INTUBATION OF THE LARYNX, 
WITH A 
REPORT OF EIGHTEEN CASES, 
BY 
WALTER B. JOHNSON, M. D., 
Surgeon to the' Paterson Eye and Ear Infirmary, Paterson, N. J. 
Reprinted from the 7 ransactions of the Medical Society of New Jersey, 1891. 
NEWARK, N. J.: 
L. J. Hardham, Printer, 243 & 245 Market Street. 
1891 INTUBATION OF THE LARYNX, 
WITH A 
REPORT OF EIGHTEEN CASES, 
BY 
/ 
WALTER B. JOHNSON, M. D., 
Surgeon to the Paterson Eye and Ear Infirmary, Paterson, N. J. 
Reprinted from the 7 ransactions of the Medical Society of New Jersey, 1891. 
NEWARK, N. J.: 
L. J. Hardham, Printer, 243 & 245 Market Street. 
1891. Intubation of the Larynx, with a Report 
of Eighteen Cases. 
In preparing the paper on Intubation which I have 
the honor of presenting at this meeting of the Medical 
Society of New Jersey, an effort has been made after a 
careful study of the literature, to briefly and comprehen- 
sively arrange the opinions and observations of prom- 
inent workers in the field. The operation has a great 
future, and is destined to come into more general use 
than tracheotomy ever could have done, although it is 
not intended to, and never can, entirely supersede the 
old operation, which may still be performed when 
indicated. 
Should the compilations under separate headings here 
appended be of service to the practitioners of our own, 
or other States, who have recently undertaken the study 
or performance of Intubation, the effort will certainly be 
fruitful in the consequent relief of suffering and saving 
of life. 
HISTORY. 
Effort at the removal of pseudo-membrane from the 
larynx, in cases of stenosis with accompanying dyspnoea, 
and attempts to relieve patients temporarily by catheter 
ization of the larynx, are recorded in early medical his- 4 
tory. In the time of Hippocrates and until the discovery 
of the operation for bronchotomy by Asclebiades, about 
ioo B. C., the laryngeal brush, probang and forceps, were 
advocated for the removal of membrane from the larynx; 
their use was reported to have afforded temporary relief. 
Catheterization of the larynx was also strongly recom- 
mended and was said to have saved lives that would 
otherwise have been lost. 
The operation for bronchotomy was received so favor- 
ably by the medical profession in general, that from the 
time of its first introduction it seems to have superceded 
all other procedures, and no account of any of the earlier 
methods appears in medical literature until revived by 
Chaussier in 1780. From 1780 until 1858, different 
methods of catheterization were advocated by numerous 
practitioners in various countries ; none of these pro- 
cedures, however, secured any extended professional 
endorsement or trial. 
In 1858 Bouchut of Paris devised an operation which 
he called tubage of the larynx. In the light of subse- 
quent developments his procedure appears to have been 
a step in advance, being the first and only record of a 
proposition to introduce a short tube, intended to remain 
within the larynx, and to permit closure of the epiglottis 
and the act of deglutition. His enthusiasm led him to 
present premature reports, and to make claims which he 
could not substantiate. Unfortunately his disposition 
was such, that in combating the objections of Trosseau 
and the committee of the French Academy of Medicine, 
appointed to investigate and report, he incurred their 
enmity. They reported adversely, and thereafter his 
operation was entirely lost sight of and forgotton. 
Bouchut reported in all ten cases, three of which were 
said to have resulted successfully. He had beyond all 5 
peradventure demonstrated the possibility of introducing 
a short tube into the larynx, which positively relieved 
dyspnoea and was capable of being retained for a con- 
siderable length of time without serious discomfort. 
The instruments used by Bouchut were crude and 
unscientific in construction. The tube was a cylinder, 
shaped like a tailor’s thimble, less than one inch in 
length and did not reach into the trachea. It had two 
collars near the upper edge between which the cords 
were to rest and thus aid in its retention. It had an 
eyelet near the edge through which a thread was passed 
and left while the tube remained in the larynx. The 
thread was attached to prevent swallowing, and also to 
permit removal of the tube when necessary. 
Plate No.l 
Bouchut lube and Introducer. 
The introducer shaped like an uethral sound fitted 
into the tube and could be easily detatched from it. 
The sketch of the Bouchut instruments here presented 
was kindly furnished by Dillon Brown, M.D., of New 
York. A very complete history of catheterization, 
tubage intubation, etc., has been written by him.* 
* Transactions Ninth International Medical Congress. Vol. Ill, Diseases of 
Children. 6 
In 1880 intubation of the larynx was introduced at 
the New York Foundling Asylum by Joseph O’Dwyer, 
M.D., of New York, who, after years of study and 
experiment and without any knowledge of previous 
efforts in the same direction having been made, perfected 
the operation and the instruments, and presented them to 
the medical profession. His painstaking labor, and his 
modesty, have fortunately for thousands of little suf- 
ferers, obtained for himself and his operation, the recog- 
nition of the medical men of this and other countries 
that it deserves. 
INDICATIONS FOR INTUBATION. 
A diagnosis by exclusion of all other possible causes 
for the condition should first be made. The chest and 
neck should be exposed, as in some cases the dyspnoea 
may be produced by external pressure, the result of 
abscess or cervical tumors. The lungs should be care- 
fully examined, as capillary bronchitis atelectasis, 
broncho-pneumonia, deposits of pseudo-membrane in 
the bronchi or some other pulmonary complication may 
be present. The condition of the fauces should be 
noted, post pharyngeal abscess or excessive tumefaction 
of the tonsils with closure of the nares may be the 
cause of the dyspnoea, in which case the voice and cough 
will not be affected. 
Some writers have urged the use of the laryngoscope 
to determine the condition ; if such an examination could 
be made without the use of force, the actual demonstra- 
tion of the stenotic condition and the presence of the 
laryngeal membrane might be desirable, although care- 
ful consideration of the physical signs could hardly fail 
to locate the trouble. 7 
Extreme restlessness, long continued in children, 
affected by marked dyspnoea, is an indication, if con- 
sciousness be impaired, that there is undoubtedly laryn- 
geal stenosi. 
Intubation should be performed when continued 
dyspnoea is present from any laryngeal cause, unless 
it result from the presence of a foreign body, in which 
case the special tubes designed for that purpose may 
be used. Dr. O’Dwyer believes that the foreign body 
tube adapted to the age of the patient will allow any 
foreign body which has passed into the larynx to pass 
out though the tube, unless the body is absorbent in its 
nature, when the tube could hardly prove satisfactory as 
the size of the body would increase very rapidly after 
passing into the trachea. 
The intubation should be performed at the very first 
onset of the suffocative stage, as indicated by sinking in 
of the yielding portions of the chest, lower ribs and 
sternum, episternal notch, and supra-clavicular region, 
with downward motion of the larynx on inspiration, and 
sinking of the epigastric region. The amount of sinking 
being proportionate to the stenosis present and simply 
proving that sufficient air cannot enter the lungs to fill 
the vacuum created by the expansion of the chest, and 
that recession occurs as a result of atmospheric pressure. 
