WATION OF THE LARYNX IN PRIVATE 
PRACTICE. 
Results in Seventy-Eight Cases. 
BY 
CHARLES M. WHITNEY, M. D. 
Reprinted from the Boston Medical and Surgical Journal 
of October 5, 1893. 
BOSTON: 
DAMRELL & UPHAM, Publishers, 
283 Wathington Street. 
1893. INTUBATION OF THE LARYNX IN PRIVATE 
PRACTICE: RESULTS IN SEVENTY-EIGHT 
CASES.1 
BY CHARLES M. WHITNEY, M.D. 
During the seven years that intubation has been 
before the medical profession, evidence has been slowly 
accumulating as to its value in the treatment of mem- 
branous obstruction in the larynx. It was but natural 
that an operation of such apparent simplicity and free- 
dom from danger should be received with enthusiasm 
as a substitute for the older and severer operation of 
tracheotomy. 
The experience of many observers in different parts 
of the world has placed us in a position to-day to calmly 
judge of its merits as an operative procedure. 
The frequency and fatality of laryngeal obstruction 
in children is so great that a clear understanding of the 
elements which guide us in a selection of one or the 
other operation is of the greatest consequence. 
The majority of the reported cases of this operation 
have been performed in the large metropolitan hospi- 
tals, where the cases could be watched with the great- 
est care and where careful nursing was available. 
While this is of value it also follows that the children 
are usually taken to the hospital only after every 
method has been exhausted to expel the membrane 
and when suffocation is imminent. 
The resulting weakened condition materially affects 
the outcome of either operation. Where one can watch 
the child from the onset of the symptoms, an earlier 
operation is possible, and the strength can be saved to 
fight the disease. 
1 Read before the Surgical Section of the Suffolk District Medical 
Society, April 5, 1893. 2 
It is in this class of cases that I desire to present 
the result of five years' experience in the performance 
of laryngeal intubation. 
Every practitioner of large experience has met with 
cases where a child suffering with membrane in the 
larynx, was growing steadily worse, and where the 
parents would not permit it to be removed to a hos- 
pital where an intelligent selection of one or the other 
method could be made, nor would they submit it to the 
cutting operation. In this class of cases, there was 
nothing for the physician to do but to watch the child 
slowly suffocate, until the originality and patient inves- 
tigation of Dr. O'Dwyer placed at his disposal a 
method of relief. 
It is here that intubation occupies a field peculiarly 
its own and no comparative statistical tables can show 
the number of lives which have been saved by it. My 
own experience has fully substantiated this statement. 
Not the slightest objection has ever been made to 
the operation or to a re-intubation when the tube has 
been coughed out. 
A case illustrating this fact came to my notice some 
three years ago through the kindness of Dr. Record, of 
Wollaston. A child of three years was attacked by 
diphtheria and rapidly developed symptoms of laryn- 
geal obstruction. An operative relief was recom- 
mended and a surgeon was summoned to perform the 
operation. At the last moment the mother refused to 
permit the operation. As no tubes were available I 
was summoned to do an intubation. The operation 
was easily done and the child completely relieved. 
The relief continued for two days, when it perished 
from septic poisoning. 
Intubation, then, has for its first advantage availa- 
bility. 
Any one who has watched a child with the disease 3 
in question, and has noted the labored breath, the rest- 
less tossing and gradual change in color, must agree 
that both exhaustion and carbonic-acid poisoning are 
very important elements in deciding the result of either 
operation. 
In the beginning this change is so gradual that the 
parents are loth to believe that a little delay will not 
result in an amelioration of the symptoms, and thus 
postpone an operation which is so severe as tracheot- 
omy. An operation so simple, so painless and blood- 
less as that under consideration is readily consented to 
and hours of suffering are saved the child and the 
strength is by just so much the greater. 
This, then, is the second advantage of intubation 
that it can be done early. To safely perform a trache- 
otomy at the home of the patient, at least one trained 
assistant is needed and one man with steady nerves to 
manage the anaesthetic if one is used and to steady the 
head. 
