper is to awaken an interest in a com- 
paratively new method of relieving dyspnoea, and also to present 
for your consideration an analysis of fifty cases of intubation in 
private practice. Where this interest has not been thoroughly 
established, it is necessary to take into account the claims and 
vantage of the older operation for the same purpose. I shall 
endeavor, therefore, to sketch briefly the history of tracheal 
operations for the relief of dyspnoea, to indicate the lines along 
which a comparison between tracheotomy and intubation should 
be made; to describe the technique of the new operation; to 
consider its own peculiar problems and difficulties ; and to state 
my own experience in so far as that sheds light thereon. 
If one were to search historical records for the first recorded 
operation upon the trachea for the mechanical relief of unre- 
mitting dyspnoea, one would have to consult some of our oldest 
medical literature. Prior to the beginning of Christianity, As- 
clepiades of Bithynia, it is said, won for himself a great rep- 
utation by his practice of tracheotomy in angina. 
During the barbarism of the dark ages, when not only science, 
literature and art were submerged in the advancing waves of 
superstition and ignorance, but when even the slightest mani- 
festation of intellect for the betterment of human conditions 
was, if not repressed, at least not stimulated, tracheotomy fell 
into disuse, and we do not hear of it again until the revival of 
learning in the fourteenth century, when it was performed at 4 
various intervals with unfavorable results. Home, in 1765, was 
the first to recommend tracheotomy in croup. A successful 
operation was also performed by Bretonneau in 1825, and 
another by Trousseau in 1833. Through the. latter’s industry 
and careful attention to details, the operation was placed upon 
a firm basis, so that, although prior to 1850, owing to the in- 
frequency of success, it had been regarded with doubt, yet it 
became established as a valuable addition to surgery. 
Nevertheless, the unfavorable results ascribed to tracheotomy, 
together with the time required for its performance, and the 
shock and haemorrhage attendant upon it, led an American 
surgeon, Joseph O’Dwyer, of New York, to devise the operation 
known as intubation. Says O’Dwyer, “ If f had had one re- 
covery in ten from tracheotomy, intubation would probably be 
still a thing of the future.” Thus impressed with the insuffi- 
ciency of the only method in vogue for relieving dyspnoea, Dr. 
O’Dwyer instituted experiments with a definiteness, and con- 
tinued them with a persistence imparted only by a clear formu- 
lation of the end in view and the conditions of its achievement. 
It is by these characteristics, as well as by the ensuing success- 
ful results, that his labors are distinguished from the few pre- 
ceding timorous suggestions of, and abortive attempts at intuba- 
tion. We must not on this account, however, fail to notice and 
honor the first appearances of the idea. 
Over two thousand years ago, the idea of inserting a tube 
into the throat to admit air to the lungs was conceived by 
Hippocrates. The suggestion of Hippocrates seems not to have 
been duplicated or expanded until Chaussier, in 1780, advocated 
the insertion of flexible tubes into the larynx in cases of laryn- 
geal obstruction. The practicability of this proposition was 
demonstrated in 1801 by Dessault; in a case of oedema of the 
glottis he passed into the larynx a flexible catheter, which he al- 
lowed to remain two days, thereby saving the life of the patient. 
This device, however, did not come into general use. Although 
mention of the operation is made in literature by such observers 
as Ducasse, Finaz, Dieffenbach, Benoit and others, we do not 5 
hear of any attempts to intubate the larynx until September, 
1858, when Bouchut read before the Academy of Medicine in 
Baris a paper entitled “A New Method of Treatment of Croup 
by Tubage of the'Larynx.” In this paper he described the ill- 
adapted tubes lie had devised and the manner of placing them 
in the larynx. It was, however, Bouchut who performed the 
first intubations ; but his procedure, ridiculed and condemned 
by Trousseau, fell into disuse and was soon forgotten. 
In 1885, Dr. O’Dwyer, after five years of careful experimen- 
tation, pursued without prior knowledge of what had been done, 
proposed his method, and described the ingenious instruments 
he had evolved. Although little more than a decade has elapsed 
since he first gave to the world this brilliant contribution to 
legitimate surgery, yet it has already been the means of bring- 
ing relief to thousands of suffering children throughout the 
civilized world. 