Under such conditions the respiratory murmur over the 
posterior portion of the chest is very feeble or entirely 
absent. The operation should not be delayed until 
abiding cyanosis is present, or until that peculiar con- 
dition of paleness of the surfaces, indicating excessive 
determination of blood to the lungs appears. The car- 
bonic acid poisoning resulting from said conditions seri- 
ously complicates the disease. 8 
SYMPTOMS. 
The characteristic symptoms of stenosis are the croupy 
cough, nearly always present, the noisy or croupy breath- 
ing, increasing as the disease develops, hoarseness coming 
on early in the disease, considerably proceeding all other 
symptoms and developing as the disease progresses, 
until nearly complete aphonia is produced. Membrane 
about the vestibule of the larynx, tonsils and pharynx, 
or below the larynx in the trachea may seriously inter- 
fere with respiration, without in any way affecting the 
cough or voice sounds. Dyspnoea unless spasmodic is 
always a late and a very grave symptom. It may affect 
inspiration only, or both inspiration and expiration may 
be difficult. Expiration may be more effected than 
inspiration when emphysema may result. Impediments 
in the larynx generally produce greater difficulty on 
inspiration than expiration. In a patient seen for the 
first time when moribund or nearly so, presenting no 
symptoms but the extreme cyanosis and labored breath- 
ing, it may be difficult to determine the true cause of 
the condition; foreign body being excluded, and the 
physical signs present, locating the trouble in the larynx, 
indicate immediate intubation, regardless of the exact 
nature of the obstruction. Return of dyspnoea after the 
tube has been introduced and the patient doing well for 
some time, indicates some complicating condition and 
demands the immediate presence of the operator. The 
patient may be progressing favorably and the membrane 
clearing from the fauces, when complications or sepsis 
may supervene and the exudation reappear with accom- 
panying increase ip the laryngeal infection. 
Coughing out the tube indicates a decrease in the 
cedema from pressure. It may be left out if the 
dyspnoea does not immediately call for its re-introduc- 9 
tion, as the patient will probably not require it for some 
hours, and will certainly receive as much benefit as 
though the tube were constantly in the glottis, especially 
if the intervening periods are long and comfortable, and 
allow the patient to take nourishment without difficulty. 
Disturbing dyspnoea should be immediately relieved by 
re-intubation. 
Sudden dyspnoea with occlusion of the tube causing 
asphyxia is almost certainly followed by its expulsion, 
although death has occurred from this cause. Unless 
the tube is removed or expelled in a minute or less, death 
will ensue. 
Loose membrane in the trachea is indicated by a 
peculiar rasping cough, with occasional sudden closure 
of the tube on expiration, which signifies the necessity 
for preparation to remove the tube quickly in case of 
occlusion. 
If the dyspnoea is due to subglottic, or tracheal 
oedema or membrane, the relief after intubation is only 
apt to be partial and not complete, as it always is for 
the time being when the obstruction is confined to the 
larynx. 
ADVANTAGES OVER TRACHEOTOMY. 
1. No anaesthetic is required. 
2. The operation should be easily performed, after a 
careful study of the literature, and frequent trial on the 
cadaver, by any practicing physician. 
3. There is comparatively little danger and no shock. 
4. The advantage to the practitioner of being able to 
perform the operation alone, without trained assistants. 
5. The patients are more readily induced to permit 
an operation which requires no cutting and is not 
attended by bleeding. 10 
6. The percentage of recoveries is greater, especially 
in cases under three years of age. 
7. There is no wound that may permit absorption 
and be a source of constitutional infection. 
8. Is susceptible of use in mild cases of croup, which 
seem likely to continue as such, in which tracheotomy 
would be too severe a remedy. 
9. Parents are gratified for the relief of the dyspnoea, 
as the result of so moderate a procedure, even if the 
patient die. 
10. Intubation can be better used when accommoda- 
tions are poor and attention indifferent, as the tube 
requires comparatively little care. 
11. The ability to speak and breathe quietly, and the 
comfortable tolerance of the tube. 
12. The contact of the tube causes some disintegra- 
tion of the false membrane, hastening its disappearance 
and preventing its re-formation; this pressure also has a 
decided tendency to diminish oedema. 
13. The tube allows the mucus and detrus to be freely 
expectorated, and the ability to close the glottis is re- 
tained, thus preserving the explosive quality of the 
cough, which renders the tube less apt to fill with mem- 
brane, or, if it should fill, assists in its almost certain 
expulsion. 
14. The inspired air is always warm and moist from 
its passage through the natural channels. 
15. Deep ulceration is not apt to occur, and the 
superficial ulceration is not of serious moment. 
16. Does not preclude subsequent tracheotomy. 
17. May be used to replace a tracheotomy canula in 
case of obstructing granulations or tissue in the larynx. 11 
INSTRUMENTS. 
The O’Dwyer tubes for children, under the age of 
puberty, were originally, and are still made of brass, 
heavily gold plated, six in a set, from to 2-f inches in 
length, each fitted with an obturator, attachable to the 
introducer. 
Plate No. II. 
In the same case with the tubes, Plate II, for use in 
connection with them, are the introducer, Plate II, No. i ; 
the mouth gag, Plate II, No. 2 ; the extractor, Plate II, 
No. 3, and the scale, Plate II, No. 4. In addition, there 
are now manufactured two other distinct sets of tubes, 
one set of ten, each tube being three inches in length, 
for use in stenosis of the larynx in adults. These tubes 
are of the same shape as the set for children, but of 
Correct set of croup-tubes. 12 
larger size. They may be made of brass, gold plated, or 
of hard rubber, either having some special advantage 
over the other. The third set is for use in children, for 
the removal of foreign bodies and loose membrane in the 
trachea and bronchi; seven tubes of the same length, 1-f- 
inches, but differing in size with the age of the patient. 
They are straight, cylindrical, and slightly decreased in 
size of calibre at the lower end, made of very thin 
German silver, with no retaining swell, as they are only 
intended for use for short periods of time, and are held 
in position by the pressure of the parts. 
Plate No. III. 
~ J. REYNDERS—CO. M 
Set of tubes for foreign bodies or loose membrane in trachea and bronchi. 
The introducer for the foreign body tubes is made 
upon the same principle as the one used with the 
children’s set. It has, however, a longer curve, and 
instead of two flanges to release the tube, it has a single 
flange behind, which runs along a groove in the head of 
the obturator. 
In the selection of a set of tubes it is necessary to take 
all possible precaution to have them correct in style, and 13 
of the latest and most approved pattern. A careful con- 
sideration of the following suggestions will be helpful : 
First. That the workmanship and material are of the 
first quality, and that there are no checks or rough 
points to encourage the accumulation of secretions. 
Plate No. IV. 
J. REYNDERS—CO. 
Cross-section of tubes, natural size, before and after being hammered on a 
mandrel. 
