Analysis of Fifty Cases of 
Croup treated by Intuba- 
tion of the Larynx. 
JOSEPH O’DWYEK, M.D., 
ATTENDING PHYSICIAN YORK FOUNDLING 
» 
ASYLUM, ETC. 
REPRINTED FROM 
Keto STorft i&eaicscl Sournal 
for January lBBB,  
I 
DURATION, BE- 
FORE INTUBA- 
TION, OF— 
Compiica- 
No 
Date. 
In consultation with 
Age. 
1 
Urine. 
Cause of death. 
tions before 
Result. 
1 Pharyn- 
intubation. 
Cron j 
geal diph 
theria. 
1886.* 
51 
Dec. 
Drs. Wallace and McLoughlin 
F. 
9 y- 
2 d. 
10 d. 
Not exam. 
Inanit’n, paralysis 
Died 3 w. aft’r remov’l of tube 
52 
1 Mv own ease 
M. 
3 V. 3 m 
1 d. 
No album’n 
1887. 
53 
I Dr. O. P. Honeca'er. 
F. 
Ik d 
U 
a ( 
Died 5 d. 2 b. “ 
U 
54 
1 Dr. J. M. F. 
Egan and Dr. J. 
P. Dalv . 
M. 
1 d. 
a 
Not known . 
u 
u 
Dr. B. G* Cook 
F. 
3 y. 4 m. 
1 d. 
u 
Sensis 
A hopeless, 
Died 17 b. “ 
u 
septic case. 
56 
U 
M 
44 y. 
3 d. 
u 
<< 
u 
57 
u 
Dr. J. F. Holmes 
F 
14 d. 
a 
U 
u 
58 
u 
Dr. J. (I. Dew 
M. 
H y. 
Id. 
“ 
Extensive 
a 
pneumonia, 
measles. 
59 
Dr. Gluck . . 
M. 
U y. 
U d. 
it 
Exten. to bronchi. 
u 
60 
U 
F 
24- y. 
15 h. 
3 d. 
U 
a u 
u 
61 
u 
Dr. Conrad Lange 
M. 
2 y. 8 m. 
4 d. 
5 d. 
u 
62 
Mar. 
Dr. J. Lewengood and Dr. P. 
k 
• 
V 
* 
• 
W. Cremin 
M 
34 y■ 
3 d. 
6 d. 
u 
63 
u 
Dr. G. C. H. Meier 
F 
24 y. 
1 d. 
Not exam. 
64 
U 
Dr. Robert Milbank 
F. 
5 y. 
2 d. 
Albumin. 
65 
u 
Dr.Feigenblattand Dr. Conrad. 
M. 
18 m. 
14 d. 
4 d. 
Vo album’n. 
66 
U 
Dr. Janvrin and Dr. C. E. Bil- 
lino-ton . . 
F. 
4 m. 
2 d. 
7 d. 
Not exam. 
Died 1 d. 16 h. after intub’n. 
(57 
u 
Dr. S. Meltzer 
F. 
8 y. 9 in. 
4 d. 
7 d. 
Exhaustion 
Died d. after intubation. 
68 
u 
Dr. J. T. Devo 
M. 
3 y. 7 m. 
2 w. 
2 w. 
No album’n. 
Recov’d; wore tube 3 d. 21 h. 
69 
M 
3 d. 
1 d. 
Not exam. 
70 
u 
Dr. R. B. Burton 
M. 1 
2 y. 2 m. 
3 d. 
No album’n. 
u u 
Died 2 d. after intubation. 
71 
u 
Dr. E. Elliot and Dr. A, Jacobi. 
F. 
19 m. 
3 d. 
a 
Albumin. 
Died 2 d. 24h. after intub’n. 
72 
u 
F 
4 y. 
3 d. 
10 d 
Died 2 d. 4 h. “ 
u 
73 
May. 
Dr. P. W. Cremin 
F. 
4 y. 9 m. 
3 d. 
3 d. 
a 
Nenhr. & exhaus . 
Died 7 d. “ 
u 
74 
Dr. H. Roscli 
M. 
5 y. 9 in. 
1 d. 
