Makers of Modern Medicine

by James J. Walsh

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.