That a hole of the requisite size is first drilled through 
a solid rod of brass, which is then placed on a mandrel 
and hammered until the lumen of the tube anterio- 
posteriorly is about twice its lateral diameter, which is 
the shape least likely to produce pressure on the vocal 
chords. 
Second. That the head of the tube, which is made 
separately, is oval, correct in shape and size, and that the 
edges throughout are carefully rounded off 
and smooth, that they may not cut into the 
tissues. The eyelet for threading the guarding 
string is drilled just to the left of the ante- 
rior edge, and does not enter the lumen of the 
tube. 
Third. That the upper end of the tube is rounded off, 
and thrown backwards by removing near the head of the 
Plate 
No. V. 
Head of tube. 14 
tube a triangular section, with the base of the 
triangle at the posterior edge of the tube, 
then hammering the edges of the triangular 
space together and soldering them in that 
position. This throwing backwards of the 
upper end of the tube can be demonstrated by 
laying the anterior edge of the tube on a flat 
surface. It is for the purpose of removing 
pressure from the base of the epiglottis. 
Fourth. That the tube be constructed with 
a retaining swell, to belly-out laterally at the 
centre, and having the shape of a double 
wedge, which assists in maintaining its position 
in the larynx, and in preventing its expulsion 
during coughing. 
Fifth. That the lower end of the tube is 
very carefully rounded off and the sharp edges entirely 
removed, and that the anterior edge is thickened to 
prevent ulceration of the anterior wall of the 
trachea, from the up and down movement of 
the tube during deglutition. The probe point 
of the obturator must fit the tube so accurately 
that no edge is left to detach membrane during 
its insertion. 
The obturators, one for each tube, are made 
to screw on to the introducer, to accurately fit 
the tube at its head, and extend into it sufficiently to 
prevent its wabbling antero-posteriorly ; to be jointed in 
the centre of the shank to facilitate removal after the 
tube is in the larynx; to have the greatest diameter of 
the bulbous tip fit exactly at the inferior edge of the 
tube, thus presenting a perfect probe point ; to have the 
long diameter of the top exactly parallel with the 
handle of the introducer, to prevent difficulty in 
Plate 
No. VI. 
Tube in rough, 
after removal of 
wedge- shaped 
piece. 
Plate 
No. VII. 
Lower end of 
tube, showing 
the rounded and 
thickened ante- 
rior edge. 15 
releasing the tube. In case the instruments 
are much worn, it may be necessary to use a 
paper washer to make a perfect adjustment 
between the introducer and the obturator. 
The introducers, Plate II, No. I, are manu- 
factured in parts, easily detachable, which per- 
mits thorough disinfection and cleansing. The 
one for intubation has two flanges at the side, 
movable from the handle of the instrument, 
for releasing the tube ; the one for foreign 
bodies has a single flange behind. 
The extractor, Plate II, No. 3, is so con- 
structed that its duck-bill, when closed, is 
smooth, round and probe-pointed, to prevent 
injury to the softened, inflamed laryngeal 
tissues; the bill farthest from the operator is 
the fixed point continuous with the handle ; the movable 
bill opens towards the handle to facilitate the removal of 
the tube and prevent slipping; a set-screw is placed on 
-every instrument to prevent possible excessive opening 
and laceration of the parts during efforts at the removal 
of the tube. 
The mouth-gag, Plate II, No. 2. The most useful and 
best mouth-gag is the modification suggested by Dr. 
Denhard, of New York. It has been adopted and is 
recommended by Dr. O’Dwyer in consequence of there 
being no liability of its being displaced by the shoulder, 
if the patient is restless during the operation. 
The scale, Plate II, No. 4, is an arbitrary measure 
which indicates the size of the tube ordinarily required 
at a given age; the measurement of the tube is to be 
made entire from the distal to the proximal end. There 
are many faulty and poorly-constructed instruments and 
tubes on the market, and some useless and impractical 
.modifications. 
Plate1 
No. VIII. 
Obrtutaor. 16 
The importance of having instruments perfect in every 
detail cannot be overestimated. In order that a proper 
armamentarium may be secured, buy only from makers of 
repute. Many of the best manufacturers have adopted 
Plate No. IX. 
j. REYNDERS—C0% 
J. REYNDERS— C0% 
J. KKYNDEltS—CO. 
J. REYNDERS—CO. 
e/. REYNDERS—CO. 
J. REYNDERS—CO. 
J. R E YNDERS—CO. 
J. RE YNDERS— CO. 
J. REYNDERS—CO. 
Evolution of the tube. 
the plan of having the instruments approved by Dr. 
0’Dwyer himself. 
It is necessary to have more than one set of tubes, or 
the tube you require may be in use, or may accidentally 17 
pass into the stomach just at the critical moment and' 
the life of the patient be lost. 
Instruments should be kept perfectly clean, be properly 
disinfected after each case, and always kept in a state of 
perfect readiness for operation at short notice. There 
have been a considerable number of modifications of the 
O’Dwyer tubes. Most of the modified tubes are con- 
structed on some principle previously tried and 
abandoned by Dr. O’Dwyer. 
The tube in present use is undoubtedly best adapted 
for intubation and overcomes most of the objectionable 
features, urged against the operation. 
The evolution of the O’Dwyer tube is shown in the 
accompanying Plate No. IX. These tubes, with the 
exception of the first, a simple wire frame (used only on 
the cadaver,) have been successively used and abandoned 
by Dr. O’Dwyer. The last tube shown being the one at 
present in use. 
This plate and the others representing the details of 
the manufacture of the tubes are taken from an article 
by Dillon Brown, M. D., of New York.* This article 
gives a minute description of the process of manufacture 
and a complete table of the different measurements of 
each sized tube. 
An ingenious contrivance devised by Dr. Waxham, of 
Chicago, was a tube with an artificial epiglottis ; it did 
not, however, as was expected, entirely prevent the 
passage of fluids into the trachea, and seriously com- 
plicated the removal of the tube. It is believed to have 
been abandoned by Dr. Waxham who advocates the 
posture method of feeding. 
The necessity for the tube with jointed head, intro- 
*The construction of the O'Dwyer tubes Archives ot Pedeatrics, Philadelphia,. 
January 1891. 18 
duced by Dr. O’Dwyer, which was 
intended to enable the trained 
nurse to remove it quickly on the 
appearance of sudden dyspnoea, is 
very much lessened since the re- 
moval of the tube by the pressure 
method has been suggested by Dr. 
Cheatham, of Louisville. 
INTRODUCTION. 
In some of the cases intubated, 
the operation is perfectly easy to 
accomplish; its difficulty and the 
necessity for experience, judgment 
and skill are more apparent when 
some of the accidents occur, and the life of the 
patient is temporarily jeopardized. Force is never justi- 
fiable in introducing the tube, except when a positive 
diagnosis of extreme subglottic infiltration of the mucous 
membrane is made, in such cases it is sometimes 
necessary to use a smaller tube than indicated by the 
age of the patient and to use considerable force in plac- 
ing it in position. 