While intubation lias thus gained by its successes a certain 
prestige, it cannot be said that it lias entirely supplanted trach- 
eotomy. A delicate but necessary task confronts us in attempt- 
ing to compare as to merit the two rival operations. The reason 
for instituting this comparison is obviously pressing ; the condi- 
tions for both operations are the same, namely : laryngeal ob- 
struction as evidenced by a croupy cough ; continued depression 
of the suprasternal, supraclavicular, and intercostal spaces; 
together with the noticeable stridulous breathing. If these 
symptoms be present and progressive, it is high time that the 
dyspnoea be relieved by the creation of an artificial air-passage ; 
otherwise, death directly by asphyxia is invited. But even if 
asphyxia do not ensue, the insufficient oxygenation of the blood, 
together with the exhaustion brought about by the continued 
straining for air, reacts in the most unfavorable way upon the 
vital powers, and seriously affects them in their struggle with 
the specific poison. Moreover, a third menace, due to the de- 
pleted state of the lungs, is the imminence of capillary bron- 
chitis and pneumonia. 
Tracheotomy and intubation are the only operations designed 6 
to furnish a passage for the air into the lungs when the larynx 
is thus obstructed, and from the nature of the case it would seem 
that they are the only possible operations. Upon the develop- 
ment of the proper symptoms, the surgeon must resort to one op- 
eration or the other ; it becomes incumbent upon him, therefore, 
to sum up the evidence in favor of each procedure; to base 
thereon a general judgment as to their comparative value; and, 
finally, to consider whether there be in any special case condi- 
tions warranting a reversal of the judgment for that case. 
Inasmuch as the formal definitions of the two operations sug- 
gest the lines along which a comparison should proceed, the 
privilege of reviewing them is requested. The inquiries that 
arise can be answered, of course, only by performing and ob- 
serving the operation as experiments. 
Both tracheotomy and intubation make use of a rigid tube 
for establishing communication between the external air and 
the lungs. In intubation, however, the tube is inserted into the 
passage that is naturally provided for such connection, but 
which is blocked up by yielding membranous accretions; in 
tracheotomy, on the other hand, the tube is inserted into a new 
passage created by the knife. 
With regard to tracheotomy, we may ask the following ques- 
tions : 
(1.) Are there any features pertaining to the technique of 
the operation, that are unsuited to the exigencies and usual 
conditions of the occasion ? 
(2.) What are the possible and likely consequences of the 
incision, and of the insertion and maintenance of a tube in the 
opening ? 
(3.) Are there any disadvantages in the creation of an un- 
natural air-passage ? 
Under the first question we shall consider the time and light 
required, and the necessity of giving ether. 
To a child in danger of suffocation, the element of time is of 
primary importance. After preparations for asepsis have been 
completed, a careful tracheotomy may require from ten to fifteen 7 
minutes. While the time consumed in operating may be 
abridged, if the exigency be great, yet even by the most skilled 
this abridgment is attended with risk, especially if the trachea 
to be operated upon be imbedded in the plump neck of a young 
child. In short, it seems to me that the time necessary for a 
safe tracheotomy (and in that time I include the time consumed 
in asepticising) is so long that the confidence of the surgeon in 
the ability of that operation to meet all the exigencies of his 
practice is often shaken. 
Again, light sufficient for so delicate an operation is too often 
lacking in the usual circumstances. The writer has a vivid 
recollection of performing a tracheotomy upon a young child, 
under the flickering light of a candle held in the unsteady hand 
of the child’s father. 
The bad feature connected with the administration of ether 
is that it irritates the bronchial and pulmonary mucous mem- 
branes, thus causing them to secrete abundant mucus. In the 
attempt to cough up this mucus, the dyspnoea is temporarily 
increased, and it is likely enough that the irritation invites a 
downward extension of the diphtheritic inflammation. The ob- 
jection to substituting chloroform for ether is, that although it 
is rapid in its action and does not irritate the air tract, it may 
result in cardiac syncope. 
The second inquiry, as to the complications that may arise 
from the incision, and from the maintenance of the tube in the 
opening, deserves the most careful study. 
Haemorrhage is always to be considered; the most careful 
efforts to avoid the contiguous blood-vessels are apt to be 
thwarted by the constant motion to and fro of the field of opera- 
tion under the labored respiration. Instances are on record in 
which the carotid and even the innominate arteries have been 
wounded. A haemorrhage usually causes more or less delay in 
opening the trachea. In this connection, also, it should not be 
forgotten that in an operation upon a child loss of blood is to 
be deprecated, and especially so, if he be suffering from a disease 
of germ origin. 8 
From an a priori point of view it would seem not improbable 
that the insertion and maintenance of a tube in the aperture 
created by the incision might injure superficially, if not seri- 
ously, the exposed tissue and membrane with which it conies in 
contact. Ulcerations, due to the continued pressure and fric- 
tion of the tube, while not frequent, are almost invariably men- 
tioned by records covering a large number of cases. These 
ulcerations may be either in the wound itself, or in the posterior 
wall of the trachea at the place of contact with the distal ex- 
tremity of the canula. 
