The Present Status of Intuba- 
tion in the Treatment 
of Croup. 
BY 
J. O’DWYER, M. D. 
REPRINTED PROM THE 
Heto STorlt J&ctiical Souraal 
for March 10, 1894. Reprinted from the New York Medical Journal 
for March 10, 1894,. 
THE PRESENT STATUS OF 
intubation in the treatment of croup. 
J. O’UWYER, M. D. 
Most difficult would be the task of the impartial reader 
who would attempt to arrive at any definite conclusion re- 
garding the value of intubation from the most careful 
study of the literature of this subject, unaided by personal 
experience. So conflicting are the opinions that have been 
expressed by the numerous writers on this subject, that the 
partisan, choosing whichever side his fancy or prejudice 
might dictate, could produce an array of authorities and 
statistics in support of his arguments, either pro or con, that 
to the inexperienced would appear overwhelming. Jump- 
ing at conclusions from a limited experience, the one thing 
above all others that the practice of medicine should teach 
us to avoid is the principal cause that has led to the con- 
fusion and difference of opinion that still exist on this 
question. The more fatal a disease, the more caution is 
necessary in making deductions from the evidence derived 
from a few cases, because, under these circumstances, the 
element of chance or coincidence often plays an important 
Copyright, 1894, by D. Appleton and Company. 2 
THE PRESENT STATUS OF INTUBATION 
part which is excluded when large numbers are considered. 
For example, I recently intubated a patient for a physician 
in my neighborhood, who informed me that it was his 
eighth case of this kind, and that seven of them had recov- 
ered. For another physician, only a few blocks distant, I 
had intubated a similar number of cases, every one of which 
died. At the Great Ormond Street Hospital, London, in 
the year 1890, intubation was first tried in eleven cases of 
croup with only one recovery. This result was considered 
sufficiently unfavorable to condemn the operation, and it 
was therefore abandoned. At the end of two years, owing 
probably to more favorable reports from other quarters, it 
was again tried in another series of eleven cases, this time 
with eight recoveries (British Medical Journal, July 22, 
1893). Whether only one patient or eight patients out of 
eleven recover proves absolutely nothing except that some 
patients do recover after intubation. Neither would it have 
proved anything had every one of the twenty-two died, ex- 
cept that the mortality following intubation for croup was 
very large—a fact which no one with sufficient experience 
disputes. The literature of intubation abounds with similar 
examples of reaching conclusions from a limited experience, 
and it is on such evidence that this procedure has been 
overestimated by some and condemned as useless by 
others, according to the varying results obtained in a 
few cases. 
The fatal and complex nature of croup, which renders 
such contradictory results possible under the same method 
of treatment, is also to some extent responsible for this con- 
dition of things. 
Acute non-traumatic stenosis of the larynx in children 
that endangers life by suffocation is, with rare exceptions, 
diphtheria, either true or false. This disease, if unrelieved 
by mechanical means, proves fatal in about ninety per cent. IN THE TREATMENT OF CROUP. 
3 
of the cases, and, with all the aid that medicine and surgery 
can afford, it still continues to be, with few exceptions, the 
most fatal of all the acute diseases. The much-dreaded Asi- 
atic cholera seldom carries off more than half its victims, 
while croup claims a much larger percentage. Even some epi- 
demics of cerebro-spinal meningitis are more merciful than 
this disease, the terrors of which are less apparent because 
always present. 
In considering the causes that lead to such frightful 
mortality and the unsatisfactory results obtained from any 
method of treatment yet devised, the important fact is 
often lost sight sight of that the word croup means a good 
deal more than obstruction in the larynx. Did it only 
mean the latter, there would be no room for any difference 
of opinion as to the best method of treating it, because 
under these circumstances intubation in skillful hands 
would have no failures. 
Those familiar with the pathology of this disease know 
that the most frequent cause of death, after the laryngeal 
stenosis has been overcome by means of intubation or 
tracheotomy, is the extension of the disease to the bron- 
chial tubes, where surgery can not reach it; and that there 
are several other causes, such as pneumonia, systemic poi- 
soning, paralysis, especially of the heart, and nephritis, 
each of which contributes its quota toward swelling the 
mortality of this terrible disease. It goes without saying 
that the results of any method of treatment in a disease 
having so many complications, the fatality of which is so 
great under all circumstances, and which varies so widely in 
different epidemics, must be obtained from a large number 
of cases in order to be of any value. Not even are the re- 
sults of intubation obtained from a large number of cases 
collected from numerous operators, each contributing a few, 
of much value, because the ability to intubate without ,im- THE PRESENT STATUS OF INTUBATION 
mediate danger to life can not be acquired by the amount of 
practice derived from a few cases. 