It is extremely important that every operator should 
have made especial preparation to perform intubation by 
its careful study and practice on the cadaver, or as Dr. 
O’Dwyer suggests, opportunity for intubation post mor- 
tem being unattainable, to make use of the larynx of one 
of the smaller animals placed in the neck of a bottle, and 
the tube repeatedly passed, entirely by the sense of 
touch, unless an obstruction be encountered, when a 
careful note of the obstruction should be made and the 
procedure repeated. The subsequent progress of the 
•case often depends upon the rapidity, delicacy, and skill 
Plate No. X. 
J. REYNDETlS—CO. 
Tube with jointed head, 
which enables a trained nurse 
to remove it quickly in case 
of emergency. 19 
used in performing the operation, several abortive efforts 
at introduction of the tube are much better for the 
patient than one prolonged, exhausting trial, the actual 
introduction of the tube should not require more than 
from five to ten seconds. 
The operator and two assistants are necessary in per- 
forming intubation. Untrained assistants, if fairly intel- 
ligent may be relied upon ; one assistant holds the patient 
seated firmly on the lap, with the head placed high up 
on the left shoulder, and the hands held down at the 
side, or the body and arms wrapped about with a sheet 
or towel to prevent interference with the operator. The 
hands should not be loosened until the string has been 
removed ; the other assistant stands behind grasping the 
head of the child and slightly elevating the chin. The 
head must not be thrown too far back, as the tube may 
be arrested by coming in contact with the anterior wall 
of the larynx or trachea. The operator stands imme- 
diately in front of the patient and first introduces the 
mouth gag, gently and not too rapidly, well back in the 
mouth between the teeth on the left side ; it is retained 
by the assistant, or the pressure of the jaws upon it. If 
the gag is not used, the operator’s finger must be pro- 
tected by a strip of adhesive plaster or a metal ring ; if 
the patient has no bicuspid teeth the use of the gag or 
plaster is unnecessary. v 
If the symptoms indicate the presence of loose mem- 
brane in the trachea, introduce a small sized tube for the 
age, and thus favor its expulsion by coughing, in case it 
should become occluded. The introducer is lightly held 
in the right hand with the obturator attached, and the 
tube on the obturator threaded with a strong piece of 
braided, well-waxed thread, eighteen inches in length, 
and hooked over the little finger to prevent its passing 
into the stomach in case of accident. 20 
The index finger of the left hand is passed into the 
pharynx, drawing forward the epiglottis, moving it 
slightly to the right and fixing it against the base of the 
tongue. The tube is then passed gently and quickly 
into the larynx, the finger' being used as a guide. 
The handle of the introducer should be held lightly 
between the fingers and thumb exactly in the median 
line and well down towards the chest until the apex of 
the tube reaches the larynx, when the curve is* changed 
by rapidly raising the handle, the tube is then passed into 
the larynx, and well down into position before it is 
released ; the finger should be placed on the head of the 
tube to prevent its coming out with the obturator as it is 
withdrawn. 
If the tube passes into the oesophagus, and this is 
recognized before the obturator is withdrawn, the tube 
should be immediately removed, as the position cannot 
be rectified without performing the operation over again 
from the beginning. The string may be left attached to 
the tube until the irritative cough has stopped and some 
of the mucus and detrus is expelled; then one strand 
is cut as near to the tube as possible, the index finger is 
placed on the head of the tube and the string gently 
withdrawn. It is not generally necessary to use the gag 
in removing the string, as the patient if old enough, is 
willing to get rid of it. The string may be left continu- 
ously attached to the tube, and tied around the ear or 
fastened to the face with a strip of adhesive plaster. In 
patients at the age of puberty it is well to retain the 
string continuously, in consequence of the rapid increase 
in the size of the larynx at that age. 
The rasping breath immediately following the with- 
drawal of the obturator, the full metallic cough accom- 
panying the operation, and produced by swallowing 21 
liquids, with continued comfortable breathing, indicate 
that the tube is properly within the larynx. 
In case the tube should be coughed up or removed 
from the larynx, the time for reintubation would be indi- 
cated by the recurrence of dyspnoea and absence of the 
respiratory sounds over the lower lobes of the lungs. 
REMOVAL. 
To withdraw the tube with the extractor, follow each 
step taken in the introduction, when placing the index 
finger of the left hand behind the epiglottis, locate the 
head of the tube and pushing the finger to the right of 
the patient to uncover its orifice, guide the tip of the 
extractor into it. Never undertake to use the extractor 
unless the presence of the tube can be demonstrated by 
the touch of the finger, as its presence in the larynx is 
doubtful if it cannot be felt. The extractor is held 
lightly in the right hand between the thumb and fingers ; 
the thumb is not placed on the lever until the tip of the 
instrument has entered the lumen of the tube, when it 
is moved forward to the lever and steady pressure made 
until the tube is out of the mouth. 
It is important that the thumb is not placed on the 
lever until the proper time, as the object of the opera- 
tion may be defeated by unconscious pressure spreading 
the bills so that they cannot enter the tube, or some 
injury may be done to the part£ by catching folds oi 
mucus membrane or lacerating the softened and 
inflamed tisssues. 
It is sometimes difficult to succeed in entering the 
tube with the extractor, but cool, careful and deliberate 
efforts generally result in its successful removal ; the use 
of an anaesthetic has been suggested when the patient is 
very difficult to manage, but it is usually unnecessary. 22 
Removal of the tube by external pressure without the 
use of the extractor has been recently advocated by 
Dr. Cheatham, of Louisville, who writes regarding this 
method : “ It is by far the easiest method of removing 
the tube and is generally successful, although in my last 
case it failed entirely, and I was obliged to resort to the 
extractor. The patient was very fractious and the neck 
so short that I did not seem to get below the tube to 
press it upwards; there was also considerable oedema of 
the parts and the tube itself was full large for the case. 
The procedure is very simple—with the left hand in the 
mouth and the right thumb on the trachea, push upwards 
and backwards ; when well out of the larynx throw the 
patient’s head forward and the tube will fall to the floor.” 
The left index finger in the pharynx must be hooked 
behind the tube as it passes out to prevent its passage 
into the posterior nares. Removal of the tube by an 
electro magnet has been suggested but has not as yet 
been reported successful. 
The time for removal of the tube and the amount of 
tolerance of the laryngeal tissues vary with different 
patients and the severity of the disease. The presence 
of the tube may result in a long period of comfort and 
relief of dyspnoea, even when it is ejected after having 
been within the larynx for a very short period of time. 
If dyspnoea does not occur in half an hour after ejection 
or removal of the tube, it is not apt to occur for several 
hours and will come on slowly. When dyspnoea returns 
after having been primarily relieved, remove the tube 
regardless of what may seem to be the cause; it may be 
removed and re-introduced at any time, but should not 
be disturbed when the patient is comfortable. There is 
no advantage in removing the tube to permit feeding, as 
the patient can feed no better with the tube removed 23 
until the parts have accustomed themselves to the 
change ; the tube should be retained while the mem- 
branous deposit remains in the pharynx. In croup the 
tube may be retained from a few hours to twelve or 
fifteen days or more ; if the patient’s condition indicates 
it, the tube should be removed in from four to six days 
on trial, and re-introduced again if the dyspnoea returns; 
this removal is apt to be of advantage to the parts in 
loosening membrane, even though re-introduction sub- 
sequently becomes necessary. Dr. O’Dwyer has reported 
a case of specific stenosis of the larynx, in which the 
tube was worn for ten months and four days and the 
patient never seen or treated during that time. 