Intubation, on the other hand, can be performed by 
one moderately skilful with aid of two persons of ordi- 
nary intelligence, one to hold the child, the other to 
manage the gag. Several times I have inserted a tube 
with only the parents to help me, and in one instance 
the original operation was done on a child of thirteen 
months with the aid of two nervous women. In such 
a case the most ardent advocate of tracheotomy would 
find its performance rather difficult. 
By these comparisons I do not desire to convey the 
impression that tracheotomy is always extremely diffi- 
cult and intubation extremely easy, for it is far from 
being true. Any one who has intubed a young child, 
gasping for breath, whose small pharyngeal space pre- 
vents or prolongs free manipulation and in whom the 
attempt to enter the larynx produces an alarming de- 
gree of cyanosis, will soon realize that any operation to 4 
relieve the condition cannot be simple and easy, but is 
fraught with the gravest anxiety and responsibility. 
For this reason no operation should be done without a 
careful consideration of all the elements in the case. 
Neither should be done as a routine procedure, but 
each performed in suitable cases. Certain other self- 
evident advantages belong to intubation : freedom from 
shock and haemorrhage, absence of new infecting sur- 
faces and resulting cicatrices, rapidity of performance, 
the opportunity of breathing air warmed by the natu- 
ral passages. 
My own experience in this operation comprises its 
performance in 78 cases, all in children under ten 
years of age. Divided according to age there were: 
Cases. 
Recoveries. 
Under 1 year 
2 
0 
1 to 2 years 
12 
3 
2 to 3 years 
18 
6 
3 to 5 years 
20 
5 
5 to 10 years 
26 
12 
As regards sex, 48 were males, 30 females; of these, 
26, or 33 per cent., recovered. 
As these cases were nearly all seen in consultation 
with various physicians, they have presented a wide 
variation as to the time the operation was done. In 
some it was done early, in others very late, and taken 
altogether they represent a fair average of cases which 
one meets both as regards severity and time of opera- 
tive relief. Earlier operative relief would have saved 
even more lives. 
These cases have been of the greatest interest on 
account of their occurrence in such varying surround- 
ings. In some the most skilful nursing was available, 
in others only the simplest attentions were given. In 
all, the result was so relatively satisfactory that I de- 
sire to consider somewhat in detail the elements which 5 
have a great deal to do with the success of this opera- 
tion. 
The first important question which arises is, When 
has the proper moment arrived for operative inter- 
ference in these cases ? I am sure there can be no 
difference of opinion as to the advantage of early re- 
lief. When a child suffering with diphtheria develops 
a croupy cough with hoarse voice and harsh respira- 
tion, and when in spite of the usual treatment has ob- 
tained no relief, but is gradually growing worse, the 
intercostal, supra-sternal and supra-clavicular spaces are 
beginning to retract, then no advantage is to be gained 
by longer waiting. 
This may take a longer or shorter time, but the per- 
sistent and increasing retraction is one of the most 
important symptoms, and longer waiting is at the cost 
of the child's strength. The steady progression of the 
disease with no intervals of relief, together with its 
gradual onset, serve to distinguish it from catarrhal 
laryngitis, or spasmodic croup, especially in those cases 
where no exudation is present upon the fauces. 
The instruments which are familiar to nearly every 
one to-day, consist of the introducer, the extractor and 
gag, varying sizes of tubes with their obturators. 
It has been a matter of surprise and regret to me, 
as doubtless it has to many others, to find the instru- 
ments so carelessly made that they are often unsafe 
for both operator and patient. The original gag de- 
vised by Dr. O'Dwyer is difficult to manipulate, and 
has been replaced in most of the cases, sold now, by a 
straight one which works with a spring and ratchet. 
This, for example, is too light, the blades are made of 
soft iron, the spring and ratchet too weak, which allow 
the blades to be forced together, or to be snapped 
quickly when touched by the nervous hand of an un- 
trained assistant. Twice, with the gag furnished in 6 
my first set, were the blades forced together while in 
the mouths of three-year-old children. In these cases 
the ratchet held well enough but the soft iron of the 
blades permitted their closure from the strong press- 
ure of the jaws. The danger of diphtheritic infec- 
tion from a wound in the finger is too great to allow 
us to consider such a matter lightly. The shank in 
the introducer is not strong enough, and frequently a 
bend is produced which interferes with the sliding of 
the fork which pushes the tube from the obturator. 
