All united in honoring the marvellous genius whose work has proved of such practical utility for mankind, and whose discoveries are as yet only beginning their career of pregnant suggestiveness to scientific men. His genius has brought the great ones of earth to his level or raised him to theirs. His own thought on the equality of man is a confession of the faith that was in him. It was expressed in his discourse of reception into the French Academy in the midst of the panegyric on Littré, from which we quoted at the beginning of this sketch: "Where are the true sources of human dignity, of liberty and of modern democracy, if not in the infinite, before which all men are equal? The notion of the infinite finds everywhere its inevitable expression. By it the supernatural is at the bottom of every heart."

Pasteur, the man, is, however, if possible, even more interesting than Pasteur, the greatest of living scientists. In the midst of all his work and his wonderful success, amid the plaudits of the world, Pasteur remained one of the simplest of men and the kindest of friends to those who knew him. Dr. Roux's expression is well known: "The work of Pasteur is admirable; it shows his genius; but one must have lived on terms of intimacy with him in order to know all the goodness of his heart." He was kindness personified, and those who think of him as a cruel vivisector and encourager of experiments upon animals that cause suffering, belie him and his humanity very much. He would never permit animals to be used in experiments without an anesthetic, and even then only when he deemed that use absolutely necessary for the furtherance of projects that promised great benefit to humanity. Nothing was harder for him to do than to walk the hospitals and see human suffering when he was studying the causes of disease in human beings. Even the slight pain inflicted during the {317} injections for hydrophobia was a source of great discomfort to him, and his anxiety with regard to these patients was one of the main causes of the breakdown in health that shortened his life.

One of the most beautiful things about Pasteur's personal life is the relation to his family, and especially to his children, and their union in religious simplicity. On the occasion of the death of his father, whom Pasteur loved very deeply and for whom he had instilled the deepest affection into the hearts of his children, he wrote to his daughter, whose first communion was to occur on that day. His letter is that of a man deeply affectionate, sincerely religious, and eminently trustful of the future that faith alone points out. His letter runs:

"He died, my dear Cecelia, the day of your first communion. Those are two memories which will, I hope, never leave your heart, my dear child. I had a presentiment of his death when I asked you to pray particularly on that morning for your grandfather at Arbois. Your prayers will surely be very agreeable to God at such a time, and who knows if grandpa himself did not know of them and did not rejoice with our little Jeanne [a daughter who had died the year before] over the pious sentiments of Cecelia?"

It is not surprising, then, to find many other expressions of Pasteur's extreme interest in spiritual things, though they might have been little expected from a man so deeply immersed in scientific investigations as he was. After all, it must not be forgotten that his discoveries, by solving the mystery that surrounds the origin of disease, cleared some of the ways of Providence of that inscrutable character which is supposed in shallow minds to constitute the greatest part of their impressiveness. With epidemics explained, not as dispensations of Divine Providence, but as representing the sanction of nature for the violation of natural laws, one of the {318} reasons for which mankind worshipped the Deity seemed to be gone. The man who had done most to make clear these mysterious processes of nature was, however, himself far from thinking that materialism offers any adequate explanation of the mysteries of life, or of the relations of man to man, and of man to his Creator. Impatient at the pretensions of such pseudoscientists, Pasteur once said: "Posterity will one day laugh at the sublime foolishness of the modern materialistic philosophy. The more I study nature, the more I stand amazed at the work of the Creator. I pray while I am engaged at my work in the laboratory."

For Pasteur, death had no mysteries. He had written to his father, once, on the death of his little daughter Jeanne: "I can only think at this moment of my poor little one so good, so full of life, so happy in living, and whom this fatal year, now drawing to a close, has snatched from us. After a very short time she would have been for her mother and for me, for all of us, a friend, a companion, a helpmate. But I ask your pardon, dear father, for recalling to you such sad memories. She is happy. Let us think of those who remain, and let us try to prevent for them, as far as lies in our power, the bitternesses of life." So, when it came to the hour of his own death, Pasteur faced it with the simple confidence of a sincere Christian, and the undoubting faith of a lifelong son of the Church. For many hours he remained motionless, one of his hands resting in that of Madame Pasteur, while the other held a crucifix. His last conscious glance was for his lifelong companion, his last conscious act a pressure of the image of his Redeemer. Thus, surrounded by his family and disciples in a room of almost monastic simplicity, on Saturday, September 28, 1895, about five in the afternoon, passed peacefully away the greatest of the nineteenth century scientists.

Almost needless to say, the life of a man like Pasteur contains the most wonderful lessons for the young scientists of the twentieth century. Few men have lived their lives so unselfishly, and with so much preoccupation for the good that they might accomplish, as he did. To have remained in the midst of it all simple, earnest and faithful to duty, without self-seeking, is a triumph worthy of recording, and makes a career well deserving of emulation. When Pasteur made his discoveries with regard to fermentation the Empress of the French asked to be shown just what his investigations had demonstrated. Pasteur went to Court for the purpose, and after the Emperor and Empress had been shown the ferment cells, and expressed their interest, Eugenie said: "Now, you will develop this discovery industrially, will you not?" Pasteur replied. "Ah, no, that will be left for others. It does not seem to me that it would be worthy of a French scientist to allow himself to be diverted to the industrial applications of his discoveries, even though it might prove eminently lucrative for him." As a matter of fact, had Pasteur allowed himself to be allured into the foundation of an immense manufactory constructed and directed on the great principles which he had discovered, there seems no doubt that this would have been a wonderful money-making scheme. Certain it is that the capital for such an adventure would have been readily available. Had Pasteur yielded to the solicitations made him he might have died worth many millions, instead of the very modest competency which came to him in the ordinary course of his scientific labors. The money might have seemed a temptation for the sake of his children, but the world would have lost all the great discoveries with regard to human diseases. It is not unlikely that these would have been made even without Pasteur, There is no doubt, however, that their discovery {320} would have been very much delayed and that as a consequence almost untold human suffering that has been prevented would have occurred. It must never be forgotten that such men as Lister and Koch derived their most fertile suggestions from the discoveries made by Pasteur.

Pasteur's life may very well be held up, then, as a model to the present and future generations of what the highest ideals of a scientific career can be. Dr. Christian Herter, in the discourse already quoted from, has stated this so well and at the same time has joined with it so felicitously a quotation from Pasteur's advice to young men, that we can find no better way in which to close this consideration of Pasteur's career than by quoting him once more:

"To have fought the long battle of life with unwavering constancy to the loftiest ideals of conduct, toiling incessantly without a thought of selfish gain; to have remained unspoiled by success and unembittered by opposition and adversity; to have won from nature some of her most precious and covert secrets, turning them to use for the mitigation of human suffering;--these are proofs of rare qualities of heart and mind. Such full success in life did Louis Pasteur attain, and from the consciousness of good achieved his noble nature found full reward for all his labors.

"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 gratitude 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.'"

JOSEPH O'DWYER, THE INVENTOR OF INTUBATION

I have hope and wish that the nobler 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

JOSEPH O'DWYER, THE INVENTOR OF INTUBATION.

At the beginning of the nineteenth century a young medical practitioner, 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 nobility and members of the wealthy classes, 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 passed 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 competitive 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 nobly 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 assured 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 passed 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 practitioner 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 antitoxin 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 passages. 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 passage of air and secretions through the larynx. He knew that tracheotomy, as a serious, bloody 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 passage 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 passed, 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 assistants 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 circumstances, 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 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."