Part 30

His first tubes, however, were not without serious defects. For instance, in order to permit of the extraction of the tube afterward, there was a small slit in the side of the tube, into which the extractor hooked. Into this slit the swollen and edematous mucous membrane was apt to force its way, and (as can readily be understood) in the removal of the tube considerable laceration in the tissues usually was inflicted. Accordingly the tubes subsequently made were without this slit. Moreover, the first tubes that were employed were not quite long enough, a defect which led to their being rather frequently coughed up. This inconvenience was not wholly obviated even by the lengthening of them.

O'Dwyer continued his studies, and finally hit upon the idea of putting a second shoulder on the tubes. This, it was hoped, would fit below the vocal cords, and with the cords in between the two shoulders the tubes would surely be retained. This improved tube was actually retained, but the drawback to its adoption (as shown in practice) proved to be that it was retained too tightly. When the time for its removal came it was almost impossible to get it out. It was evident then that some other model of tube would have to be constructed in order to make the process of intubation entirely practical, and thus do away with certain dangers.

One of O'Dwyer's assistants at this time at the Foundling Asylum tells of the amount of time the doctor gave to the {334} study of the problem involved in these difficulties and of his ultimate success therein. Putty was moulded in various ways on tubes, which were inserted in specimen larynxes, and plaster casts were taken, with the idea of determining just the form of tube which would so exactly fit the average normal larynx as to be retained without undue pressure, yet at the same time keep the false membrane from occluding the respiratory passages and furnish as much breathing space as possible. Finally Dr. O'Dwyer decided that the best form of tube for all purposes would be one with a collar, or sort of flaring lip at the top, which was to rest on the vocal cord, with, moreover, a spindle-shaped enlargement of the middle portion of the tube, which lay below the vocal cords, fitting more or less closely to the shape of the trachea. To avoid the pressure and ulceration at the base of the epiglottis--a very sensitive and tender portion of the laryngeal tissues--a backward curve was given to the upper portion of the tube. On the other hand, the lower end, which rests within the cricoid ring and which was likely to be forced against the mucous membrane of the trachea occasionally, was somewhat thickened to avoid the friction and leverage that might be exerted if there were any free-play allowed. At the same time the lower end of the tube was thoroughly rounded off.

Thus Dr. O'Dwyer, realizing all the difficulties of this new method of treatment, solved them, as experience proved that the tubes could be made of still smaller calibre than had been hitherto supposed and yet be efficient in relieving respiratory dyspnoea. Experience also proved that the metal tubes at first used had a number of serious disadvantages. They were heavier than those which could be made of hard rubber in the same size and shape, while the metal tubes besides had a tendency to encourage the deposition and {335} incrustation on their surfaces of calcium salts. These incrustations, roughening the surface of the tube, increased its tendency to produce pressure ulceration, as well as added to the difficulty of its removal, and consequently to the liability of producing laceration of tissues after convalescence had been established. Accordingly tubes were made of hard rubber, which could be allowed to remain in the larynx almost for an indefinite period without any inconvenience. While at first intubation was looked upon as a merely temporary expedient, clinical experience showed that sometimes in neurotic patients it was necessary to let the tube remain in the throat for several weeks or even months.

Dr. O'Dwyer's originality in the invention of intubation has sometimes been doubted. The idea of some such instrumental procedure as he finally perfected seems to have occurred to practitioners of medicine a number of times in medical history. No one reduced the idea to practice in any successful degree. O'Dwyer's invention was not some chance hit of good fortune in lighting on a brilliant idea, but the result of years of patient investigation and shaping of means to ends. Often failure seemed inevitable, but he continued to experiment until he forced the hand of the goddess of invention to be favorable to him. The history of intubation is interesting mainly because it brings out clearly O'Dwyer's success where others had failed.