The thread which unites the obturator to the intro- 
ducer wears away so rapidly that after a short time 
the tube turns half-way round when screwed on tightly. 
Experience at the City Hospital has shown that this 
part may even break - a very undesirable accident. 
I have considered the tubes to be fairly well made, 
aside from occasional deviations from the correct shape, 
but a recent experience has taught me that they, too, 
have the same faults of careless and poor workmanship. 
In one of my most recent cases, after removing a 
five-year-old tube from a dead child, a matter of no 
difficulty whatever, I was surprised to find an opening 
had been made in the posterior wall of the tube just 
below the collar, which was produced by the moder- 
ate pressure of the jaws of the extractor. What the 
effect of the accident would be in extracting from a 
living child is at once apparent. The walls of this 
tube w'ere as thin as paper. 
I have attempted to overcome some of the disadvan- 
tages of these instruments by certain slight modifica- 
tions. The obturator is so easily removed from the tube 
when the latter is held in position by the finger, after 
introduction, that I have omitted the apparatus for re- 
moving it and have had the shank made larger and 
stiffer, and the thread hardened to prevent wearing. 
As the sizes below two years will not admit a large 7 
thread I have two shanks which are easily interchanged. 
In the original introducer, the angle made by the shank 
and obturator is a trifle more obtuse than a right angle. 
As the larynx is directed slightly backward, with this 
instrument the handle must be elevated so that the 
tube will easily enter it. 
I have made this angle a trifle more acute than a 
right angle so that the tube will be directed forward 
and more easily enter the larynx. The joint in the 
obturator should be carefully oiled to prevent rusting 
and a possible breakage when removing it from the 
tube when in the larynx. To perform this operation 
quickly and with as little shock as possible, certain 
precautions are of value. The child's arms should be 
placed by its sides and a blanket should be firmly 
wrapped about it leaving the neck as free as possible. 
In young children two safety pins will make this se- 
cure, but in older ones a bandage should be added. 
If this is not thoroughly done, the child will seize the 
thread and pull the tube out in the struggle immedi- 
ately following the introduction. A firm, straight- 
back chair should be placed so that there is plenty of 
space about it. The person who is to hold the child 
should be seated squarely on this chair, and the child 
placed in his arms, and firmly held. The position 
which I have found most convenient and which gives 
the most working space in the pharynx is one midway 
between the upright and reclining, the head resting on 
the bend of the elbow of the person who holds the 8 
child. Displacement of the gag by the shoulders strik- 
ing it, or the hand of the assistant, is thus avoided. 
The gag is then inserted far back in the mouth, tak- 
ing care to open it widely or it may slip out. The as- 
sistant then holds this, and also steadies the head if no 
other person is available to do this. The operator, 
standing opposite the child, passes the left index finger 
well back into the pharynx and on bringing it for- 
ward the epiglottis is quickly seized and retained. 
The finger and metacarpal joint of the operator 
should be well covered with adhesive plaster to pre- 
vent injury in case the gag slips. The threaded tube 
is then introduced precisely on the median line, the 
handle being at first depressed and then quickly ele- 
vated so that upon entering the larynx the tube is di- 
rected slightly forward. If the case is an easy one 
the tube slips quickly into the larynx, and as it is 
nearly in position the finger is pressed firmly upon the 
collar of the tube and the obturator removed. 
It frequently happens, however, that after the tube 
enters the larynx it meets with some obstruction, 
the child stops breathing, gives a gasp and the tube 
slips in easily. This is caused, I imagine, by the ap- 
proximation of the vocal cords, which upon separation 
permit the entrance of the tube. 
The presence of the tube in its proper position is 
determined by two facts: first, the peculiar dry cough, 
which if once heard is sufficient to make one fairly 
sure ; and second, by the presence of a septum between 
the finger passed into the oesophagus and the tube in 
the larynx. If this is felt its position is assured. With 
finger resting on the collar of tube the thread, which 
should be waxed to prevent sticking together, can be 
quickly removed and the operation is completed. 