4 w. 
u 
Scarlet fever 
Recov’d • wore tube 4 d. 1 0 h. 
with diph- 
theria four 
wks. before. 
75 
“ 1 
Dr. L. Bursdieim 
7 y. 1 m. 
i 2 h. 
None. 
N 0 album’n. 
Recov’d ; wore tube 4 d. 10 h. 
76 
U 
Dr. Rndisch 
F. 
3 y. 1 m. 
14 d. 
14 d. I 
Died 2 d. 5 h. after intub’n. 
77 
u 
Dr. Bleyer and Dr. Reid 
3 y. 
14 d. 
None, j 
a 
Exten. to bronchi. 
Died lid. “ 
u 
78 
u 
Dr. J. F. Currv 
M. 
4 v. 9 m. 
3 d. 
4 d. 
Not exam. 
Recovered; wore tube 4 d. 
79 
u 
Dr. J. Baran. 
F. 
4 y. 8 m. 
1 d. 
3 d. 
Heart failure 
Sepsis ... 
Died 17 h. after intubation. 
80 
u 
Dr. V. Mravlag and Dr. 
J. s. 
. 
• 
Green 4 . . 
M. 
3 y. 2 m. 
2 d. 
5 d. 
Albumin. 
Exten. & pneumo. 
. 
Died 1 d. “ 
81 
u 
Dr. Vedder and Dr. Wilcox . 
M. 1 
hy. 
H d. 
2 d. 
Nenhritis.nneumo. 
Died Id. 18 h. after intub’n. 
82 
J uly. 
Dr. W. B. Anderton and Dr. 
A. J. Masrnin 
M. 
2 y. 5 m. 
12 h. 
2 d. 
Exten. & nneumo. 
Died 22 h. “ 
a 
83 
U 
Dr. E. Sanders 
M. 
2 y. 5 m. 
1 d. 
2 d. 
U 
Pneumonia. . 
Died 8 d. 19J h. “ 
u 
84 
a 
Dr. R. Stein 
F. 
16 m. 
1 d. 
2 d. 
u 
Died 26 h. “ 
u 
85 
Dr. J. M. F. Egan 
F. 
4 y. 
4 d. 
12 d. I 
Convulsions,exten. 
Died 1 d. 22f h. “ 
u 
86 
Dr. L. Conrad 
F. | 
H y. 
2 d. 
4 d. 
a 
Extension, nenhri- 
Died 1 d. 13 h. “ 
U 
tis, sepsis. 
87 
a 
Dr. A. H. Goelet 
M. 
4 y. 5 m. 
3 d. 
a 
Recov’d; wore tube 10 d. 
88 
u 
Dr. Gluck and Dr. Holthusen. 
M. 
5 y. 
2 d. 
None. 
No album’n. 
Recov’d ; -wore tube 5 d. 
89 
a 
Dr. G. M. Vandeirrift.. 
M. 
2 y. 
12 h. 
6 d. 
Not exam. 
Recov’d; wore tube 3 d.l 94 h. 
90 
a 
Mv own ease 
M. 
5 y. 
14 d. 
Exten. & nneumo. 
Died 6 d. 18 h. after intub’n. 
91 
Dr. Daniel Lewis 
F. 
4 v. 5 m. 
3 d. 
None. 
No album’n. 
Recov’d; wore tube 6 d. 6 h. 
92 
a 
Dr. W. G. Robinson 
F. 
5 y. 
1 w. 
1 d. 
Died 1 d. after intubation. 
93 
u 
Dr. P. H, Pvne \ 
F. 
51 y. 
3 d. 
Present. 
Albumin. 
Recov’d; wore tube 7 d. 214h. 
94l 
u 
Drs. J. B. and B. C. Mclntvre. 
M. 
22 m. 
14 d. 
H d. 1 
Not exam. 
Recov’d; wore tube 6 d. 21 h. 
95 
a 
Dr. W. N. Guernsey . . 
F. 
4 y. 2 m. 
2 d. 
3d. 1 
Albumin. 
Sepsis, extension. 
Died 1 d. after intubation. 
96 
u 
Dr. H. J. Schiff . . 
F. 
3 y. 2 m. 
2 d. 
Present. 
U 
Double nneum’nia. 