Loose secretions in the tube that can be blown out or 
washed out by a stream of water do not cause serious 
obstruction. If the tube become occluded by loose 
membrane, it is almost certainly expelled, as the ability 
to inspire air is still present, the membrane acting as a 
valve, stops expiration, making the internal pressure 
greater at each breath ; if the tube is not expelled it must 
be immediately removed in some manner, or death fol- 
lows at once. Placing the patient in the dorsal position, 
with the hand pressed firmly on the abdomen to prevent 
descent of the diaphragm, and striking the chest forcibly 
with the open hand, is suggested as a means of assisting 
the explosive action in such cases. 
ACCIDENTS. 
Accidents of a more or less moment occur with nearly 
every operation ; they may be tabulated as avoidable 
and unavoidable; the avoidable accidents maybe over- 
come by a thorough knowledge of the technique of the 
operation. 24 
Avoidable Accidents.— 
1. False passage made in attempts at introduction ; use 
no force and hold the instruments lightly. 
2. Injuries to the parts in efforts at removal; careful, 
steady operating will not result in material injury. 
3. Passing the tube into the oesophagus; may happen, 
but it can be easily removed by the string. 
4. Asphyxia from slozv accumulations of secretions in 
the tube ; use the steam atomizer constantly, and remove 
the tube if necessary. 
5. Asphyxia from prolonged efforts at introduction ; 
make several efforts of short duration rather than one 
continuous and exhausting one. 
6. Asphyxia from swelling of membrane over the tube's 
head, fixing it, and feeling as though the tube had passed 
into the trachea; remove tube and introduce one with 
larger head. 
7. Slipping of tube into trachea ; will not occur and is 
not possible when a proper sized tube is used carefully. 
The subglottic construction of the larynx prevents the 
tube from passing below the ventricular bands, unless 
the circoid cartilage is split. 
8. Spasm of the glottis immediately following removal 
of the tube as a result of irritation of inspired air; may 
be prevented by the administration of an opiate shortly 
before removal. 
9. Catching the thread in the eyelet hole of the tube, 
may be prevented by using braided linen or silk thread 
well waxed. 
10. Cutting the parts in the removal of the string, may 
be prevented by cutting the string as close as possible to 
the tube and withdrawing slowly. 
11. Lacerations made by the gag or finger during the 
operation, will be immaterial if the patient is carefully 
handled. 25 
Unavoidable Accidents.— 
1. The presence of partly adherent membrane. The 
removal of such membrane is a difficult problem to solve, 
many forceps have been devised for this purpose. Dr. 
O’Dwyer has introduced the set of foreign body tubes 
to be used in such cases ; the solution which is still 
in doubt, consists in the means of detaching the mem- 
brane that it may be expelled or removed. 
2. Pushing down pseudo membrane before the tube. The 
membrane will be less apt to be pushed down in front of 
the tube, if it is placed well in position before removal 
■of the obturator, and held in position during its removal, 
as the tube if drawn partially out may with its edge 
detach membrane, in being pushed back into the larynx. 
3. Fatal obstruction from membrane in or below the 
tube. The tube is generally coughed up if obstructed ; 
it must, however, be removed in some manner, or death 
will ensue. Always, if practical, leave the string attached 
in cases of this character. It is well to undertake to rid 
the patient of the membrane, either by introducing and 
withdrawing the tube, using a larger tube, or resorting 
to the foreign body tubes. If the patient is young there 
is danger of pulling at the string or of chewing it apart, 
the latter may be overcome if there is room, by passing 
the thread between the two double teeth. It may be 
necessary to use a small tube in order that it may be 
readily expelled by coughing in case of obstruction. 
4. Partial obstruction from aspiration of food or vom- 
ited matter into the bronchi. It is very rare, if it occur 
at all. 
5. Coughing out the tube and swalloiving it; has 
occurred, and the absence of the tube was not dis- 
covered until too late or until harmful efforts at its 
removal with the extractor has been made. 26 
6. Coughing out the tube or expulsion during vomiting. 
This accident is not serious unless paralysis is present. 
The dyspnoea does not often return until the operator, 
who should be immediately summoned, has had time to 
return and re-introduce the tube, which should be one 
with a greater retaining swell than the tube expelled. 
DANGERS. 
In any pperation there are dangers of greater or less 
moment to encounter. These dangers may or may not 
be susceptible of prevention. The dangers attending 
intubation over which the operator has no absolute con- 
trol, are— 
1. The unavoidable accidents. 
2. Shock of the operation, which is very slight if it is 
rapidly and skilfully performed. 
3. Septic air passing into the lungs on inspiration. 
4. Food and liquids entering the bronchi. Of this dan- 
ger Dr. W. D. Northrup, pathologist to the New York 
Foundling Asylum reports in substance as follows: 
“ There has been no evidence of the presence of food in 
the finer bronchi or alveoli found in the one hundred and 
seven autopsies held at the asylum, and no pneumonia 
was present which could be fairly called Schluck pneumo- 
nia, aspiration, or food pneumonia, or nothing was found 
corresponding to the recent description reported by Orth, 
of Gottingen. Pneumonia was present, however, to some 
extent as demonstrated by obvious signs of consolida- 
tion, or the microscopic findings in about seventy-five 
per cent, of all the autopsies.” 
5. Ulceration from pressure of the tube on the trachea 
is not frequently deep enough to be of moment, but in 
patients who have previously suffered from exhausting 27 
disease, ulceration may occur and easily amount to a 
complication, even when the tube is only worn the usual 
number of days. 
6. CEdema from pulmonary or glottic infection, may 
result from the severity of the disease, or from local 
application of medicants applied on the tube; the tube 
itself diminishes the oedema by pressure on the parts. 
7. Hemorrhage from rupture of tracheal blood vessel. 
8. Paralysis, septic, of the muscles of deglutition; 
necessitating feeding by the stomach tube or per rectum. 
The following reasons for operating for tracheotomy 
after intubation has failed, were tabulated by I. H. 
Hance, M.D., New York : 
1. Intolerance of the larynx for retention of the tube. 
2. Inability to administer a proper amount of nour- 
ishment. 
3. Dislodgment of membrane, during the operation. 
4. Frequent plugging of the tube with thick mucus 
and shreds of membrane. 
5. Passing the tube below cords with inability to 
extract. 
6. False passage in which event tracheotomy must 
be performed immediately. 
TREATMENT. 
