Makers of Modern Medicine Part 18

"Of the children whom nature has endowed with splendid gifts there are few whose lives have affected so profoundly and so beneficently the fate of their fellows, few who have earned in equal degree the grat.i.tude and reverence of all civilized men. Although not many can hope to enrich science with new principles, all of us may gain from Pasteur's life the inspiration to cultivate the best that is in us.

Let us keep living in our memories the inspiring words which the master spoke on the seventieth anniversary of his birthday:

"'Young men, young men, devote yourselves to those sure {321} and powerful methods, of which we as yet know only the first secrets.

And I say to all of you, whatever may be your career, never permit yourselves to be overcome by degrading and unfruitful skepticism.

Neither permit the hours of sadness which come upon a nation to discourage you. Live in the serene peace of your laboratories and your libraries. First, ask yourselves, What have I done for my education? Then, as you advance in life, What have I done for my country? So that some day that supreme happiness may come to you, the consciousness of having contributed in some manner to the progress and welfare of humanity. But, whether our efforts in life meet with success or failure, let us be able to say, when we near the great goal, 'I have done what I could.'"

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JOSEPH O'DWYER, THE INVENTOR OF INTUBATION

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I have hope and wish that the n.o.bler sort of physicians will advance their thoughts, and not employ their time wholly in the sordidness of cures; neither be honored for necessity only; but that they will become coadjutors and instruments in prolonging and renewing the life of man.

--Bacon

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JOSEPH O'DWYER, THE INVENTOR OF INTUBATION.

At the beginning of the nineteenth century a young medical pract.i.tioner, working faithfully in the wards of his hospital in Paris, pitying especially the patients who suffered from pulmonary disease, and realizing how hopeless was their treatment, since medical science knew so little of the real nature of the ailment from which they suffered, invented the stethoscope and established the principles on which modern physical diagnosis is based in a method so complete that after the lapse of three-quarters of a century very little has been added to what was then discovered. This genius was the famed Laennec, of whom we have written in a preceding chapter, who was wont to spend his days walking the wards of the Necker Hospital in Paris, caring more for his poor patients than for the n.o.bility and members of the wealthy cla.s.ses, who willingly would have taken advantage of his clinical knowledge so conscientiously gained. Laennec made possible progress in medicine that places him among the five or six greatest medical men of all times.

At the end of the nineteenth century a man of about Laennec's age was touched with pity for the sufferings of the poor children whom he saw dying from suffocation because of the ravages of laryngeal diphtheria.

Nothing could be done for them except, perhaps, to benumb their senses by means of narcotics, while nurse and medical man stood idly by suffering excruciatingly themselves while their little patients bore all the lingering, awful pains of death by asphyxiation. {326} For years Joseph O'Dwyer labored at the problem of relieving these little patients, and finally achieved similar success to Laennec with his stethoscope. The modern doctor, moreover, was quite as patient in his work of research as Laennec, and though his discovery had not so wide an application as the latter's it was accomplished through the same tireless, persevering labor, and through the same instinct of genius that finally led to the culminating invention which no one has been able to improve, and which has made its inventor's name a familiar word to medical men over the world. American medicine has no more shining light than the name of Joseph O'Dwyer, and the record of his simple, sincere, straightforward life, faithful during his successful career to the simple religious principles imbibed in the bosom of an old-fashioned Catholic family, who, during a long career, thought little of self and mainly of the possibilities for good presented by his profession, cannot but prove one of the standard biographies in this country's medical history.

Dr. Joseph O'Dwyer, the inventor of intubation, was born in 1841, in Cleveland, Ohio. Shortly after his birth his parents, who were only moderately well to do, moved to Canada, so that O'Dwyer's boyhood was pa.s.sed not far from London, Ontario. There he received his early education, and there also, as was the custom in those days, he began his medical studies by becoming a student in the office of a Dr.

Anderson. After two years of apprenticeship, he came to New York and attended lectures in the New York College of Physicians and Surgeons, where he was graduated in 1866, at the age of twenty-five. Immediately after graduation he obtained the first place in the compet.i.tive examination for resident physician and sanitary superintendent of the Charity or City Hospital of New York City, on Blackwell's Island.

Shortly after his appointment {327} an epidemic of cholera broke out in the workhouse (under his charge), and Dr. O'Dwyer n.o.bly devoted himself to the care of the patients. While engaged in this work he contracted the disease himself, but fortunately recovered completely without suffering from any of its usual after-effects.