After a long wearing of the tube, granulations are apt to form, 
not only at the external orifice of the wound, but also in the 
trachea itself. Those in the trachea may occlude the natural 
passage so completely as to render it impossible to dispense 
with the canula until they have been removed. . 
Another contingency is the infection of the wound. It would 
seem that the wound in the condition in which it is left would 
present difficulties in the way of asepsis that are not amenable 
to the usual aseptic technique. Beside the entrance of sepsis 
from without, the invasion of the wound and adjoining skin by 
the diphtheritic inflammation is not an impossibility. 
Immediately after the incision has been made, and the tube 
successfully inserted, the patient is liable to a shock that some- 
times becomes an important factor in the prognosis of the 
disease. 
We have raised the question as to whether there be any dis- 
advantage in the creation of an unnatural air channel, from 
consideration of the fact that air entering the lungs naturally 
through the nasal channels is purified, warmed, and moistened 
in the passage. Bronchitis and pneumonia have been traced to 
the unfitness for respiration of the air thus admitted immedi- 
ately into the lungs. The objection contained in this inquiry, 
however, may be removed, to a certain extent, if the air in the 
room in which the patient is confined can be heated to the 
proper temperature and supplied with sufficient moisture. 
Finally, then, we may say of tracheotomy, that while it is a demonstrated means of admitting air to the lungs without hind- 
rance to deglutition, and thus of relieving dyspnoea, neverthe- 
less it is attended with possibilities of danger, which may 
become more likely according as the skill of the surgeon is less. 
Certainly, if it be possible to restore the respiration through the 
natural passages by a bloodless operation, the creation of an 
open wound and the exposure of membrane immediately adjoin- 
ing the seat of diphtheritic inflammation, appears to me, if not 
irrational and dangerous, at least, an unnecessary exhibition of 
a skill developed by a practice that perhaps was not so suc- 
cessful. 
Historically, the objections to tracheotomy led to the attempt 
to restore respiration by a simpler procedure, which consists in 
maintaining the natural passage by means of a metal tube in- 
serted in the larynx and trachea. That the larynx will not 
spasmodically eject a tube has been abundantly proved; the 
sudden irritation and reflex action caused by the entrance into 
it of a drop of water or a crumb of food is entirely absent in 
case a tube be fitted into it. Intubation is defined in the Nat- 
ional Medical Dictionary as “the insertion and maintenance of 
a tube within the chink of the glottis.” Whatever difficulties 
may lie in the path of this proposed procedure, and whatever 
consequences may attend it, a simple analysis of the definition 
shows that there can belong to it none of the unpleasant feat- 
ures that bring tracheotomy into question; the operation re- 
quires no incision, and accordingly is exempt from any of the 
dangers that might accompany the use of the knife. 
A study of the technique contrived by Dr. O’Dwyer will obvi- 
ate many of the difficulties the definition would suggest. We, 
therefore, venture to give a brief description of the operation as 
practiced at the present time. 
It is presupposed that the surgeon, before attempting to intu- 
bate a living larynx, lias rehearsed the operation many times on 
the cadaver, not confining his attention to one cadaver only, but 
extending his practice to a dozen or more. This practice should 
be executed under the guidance of a competent instructor. In 10 
this way only can the operator hope to acquire the tactual skill 
so essential in the performance of this operation. The unfavor- 
able results reported by some operators are no doubt due to a 
lack of skill in operating. 
O’Dwyer’s Intubation Instruments. 11 
Familiarity with the appearance and utility of the introduc- 
tor, extractor, mouth-gag, metal gauge or scale, tubes of various 
sizes with their proper obturators, is herein taken for granted, 
as they are accurately described in all text-books on modern 
surgery. 