Intubation is only a temporary expedient to relieve a 
symptom. The eventual recovery of the patient must 
depend upon the ingestion and assimilation of a sufficient 
quantity of nourishing food and a proper course of med- 
ical treatment. 
The medicine best adapted, and most generally used, 
is the bichloride of mercury, administered in large doses, 
grains one-sixtieth to grains one forty-eighth every hour 28 
in a wineglass of water, from the inception of the dis- 
ease, and carried to the point of salivation unless symp- 
toms appear which counter-indicate its use. 
The mild chloride of mercury is also extensively used, 
in small doses, grains one-half, frequently repeated ; it 
may be placed dry upon the tongue, one powder every 
hour or two, washed down with small pieces of ice. Dr. 
J. Lewis Smith in a paper recently read before the 
American Medical Association, has advocated the use of 
the mild chloride by incineration within a tent arranged 
over the patient’s bed. The treatment was used in the 
New York Foundling Asylum with marked benefit to 
the patient, but resulted unfortunately in the salivation 
of two of the nurses in attendance. 
Tincture of the chloride of iron and chlorate of potash 
is still advocated by many practitioners. Milk and whis- 
key are extremely important in all cases if well borne. 
Antipyretics—any of the medicines of this class may be 
used with good effect, if indicated by elevation of the 
temperature. 
Brandy, camphor, caffine, aether, aconite and belladona, 
or any of the reliable cardiac stimulants may be used if 
the pulse shows heart failure. 
Medicines may be given in such quantities as the 
patient is able to swallow and retain ; frequent small 
doses properly ingested, will be preferable to large doses 
not well borne. 
Medicines in powder may be given dry upon the 
tongue, accompanied by small pieces of ice to dissolve 
and carry them down. 
Cough may be induced, in case it is necessary to carry 
away mucus and shreds of membrane, by liquid feed- 
ing or by the use of lime water. For several hours after 
the operation it is better to allow the patient only small 29 
pieces of ice dipped out of brandy or wine, until the 
larynx has established its tolerance of the tube, when the 
medication may be commenced. A moist spray should 
be constantly passing through the room to prevent hard- 
ening of the mucus. Many practitioners favor the addi- 
tion of some medicant to the spray. 
In syphilitic stenonis it may be necessary to medicate 
the tube, or to increase its size at the retaining swell, or 
to add a retaining swell to a straight tube. This may be 
accomplished by successive coatings of gelatine dusted 
over with powdered alum, while still moist until the 
desired degree of thickness is obtained. A tube thus 
prepared has the power of absorbing moisture and 
increasing in size, thus assisting in the gradual dilata- 
tion of the parts, and also acting as an astringent ; the 
rapidity of the absorption and consequent dilatation of 
such a tube may be controlled by the application of one 
or more coats of collodion. 
FEEDING. 
The difficulty of administering a sufficient amount of 
nourishment after intubation has been one of the prin- 
cipal objections to the operation ; this objection has been 
practically overcome by the posture method of feeding 
suggested by Dr. W. E. Casselberry, of Chicago. This 
method of feeding is very simple, and is not followed as 
was a.t first feared, by any cerebral congestion or special 
discomfort. The patient is placed in the dorsal position 
with body on an incline plane, the head downward, the 
exact position varying in different cases, the angle being 
from twenty to forty-five degrees. 
The patient is held on its back in the arms of the 
nurse, the legs elevated and the head hanging over the 
arm. The feeding may be from a feeding bottle, through 30 
a glass tube or from a spoon. The only difficulty is 
encountered when the patient again resumes the upright 
position ; that portion of the food which has gravitated into 
the pharynx and post nares, then passes into the larynx 
and causes coughing. This can be overcome after the 
patient has become accustomed to the method, by hav- 
ing three or four efforts at deglutition made before allow- 
ing the child to rise, thus forcing the food into the 
stomach. The patient may be inclined in this position 
for a minute or more, giving ample time to ingest suffi- 
cient food, without serious inconvenience. 
The feeding may be also accomplished by placing the 
patient on the abdomen with the head hanging forward, 
a method previously suggested in cases having difficulty 
in deglutition from tubercular ulceration of the epiglottis. 
This procedure is not as successful as the dorsal posture. 
Feeding with a stomach tube passed through the 
mouth or nares is difficult to accomplish after the first 
trial, and if not accomplished in a short space of time 
results in vomiting. Feeding per rectum may be resorted 
to, if called for by the condition of the patient preventing 
sufficient nourishment being taken by the stomach. 
Feeding by inunctions of oil has been suggested as 
possibly of value in cases demanding more nourishment 
than can be given in any other manner. 
For several hours after intubation allow nothing but 
small pieces of ice dipped in brandy or wine to be used. 
The cough produced by the small quantity of fluid which 
passes into the larynx is beneficial in causing dislodging 
and expelling of mucus and shreds of membrane. Pain 
and cough and difficulty of deglutition are present at 
times, but decreases as the larynx becomes accustomed 
to the tube and the patient learns to swallow. 
The patient may be able to swallow more readily after 31 
intubation in consequence of the relief of the dyspnoea, 
not having been able to take time while it was present ; 
the ability improves with the continued presence of the 
tube. 
It is well for the physician to instruct the nurse how to 
feed the child, and after careful observation to determine 
the manner, quantity and frequency. Whatever method 
of feeding is used, food may be given by the teaspoonful 
or even from a medicine dropper ten or twenty drops at 
a time. Solids and semi-solids may be swallowed with- 
out much difficulty ; but fluids generally provoke cough. 
It is best that the food should be taken in small quan- 
tities frequently repeated rather than too much at one 
effort, lest the patient become discouraged by the violent 
coughing produced. Dr. O’Dwyer, however, recom- 
mends taking four to five swallows at once, then cough- 
ing. In some cases patients will not take the nourish- 
ment suggested, but desire some particular variety of 
food. If the wish is gratified, and the power of selection 
given, the patient may take an ample quantity of nour- 
ishment of the kind selected. 
DIETARY. 
Thick soup, farinaceous foods with milk, chocolate, 
cream, eggs, soft boiled or scrambled, frozen or con- 
densed milk, ice cream, jellies, custards and whey. 
Solids chopped very fine and moistened with small 
pieces of ice, oatmeal, rice or barley cooked and strained, 
served hot or cold with cream or raw eggs and milk, 
sweetened to taste. 
FOOD PNEUMONIA. 
There is little or no evidence to indicate that food 
plays any part in the production of the pneumonia 
which so frequently complicates croup, being present 32 
to a greater or less extent in nearly all the fatal cases; in 
many of the cases it is found only in a slight degree, not 
sufficient to have caused death. There have been reports 
in other countries of autopsies demonstrating the presence 
of food in the alveoli, but in the autopsies made in this 
country no evidence of food having been aspirated into 
the finer bronchi or air cells has been found in any of the 
reported cases upon which autopsies have been held. 
Vomited matter could hardly be a factor in the produc- 
tion of pneumonia, even were it proved to have been 
produced by aspiration, as it is not apt to enter the tube, 
and there is no resistance to its passage outward, as 
offered in the ingestion food. 