The evolution of intubation forms, moreover, a very interesting chapter in the story of medicine. It is curious to learn that the Greeks of the classical period, and very probably for a long time before, knew something of the possibility of putting a tube into the larynx in cases of stenoses or contractions which threatened to prevent breathing. It is clear that they thus secured patency of the air-passages after these had become occluded. Hippocrates mentions {336} canalization of the air-passages, and suggests that in inflammatory croup with difficulty of respiration, canulas should be carried into the throat along the jaws so that air could be drawn into the lungs. This is probably diphtheria, the first mention of the disease in medical literature, though it is usually said to have been first described in Spain at the beginning of the nineteenth century. There is evidence, too, in Greek medical history that these directions were followed by many practising physicians of those early times. Considering that intubation of the larynx is usually thought to be a very modern treatment, this tradition in Greek medical history serves to show how transitory may be the effect of real progress in applied science. After a time the Asclepiades, and some centuries later Paulinus of AEginetus, rejected the teaching of Hippocrates in this matter, while the latter suggested even the employment of bronchotomy.

After this episodic existence among the Greeks, there is no mention of anything like intubation of the larynx until about the beginning of the nineteenth century. In 1801, Desault, a French surgeon, while attempting to feed a patient suffering with a stricture of the oesophagus through a tube passed down the throat, inadvertently allowed the tube to pass into the larynx. This brought on a severe fit of coughing, but after a time the tube was tolerated and an attempt was made to feed the patient through it, with the production (as can be readily imagined) of a very severe spasmodic laryngeal attack. Desault realized the probable position of the tube then, and, taking a practical hint from this accident, suggested that possibly tubes could be passed down into the lungs even through a spasmodically contracted or infiltrated larynx, with the consequent assurance of free ingress of air. As these cases were otherwise extremely {337} hopeless, it was not long before he found the opportunity to put his hypothesis to the test, and in some half a dozen cases he succeeded in lengthening patient's lives and making them more comfortable for some hours at least.

Desault's suggestion was followed by similarly directed experiments on the part of Chaussier, Ducasse and Patissier. All these came during the first quarter of the century in France, while, in 1813, Finaz of Seyssel, a student of the University of Paris, in writing his graduation thesis for the faculty of medicine, suggested the use of a gum-elastic tube that should be passed down into the larynx in order to allow the passage of air in spasmodic and other obstructive conditions. In 1820, Patissier suggested that some such remedy as this should be employed for edema of the glottis. This affection, which is apt to be rapidly fatal, is a closing of the chink of the glottis, or rima glottidis, as it is called, which occurs very rapidly as the result of inflammatory conditions, especially in patients who are suffering from some kidney affection.

There was no doubt in the mind of practitioners generally of the necessity in many cases for some such expedient as the intubation of the larynx, but there was a very generally accepted notion that the mucous membrane of the larynx was entirely too sensitive to permit of a tube remaining for any considerable length of time in contact with the vocal cords and the very sensitive mucous membrane of the epiglottis. Meantime many precious lives were lost. Our own Washington was a sufferer, perhaps, from inflammatory edema of the larynx, complicated by a kidney trouble, though this was thirty years before Bright's work, and (as a matter of course) we have no definite data in the matter; or, as seems not unlikely, he suffered from a severe attack of laryngeal diphtheria, and, after hours of intense dyspnoea, {338} suffocated while his physicians stood hopelessly by, unable to do anything for him.

There are many other names in the history of attempts at intubation during the first half of the century, two of the most important of which are Liston and John Watson, who, as the result of chance observations in cases in which feeding-tubes were inadvertently passed into the larynx, came to the thought that the larynx might tolerate a tube much better than had been previously imagined. About the middle of the nineteenth century there was no little discussion with regard to the possibility of applying remedies within the larynx after the insertion of a tube, and a large number of medical articles appeared thereon. Diefenbach, the great German surgeon, interested himself in this matter particularly, and protected his left index-finger by a shield that acted also as mouth-gag in inserting the tubes. This technique was afterward to be made use of by O'Dwyer.

The first great step in intubation, as we know it at the present time, however, came from Bouchut, who suggested the use of a tube about the size of a thimble meant to be inserted into the larynx. At the upper part of this tube there were a pair of rings, between which the vocal cords were supposed to rest and hold it in place. Bouchut operated in seven cases with his tube, but five of his patients died, while two of them recovered only after tracheotomy had been performed. Bouchut succeeded, however, in showing that the larynx would tolerate a tube, though he made exaggerated claims for his method, while the very imperfect instruments he employed foredoomed his inventions to failure. It happened, moreover, that the time was unpropitious. Trousseau had not long before re-invented tracheotomy, and had employed it with considerable success in cases of croup. Under Trousseau's influence, a committee of the Academy of {339} Medicine of Paris declared Bouchut's method unphysiological and impracticable. Moeller, of Koenigsberg, tried to reintegrate Bouchut's method with certain ameliorations, but failed. The field of intubation--and a very discouraging one it seems, strewn as it was with failures made by many excellent workers--was left for O'Dwyer to exploit. How thoroughly he worked out his methods can best be appreciated from the fact that no improvement of importance has come since he presented to the medical profession the intubation system as he had elaborated it some fifteen years ago.