The patient should be enveloped from the neck down in a 
light blanket, in such a manner as to prevent interference of 
his hands or arms with the operation, and should be held up- 
right in the arms of a nurse, who should restrain the legs of the 
child with her own. Having inquired the child’s age, the physi- 
cian selects to accord with it, by the aid of the scale, a tube/\vhich 
is already fixed upon its proper obturator. The obturator imme- 
diately screws tightly to the introductor. A mouth-gag is now 
inserted into the patient’s mouth, on the left side, well back 
between the teeth ; the head is held and the gag steadied by an 
assistant standing behind. Holding lightly in his right hand 
the introductor laden as we have shown, the physician faces the 
child and is ready for the insertion. Pie passes his left index 
finger into the fauces until it reaches the epiglottis, which he 
therewith elevates ; the introductor is placed in its initial posi- 
tion with the handle vertical and close to the chest. The tube, 
which is horizontal and points in toward the pharynx, is passed 
quickly over the tongue until its distal extremity reaches the 
tip of the left index finger; the handle of the introductor is 
then raised in such a manner as to incline the tube downward 
and insert its extremity into the chink of the glottis; at the 
same instant, the finger-tip is slipped aside, and the tube is 
rapidly but gently lowered into its proper position. Immedi- 
ately the slide of the introductor is shoved forward so as to 
release the hold of the obturator upon the tube, the index finger 
is placed upon the collar of the tube, and the obturator is with- 
drawn. Insertion in this manner need not, if skill be used, 
occupy more than eight seconds; if at the end of that period 
the tube be not in its correct position, it is better to withdraw 
it, and after a short rest make another attempt. 
It should be mentioned here that no tube is properly equipped 12 
unless it be provided with a fine thread, which, drawn through 
the hole in the collar, makes possible an easy removal in case 
the tube should accidentally slide into the oesophagus instead 
of into the larynx. When ease in breathing gives evidence 
that the tube has been properly placed, the thread should be 
withdrawn. Of course no precise time for wearing the tube can 
be specified; practically it should be worn as long as there 
exists a laryngeal stenosis. The judgment of the operator as 
to when the stenosis has sufficiently subsided to warrant extu- 
bation must be based on general symptoms. 
Preparations for removal are the same as those for introduc- 
tion ; and the insertion of the point of the extractor into the 
orifice of the tube is accomplished by the same manoeuvre as 
that by which, in introduction, the distal extremity of the tube 
was thrust into the chink of the glottis. Removal, however, is 
not so easy as introduction. The first difficulty consists in the 
likelihood of the point of the extractor to slide into the spage 
between the tube and the laryngeal wall. If this misplacement 
occurs, the spreading of the beaks outside the tube may result in 
laceration of the laryngeal wall. If the walls be much torn, 
the tube is quite likely to slip into the trachea. Of course, if 
the guard screw of the extractor be properly set, the beaks can 
be spread for a distance but little greater than the diameter of 
the interior of the tube ; even then, however, misplacement in- 
volves danger. 
A second difficulty is usually experienced: a steady pressure 
maintained upon the lever of the extractor does not always pre- 
vent the beaks, when properly engaged within the aperture of 
the tube, from slipping and losing their grip. To overcome 
this difficulty, I)r. Edward H. Nichols, of Poston, has devised a 
special extractor. 
It may safely be asserted that in extubation, as in all matters 
requiring delicate sensational discrimination and adjustment, 
practice is the fundamental pre-requisite. Hence every operator 
should prepare himself by many preliminary extubations per- 13 
formed upon the cadaver. So much for the technique of the 
operation. 
It lias been asserted by some that intubation has certain 
objectionable features of its own that tend to counterbalance the 
defects of tracheotomy. I shall endeavor to embrace and con- 
sider the objections that seem to me most important in a some- 
what methodical criticism of the operation; the scope of the 
criticism is suggested by the definition we have already cited, 
and indicated by the following questions : 
(1.) What are the risks of insertion, and to what extent may 
these be nullified by technique ? 
(2.) Are there any bad effects made possible by the mainte- 
nance of the tube within the larynx for a considerable time ? 
As regards insertion, it must be remembered that until the 
tube is in its correct position, the obturator completely blocks 
its interior space; accordingly, during the period occupied by 
insertion, the passage of air is completely shut off. Is this 
period of sufficient duration to give the already weary patient 
a perceptible shock ? I am convinced that if care and skill be 
used, such an event is only a remote contingency. 
Let it be remembered, that while the left index finger holds 
the epiglottis, respiration need not be completely obstructed; 
then to incline, insert and lower the tube are adjustments that 
admit of so speedy, and withal so nice, an execution, that no 
shock need result. In but four of my cases, and those among 
the first ten, was a second attempt necessary; in two or three 
of the first cases the time consumed was somewhat over ten 
seconds ; in no one of my last forty intubations did the bare in- 
sertion occupy more than eight seconds. 