Died 9 d. 21 h. after intub’n. 
97 
a 
Dr. A. Hodgman 
M. 
6 v. 7 m. 
3 d. 
10 d. 
U 
Recov’d; wore tube 3 d. 9 h. 
98 
u 
Dr. 0. E. Naramack 
M. 
3 y. 
2 d. 
4 d. 
Exhaustion 
Died 3 d. 8 h. after intub’n. 
99 
“ 
Dr. C. IL Grube 
F. 
4 y. 
1 d. 
2 d. 
Not exam. 
Exten. to bronchi. 
Sup.of urine 
Died 2 d. 9 h. “ 
“ 
100 
My own case 
M. 
9 y. 
2 d. 
Sever’l d. 
Albumin. 
Recov’d; wore tube 44 d. 
No. 
Age. 
Recoveries 
1 No. 
Age. 
Recov’ries 
j No. 
Age. 
Recov’ries 
No. 
Age. 
Recov’ries 
Yrs. Mos. 
Yrs. Mos. 
Yrs. Mos. 
Yrs. Mos. 
1 
0 4 
0 
2 
2 
6 
0 
2 
3 6 
1 
2 
5 6 
1 
1 
1 4 
0 
2 
8 
0 
1 
3 7 
1 
1 
5 9 
1 
1 
1 6 
1 
1 
2 10 
0 
3 
4 0 
0 
1 
6 5 
O 
1 
1 7 
0 
2 
1 3 
0 
0 
1 
4 2 
0 
1 
6 7 
1 
1 
1 10 
1 
1 
3 
1 
0 
2 
4 5 
2 
1 
7 I 
1 
1 
1 11 
0 
2 
3 
2 
0 
2 
4 6 
0 
1 
7 6 
0 
1 
2 0 
1 
1 
3 
3 
0 
1 
4 8 
0 
1 
8 9 
0 
1 
2 2 
0 
1 
3 
4 
0 
2 
4 9 
1 
2 
9 0 
I 
2 
2 5 
0 
1 
3 
5 
0 
4 
6 0 
2 
50 
. 
15 
Total, 50; males, 25 ; females, 23 ; not stated, 2 ; recoveries, 15, or 30 per cent. Average age of patients that recovered, 4 yrs. 8 mos.; 
of patients that died, 3 yrs. 9 mos. 
* The case referred to in a former table as having been overlooked I have transferred and, for ray own convenience, numbered 170. 
f This case was in Elizabeth, N. J. \ Yonkers, N. Y. Reprinted from the New York Medical Journal 
for January If 1888. 
ANALYSIS OF FIFTY CASES OF CROUP 
TREATED BY INTUBATION OF THE LARYNX. 
JOSEPH D’DWYER, M. D., 
ATTENDING PHYSICIAN TO THE NEW TOEK FOUNDLING ASYLUM, ETC. 
In the “Medical Record” of October 29, 1887, I pub- 
lished a summary of my first fifty cases of croup in private 
practice treated by intubation of the larynx. I also referred 
to the cases of sixty-five hospital patients who were operated 
on during the preceding five years while I was developing 
and perfecting the tubes and accessory instruments. 
The following table comprises another series of fifty 
cases, also in private practice, treated during the past year, 
or from November 16, 1886, to November 18, 1887. Of 
several additional cases seen during the same period in 
which intubation was at one time considered necessary but' 
that finally struggled through without operative interfer- 
ence, I will refer briefly to only two. Quite recently I was 
called in the night by Dr, E. Le Fevre to intubate a patient 
of his, a boy six years old, on the seventh day of croup. 
The stenosis was so marked that each inspiration suspended 
the pulse at the wrist, owing to the excessive quantity of 
blood sucked into the lungs. When I arrived the patient 
was somewhat better, and was still further improved by an 2 
ANALYSIS OF FIFTY CASES OF GROUP 
emetic of turpeth mineral. I watched him for over an hour, 
and left without operating. We believed that if we could 
get him through that night the danger, in all probability, 
would be over, as the disease had already lasted about the 
average length of time, and the early morning, which often 
brings some relief, was near at hand. The sequel proved 
that this view was correct, as there was no recurrence of 
serious dyspnoea. The voice in this case was good, not- 
withstanding the marked obstruction, and this, together 
with co-existing expiratory dyspnoea, proved the stenosis to 
have been subglottic. This patient was also seen by Dr, 
Jacobi. 