The relief in most cases is immediate. The child, 
after coughing a short time, breathes quietly, the face 9 
loses its drawn and anxious look, and for the first time 
in many hours goes quietly to sleep. This quick tran- 
sition from the sufferings of severe dyspnoea to peace- 
ful slumber is one of the pleasantest features of this 
operation, and it is one not so constantly seen after 
tracheotomy in my experience. While this is by far 
the most common result after this operation, it must 
not be forgotten that frequently certain variations are 
found, and (rarely, fortunately,) other grave emergen- 
cies arise, which one should always be prepared to 
meet. Among the former we find introduction difficult 
from enlarged tonsils, from swollen epiglottis and ary- 
epiglottic folds, and from a larynx small and deeply 
placed. In all these the first attempt may fail, but it 
rarely fails to dislodge a considerable quantity of tena- 
cious mucus, or even membrane, which clears the way 
for the second attempt. 
Not more than eight to twelve seconds should be 
allowed for any one attempt and frequent short at- 
tempts are far less productive of shock than a single 
prolonged one which should never be made. 
Among the latter, we have the one possible danger 
of this operation, one fortunately so rare that it does 
not deter us in the least from performing it. That is, 
the danger of the membrane blocking the end of the 
tube, either by being pushed down and folded up, or 
by its presence below the lower end of the tube. In 
these cases the operation gives no relief, and the child 
may stop breathing. 
The tube should be instantly removed and the cough 
which follows the procedure may dislodge the mem- 
brane, and render a second attempt possible. When 
this does not occur an immediate tracheotomy is the 
only alternative and it must be done quickly. 
The outcome of these cases is usually fatal. The 
more strictly the tube is kept in the median line the 10 
less liable is it to dislodge membrane from the sides of 
the larynx and carry it before it into the trachea. As 
the tube reaches to within a half-inch of the bifurcation, 
it is not often that membrane is present in large 
enough amount below this to cause trouble. 
In contrast to the number of deaths which occur 
from shock and haemorrhage during tracheotomy, in- 
tubation has nothing to fear from a comparison of 
possible accidents. 
It not infrequently happens that during the cough- 
ing which follows its introduction the tube may be 
ejected. One size larger should be selected and will 
usually be retained. If the tube is coughed out later 
in the progress of the case the same rule should be 
observed. 
There is usually in these cases an interval of relief, 
long enough for the operator to reach the patient, and 
after the first twenty-four hours it occasionally happens 
that its re-introduction is unnecessary. In general, I 
have found that the tubes were a little small, and that 
the relative size of the child was the best guide in the 
original selection of the proper size of tube. 
The after-treatment of these cases requires patient 
and unremitting care. Children have been, and will 
be, lost from lack of attention to certain essential de- 
tails. Where it is possible, the care that a trained 
nurse can give, will greatly aid in carrying out these 
details. 
To my mind the most important weapons we have 
to fight this dread disease are : abundant stimulation 
and nourishment; the free use of steam, and mercurial 
medication locally and internally. 
The child must not be wakened from its sleep, how- 
ever long it may be, for any purpose whatever. After 
wakening, however, if it is given some thin liquid and 
be allowed to take it in the usual upright posture, a 11 
violent attack of coughing ensues from lack of complete 
closure of the epiglottis over the tube. It does not take 
many such attacks to discourage a child from taking 
anything. 
If, on the other hand, a semi-solid, like ice-cream, 
thick cream or the like be given the coughing is much 
lees, or none at all, and the child soon adapts itself to 
its new condition and will soon attain a certain facility 
of swallowing which will permit even liquids to be 
swallowed with comparative ease. 
The most important advance in the treatment of 
these children was made when Dr. Casselberry, of 
Chicago, showed us that a child lying down so that 
the pharynx was lower than the larynx could swallow 
with the greatest ease. When this position can be 
maintained the battle, so far as nutrition is concerned, 
is half won. This position, in my experience, is very 
difficult to get children to submit to, but by patience 
and firmness considerable can be done in this direction. 
In young children a nursing bottle is a great help and 
in older ones a tube through which they can take liquids 
when lying down. As a rule, the younger the child 
the more difficult is the swallowing. 