There are, however, other and more important risks involved 
in insertion, from the fact that the distal extremity of the tube 
must traverse the swollen interior of the larynx and trachea 
for a distance equal to the length of the tube. A pertinent 
question arises as to whether this movement may be brought 
about by so slight and successfully directed a force as to cause 
no injury to the tissue along which it takes place. It here be- 14 
comes evident that a most essential presupposition of a success- 
ful insertion is a knowledge of the anatomy and internal shape 
and contours of the larynx and trachea. If the operator have 
this knowledge, and if through practice he has brought his hand 
to conform its movements to the picture in his mind, there is 
only a very slight possibility of his thrusting the tube into the 
soft tissues of the larynx. The false membrane that fills the 
passage readily yields under a slight pressure, so that the inte- 
rior contours of the normal larynx remain a valid basis for work 
upon the diseased larynx. Indeed, the ventricles that in the 
normal larynx would tend to catch the end of the tube and 
cause it to diverge from its proper path are, in the diseased 
organ, filled in with masses of membrane. 
The possibility of detaching portions of the false membrane 
and forcing them into a lower position than they would have 
occupied, seems to me the only contingency entirely unavoid- 
able by a careful technique; and it is in dealing with this pos- 
sibility that we must avoid the slighest appearance of dogmatiz- 
ing. If the actual occurrence be other than very rare, it cer- 
tainly constitutes a valid basis for opposing intubation, except 
in those circumstances that permit the patient to be watched 
by a trained eye with adequate closeness. Even if there be but 
a remote possibility of the occurrence, the assertion is thereby 
made good, that it would be better to have intubated patients 
placed together in a hospital where they can remain under the 
constant scrutiny of a physician and nurse. The danger of the 
occurrence lies, of course, in the fact that the membrane, when 
pushed down, is quite apt to cover the lower orifice of the tube, 
and thus produce, in a sudden and most startling manner, the 
death which the insertion is designed to avoid; the membrane 
may act as a valve, permitting inhalation, but shutting off exhala- 
tion. Let us consider this contingency under three headings : 
(1.) How far may it be avoided by technique ? 
(2 ) The manner of relieving the intense dyspnoea produced 
by its occurrence. 15 
(3.) The testimony of recorded statistics with regard to the 
frequency of its occurrence. 
How far may the contingency he avoided by technique ? We 
answer, to a considerable degree, although not entirely ; if the 
tube be inserted in conformity with the interior direction and 
structure of the passage, and if it be inserted with the gentlest 
possible pressure, there is obviously much less danger of the 
membrane’s becoming detached and crowded down than there 
would be if the extremity of the tube were tentatively scraped 
in a nervous manner, first against one side of the organ and 
then against the other. 
How may the produced dyspnoea be relieved ? Immediate 
extubation is imperative, and when performed is usually fol- 
lowed by the expectoration of the membrane. 
What and how valuable is the testimony of recorded statistics 
as to the degree of probability belonging to this contingency ? 
We reply that the records of cases performed under the condi- 
tions of careful technique are invaluable here, because they con- 
stitute our only basis for estimating the importance of this 
possible accident as a ground for opposing intubation. Dr. 
Johann Bokai, Professor in the University of Budapest, in the 
Jahrbuch fur Kinderheilkunde und Physische Erziehung, 
Leipzig, June 5, 1894, concludes from his own experience in 
five hundred cases, that pushing down the pseudo-membrane 
seldom occurs, and only in rare cases terminates fatally. Dr. 
V. Banke, of Munich, the pioneer of intubation in Germany, also 
states from an extended experience that the likelihood of the 
occurrence has been greatly exaggerated. Says Dr. George 
McJSTaughton : “ I can recall but three instances in 143 cases ; 
it proved fatal in two cases; the patient in the other case re- 
covered her breath and lived several days after.” The acci- 
dent has happened to O’Dwyer only three times, and then in his 
first 209 cases. Prancis Huber, Dillon Brown, Waxham, Gang- 
liofner, Baer, and Northrup, all emphasize the fact that this ac- 
cident is of very rare occurrence. A- 
We conclude, therefore, that inasmuch as the contingency we 16 
have been discussing is of so rare occurrence, that since its bad 
effect may be stopped by extubation, it deserves very little 
weight as a general objection to the operation. 