PROGNOSIS. 
The prognosis without operation in diphtheritic or 
fibrinous croup is very unfavorable; the disease results in 
from ninety to ninety-five per cent, of deaths. The latest 
statistics collected and the compilation of cases intubated 
indicate from sixty to seventy per cent, of deaths, or 
from twenty-seven to thirty per cent, of recoveries; the 
percentage of the recoveries is increased as the technique 
of the operation is more generally understood. 
Important factors in the prognosis are— 
1. The age of the patient. 
2. Time of origin. 
3. Nature and extent of the membrane, the prognosis 
being better when the membrane is not present in the 
pharynx, having been present and disappeared. 
4. The presence of complications. 
5. The severity and heighth of the epidemic; during 
a fatal epidemic of diphtheria, and at the heighth of the 
epidemic, the cases are proportionately more fatal from 
septic systemic infection. 33 
6. From nephritis. 
7. From pneumonia. 
8. From greater tendency to invade the bronchial 
tubes. 
In the early or declining period of an epidemic the 
fatality is very much lessened. The intubations reported 
with this paper, eighteen in number, with only three 
recoveries, were all performed during the heighth of the 
very fatal epidemic of diphtheria which occurred at 
Paterson, N. ]., in the winter of 1890 and 1891. This 
epidemic was attended by an unusually large percentage 
of deaths, as shown in the following table furnished by 
J. L. Leal, M. D., Health Officer. The intubations were 
all made between July, 1890, and February, 1891, when, 
in seven months 259 cases of diphtheria were reported 
with 103 deaths. 
No. of Cases of Diphtheria and Deaths Reported during 
the Years 1890-1891. 
Month. 
No. of Cases. 
Diphtheria. 
No. of Deaths. 
Croup. 
No. of Deaths. 
1890. 
January 
4 
During the time 
F ebruary 
3 
O 
of intubation 
March 
I 
of cases here- 
April 
4 
in reported. 
May 
4 
J une 
10 
4 
July 
13 
5 
August 
19 
5 
1 
September .... 
33 
14 
3 
October 
59 
17 
3 
November .... 
4° 
16 
2 
December .... 
52 
16 
3 
Total 
271 
90 
1891. 
January 
.... 43 
18 
February 
21 
2 
March 
21 
12 
7 
April 
33 
15 34 
Many of the deaths due to croup are reported as 
caused by diphtheria, no special clinical note of the croup 
being made. This neglect on the part of the physician 
in reporting the cases nullifies the comparative value of 
the statistics. 
The prognosis is worse under the following conditions: 
1. When the patient is young. 
2. When no membrane has yet invaded the fauces 
or has only recently appeared. 
3. When the septic poisoning is very well marked. 
4. When complicating conditions are present, fibrin- 
ous bronchitis, extending from the seat of the disease ; 
nephritis, which is likely if present to be in proportion 
to the severity of the disease, with scanty secretion of 
urine containing large quantities of albumen and blood ; 
pneumonia which may develop at any time, but generally 
comes on in the later stages. 
5. When there is loss of appetite and disgust of food, 
complicating conditions are almost always present. 
6. When high temperature comes on the second or 
third day after intubation. 
7. When an increase in the respirations occurs, they 
may run up from forty to one hundred per minute, 
according to the age of the patient; such an increase 
would indicate diminution in the calibre of the tube or 
the presence of pneumonia. 
8. When the disease comes on very rapidly and 
violently with excessive membranous deposits of dark 
color and foul odor with great tumefaction of the cervi- 
cal glands and softening of the tissues in the pharynx 
and larynx. 
9. When the stenosis comes on rapidly and the 
laryngeal symptoms have not been present for a con- 
siderable time before intubation was necessary. 35 
10. When the epidemic is at its heighth the prog- 
nosis is more grave than it would be earlier, or later 
when the epidemic was on the decline. 
11. When severe asphyxia, long continued before the 
operation could be performed, has been present pro- 
ducing a rarefaction of the air in the lungs with subse- 
quent exhaustion, more or less ateletasis, collapse of the 
lung tissue, dilitation of the blood vessels, disturbance 
of the pulmonary circulation and resulting carbonic acid 
poisoning. 
The eighteen cases here tabulated would have un- 
doubtedly resulted much more favorably had the opera- 
tions not been performed during so severe an epidemic 
of diphtheria, in which the sepsis was so great and the 
complications so frequent as to have resulted in about 
forty per cent, of deaths in all the diphtheritic cases 
reported to the Board of Health. The tube was a 
source of relief and comfort in nearly every case op- 
erated, was well borne, and did not present in any case 
an insurmountable barrier to the administration of con- 
siderable quantities of nourishment. In addition to the 
three cases which recovered, at least three more should 
have resulted favorably had the disease been attended 
only by its customary malignancy. Even though the 
percentage of recoveries should be smaller than it usually 
is, the comparative comfort of the patient and the relief 
of the dyspnoea would recommend intubation to the 
favorable consideration of medical men in general. 
CASES. 36 
DATE. 
6 
z 
IN THE 
PRACTICE OF 
SEX. 
AGE. 
DURATION 
OF 
LARYNGEAL 
SYMPTOMS. 
DURATION 
OF DIPH- 
THERIA. 
CAUSE 
OF DEATH. 
COMPLICA- 
TIONS. 
RESULT. 
July, 1890 
I 
Dr. Salatino. 
Female. 
18 months. 
24 hours. 
5 days. 
Sepsis. 
Carbonic acid 
poisoning. 
Died 5 hours after intuba- 
tion. 
Aug., 1890 
2 
Dr. J. L. Leal. 
Male. 
2 years. 
8 hours. 
3 days. 
Extension to 
Bronchi. 
Tube coughed 
up into nares. 
Died 12 hours after intu- 
bation. 
Aug., 1890 
Dr. J. W. Smith. 
Female. 
12 years. 
12 hours. 
1 week. 
Recovery; tube remained 
2% days after intuba- 
tion. 
Sept., 1890 
4 
Dr. T. J. Kane. 
Female. 
2 years. 
18 hours. 
4 days. 
Meningitis. 
Convulsions. 
Died 4 hours after intuba- 
tion. 
Sept., 1890 
5 
Dr. J. S. Bibby. 
Male. 
5 years. 
36 hours. 
2 weeks. 
Extension to 
Bronchi. 
Died 33 hours after intu- 
bation. 
Sept., 1890 
6 
Dr. B. C. Magennis. 
Male. 
4 years. 
3 days. 
10 days. 
Recovery; coughed up 
tube 6 days after intu- 
bation. 
Sept., 1890 
7 
Dr. Doty. 
Male. 
5 years. 
24 hours. 
6 days. 
Extension to 
Bronchi. 
Sudden 
heart failure. 
Died 12 hours after intu- 
bation. 
Sept., 1890 
8 
Dr. P. A. Harris. 
Female. 
7 years. 
18 hours. 
7 days. 
Pneumonia. 
Died S days after intuba- 
tion. 