It is therefore to large individual experience alone that 
we must appeal for conclusive evidence as to the value of 
intubation, not only as a means of saving life, but also as 
to its more important function as a means of euthanasia in 
the most excruciating of all forms of human suffering— 
that of slow strangulation. 
There are at present a sufficient number of operators, 
both in this country and Europe, who possess this kind of 
experience, and they speak on this subject with no uncer- 
tain voice. Among the American intubationists who have 
had large individual experience and whose opinions on this 
question are well known I may mention Waxham, formerly 
of Chicago, now of Denver; Brown, Northrup, Huber, 
Caille, Lester, Stanton, and the author, of New York; 
McNaughton, of Brooklyn ; Hailes, of Albany ; Eichberg, 
of Cincinnati; Richardson and Henrotin, of Chicago ; 
Shimwell and Montgomery, of Philadelphia; Cheatham 
and Pusey, of Louisville ; von Glahn, of Cleveland ; Pyne, 
of Yonkers ; and Graham, of Toronto. All of these and 
many others whose names I have not at hand have each had 
in the immediate neighborhood of or exceeding a hundred 
cases. Several of the operators mentioned can count their 
cases by hundreds, and four names could be selected whose 
aggregate number of cases now exceeds two thousand. 
The latest intubation statistics are those by Dr. Mc- 
Naughton and Dr. Maddern, of Brooklyn, who have col- 
lected from 242 operators in various parts of this country 
and Canada 5,546 cases, with 1,691 recoveries, or 30-5 per 
cent. (.Brooklyn Medical Journal, August, 1893). Not- 
withstanding that it is only within the last three or four 
years that intubation has been adopted to any considerable 
extent in Europe, some valuable statistics have already been IX THE TREATMENT OF CROUP. 
5 
accumulated. And these statistics are valuable not only 
because they are the result of large individual experiences, 
hut also from the fact that they have been obtained exclu- 
sively from children’s hospitals in which tracheotomy had 
hitherto been the only surgical measure available in the 
treatment of croup. 
Professor Ranke, of Munich, as the result of a collect- 
ive investigation on the subject of intubation in Germany, 
reports 1,324 cases of primary laryngeal diphtheria intu- 
bated, with 516 recoveries, and 121 cases secondary to 
measles, scarlet fever, pneumonia, etc., with 27 recoveries— 
a total of 1,445 cases, with 553 recoveries, or thirty-eight 
per cent. (Munchener medicinische Wochenschrift, No. 44, 
1893). Of this number, Ganghofner, of Prague, contrib- 
uted 498 cases, with 213 recoveries, 42-7 per cent.; Ranke, 
of Munich, 368 cases, with 128 recoveries, 34-7 per cent. ; 
von Muvalt, of Zurich, 106 cases and 38 recoveries, 35’8 
per cent.; Jaburowski, of Cracow, 165 cases and 73 recov- 
eries, 44-2 percent.; and Unterholzner, of Vienna, 164 cases 
and 55 recoveries, 35’5 per cent. 
Secondary tracheotomy was resorted to in 250 of the 
cases, with only 20 recoveries, or about seven per cent. 
In regard to the value of these statistics Ranke speaks 
as follows : “ This number proves for itself that O’Dwyer’s 
intubation, which at first and until lately was severely 
fought on all sides, has in the course of a few years gained 
more and more friends on this side of the Atlantic, and it 
proves that the dangers which were formerly charged against 
intubation must have been very greatly exaggerated.” 
And again, in giving the true explanation of the insig- 
nificant results obtained by means of secondary tracheoto- 
my after intubation had failed, as follows; “ The extraordi- 
narily small percentage of recoveries from these secondary 
tracheotomies is explained in this way : that in the majority 6 
THE PRESENT STATUS OF INTUBATION 
of these cases secondary tracheotomy is resorted to after the 
diphtheritic process has extended to the bronchi, and that, 
under these cimimstances, tracheotomy could not accom- 
plish any more than intubation.” 
Similar testimony as to the value of this procedure 
comes from Hungary. Bokai, medical director of the Ste- 
fanie Children’s Hospital of Budapest, has already intubated 
over 500 cases of croup, with recoveries of thirty-six per 
cent. In the medical report of the hospital for the year 
1892, with an experience at that time of nearly 300 cases, 
Bokai, after referring to the necessity of having an ad- 
ditional diphtheria pavilion constructed, proceeds as fol- 
lows : “ That this construction was required was demon- 
strated by the fact that all the beds and extra rooms were 
continuously filled. The cause of this great attraction of 
our diphtheria division was due chiefly to the employment 
of intubation, and it gives us pleasure to be able to state 
that this procedure has given splendid results, so that 
tracheotomy has become almost wholly superfluous. In 
consequence of these splendid results, numerous friends 
have been added to the side of intubation, both in the 
country as well as in the city, and many colleagues have 
availed themselves of the rich material at our disposal to 
practice intubation under our direction. Convinced of the 
extraordinary importance of O’Dwyer’s intubation in hos- 
pital as well as in private practice, I deemed it my duty to 
so instruct my colleagues, and it gives us pleasure to say 
that this acquisition has spread from our hospital through- 
out all Hungary.” 