We come now to a consideration of the effects to be traced to 
the maintenance for a more or less extended period of the tube 
in the position it has acquired by insertion. Having in view 
the end of distinguishing and properly appreciating these effects, 
let us try to imagine what effects would occur, should the normal 
larynx be intubed, from complications that are due to the 
diseased condition of the larynx. 
When it is remembered that the larynx is in juxtaposition 
with the organs of deglutition, and that to the act of deglutition 
there is necessary a definite muscular adjustment of the larynx, 
the performance of which might be termed its negative func 
tion, and that the strength of the muscles that accomplish this 
adjustment is nicely adapted to the unvarying weight of the 
organ to be moved, it becomes a pertinent inquiry as to what 
may be the effect of suddenly fitting into this organ a tube that 
may weigh anywhere from 4 to 15 grammes. 
Experience has demonstrated that intubation usually inter- 
feres with deglutition to so considerable an extent that the tube 
is continued m the larynx with difficulty ; food and drink, in- 
stead of passing over the glottis into the aesophagus, tend to 
slip through the tube into the trachea. Out of forty-seven in- 
tubated children, I found but nine who were able to sit up in 
bed and eat in the natural manner. Of these, but one was under 
five years of age ; the rest were considerably above five. I may 
here give a general conclusion with regard to feeding intubated 
children; the younger the child the more difficult is the task of 
eating. 
Aside from the immediate disagreeableness occasioned by the 
false passage of food, the fact that it renders imminent Schluclc- 
pneumonie forces the phenomenon into our most serious consid- 
eration. Just how pronounced the tendency would be were the 
tube inserted into the normal larynx, and just to what extent it 
is intensified when the larynx is burdened with pseudo-mem- brane, it is difficult in the absence of the proper experiments 
to determine. Whether it be that the weight of the tube pre- 
vents the necessary elevation of the larynx, or whether motion 
of the epiglottis be hindered by the pressure and position of 
the collar of the tube, or whether the hindrance be due to some 
other cause obscured by our imperfect knowledge of the me- 
chanics of deglutition, that the presence of the tube in the larynx 
constitutes in a majority of cases a distinct interference with 
the act of swallowing remains a fact, the significance of which 
for our purposes is not at all lessened by the lack of an adequate 
explanation. 
It is a mistake, however, to hold up as an ideal of the sur- 
gical art an operation that is entirely unaccompanied by tem- 
porary inconvenience and positive disadvantage. Of no artificial 
invasion of the human organism, no matter how skillfully per- 
formed, can it be claimed that no restrictions attend it; the in- 
vasion is made for the purpose of producing some ulterior 
salutary effect, either upon the entire organism or one of its 
organs, and the accompanying restrictions are borne with, if 
possible, for the sake of the greater ulterior benefit. 
Of course a temporary interference with deglutition by intu- 
bation must be considered in this light, provided that by reason- 
able effort the system may be supplied with a proper amount of 
food without entrance of a portion of it into the trachea. May 
this be accomplished, and how ? The existence of this problem 
does not necessarily constitute an objection to intubation; 
rather, its solution forms a part of the eyisemble of the opera- 
tion ; if a good solution do not exist, the operation must be con- 
demned at once; if it do exist, it must be considered as a part 
of the operation, opposition to which must be on entirely 
different grounds. 
We answer that the system may be supplied witli food and 
the trachea protected from its intrusion in one of the four ways 
that follow : 
First, by the Casselberry method. This method consists in 
placing the child in a position, the advantage of which was 18 
made known by Dr. Casselberry, of Chicago; Dr. Casselberry 
discovered that by placing the child horizontally on its back 
and lowering its head* from the plane of the rest of the body 
until the pharynx is on a lower plane than the larynx, degluti- 
tion takes place naturally and with comparative ease. When 
the head is in this position the force of gravity helps to carry 
the food safely past the glottis. 
Whether the child eat in the erect or in the Casselberry pos- 
ture, the food should be of a semi-solid consistency; under no 
circumstances should liquids be used, as they are apt to trickle 
into the tube and thus become a prolific cause of Schluckpneu- 
monie. 
I have made use of the following articles of food: custard, 
corn starch pudding, blanc mange, ice cream or sherbet, oranges, 
bananas, jellies of various sorts, together with solids, such as 
small cakes, cinnamon buns, bread, etc., soaked in milk or 
sherry wine. 
My usual method has been to ascertain first whether the 
child could eat in the erect posture, and failing this to try the 
Casselberry position. I have resorted to the latter position 
successfully in thirty-two cases, and have failed to make it suc- 
ceed in six cases. 
