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."
{345}
"Ah, sister," he said, "it was a child suffering, and I couldn't stay
home and think that perhaps there was something I might suggest that
would relieve that suffering even a little during the night."
It was this beautifully tender sympathy that urged him on against many
discouragements to continue his investigations with regard to the
possibility of intubation, and finally led him to his brilliant and
perfected discovery. Yet it is even more interesting to find that
after all these years of labor, just as soon as antitoxin was
introduced, and it became clear that a new and great advance in
therapeutics had probably been made, O'Dwyer immediately took up the
new remedy in order to test fully its possibilities. If antitoxin were
to prove the success that was claimed for it abroad, if cases of
diphtheria were to recover under its influence as they apparently had
done in France and Germany, then the role of intubation would soon be
a very small one and O'Dwyer's years of patient investigation would go
for very little. Such considerations, however, had no weight with him,
and it may be said that during his superintendency at the New York
Foundling Asylum antitoxin had for the first time a full, unrestricted
opportunity given it to demonstrate its power for good.
Notwithstanding discouragements of many kinds, the test of the
efficacy of diphtheria serum was persevered in when others with more
apparent reason for interest in it became disheartened and were ready
to give it up, if not even actually deprecating its use. The medical
profession understands very well now how unfavorable were the
conditions under which diphtheria antitoxin was used at first. The
original experiments had been made in the laboratory with small
animals, and the amount of antitoxin necessary to produce good effects
in human beings was not well understood. As {346} a distinguished
authority in children's diseases, who is himself a great advocate of
the efficacy of antitoxin, once said: "It can practically be admitted
that when first antitoxin was introduced its use was scarcely more
than expectant treatment." That is to say, so little of antitoxic
power was contained in the serum injected at first that the children
were practically only kept from other and more exhausting forms of
treatment, while the physicians awaited the results with nature as the
only really active therapeutic agent.
After all, it must not be forgotten that the first doses of antitoxin
contained at most 50 to 100 antitoxin units, as we now measure serum
efficacy for the treatment of diphtheria. At the present time no one
would think of using less than five hundred units as a beginning dose,
and those who obtain the best results begin with 1000 to 1500, or in
severe cases with 2000 to 3000 units of antitoxic strength. It is
almost providential that, notwithstanding this failure to understand
the serum properly, the verdict of the profession did not go so
generally against antitoxin as to condemn its use hopelessly. It is
owing to O'Dwyer and a few other sympathetic souls, who "hoped almost
against hope," that finally experience succeeded in demonstrating the
true value of diphtheria antitoxin.
There was another difficulty, however, in the way of the adoption of
antitoxin that had to be overcome, one that proved no little source of
discouragement to many of those who were testing the remedy. The
original diphtheria serum employed was not concentrated; so when a
sufficient amount of antitoxic units to neutralize the toxins of the
disease under treatment was employed, a large quantity of serum had to
be injected. Experience shows that the injection of any foreign blood
serum into an animal is followed by a certain amount of haemolysis, or
blood destruction, and by {347} certain cutaneous manifestations, such
as urticaria, erythemata, the familiar hives-like eruption and red
itchy spots, which prove a great source of annoyance. In very
susceptible cases the injection of even a small amount of foreign
serum is followed by some fever, by restlessness, and red and swollen
joints. In the early days of the employment of diphtheria antitoxin,
all of these complications were noted in many cases. They were
sufficient to make many who were interested in the demonstration of
the value of antitoxin so disappointed and discouraged that they gave
up the task. Not so, however, with O'Dwyer, who continued its use, and
encouraged others by his example so that in spite of these objections
antitoxin obtained a firm foothold.
Dr. O'Dwyer's conduct, with regard to the continued use of antitoxin
under the discouraging conditions we have sketched, stamps him as a
great member of his humanitarian profession, whose only purpose was
the relief of suffering and the cure of disease, without any thought,
moreover, of self-glorification. The use of antitoxin has made the
necessity for intubation occur much less frequently than before, and
thus has undone some of the good contemplated by Dr. O'Dwyer, but has
accomplished it in a way which he eminently approved and helped on as
far as lay in his power, even at the time when others were doubtful,
not without good reasons, as to the results that were being obtained
from the use of antitoxin.