Such is the evidence regarding the present status of in- 
tubation in Europe furnished by men whose reputations are 
more than national, and whose experience with this proced- 
ure has been amply sufficient to entitle them to speak on 
this subject with the voice of authority. IN THE TREATMENT OF CROUP. 
7 
It will be noticed that the percentage of recoveries is 
considerably larger in Europe than is generally obtained in 
this country, and the same is also true of tracheotomy. 
The ready accessibility at all times of a skilled intubationist 
should give some better results in hospital than in private 
practice, which may in part explain the difference, as the 
statistics from the other side come exclusively from the 
hospitals, while in this country they are furnished, with few 
exceptions, from private practice. In 186 patients treated 
at the Willard Parker Hospital in New York, thirty-eight 
per cent, recovered, while at the Boston City Hospital 392 
cases gave only twenty per cent. 
In the former the resident physician and one trained 
assistant performed all the intubations, while in the latter 
they were done by successive house staffs, each member of 
which had charge of the diphtheria division in rotation. 
Under the latter circumstances the individual experience 
was necessarily small, so that no single operator could have 
had a sufficient amount of practice to enable him to avoid 
the accidents, not infrequently fatal, that are inseparable 
from intubation in the hands of the novice. That the dif- 
ferent conditions which existed in these two hospitals ex- 
plain the great discrepancy in the results I do not believe 
but that they were sufficient to produce a very considerable 
difference in the percentage of recoveries there is not the 
slightest room for doubt. 
In regard to the comparative merits of intubation and 
tracheotomy as life-saving measures in the treatment of 
croup, I do not know of any stronger argument that could 
be produced in favor of the new procedure than a short 
quotation from a paper by Dr. L. S. Pilcher, of Brooklyn, 
during a discussion on this subject before the Kings County; 
Medical Society (Brooklyn Medical Journal, August, 1893). 
Dr, Pilcher, while advocating the claims of tracheotomy 8 
THE PRESENT STATUS OF INTUBATION 
as the greater life-saving operation, makes the following 
very candid statement: “ I believe that it has been my lot 
to be called upon to do tracheotomy for the relief of croup 
in a considerable proportion of the cases that have sought 
surgical relief, and yet during the seventeen years during 
which I have been operating I have been called upon to do 
the operation but 66 times, notwithstanding the deaths 
from croup in our city during this period amounted to 
between 400 and 500 every year. On the other hand, dur- 
ing the past four years Dr. McNaughton has been called 
upon to intubate 142 times. He has been instrumental in 
saving 42 lives in four years, I but 22 in seventeen years, 
notwithstanding 33-33 per cent, of my cases recovered and 
but 29-5 of his.” In other words, Dr. Pilcher was doing 
tracheotomy on an average of four times in a year, when 
the deaths from croup during the same period amounted to 
between 400 and 500. 
Estimating from the deaths as given above, the total 
number of croup cases that occurred in Brooklyn during 
the seventeen years referred to was somewhere between 
8,000 and 9,000, and out of this vast number the most cele- 
brated tracheotomist of that city succeeded in saving the 
lives of only 22. This is a good example of the life-saving 
qualities of tracheotomy, an operation which the poorer 
classes, among whom croup principally prevails, seldom con- 
sent to, and if they did the skilled nursing so essential to the 
proper after-treatment would not be available. Intubation, 
on the contrary, is rarely objected to by either the rich or 
the poor, the ignorant or the intelligent, and no skilled 
nursing is required, the one and only requisite being trained 
operators. Outside of hospital practice there is, therefore, 
no room for comparison between these two procedures, 
the question as to whether, in a given number of cases, 
one operation may save a small percentage more or less IN THE TREATMENT OF CROUP. 
9 
than the other being one of scientific rather than of prac- 
tical interest. 
The difficulties and dangers of placing a tube in the 
larynx or removing it in the short space of time that is 
compatible with safety are either great or small according 
to the practical experience of the operator. When this im- 
portant fact shall have been more generally recognized in- 
tubation will not be attempted by so many as heretofore, 
but will be left to those who have had some sort of pre- 
liminary training, if not on the cadaver, at least on a 
larynx, or on one of the smaller animals. By any of these 
means sufficient dexterity with the use of the instruments 
may be acquired to avoid at least some of the accidents in- 
separable from this operation in the hands of beginners. 
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