Another case occurring in my own practice about the 
same time was that of a girl, aged seven years, in whom the 
larynx was invaded almost coincidently with the appearance 
of the exudation in the pharynx. Urgent dyspnoea lasted 
throughout the second night and up to noon of the third 
day, at which time I visited the patient with the intention 
of intubating. I waited for the effect of five grains of tur- 
peth mineral, which acted promptly, and gave so much re- 
lief that the operation was postponed. Croupy cough, with 
loss of voice and occasional attacks of spasmodic dyspnoea, 
continued for a week longer, but operative interference was 
never necessary. The air was kept moist by a constant 
supply of steam carried under a sheet thrown over the head 
of the bed, the latter being very high and the temperature 
of the room at about 75° F. Dover’s powder in doses of 
two grains was found very effectual in relieving the painful 
irritating cough and the spasm of the glottis to which it 
gave rise. 
Both of these patients took the bichloride of mercury 
from the very inception of the disease, and I believe that 
if this remedy were administered in all cases of croup from 
the beginning, with proper care, a larger percentage of re- TREATED BY INTUBATION OF THE LARYNX 
3 
coveries, both with and without surgical aid, would be the 
result. 
In my own case gr. diluted with two teaspoonfuls of 
water, was given every hour, but this proved too irritating 
and gave rise to pain in the stomach and repeated attacks 
of vomiting when administered for less than twentv-four 
hours. It was therefore suspended for several hours and 
then given more largely diluted, without further inconven- 
ience. It was again suspended for several hours on the fifth 
day, owing to the occurrence of two or three loose passages, 
and subsequently given in half the dose. 
Dr. Jacobi, who also saw this case in consultation, says 
that gr. -gL should be diluted in half an ounce of water, and 
larger doses proportionately. While preparing this article 
I was called to intubate a girl five years old, croupy less 
than twenty-four hours, who was taking gr. -fa 0f the bi- 
chloride in tablet form placed on the tongue every hour. 
She was complaining of severe pain in the stomach, the 
cause of which was not suspected. I find that this is the 
most common method of administering this drug, and the 
only reason that it does not more frequently excite gastritis 
or gastro-enteritis is the fact that the stomach usually con- 
tains more or less food or drink, and generally of an albu- 
minous nature. Given in such concentrated form on an 
empty stomach, it must prove highly injurious. 
By referring to the following table it will be noticed that 
out of the fifteen cases intubated during the past autumn 
there were eight recoveries. This I attribute in part to the 
bichloride of mercury which was used in the majority of 
them, and in part to a less fatal type of the disease than 
prevailed last winter and spring. 
Case Ll.—This case presents several interesting features. 
The patient was recovering from an ordinary pharyngeal diph- 
theria, the membrane having almost entirely disappeared, when 4 
ANALYSIS OF FIFTY CASES OF CROUP 
she was attacked with measles. The exudation reappeared in 
the pharynx and rapidly invaded the larynx. Dyspnoea recurred 
on the fifth day after intubation, and a very thick cast of the 
trachea was expelled immediately after the removal of the tube, 
with complete relief. Two days later I was sent for again and 
found her suffering from extreme dyspnoea, expiratory as well 
as inspiratory, but having a good voice. I recognized it as a 
case of subglottic stenosis and was prepared to use some force 
in reinserting the tube, which I found to be necessary. The 
tube was again removed in two days and there was no recur- 
rence of the dyspnoea, but complete paralysis of the muscles of 
deglutition soon developed and it was found impossible to give 
any kind of nourishment by the mouth. Feeding by the rectum 
was resorted to as long as it could be borne, but the stomach- 
tube could not be used owing to the opposition of the ignorant 
parents, and the patient died from inanition almost three weeks 
after the final removal of the tube. 
Note.—A boy, six years and a half old, seen with Dr. 
W, H. Hall, and intubated December 31, 1886, for the fol- 
lowing reasons was not counted : On the second day fol- 
lowing the operation he was progressing without an un- 
favorable symptom, but after my visit coughed out the tube. 