How thoroughly Dr. O'Dwyer realized all the difficulties attached to the practice of intubation may be gathered from some of his articles on details of the treatment of patients necessary in order to make intubation a success. One of the great difficulties in the matter was the liability, when a tube was in place, for food and drink to find their way, during the process of swallowing, into contact with sensitive tissues of the larynx. To overcome this difficulty, Dr. O'Dwyer made many modifications of the upper part of the tube. Accordingly he made many wax models of the larynx, and studied the function of the epiglottis and its method of covering the larynx in order to facilitate the complete protection of the laryngeal tissues during the process of swallowing. Finally, he succeeded in making a tube that enables most patients to learn how to swallow without much difficulty.

In the mean time O'Dwyer was full of practical suggestions with regard to the management of these cases. His clinical experience showed him that it was better to teach the patients to swallow rapidly and then cough up any material that might find its way into the larynx rather than to take small sips with a spasm of coughing after each sip. He showed that, notwithstanding the apparently great danger {340} of portions of food being carried past the larynx into the trachea, and so to the lungs, there was not nearly so much risk in this matter as had been anticipated. The almost inevitable occurrence of pneumonia was supposed to be one of the serious objections to the use of the intubation methods. Careful pathological investigations, however, soon showed that pneumonia developed much less frequently than had been expected, and, as a rule, when it did develop, it was due to an extension of the diphtheritic processes from the throat rather than to any infection by material that, because of the presence of the tube, had been inadvertently allowed to find its way into the respiratory tract.

However, O'Dwyer's work was not done without considerable opposition. Bouchut's original invention of tubes for the larynx had failed to attract attention because of its condemnation by the Academy of Medicine of Paris, under the influence of Trousseau. When O'Dwyer's tubes were first suggested, then, there were not lacking critics, who said at once that his method was not new, that it had been fairly tried already and found wanting, and that it was hopeless to expect that any intubation method would succeed, since the larynx would not tolerate such a foreign body. There are always those who are sure, on a priori grounds, that a new invention cannot succeed because it infringes on certain well-known physical laws that make it impossible. Similarly there were a number of experienced clinicians who were sure that O'Dwyer's reported results could not be as represented.

It was not only from members of the medical profession that O'Dwyer met with discouragement. His work at the Foundling Asylum was carried on in spite of many difficulties and disappointments. His first contrivances for keeping the larynx open in spite of the inflammatory swelling were all failures, and, as owing to unfamiliarity considerable {341} difficulty was experienced in the insertion of the various mechanical appliances, he seemed to be adding to the torture of his little patients. Many of the attendants at the hospital became discouraged and almost dreaded to see any attempt made to save the children. From one of the sisters attached to that institution O'Dwyer received the greatest possible encouragement. Sister Rosalie had often been known to weep at the death of her little charges, orphans though they were, and, though death frequently seemed a welcome relief from suffering, she hoped against hope that something would be accomplished to make deaths by asphyxiation rarer; so that even in the face of repeated failure she was ever ready to encourage O'Dwyer in further attempts in the accomplishment of his humane purpose. Not a little of his ultimate success is due to her sympathy and the enthusiastic faith inspired by her motherly love for the little homeless waifs who had come to occupy places in her heart.

At the beginning, some of the specialists in children's diseases gave the new method a trial, yet without obtaining satisfactory results. Professor Jacobi, our most distinguished specialist in that field in America, to whom the German government offered the chair of pediatrics at the University of Berlin, contended, in writing his article on diphtheria for Pepper's System of Medicine, that intubation could not be expected to accomplish all that was claimed for it. It was not long, however, before Jacobi realized his mistake in this matter and handsomely made up for it. While he was president of the Academy of Medicine, in opening a discussion on intubation before the academy, in 1886, he said that O'Dwyer's work deserved all possible praise, and that his untiring devotion to the subject, in silent patience until he had brought it to perfection, was a model {342} that might well be held up for the emulation of American physicians, commonly only too prone to announce discoveries even before they were made.