Sept., 1890 
9 
Dr. Wm. Blundell. 
Female. 
9 years. 
24 hours. 
4 days. 
Sepsis. 
Gastritis. 
Died 3 days after intuba- 
tion. 
Oct., 1890 
IO 
Dr. C. P. Townsend. 
Female. 
5 years. 
26 hours. 
S days. 
Sepsis. 
Carbonic acid 
poisoning. 
Died 27 hours after intu- 
bation. 37 
DATE. 
6 
z 
IN THE 
PRACTICE OF 
SEX. 
AGE. 
DURATION 
OF 
LARYNGEAL 
SYMPTOMS. 
DURATION 
OF DIPH- 
THERIA. 
CAUSE 
OF DEATH. 
COMPLICA- 
TIONS. 
RESULT. 
Oct., 
1890 
II 
Dr. Wm. Blundell. 
Female. 
4 years. 
14 hours. 
4 days. 
Heart failure. 
Died 48 hours after intu- 
bation. 
Nov., 
Dec., 
1890 
1890 
12 
13 
Dr. Henry Parke. 
Operated by 
Dr. Parke. 
Female. 
Female. 
8 years. 
5 years. 
12 hours. 
10 hours. 
4 days. 
4 days. 
Exhaustion. 
Died 2y2 days after intu- 
bation. 
Recovery ; tube coughed 
out 6 days after intuba- 
tion. 
Dec., 
1890 
14 
Dr. P. A. Harris. 
Female. 
6 years. 
8 hours. 
12 days. 
Dyspnoea, the 
tube having 
been removed. 
Scarlet fever. 
Died; the tube did not 
relieve her. 
Dec., 
1890 
IS 
Dr. T. J. Kane. 
Female. 
4 years. 
7 hours . 
2 days. 
Convulsions. 
Bronchitis. 
Died 2 days after intuba- 
tion. 
Dec., 
1890 
16 
Dr. Wm. Blundell. 
Female. 
2% years. 
9 hours. 
8 days. 
Exhaustion. 
Died 1 week after intuba- 
tion. 
Jan., 
1891 
17 
Dr. Wm. Blundell. 
Male. 
5 years. 
28 hours. 
3 days. 
Sepsis. 
Gastritis. 
Died 10 days after intu- 
bation. 
Jan., 
1891 
18 
Dr. Wm. Blundell. 
Female. 
7 years. 
3 hours. 
8 days. 
Asphyxia. 
Died before the tube 
could be introduced. 38 
CONCLUSIONS. 
Intubation to be successfully performed depends upon— 
1. The use of properly constructed instruments. 
2. The skill and judgment of the operator. 
4. The delicacy of the operation. 
4. The thorough and complete knowledge of the re- 
quisite medical treatment. 
5. The proper feeding and care. 
6. The variety of the disease. 
7. The severity and period of the epidemic. 
8. The extent and number of the complications. 
9. The careful examination of the patient at frequent 
intervals, and preparations to combat complications, or 
obstruction of the tube. 
Intubation may be performed quickly under almost 
any circumstances in which tracheotomy is desirable, and 
also many times when tracheotomy is undesirable or 
impossible. The severity of the disease, the age and 
condition of the patient, the complications, the sur- 
roundings, the cause of the dyspnoea, no matter what 
the extent, do not militate against the operation. .It 
may be performed early or late in the disease, and should 
be performed in all cases, even when apparently hopeless, 
to give comfort to the patient by preventing asphyxia, 
and give the possible chance of recovery. 
The posture method of feeding has relieved the opera- 
tion of one of the most objectionable features. 
The pressure method of removal of the tube has 
relieved the operation of its most difficult procedure. 
The presence of the tube in the larynx must be 
demonstrated by the sense of touch before the extractor 
is used. 
The tube must be removed at once if not expelled on 39 
the onset of sudden dyspnoea, and should be removed on 
trial if dyspnoea return after having been relieved. 
The percentage of recoveries has increased as the 
operation grows older and the operators more skillful. 
No evidence of the production of pneumonia by the 
aspiration of food has been noted in autopsies made in 
this country. 
Tracheotomy should be performed when intubation 
fails. It is desirable for every intubator to have at hand 
the instrument for trachotomy in case one of the un- 
avoidable accidents should necessitate the operation. 
REFERENCE. 
Dr. O’Dwyer, Intubation in Croup, William Wood & Co., 
1889. 
Dr. Dillon Brown, Construction of O’Dwyer tubes 
Archives Pedeatrics, January, 1891. Reprint. 
Drs. Jacobi, O’Dwyer, Huber, Brown, Northrup, Caille, 
Hance, Intubation of Larynx, Medical Record, N. Y., 
June 18th, 25th; July 23d, 1887. Reprint. 
Dr. Dillon Brown, The New York Medical Journal, 
March 9th, 1889. Reprint. 
Dr. O’Dwyer, The New York Medical Journal, Janu- 
uary 14th, 1888. Reprint. 
Dr. O’Dwyer, The New York Medical Journal, March 
10th, 1888. Reprint. 
Dr. O’Dwyer, Transactions Philadelphia County Medical 
Society, May 23d, 1888. Reprint. 
Dr. Casselberry, The Chicago Medical Journal and Ex- 
aminer, October 1888. Reprint. 
Dr. Casselberry, The Journal of, the American Medical 
Association, Vol. 13, August 24th, 1889. 
Dr. Waxham, Intubation of the Larynx, Chicago, 1888. 40 
Dr. Lennox Browne, H. C. Lee, Philadelphia, Pa., 1890. 
Dr. T. Stern, Trans. International Medical Congress, 
1887. 
Dr. Dillon Brown, Trans. Ninth International Medical 
Congress, Vol. 3. 
Dr. Montgomery, The Medical News, March 5th, 1887, 
Vol. 50, No. 10. 
Dr. Eichberg, Lancet and Clinic, Cincinnati, Vol. 18, 
Nos. 4 and 11. 
Dr. Mudel, Weekly Medical Review, St. Louis, Vol. 15, 
No. 3, January 15th, 1880. 
Dr. Tipton, The Medical Record, N. Y., Vol. 31, p. 608, 
1887. 
Dr. Dillon Brown, The Medical Record, N. Y., Vol. 29, 
p. 410, 1886. 
Dr. Northrup, The Medical Record, N. Y., Vol. 30, 
p. 487, 1886. 
Dr. Bates, The Medical Record, N. Y., Vol. 30, p. 683, 
1886. 
Dr. Northrup, The Medical Record, N. Y., Vol. 30, 
p. 645, 1886. 
Dr. Mackenzie, British Medical Journal, May 24th, 1890. 
Dr. Bell, Journal of the American Medical Asso., August 
30th, 1890. 
Dr. Staverley, The Lancet, Vol. 2, 1889. 
Dr. Lester, The Medical Record, N. Y., Vol. 38, p. 232, 
1890. 
Dr. Waxham, North American Practitioner. 
Dr. Waxham, Transactions Chicago Medical Society, 
1885.