Among the articles of food from which a selection 
can be made the following are of the most value - 
cream, ice-cream, egg-nog, bread and milk, blanc- 
mange, rennet, oysters raw or stewed, bananas and 
cream, shaved-ice, eggs in various forms, milk, milk- 
punches, beef-meal, peptonoids solid and liquid, Valen- 
tine's extract, bovinine, custard, Charlotte Russe, corn- 
starch pudding, sherbet, Roman punch, jellies of various 
sorts, thick gruels. 
Rectal feeding has proved very disappointing, the 
rectum soon becomes intolerant of even the blandest 
injections, and there is more or less exhaustion result- 
ing from the necessary manipulation. Before we un- 12 
derstood the proper method of feeding it often became 
necessary, now, it is seldom required. If one wishes 
to use this method, peptonized milk, with the addition 
of peptonoids liquid or powdered, gives the most satis- 
factory results. Half-hourly administration of nourish- 
ment during the day is advisable unless the coughing 
is extremely troublesome when hourly administration 
may be substituted. 
I u obstinate cases where other means have failed, re- 
sort may be had to feeding through a tube. The child 
is held in the arms, a gag inserted, and a soft catheter 
passed into the oesophagus and the milk poured into the 
stomach. The procedure is easily accomplished after a 
little practice and any nurse can quickly learn to do it. 
About four ounces should be used each time, with 
some form of stimulant. 
The free use of alcoholic stimulants in these cases 
serves to most effectually fight the septic poisoning of 
the disease. It seems impossible to over-stimulate 
these cases, enormous amounts are taken without Hush- 
ing or other evidences of too great an amount ingested. 
For a child of three years, from a half to a tablespoon- 
ful of whiskey or brandy can be safely given hourly 
to be increased or diminished as the case demands. By 
combining it with milk it is more easily taken and is 
less liable to cause coughing. When a child objects 
strongly to these two, champagne may be substituted. 
In order to loosen the tenacious secretions steam is one 
of our most valuable agents. I have given up entirely 
the various steam atomizers, they are always untrust- 
worthy, a cool vapor is produced and they are not 
available in all cases. I have found the most practical 
method was to utilize the ordinary tea-kettle which is 
always at hand. To the nose of this a rubber tube is at- 
tached and conducted to the bedside of the patient. 
The objection which 1 found to this was that so large 13 
a calibre of tube was required that much of the steam 
was lost by condensation. To obviate this I have 
availed myself of a device of steam fitters, which is 
shown in the diagram, called a " reducing coupling." 
By means of this a large tube may be used on one side 
and a small one on the other. They can be ordered 
from any plumber, by simply designating three-fourths 
inch and one-eighth inch nipples and a three-fourths- 
inch reducing coupling. The cost is slight, about 
thirty cents, and the convenience great. If a large 
volume of steam is to be used, the child's bed or crib 
should be enclosed in a sheet-tent and the steam in- 
troduced beneath it. 
Nipple (J in.). 
Reducing 
Coupling. 
Nipple (f in.). 
Gas Tip. 
Among the various medicinal agents which have 
been used to prevent the formation and extension of 
membrane in the larynx, mercury occupies the first 
place. Children suffering from diphtheria exhibit a 
remarkable tolerance to this drug. Doses which would 
salivate an adult are taken with perfect immunity by 
them. To accomplish anything, large doses must be 
used. In a child of three years it is well to begin with 
one-sixtieth of a grain of corrosive sublimate every 
hour, in Fairchild's essence of pepsin ; and this should 
be increased to one-thirtieth of a grain every hour, if ex- 
udation on the pharynx is increasing, or if extension 
below the tube is taking place. I have occasionally, 
in severe cases, given one-sixteenth of a grain every 
hour, and no toxic symptoms were produced. In one 14 
case, which was treated under conditions particularly 
favorable for careful observation, being the child of a 
physician, during the eight days of the laryngeal in- 
vasion six grains of corrosive sublimate were taken in 
hourly doses of one-sixteenth of a grain. Absolutely 
no discomfort was noticed. 
The symptoms of the toxic action are quickly detected 
by abdominal pain, nausea and vomiting, and by loose 
greenish stools. Even more remarkable is this toler- 
ance as shown in the results of the method known as 
" calomel fumigation." A half-drachm of calomel is 
sublimed under a tent, and the child breathes this 
without injury, and with apparent benefit, while the 
nurses are usually mildly salivated by the slight amount 
of vapor which escapes from the tent. This method 
seems to promise good results in the treatment of this 
disease, but I have not as yet had a good opportunity 
to try it. 