Perhaps the best index of the sincere simplicity and frank goodness of
O'Dwyer's character is to be found in his relations to the religious
community of which he had been so long a medical attendant. In the
words of one of their superiors, he was looked upon by the sisters at
the Foundling Asylum as the father of the house, who had, as might be
expected, the confidence and trust of every member of the {348}
community. His relations to Sister Irene, the famed superior of the
asylum, became those almost of brother to sister. Sister Irene (as is
well known), though a woman who accomplished some of the best
philanthropic work that, at least, our generation has known, was
always in delicate health. For several years before his death, Dr.
O'Dwyer scarcely ever let an evening go by without coming to see her
personally. He, better than anyone else, realized how much she had
done for the Foundling Asylum, and how much her wonderful influence
was still accomplishing in making the extension of that work possible.
There is, of course, another side to this story of Dr. O'Dwyer's
solicitude for Sister Irene that deserves to be noticed. Few women
have ever accomplished work of the extent and character that Sister
Irene succeeded in doing with so little friction. In the parlor of the
Foundling Asylum there is an engrossed scroll--a tribute to her memory
from the medical board of the Asylum--which shows how well she was
appreciated. As a bit of hospital history it deserves a place here,
especially as there seems no doubt that O'Dwyer's mutual relations to
the sisters and to the medical staff were of a kind that helped
wonderfully in securing the frictionless co-operation that meant so
much for the institution. The memorial scroll reads as follows:
"Tribute to the memory of Sister Irene--to the Sister Superior who
secured friends and funds for the building of the first and largest
foundling hospital in America.
"To the sweet-souled woman--the friend of the foundling and fallen;
to the best friend any medical board ever had, this tribute is
presented with their sympathies to the Reverend Mother and the
Sisterhood of the Sisters of Charity by the Medical Board of the New
York Foundling Hospital."
While an extremely modest man himself, and one of very {349} few
words, Dr. O'Dwyer delighted in teaching others anything he felt that
he knew well himself. His conduct with regard to the teaching of
intubation was especially admirable. He was ready to show any
serious-minded physician just how the operation was accomplished, and
many a young doctor obtained precious training in the exercise of the
rather difficult manipulation involved in placing a tube in a child's
larynx from the hands of O'Dwyer himself. He never lost patience with
the awkward ones and never seemed to consider that too many calls were
made on his time. He might easily have made money on the operation or
the instruments, but deemed such considerations unworthy of his
professional dignity. Personally he was a very reticent man, but, as a
number of friends have said of him, "he made every word count;" and
those who knew him best justly appreciated the expression of an
opinion from him, since it was always sure to be the fruit of mature
consideration and the result of personal clinical experience, usually
extending over long periods.
The opinion held of Dr. O'Dwyer by his colleagues in the
profession--and, be it well understood, there is no more searching
appreciation of practical methods and theoretical opinions than that
obtained by brother-physicians--is the best possible tribute to his
greatness as an investigator, his honorableness as a practitioner, and
his distinction as a man. We quote the summing up of his character
given by Dr. Northrup, who had been his colleague for a score of years
at the New York Foundling Asylum, and whose paper on the subject was
read before the New York Academy of Medicine shortly after O'Dwyer's
death:
"What the world knows of O'Dwyer," said Dr. Northrup, "is his genius
as an inventor, his achievement in adding a great operation to the
equipment of the profession, and thus {350} making the most
conspicuous real contribution to medical progress within the last
fifty years. This the world knows and has acknowledged. To us there is
another and a pleasant duty to testify, that with this genius there
was all that goes to make a man. His home life, his religious life,
his civic life, his professional relations with both colleague and
patient, his hospital relations, were such as befit a high-principled
man. As highly as we esteem him as an inventor and genius and
practitioner of wide knowledge, as much as we valued his superior
medical judgment, we would write upon the monument of his
achievements, 'O'Dwyer the Man.'"
In a previous passage of his address before the Academy, Dr. Northrup
had said:
"If I were asked what most contributed to Dr. O'Dwyer's medical
excellence I would say his habit of thinking and his good logic. He
had a good medical mind, an excellent medical judgment. Above all,
that quality of intellect which allows a man to grow after the age
of forty. To the New York Foundling Asylum, with which Dr. O'Dwyer
was connected for twenty-five years, he was everything; to the
maternity service he was the expert obstetrician; in intubation he
was the inventor and teacher; in the general medical service he was
the constant consulting mind, whose opinion in times of difficulties
and in the midst of puzzling clinical problems every one voluntarily
sought. To the Sisters of Charity he was physician and friend,
consulted with regard to every important concern of the house,
whether medical or not. All adored him."