Besides the application of O'Dwyer's tubes in acute diseases affecting the larynx and causing difficulty of breathing, the method of intubation has proved of special service in the treatment of stenotic diseases of the larynx. There are certain diseases in which deep ulcerations of the vocal cords, and of the laryngeal structures in their neighborhood, are followed by persistent contraction. This contraction may extend so as to cause serious narrowing of the chink of the glottis, producing difficulty of breathing, and an intense breath-hunger that usually causes excruciating agony. Such patients formerly were objects of very special pity, but unfortunately very little could be done for them. Since the introduction of O'Dwyer's tubes, the lot of these patients has been made not only more tolerable, but, in course of time, even actual cures have been obtained, the tendency to contraction in the scar-tissue in the larynx being eventually overcome, with consequent relief of all the symptoms.

Dr. O'Dwyer himself tells the story of the first patient thus treated. It was a woman, about forty years of age, the innocent victim of a dissolute husband, who came suffering with labored, stridulous breathing. The morning of the previous day she had visited a prominent laryngologist of New York City, who advised her to have tracheotomy done before the sun went down. A colleague suggested that she should go to Dr. O'Dwyer to see if he could not give her relief by means of his process of intubation. The stricture in the larynx had resulted after the healing of frequently repeated ulcerations. The tissue all around the site of the old ulcers was densely cicatricial, with a very marked tendency to contract. The aperture through which the breathing {343} had to be done was just sufficient to admit air enough to allow the patient to continue on her feet, but it was becoming ever narrower, while her discomfort was very marked. The stenosis had been coming on for two years, and was slowly progressive in spite of every form of treatment then known to the medical profession.

At this time there was no such thing as intubation tubes suited for adults. Dr. O'Dwyer, therefore, had a set made, using as models casts taken from a series of various-sized bodies, and furnishing directions to the instrument-maker from careful measurements of adult larynxes. The tubes were made in various sizes for different-sized people, but none of them was small enough to be of service in this case, and even the largest of the tubes that had been made for children could be inserted only after the use of considerable force. This tube was inserted and allowed to remain for several days and then the next larger size was introduced. As considerable irritation had been set up by the previous tube, however, an interval of several days' rest was allowed. At the end of about eighteen days, breathing had become quite comfortable and the patient was allowed to return to her home in a suburban town. In two months and a half, however, all her symptoms had returned.

Another course of dilatation was then undertaken, and the patient was instructed to return thereafter every week for some time, until the tendency to contraction had been overcome. After a time, the intervals between dilatations were increased to a month, and then to six weeks, without any return of the dyspnoea. It is characteristic of O'Dwyer's very conservative view of things to find his prognosis of this case as given to the "Laryngological Section" of the Ninth International Medical Congress. He said:

"It is now one year and nine months since I began the {344} dilatation of this patient's larynx, and there is scarcely any doubt that it will be necessary to continue it during the rest of her life."

Later, however, we find the report:

"The cicatricial tissue in the larynx (as reported by the doctor) lost its tendency to contract, and the patient has remained now for over five years free from any return of the stenosis."

This last sentence is from Dr. O'Dwyer's note of the case, when by special invitation he discussed the subject at the annual meeting of the British Medical Association, held at Bristol, England, in July, 1894.

Interesting as is the career of Dr. O'Dwyer as an investigator and discoverer in medicine, his character as a man is still more worthy of attention. For nearly thirty-five years he was a member of the staff of the New York Foundling Asylum; during which time he endeared himself to sisters and nurses, to his brother-physicians on the staff and to his little patients. He was eminently conscientious in the fulfilment of his duty, and had a tender sympathy that made him feel every slightest pain of his child-patients almost as personal.

One very stormy evening, in the closing years of his life, after his more than twenty years' service as a member of the asylum staff, a little child fell ill and he was sent for. Though not well himself, the doctor came out into the night and the storm to attend the little patient. As he was leaving the hospital, long after midnight, one of the sisters, who had been longest in the hospital and who knew him very well, said to him:

"But Doctor, why did you come out on such an awful night? The house physician might have gotten on very well without you until morning, even though the little one was much worse than usual."

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