I had given particular instructions that in case this acci- 
dent occurred there was no necessity for calling me as long 
as the breathing continued free. This advice often saves 
a hasty summons in the night, as in many cases the obstruc- 
tion does not return for several hours after the rejection of 
the tube. On making my visit the next day, I found the 
patient moribund and reinserted the tube, but he never 
rallied. The struggle for breath had continued for about 
fifteen hours, and was fully recognized by those in attend- 
ance without any effort to notify me. I subsequently 
learned that the child was an orphan and probably very 
much in the way. 
Case LV.—This was a septic, hopeless case with such ex- 
treme tumefaction of the epiglottis and aryepiglottic folds that TREATED BY INTUBATION OF THE LARYNX. 
it was difficult to locate the entrance to the larynx. The 
mother readily consented to the operation after being informed 
that there was no hope whatever of recovery, but that it would 
prevent death by slow strangulation. 
Case LYIII.—The patient had extensive pneumonia follow- 
ing measles when intubated. 
Case LXll.—This case is of interest as being the only one 
up to the present time in which I pushed down membrane in 
sufficient quantity to produce apnoea on the first introduction 
of the tube. As soon as it was removed by the string, which 
was still attached, a cast of the trachea was expelled, but the 
dyspnoea continued as before and reintubation gave complete 
relief. The tube was expelled in twenty-six hours and never 
needed again. With one exception, this is the shortest time 
the tube has been retained in the larynx with recovery in my 
own cases. 
Case LXXV.—It is not known how long the tube was re- 
tained in this case. Dr. Burgheim believes that it was expelled 
from the larynx and swallowed during an attack of vomiting 
within an hour after its introduction. It was certainly not in 
the larynx the next morning—inserted at 10.80 p. m.—as both 
cough and breathing were croupy with considerable dyspnoea, 
which continued with loss of voice for almost a week, but no 
further interference was called for. 
This case is of interest as being only the second out of 
173 cases so far in which the tube after escaping from tire 
larynx and without any interference entered the stomach ; 
also for the length of time—ten days—required for its 
passage through the alimentary canal. The tubes are so 
long that when the lower extremity leaves the larynx the 
upper extremity is in close proximity to the front teeth. 
This accident can, therefore, occur in only one of two ways : 
(1) Coughing it out during sleep or semi-consciousness, and 
(2) by being projected up behind the soft palate in the act 
of coughing or \ omiting. In the latter case it must of 
necessity enter the oesophagus. It is quite possible that 6 
ANALYSIS OF FIFTY CASES OF CROUP 
some children intentionally swallow the tube in order to 
get rid of it and prevent its farther use. I had one boy 
four years old who, with this object in view, dented the 
tube with his teeth. I have known others, on getting pos- 
session of the tube when no one was present, to throw it to 
a considerable distance or hide it where they supposed it 
would not be found. 
I was recently requested by a physician who had had con- 
siderable experience with intubation to perform tracheotomy 
on a little patient of his for the purpose of removing a tube 
that had passed into the trachea. At the usual time repeated 
attempts to remove it were made without success. He pos- 
sessed an unusual amount of coolness and dexterity, and was 
certain that he had not lacerated the larynx with the extractor, 
and I was equally certain that by no other means could the 
tube have entered the trachea. I found the patient suffering 
from extreme dyspnoea, which had recurred only after the last 
attempt at extraction, with croupy cough and croupy breathing, 
and, instead of opening the trachea, placed another tube of the 
same size in the larynx with complete relief. I then requested 
the physician to insert his finger and push it through if he 
could. This convinced him that the other tube was not in the 
trachea, and a more thorough search of the apartment resulted 
in finding it behind the bed, where the little fellow had con- 
cealed it, in all probability, several days before the attempt to 
remove it from the larynx had been made. This patient made 
a good recovery, notwithstanding the excessive irritation to 
which the larynx was subjected and the fact that he was obliged 
to take care of himself as best he could during the night, his 
parents being poor, hard-working people who could not lose 
their sleep and work during the day. 