I have seen several cases of beginning laryngeal 
obstruction which have subsided without an operation 
where steam and mercury had been freely used, and 
in these cases the improvement seemed to be due to 
the mercury. In three cases, I have seen a fresh ex- 
udation form on the tonsils where it had disappeared 
after the use of this drug, and when from fear of poison- 
ing its use had been discontinued. Upon again using 
it, the exudation promptly disappeared. If enough 
similar cases can be observed, it will materially aid us 
in deciding as to its value. 
From my experience so far I should hesitate to 
treat diphtheritic croup without it. In addition to the 
drug internally, a spray of corrosive sublimate (1- 
2,000) is of service, used both in the nose and throat. 
I have given up the use of local applications if a child 
objects very strongly ; for the exhaustion more than 
balances any benefit to be derived from their use. 15 
Among other agents which are of service are digitalis* 
if there is defective action of heart or kidneys ; also 
iron and peroxide of hydrogen in very septic cases, 
applied by spray or swab in the strength of one to 
four. The temperature of the room should be moder- 
ately elevated, 70° to 74°, and the air should be fre- 
quently changed to ensure plenty of fresh oxygen. 
In favorable cases the child soon becomes reconciled 
to the presence of the tube, breathes quietly but rather 
more rapidly than normally, has now and then a 
severe paroxysm of coughing as it raises masses of 
tenacious mucous membrane through the tube, and often 
sits up in bed playing with its toys. More or less 
cough is constantly present, chiefly for the raising of 
the large quantities of secretion which come through 
the tube, but which being swallowed are not so easily 
noticed, and do not require the care that the secretion 
from a tracheotomy tube does. In fatal cases the 
child may gradually sink, the respiration becoming 
more frequent and the pulse weaker, and death may 
occur within the first ten hours. The shortest interval 
that I have observed has been eight hours. In many 
cases no unfavorable symptoms arise until the third 
day, when the temperature begins to rise, the respira- 
tion becomes rapid and somewhat labored, and the child 
dies from the resulting broncho-pneumonia in twenty- 
four to forty-eight hours. In the majority of fatal 
cases death occurs before the fourth day ; and if they 
pass the third day without the development of these 
symptoms we can feel tolerably sure of a favorable 
outcome. The longest time that has elapsed in these 
cases which I have met with has been six days. If 
sudden occlusion of the tube occurs, a rare accident in 
the experience of those who have seen the largest 
number of these cases, the only resource is to use the 
method mentioned by Drs. Prescott and Goldthwaite, 16 
as used by a nurse at the City Hospital, which was to 
raise the child by its feet, wheu the tube may be 
moved enough to dislodge the obstructing membrane. 
Dr. O'Dwyer suggests the value of firm pressure on 
the chest in cases of this kind, in the hope that the air 
thus compressed may force the tube out. It seems 
reasonable and deserves a trial. 
The prognosis in these cases is a matter very difficult 
to estimate. Cases which look favorable will develop 
the most serious symptoms, and die; while those who 
have apparently no chance will pull through. In the 
cases which have come under my notice there were 
two well-marked classes: 
The one, where there was or had been, little or no 
exudation upon the fauces, glandular enlargement or 
nasal discharge. This class of cases is often mistaken 
in the beginning for ordinary follicular tonsillitis, and 
I have in several cases noted the history of an attack 
of follicular tonsillitis perhaps a week before the onset 
of the laryngeal symptoms. Too great care cannot be 
taken in clearly establishing the diagnosis in such at- 
tacks ; and in the present state of our knowledge I 
do not believe it can be done absolutely until a bacteri- 
ological examination has been made. 
The other class has the ordinary symptoms of diph- 
theria ; the fauces are more or less covered with mem- 
brane, the glands are enlarged, and more or less nasal 
discharge is present. 
In fatal cases, the cause of death in the first class 
is from bronchial extension, and in the latter from 
septicaemia. 