Dr. O'Dwyer's domestic life was most happy. He had married, very
suitably, a woman of bright disposition, who was a foil to his own
soberer and more melancholy ways, and the relations between husband
and wife growing tenderer with the progress of years, their home-life
became the model {351} of an ideal Christian family. When he lost her
through death, more than half of his life seemed to have gone, and he
never quite recovered from the blow. The circumstances of her death
added to his sense of loss, as it must have increased his appreciation
of her worth. She died a martyr to what she considered her duty as a
Christian mother. During the course of a pregnancy she was taken with
what is known as pernicious vomiting, an affection that is likely to
prove fatal unless the irritated uterus should be relieved of its
burden--a means that neither she nor her husband would consent to
adopt. Her death thus was the result.
During the years after the death of the doctor's wife, intimate
friends found out what an effort of Christian fortitude it was for him
to keep up his spirits and his work. Though he was one of the busiest
of professional men, in very active practice, not a week passed but he
found time to go to her grave and put flowers thereon. Just after her
death he was as a man stricken by some dazing mental affection. Yet
his sense of duty was so great that on his return from her funeral,
being informed that a little child suffering from diphtheria needed
his services for the performance of intubation, he at once made haste
to comply with the untimely demand on him, and had given the little
patient relief within the quarter of an hour after he had alighted
from the funeral carriage.
Personally, Dr. O'Dwyer was of cold exterior, nor had he many close
friends. Those who knew him well understood that beneath the layer of
ice there was a warm, considerate, tender heart for those whom he
admitted to the penetralia of his intimacy. On the other hand, few men
have ever had friends more devoted than were O'Dwyer's. He was,
however, of an extremely sensitive disposition. His conclusions in
medicine had always been worked out with {352} the greatest care, and
were the results of personal observations. To have them criticised
then by those who had much less experience, or who had never thought
along the same lines, was always intolerable to him, and generally
kept him out of medical discussions. Those who knew him best realized
that his opinions were of the greatest value, nor ever failed to
contain a germ of original thought, the result of his personal
experience. After his long years of work at intubation, many of his
medical brethren refused at first to accept his new method of
treatment, claiming that it did not reduce the mortality, even though
it did for a moment relieve the sufferings of the patient. This
position was a source of the keenest disappointment and depression to
O'Dwyer.
After the method of treatment by intubation had been for some time
before the medical profession of the country, a thorough discussion of
it was held at one of the meetings of the Academy of Medicine of New
York. Authorities in children's diseases from several of the large
Eastern cities were invited to be present to give their opinions of
intubation. Most of them were agreed that O'Dwyer's invention was of
very little service. It was not a novelty in the history of medicine
to have a really great and helpful discovery thus at first rejected by
those who were later to be its ardent advocates. To O'Dwyer, however,
who was present and took part in the discussion, the criticism of his
method of treatment was a source of veritable torment. He did not show
at the meeting how deeply wounded was his spirit, but for three days
afterward he practically shut himself up in his room and refused to
see anyone.
Naturally he was of a rather melancholic tendency, prone to dwell on
the sadder side of things, and was constantly interested in sad
stories and songs. He liked sad music, {353} and usually refused to
listen to the livelier airs that others, especially of his race, were
apt to find so refreshing. Something of this sterner side of his
character entered into all his relations with others, and even with
his own family. Though deeply affectionate, he very seldom permitted
them to see and appreciate that fact. He was rather apt to be stern
than otherwise, fearful lest his affection should in any way spoil
them. To the very young children, in whose regard he did not consider
this objection to hold, he was almost demonstratively affectionate,
and those who knew his love for little children appreciated the
sacrifice he made in denying himself demonstrations of affection to
his own.
With all his sadness there was, as might be expected from his racial
descent, a vein of dry humor, not infrequently manifest, though only
to very near friends. He appreciated a good story, though the
slightest tendency to vulgarity was extremely displeasing to him. He
is said to be the originator of the humorous expression that has since
been used often enough. While one day calling at a friend's house, in
the absence of the friend, the servant asked him to leave his name,
but was met with the reply (from the doctor) that "he preferred not
to, as he thought he might have use for it before he got home."