No doubt many cases similar to this have occurred, and 
it is not the first of this nature that has been reported. ' It 
teaches the important lesson that the extractor should never 
be inserted until the head of the tube is distinctly felt by 
the finger. The swollen epiglottis and ary-epiglottic folds TREATED BY INTUBATION' OF THE LARYNX. 
7 
may overlap its upper extremity even to the extent of pro- 
ducing serious obstruction in rare cases, but offer very little 
resistance to the entrance of the tip of an ordinary-sized 
finger, and one of extraordinary size should be used only in 
the less vital cavities. 
Case LXXXVII.—Before the removal of the tube, which 
was very ranch obstructed, on the fifth day the respirations 
were sixty-eight a minute, temperature 104'5°, mucous rales 
all over the chest, urine loaded with albumin. Marked cya- 
nosis showed itself in ten minutes, and the tube was cleaned 
and reinserted with great relief to the breathing. It was again 
seriously obstructed, and the patient suffered from severe dysp- 
noea during the greater part of the night preceding its final re- 
moval on the tenth day. The relief was immediate and perma- 
nent. 
This case shows the importance of warning the parents 
or nurse to notify the physician immediately on the return 
of any difficulty in the breathing. As soon as the lumen 
of the tube becomes seriously encroached upon, the cough 
ceases to be effective owing to the great reduction in the 
amount of tidal air, expectoration diminishes or ceases alto- 
gether, and the secretions accumulate in the air-passages. 
In the case just quoted the numerous moist rales heard over 
all parts of the chest indicated that a fair amount of air 
was entering the lungs, and yet when the tube was removed 
there did not appear to be one fourth of its caliber free 
Loose secretions that can be blown out, or that will wash 
out by allowing a stream of water to pass through the tube, 
do not cause obstruction. 
Case XCVII.—I have already referred to several cases in 
which the retention of the tube for a few hours in the larynx 
relieved the dyspnoea for a considerable length of time. In 
this case it was retained on the first occasion for only five hours, 
and the dyspnoea was I'elieved for twenty-three hours. The 
same tube was then reinserted, instead of a larger one, in order 8 
ANALYSIS OF FIFTY CASES OF CROUP 
to favor its rejection again as soon as the pressure had reduced 
the swelling sufficiently to permit of this. This time it was 
retained sixteen hours, but had to he replaced in four hours. 
The third time it remained in the larynx nine hours, and the 
stenosis was permanently relieved. Had it not been expelled, 
I should have allowed it to remain in position about five days, 
instead of the thirty hours that it was actually required. 
Besides the advantage of taking an ample supply of 
nourishment without difficulty that these intervals afford, it 
is the best means of getting rid of the tube at the earliest 
possible moment. There are still other advantages to which 
I have already called attention. 
As a matter of course, nothing would be gained by 
using the same tube when the obstruction returns soon after 
its rejection. It is only in such cases as the foregoing, 
which are exceptional and very rare in young children, that 
this plan is advisable, except where loose membrane is 
known to exist below the tube. 
I have already reported two cases in which the tubes 
suddenly became occluded with a cast of the trachea too 
large to pass through, and were promptly expelled. 
I will briefly report the third accident of this kind in 
my experience where the tube wTas not expelled, and sudden 
death from apnoea resulted. It is not included in the table, 
and my object in referring to it now is to point out the 
means by which the accident may be avoided. 
On the afternoon of November 25, 1887, I was requested by 
Dr. 0. E. Bruce to see a little girl patient of his of delicate 
constitution, who had been croupy for only twenty-four hours. 
The tonsils were hypertrophied, and the mucous membrane pre- 
sented the ordinary appearances of follicular inflammation, but 
no false membrane could be seen. As the dyspnoea was ex- 
treme, I immediately inserted the 5 to 7 tube, with prompt but 
not absolutely complete relief, such as always occurs when the 
obstruction is confined to the larynx. With the first cough I TREATED BY INTUBATION OF THE LARYNX, 
9 
recognized the existence of loose membrane below the tube. I 
had encountered the same thing so often before without accident 
that I had ceased to fear it, and removed the string as usual. 