When, not long subsequently, another epidemic of cholera occurred in New York, and a number of cases of the disease were transferred to Hart's Island and there quarantined, volunteers for their medical attendance were asked from among the members of the medical staff of the Charity Hospital. Dr. O'Dwyer was one of the first to come forward and offer his services. Again he contracted the disease, but recovered from it as completely as from typhus. Years afterward he described to a friend his feelings as he lay in one of the hospital tents, the only accommodation that could be provided for him owing to the crowded condition of the wards. His attack was rather severe and yet left him his consciousness, while as he lay expecting death at almost any moment, the thought (as he was wont to relate) sometimes came to him that it was perhaps foolish of him to have volunteered in so dangerous a service. This thought was always put away, however, and he a.s.sured his friend that at no time had he ever regretted his exposure to the disease in the cause of suffering humanity. The risks that usually come with professional obligations (it appeared to him) are not to be avoided at the cost of the consciousness of a duty refused.

During his service at the Charity Hospital, Dr. O'Dwyer endeared himself to all those with whom he came in contact. In examination for the position of resident on the Island he had pa.s.sed first, and during his service there it was generally conceded that he towered above his companions in his efficiency and attention to duty. Some of {328} those who were residents with him afterward made names that are distinguished in the history of the practice of medicine in New York City, yet all of them were ever ready to acknowledge that O'Dwyer had been a leader among them in the service. With a very practical turn of mind, he united the capacity for patient work that enabled him to master difficulties, while his devotion to his profession gave him a deep interest in every department of medicine. The foundation of his future success as a pract.i.tioner of medicine was laid in these fruitful years of hard work among the poor charity patients of New York City, for whose welfare, as is evident from what we have said, he was ready to make any sacrifice.

After about two years of service on Blackwell's Island, Dr. O'Dwyer, who had attracted no little attention by his faithful fulfilment of duty, was appointed examiner of patients--applicants for admission to the hospitals under the control of the City Board of Charities and Correction. He therefore resigned his position on the Island, and in partnership with Dr. Warren Schoonover opened an office on Second Avenue, between Fifty-seventh and Fifty-eighth Streets. With his colleague, he devoted himself especially to obstetrical practice, in which he had great success, delivering in one year, it is said, over three thousand patients.

In 1872 Dr. O'Dwyer was appointed to the staff of the New York Foundling Asylum, in connection with which his real life-work was to be accomplished. While there Doctors Reynolds and J. Lewis Smith were his colleagues, and all three of them have added no little distinction to American medicine by the careful observations made at that asylum.

At this time one of the most fearful scourges that could afflict a foundling asylum or children's hospital was an epidemic of diphtheria.

Those who pretend not to believe {329} in the efficacy of the ant.i.toxin treatment of diphtheria should listen to the account given by some of the Sisters, who for long years were in service in the New York Foundling Asylum, of the fear that came over them when it was announced that diphtheria had entered the wards in their charge. It was always certain beyond doubt that this disease would spread very extensively, and, in spite of all precautions and the enforcement of whatever quarantine was possible, the mortality rate would be very high. Usually forty or fifty per cent, of those who were attacked by diphtheria would perish from the disease, nor was it easy to foresee the end of any epidemic.

In not a few cases death took place from that most excruciating of all fatal terminations--asphyxia. The false membrane, characteristic of diphtheria, would form, in a certain proportion of cases, in the larynx and upper part of the trachea of the little patient, the inflammatory swelling that accompanied it further decreasing the naturally small lumen of the child's undeveloped air pa.s.sages.

Gradually dyspnoea would set in, the dreaded croup begin to be heard, and difficulty of breathing developed at times to such a degree that the little one would use every effort to secure breath, the aeration of the blood growing less and less, and cyanosis--that is, an intense blueness of the face and hands--becoming evident, till finally the child died slowly in all the agonies of asphyxiation, while doctor and nurse stood sadly by, absolutely powerless to do anything to relieve the heart-rending symptoms.

About the middle of the nineteenth century tracheotomy--that is, the surgical opening of the trachea, or wind-pipe, below the larynx, for the purpose of admitting air to the lungs through such artificial opening--had been introduced by Trousseau, of Paris. In many cases this afforded relief; {330} at least the little patients did not die the awful death by asphyxiation, though not many recovered from the diphtheria or the results of the operation. O'Dwyer himself, when asked what had led him to think of intubating the larynx, said that he had been aroused to experimentation in this direction by the complete failure of tracheotomy during the years from 1873 to 1880 at the New York Foundling Asylum.

In 1880, Dr. O'Dwyer began to devise some method of providing a channel for the pa.s.sage of air and secretions through the larynx. He knew that tracheotomy, as a serious, b.l.o.o.d.y operation, always is put off until the condition of the patient is quite alarming, if not hopeless, and that some device for holding the larynx open, if not too difficult of application, would surely prove life-saving in a great many cases. His first thought was that the introduction of a wire spring within the larynx might serve to hold the inflamed sides apart.