For cases in which the Casselberry method does not prove 
effectual, there is open one of the three remaining methods. 
Recourse may be had to rectal alimentation. My experience 
in rectal feeding proved very disappointing ; not did the 
necessary manipulation cause more or less exhaustion, but the 
rectum soon developed a tendency to repel the blandest injec- 
tions. Nevertheless, in four of the six cases above mentioned, 
the only nourishment given was in the form of nutritious ene- 
mata. Among the articles of food used in this way were milk, 
eggs, bovinine, extracts of beef, pure beef-juice, etc. The most 
satisfactory results were obtained from the use of milk pepton- 
ized by the addition of Fairchild’s pepsin. 
If rectal feeding be not feasible, we may resort to feeding 
the child through a stomach tube. This procedure, beside being 19 
extremely disagreeable to the child, is apt to wound the throat 
and nose. To be fed properly in this manner the child should 
be seated upright in the lap of a nurse. A soft rubber catheter, 
well lubricated, is then introduced through the nose into the 
oesophagus; through this catheter milk is poured into the 
stomach. The physician should in all cases do this himself, 
unless he have the good fortune to be assisted by a nurse who 
has had previous experience in this procedure. 
It was necessary for me to resort to this mode of feeding 
with but two patients, both of whom were between one and two 
years of age. The amount of nourishment given in this way 
will of course vary somewhat with the age and circumstances 
of the case ; in my cases the usual amount given at a time was 
from three to four ounces. I have employed with great advan- 
tage Bryson Delavan’s alimentation bottle. A flexible catheter 
of small size replaces the ordinary stomach-tube, and is intro- 
duced not into the stomach, but simply below tlu/iaryngeal 
constrictors. 
Bbkai has recommended the removal of the tube each time 
before the taking of food. In no case have I resorted to this 
method of feeding; the excessive manipulation of the diseased 
structures in and about the air-passages has been the ground on 
Avhich I have avoided it. 
It has been objected by Sajous, among* others, that the tube 
may fail to remain in the position into which it has been placed, 
either by sinking further into the trachea or by being coughed 
up as a foreign body. Obviously this objection cannot be 
adequately considered until the tubes evolved by Dr. O’Dwyer 
have been made the subject of careful examination and study. 
The relevant facts are these: 
(1.) The external conformation of the tube is studiously 
adapted to the internal conformation of the organ. 
(2.) The size of the tube may be made to correspond ac- 
curately with the size of the larynx by the aid of the scale. 
(3.) The collar of the tube, if properly selected, rests upon 20 
the ventricular bands in such a manner as to form a mechanical 
barrier to further movement downwards. 
(4.) The tube at its middle is provided with a swell that 
serves to tighten the clasp of the larynx upon it. 
(5.) The weight and length of the tube are no inconsider- 
able factors in its ability to oppose the force involved in cough- 
ing. 
In no case of mine has a tubfe failed to remain in its proper 
position. 
It is possible, and in certain cases probable, that the tube may 
become gradually or suddenly occluded with mucus. Inasmuch, 
however, as the air that circulates through the intubation canula 
has usually been warmed and moistened by its passage through 
the nasal chambers, there is little probability, unless there be an 
extraordinary secretion, that the mucus will at any stage become 
dry, to such an extent that it will fail to yield to the current 
of air. If the patient breathes through the mouth and has a 
high temperature, especial care should be used to provide the 
room with abundant moisture. This may be accomplished either 
by the steam-atomizer, or, perhaps better, by means of a device 
contrived by Dr. Charles M. Whitney, and described by him in 
the Boston Medical and Surgical Journal for October 5, 1893. 
In those cases in which an extraordinary secretion and flow 
of viscous mucus is observed, it is well to leave the thread at- 
tached to the canula, and to caution the attendant to watch the 
patient closely, and upon the manifestation of a pronounced 
dyspnoea, to remove the tube. For cases in which there is this 
flow of mucus, or in which there is much loose membrane in the 
trachea, a special tube has been devised by O’Dwyer. This tube 
is shorter, of larger caliber, has no retention swell, and is made 
in seven sizes. As it is more likely to be coughed up, the largest 
possible size should be used. 