From the fourth to the sixth day the tube should be 
removed. It is often difficult to decide just when this 
should be done. In general the younger the child 
the longer the tube is required ; and it is also true that 
the shorter time a tube is in the less the liability to 17 
to produce any ulceration from pressure, or to produce 
an irritation in the larynx which may be sufficient to 
require its insertion even in the absence of membrane. 
In cases where there is an exudate on the fauces, the 
disappearance of this is a valuable guide in deciding 
this point. If the temperature is normal or nearly so, 
the respiration easy and not increased in frequency, 
and if, in other words, the pathological process is at 
a standstill, the removal of the tube is advisable as 
soon as possible after the fourth day. 
The operation of removal of the tube is far more 
difficult in my experience than its introduction. If 
any one doubts that it is difficult, let him attempt to 
localize the opening in a small tube, where the pharynx 
is small, and where every thing is covered with slip- 
pery mucus and feels alike, and after having done this 
successfully to attempt at the same time to hold the 
epiglottis out of the way while the point of the ex- 
tractor is inserted into the tube. Far more practice 
is required and less is available (for removal from a 
dead child is quite another matter than from a living 
one), in the extraction of a tube than its introduction. 
The instrument designed by Dr. O'Dwyer has the 
marked disadvantage that it does not hold the tube 
firmly enough, so that when partial removal is accom- 
plished the tube slips off. Dr. Nichols of the City 
Hospital has skilfully worked out the mechanical prob- 
lem, and has devised an extractor so excellent that 
any trouble in this direction will be avoided. Two 
points should be kept in mind in removing a tube : 
keeping the handle depressed as the tube is raised from 
the larynx, and also avoiding too great pressure down- 
ward in difficult cases. If there is much difficulty, it 
is safer to have an assistant place a thumb against the 
trachea where the lower end of the tube can often be 
easily felt, and by pressure upwards a greater firmness 18 
is given which renders a pushing into the trachea im- 
probable. 
If the tube is to be reinserted, the dyspnoea may at 
once recur, but in most cases not for four or five hours ; 
after twelve hours they are usually safe. A most in- 
teresting exception to this was seen in a case which I 
saw with Dr. Francis Murphy, of Roxbury. 
A child of eight and one-half years was intubed on 
November 27, 1890. The case progressed favorably, 
and the tube was removed on the sixth day. No re- 
currence took place until December 7th, when a second 
intubation was necessary. Removal was again accom- 
plished on the fifth day, December 12th, and the case 
continued to perfect recovery. This is the only case 
of the kind I have ever seen, and the only one in 
which I have been obliged to reinsert a tube. After 
removal, the same treatment should be kept up for 
twelve hours. Children, from a stiffness of the epiglot- 
tis swallow little if any better for that length of time 
than when the tube is in position. Steam can usually 
be omitted on the second day, and the bichloride dimin- 
ished rapidly till it is omitted on the fourth day. 
From the foregoing considerations it will be seen 
that intubation is an operation especially adapted to 
private practice. It is always available, can be done 
early, is both painless and bloodless. In a majority 
of cases it relieves the dyspnoea perfectly and leaves 
no after-effects. It saves as many lives as tracheotomy, 
and many more where the latter could not be per- 
formed. On the other hand, it cannot be selected in 
all cases. It is not advisable where the tonsils are so 
large that they prevent the necessary manipulation, or 
where the fauces are full of putrid debris and the epi- 
glottis immovable from the destructive action of the 
disease. Nor is it advisable in cases at a great dis- 
tance on account of the possibility of the tube being 19 
coughed out and the dyspnoea recurring before the op- 
erator could reach the patient. 
. If one is called upon to operate upon his first case 
of croup, it would be wiser to select tracheotomy; but 
after a certain familiarity with the feel of the parts 
has been attained, which largely does away with the 
awkward and even brutal attempts seen in the begin- 
ner, I am sure that intubation would nearly always be 
selected. The operation is not and can never be an 
easy and simple one; extremely so at times, at others 
it is so difficult as to perplex the most skilful intubator. 
When its advantages have become thoroughly known, 
I am sure that many lives will be saved which now 
are lost, and that the profession will feel an increasing 
sense of gratitude to the skilful physician who devised 
it, Dr. Joseph O'Dwyer. S. J. PARKHILL 4 CO., PRINTERS 
BOSTON