He realized, however, that the edema and false membrane would force their way around the wires, and so gradually occlude the throat pa.s.sage in spite of the presence of the spring.

His next thought was a small bivalve speculum, that is to say, two portions of tubes cut longitudinally and fastened together in such a way that the ends could be forced apart. Such instruments are used very commonly for the examination of various cavities in the human body. The laryngeal spring, or speculum, was more successful than the wire, but it had one of the faults of the wire spring. Into the slit between the two portions of the speculum the inflamed mucous membrane was apt to force itself, so that before long difficulty of breathing would recur. Besides, if the spring which kept the blades of the speculum apart were weak, the instrument would fail of its purpose in {331} keeping the mucous membrane apart, while, if it were strong, the pressure of the blades would cause ulceration.

Notwithstanding its faults, however, the bivalve laryngeal speculum accomplished somewhat of the purpose intended. In one case it kept a child alive until the dangerous period of the disease was pa.s.sed, and thus was the means of saving the first little patient suffering from membranous croup in the thirteen years that the Foundling Asylum had been in existence. Dr. O'Dwyer continued to experiment with the speculum for some time, but finally gave it up and began to study the detailed anatomy of the human larynx. These studies included not only the normal larynx, but also its conditions under the influence of various pathological lesions. Finally (as one of Dr. O'Dwyer's a.s.sistants at that time says), he appeared one day in the autopsy-room with a tube. This tube was a little longer than the speculum that before had been in use. It was somewhat flattened laterally, and had a collar at its upper end. This tube was very soon to prove of practical value.

In the first case in which it was employed it was a failure, inasmuch as the patient died from the progress of the diphtheria, though the notes of the case show that after the introduction of the tube the dyspnoea was relieved and the child breathed with comparative ease for the sixteen hours that elapsed before death took place. To any one who knows the harrowing agony of death from asphyxiation, and who appreciates the fact that this form of death was now to be definitely done away with, the triumph of this first introduction of the tube will be at once clear. Dr. O'Dwyer himself was very much encouraged.

The relief afforded the patient was for him a great personal satisfaction, since one of the severest trials to his sensitive nature in the midst of his professional work had always {332} been to have to stand helplessly by while these little patients suffered.

The fact that this tube had been retained for sixteen hours demonstrated definitely that the larynx would tolerate a foreign body of this kind without any of the severe spasmodic reflexes that might ordinarily be expected under such circ.u.mstances, while the fact that the tube had not been coughed up showed definitely that the inventor was working along the proper lines for the solution of his life-problem. The second case in which the tube was employed resulted in recovery, and Dr. O'Dwyer's more than a dozen years of labor and thought were rewarded by not only relief of symptoms, but the complete recovery of the patient without any serious complications and without any annoying sequelae.

As the first case (alluded to above) is now a landmark in the history of medicine, the details relating to it seem worth giving. The little patient was a girl of about four years of age, who on the fifth or sixth day of a severe laryngeal diphtheria developed symptoms of laryngeal stenosis, with great dyspnoea. Hitherto the only hope would have been tracheotomy, but Dr. O'Dwyer introduced one of his tubes.

The little patient was very much frightened and, as might be expected, in an intensely irritable condition because of the difficulty of breathing. She absolutely refused to permit any manipulations, and it was only with great difficulty that he finally succeeded in introducing the tube. After its introduction the little one shut her teeth tightly upon the metallic shield which the doctor wore on his finger for his protection, and he was absolutely unable to withdraw it from her mouth. It was only after chloroform had been given to her to the extent of partial anesthesia, with consequent relaxation of muscles, that he succeeded in freeing himself.

This proved to Dr. O'Dwyer the need of another {333} instrument (to be employed in the introduction of tubes)--an apparatus by which the mouth could be kept widely open so as to allow of manipulation without undue interference by the patient. For this purpose he contrived the mouth-gag--a very useful little instrument that has been found of service in many other surgical procedures about the mouth besides intubation.

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 a.s.sistants 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 pa.s.sages and furnish as much breathing s.p.a.ce 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 pract.i.tioners 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 G.o.ddess 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 cla.s.sical 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-pa.s.sages after these had become occluded. Hippocrates mentions {336} ca.n.a.lization of the air-pa.s.sages, 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 pa.s.sed down the throat, inadvertently allowed the tube to pa.s.s 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 pa.s.sed down into the lungs even through a spasmodically contracted or infiltrated larynx, with the consequent a.s.surance 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, Duca.s.se 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 pa.s.sed down into the larynx in order to allow the pa.s.sage 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 c.h.i.n.k 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 pract.i.tioners 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 pa.s.sed 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.