In five cases, I have met with this abundant secretion of 
mucus. In the first three cases I used the long tube, leaving 
the string attached and cautioning the attendant. In the third 
case, after the patient, a child between five and six, had been 21 
O’Dwyer’s Short Large Caliber Tubes. 
intubated two days, the lumen of the tube became occluded by 
mucus of so tenacious a quality that apnoea resulted, from 
which the child died. Upon introducing the tube I had left a 
string attached. The parents, either from fright or stupidity, 
had failed to follow my explicit directions to remove the tube 
upon the manifestation of any serious difficulty in breathing. 
In the next case of this kind I first inserted the usual tube, and 
after an hour changed it for a short tube, which I allowed to 
remain two days; no ulcerations resulted, nor was it necessary 
to re-insert the long tube; the child recovered. In the fifth 
case, I inserted without delay a short tube, which after twenty- 
four hours I exchanged for a long tube. The latter was allowed 
to remain in the larynx for two days. No ulcerations occurred. 
The child recovered. 
I have endeavored to make clear the most important conclu- 22 
sions drawn from my own experience in intubation. These 
conclusions and the questions of technique and practicability to 
which they pertain have been, and it seems to me, advisably, 
isolated from any account of the cases based upon a consider- 
ation of the course of the specific diseases causing the stenoses. 
At the expense of repeating, it should be emphasized that intu- 
bation makes no attack upon the constitutional disease. I have, 
therefore, presented my experience merely with regard to the 
success and safety with which the operation may be made to 
accomplish its mechanical end of relieving dyspnoea. 
Inasmuch, however, as I have, since taking up intubation, re- 
sorted in no case to the other operation, some determination of 
the scope of my experience seems necessary. 
Of the fifty intubations, forty-seven were performed for the 
relief of acute laryngeal stenosis in children, while three were 
done for the relief of chronic stenosis in adults. 
First, with regard to the forty-seven children. Of these 
thirty were males; with the exception of two cases, their ages 
were all between five and seven years ; of the two cases, one 
was an infant of one year, while the other was a boy of ten 
years. 
In eight cases the primary lesion was confined to the larynx, 
—the mucous membranes of the mouth, pharynx, soft palate 
and nasal passages remaining from the first, as far as I could 
judge, in a perfectly normal condition. With the treatment of 
these eight cases, together with one other in which the lesion 
was manifested first on the tonsils, I am familiar, as they came 
in my own practice ; they were fortunate enough to come after 
the advent of antitoxine ; all recovered. 
The remaining thirty-eight cases were consultation cases, in 
which I attended simply to the tubeage. Without doubt they were 
characterized by radical variations in constitutional treatment, 
due as well to variations in judgment on the part of the physi- 
cians in charge as to the different times at which they occurred 
In thirty-one of the thirty-eight cases, the local manifestation 
first appeared over the tonsils and soft palate, and thence 23 
extended to the larynx ; in all but two of these cases the down- 
ward extension ceased in the larynx; in the two cases it ex- 
tended from the larynx through the trachea into the ramifica- 
tions of the bronchi, thereby producing broncho-pneumonia, from 
which both died. In three of the seven remaining cases the 
initial lesion was in the nasal passages, and extended thence to 
the adjoining mucous membranes of the pharynx and air-pas- 
sages. Of the four remaining cases I have no record save that 
at the time of intubation the mucous membranes of the pharynx 
and air-passages were all invaded. 
Of the twenty-eight deaths that took place among these forty- 
seven diphtheria cases, but one, in my judgment, can be traced 
either directly or indirectly to intubation. The circumstances 
of that case I have described. 
Chronic Stenosis Tubes. 
There remain to be considered three cases of chronic stenosis 
in adults. In two of these the stenosis was the result of the 
cicatrization of syphilitic ulcers ; in the other case the stenosis 24 
was due to an oedema of the glottis that was a complication of 
Bright’s disease. 
In the cases of cicatricial stenosis, as no permanent improve- 
ment followed the use of the dilators of Mackenzie and Navratil, I 
resorted to continuous laryngeal pressure by means of O’Dwyer’s 
probe-pointed, conical-shaped tubes. These were taken out, 
cleaned, and re-inserted every seven days through a period in 
the first case of about four months, and in the second of about 
three. In the first case, although the tube has been out for 
a year, no return of the stenosis has been reported. In the 
second case an occasional re-insertion has been necessary. 
It is generally supposed that in oedema of the glottis, intuba- 
tion can afford but slight relief on account of the swollen tissues 
overlapping the head of the tube. In the single case I report, 
after incision of the ary-epiglottic folds, a successful and per- 
manent relief was attained by means of a large-headed tube. 
In the effort to bring the essay within the time limit, the 
account of these cases has been somewhat abridged.