The breathing soon became perfectly free, and she fell into a 
quiet sleep. The night was passed comfortably, and on the 
next morning we found her free from dyspnoea and in fair con- 
dition, but the loose membrane had not been expelled. In the 
evening, or about twenty-seven hours after intubation, during 
a violent attack of coughing excited by swallowing some lemon- 
juice, she suddenly choked, became deeply cyanosed, and died, 
the nurse says, in two or three minutes. 
The tube used was two inches and a quarter in length, and, 
in girls of this age, will reach within about half an inch of the 
bifurcation. The presence of false membrane so near the 
bronchi and so early in the disease is usually a fatal omen. I 
therefore gave a very unfavorable prognosis. 
About half an hour after death I removed the tube, and as 
I did so a distinct hissing sound of escaping air was heard by 
Dr. Bruce and myself. 
This case, aside from its other interesting features, is of 
particular interest as demonstrating the mechanism by which 
acute general emphysema, or overdistension of the lungs 
with air, which is found in a small percentage of the fatal 
cases of croup, is produced. That portion of the pseudo- 
membranous cast lying loose in the trachea which extend- 
ed below the tube acted in precisely the same manner as 
a very thin piece of rubber tubing drawn over the lower 
end of the tube, and about half an inch longer than it. 
This, while offering no obstruction to inspiration, would 
collapse on the first pressure from below, forming a perfect 
valve, and thus prevent any air from escaping. With a few 
forcible inspirations, without expiring, the lungs become 
inflated to their full capacity, and death, in all probability, 
takes place more rapidly than in the opposite condition of 
complete obstruction to the entrance of air with free exit, 10 
ANALYSIS OF FIFTY CASES OF CROUP 
because in the latter the carbonic acid is allowed to escape, 
while the residual air furnishes some oxygen to the blood. 
Had this patient’s chest been opened before the removal 
of the tube the lungs would have been found too large for 
their cavities, and containing less than the normal amount 
of blood, which was either squeezed out or prevented from 
entering by the pressure of the imprisoned air. 
In order to prevent the accident that occurred in this 
case, where loose membrane was known to exist below the 
tube, several means may be resorted to; but the most im- 
portant of these is using a smaller tube than that indicated 
by the scale of years. Had T, for example, removed the 
5 to 7 size placed in this child’s larynx and inserted the 3 to 4 
size, which would have been perfectly safe, the chances 
would have been altogether in favor of its immediate expul- 
sion, when occluded below, followed by a cast of the trachea, 
as the outward pressure of the abnormal amount of air in 
the lungs must have been very great. 
Another precaution, and one which I have adopted in 
several cases, is leaving the string attached and fastening 
it behind the ear, so that the attendant can quickly remove 
the tube if necessary. It is objectionable on account of the 
irritation it produces and the difficulty ol preventing the 
patient from removing it, or cutting it with the teeth. 
Clearing the trachea of false membrane with a suitable 
instrument would be the best safeguard against this acci- 
dent, but it is useless to discuss it until its practicability has 
been demonstrated. Tiemann & Co. have recently con- 
structed for me a set of membrane extractors which are in- 
troduced in the same manner as the tubes, and with the 
same instrument, but I have not had an opportunity to try 
them. 
There is one other expedient that might prove effectual 
at the last moment in such cases as the foregoing, and in the TREATED BY INTUBATION OF THE LARYNX. 
extrusion of foreign bodies from the larynx also. It con- 
sists in causing a sudden escape of some of the residual air, 
or, if respiration is not completely suspended, of the residual 
and tidal air, by taking advantage of the beginning of ex- 
piration. This is accomplished by placing the patient 
across the knees, on the floor, table, or other hard surface, 
and, while with one hand firm pressure is made on the abdo- 
men to prevent descent of the diaphragm, the other hand, 
open, is brought down with considerable force on the front 
of the chest. 
A slight cough has repeatedly proved sufficient to lift a 
metal tube weighing an ounce and throe quarters from the 
adult larynx, and project it to some distance in front of the 
patient. The method just described accomplishes the same 
thing as the act of coughing. 
The popular custom, so universally practiced, of strik- 
ing a person on the hack who is choking from a foreign 
body in the throat, can not have any appreciable effect in 
expelling air from the lungs, but if the blow were made on 
the front of the chest instead of the back, it would be at- 
tended with much greater success. 
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