The religious side of O'Dwyer's character is intensely interesting,
because it represents a successful professional man--the maker of an
important discovery in medicine; a logical, scientific thinker, whose
opinion was valued by all his professional brethren--as one of the
simplest of believers, tenderly pious and faithful. The sexton of the
church near which he lived tells (since his death) of frequently
seeing him steal in during the day to say his prayers at the foot of
the altar. He was one of the most faithful attendants at the
communions and retreats of the Xavier Alumni Sodality {354} of New
York City, of which he was an enthusiastic member. His deep piety can,
perhaps, be best appreciated from a characteristic incident, which
illustrates his faith in prayer--his confidence in Providence. He had
asked for something with regard to one of his children over and over
again, and finally thought that his prayer had been heard. Later on he
had reason to regret the fact that his wish had been granted, and to a
friend, to whom he told the circumstances, he said:
"All that we can do is to say with resignation, 'Thy will be done,'
and then we shall be sure that whatever happens will be for the
best."
The story of O'Dwyer's death serves to illustrate some of the weaker
points of modern medicine. During the nearly ten years after his
wife's death he had never been quite the same man, but had succeeded
in doing a large amount of work and had continued to care for a very
large practice. In December, 1897, he began to develop some anomalous
symptoms, pointing to a serious pathological condition within the
skull. He seemed to have had what are known as "Meniere's symptoms,"
that is, a tendency to vertigo, some ringing in the ears and other
unpleasant feelings. Toward the end of that month some hemiplegia, or
at least some weakness of one side of his body, developed. He was
rather neglectful of his personal health, as most physicians are, and
until this time had paid very little attention to his symptoms. Most
of the prominent New York consultants and nervous specialists were
called in, but there was a marked disaccord as to the cause of the
symptoms.
After some days in bed, comatose symptoms began to manifest
themselves, and on January the seventh following, after having been
lethargic for some days, Dr. O'Dwyer died. The _antemortem_ diagnosis
of his case was dubious, lying amid the possibilities of tubercular
meningitis, {355} secondary infection after otitis media, and
secondary infection from some external cause. During the previous
December, O'Dwyer had been treating a patient with carbuncle, and
developed himself a small carbuncle on his chin. By some it is thought
that infectious material from this lesion had been carried by emissary
veins or their accompanying lymphatics to the inside of the skull,
affecting the meninges, and perhaps portions of the brain-substance
itself.
The _postmortem_ examination did not entirely clear up the doubts of
diagnosis. The lateral sinus was found thrombosed, while there were
some suspicious signs in the middle ear, but no distinct inflammatory
condition. Just how the infection took place, then, is not clear, but
O'Dwyer's condition of lowered resistive vitality was evidently at
fault, to an important degree, in permitting infection to take place
and in not throwing it off afterward.
At the time of his death he was about fifty-seven years of age. He had
reached the maturity of his powers, and with the consciousness of
having accomplished one good work was ready for further original
investigations in practical medicine. A thought that had occupied him
very much toward the end of his life was the possibility of a
mechanical method of treating pneumonia. He had made a series of
experiments on the lungs, and many clinical observations with regard
to the possibility of producing over-inflation by mechanical measures.
He confided to one of his physician friends, who had been closest to
him during life, that he hoped thus to secure a method of treating
pneumonia successfully. This, after all, is the most serious problem
in present-day medicine. Our death-rate from pneumonia is at least as
high now as it was a century ago. O'Dwyer started from the observation
that those suffering from emphysema seldom develop true pneumonia. And
he hoped {356} to prevent the progress of the disease, or to abort it
in its inception, by producing artificial emphysema for the time
being. Had he lived, it seems not unlikely that we would have had
further original work of a high order from him.
Though of Irish descent, Dr. O'Dwyer illustrated very well the
expression that was used of the English nobility who went to Ireland
in Elizabeth's time, and who are said to have become "more Irish than
the Irish themselves." O'Dwyer became an American of the Americans. He
believed in meeting Americans on their own ground, cultivating their
acquaintance, and making them realize the worth of new citizens of the
republic by showing them how sincere was the patriotism of their
recently admitted compatriots.
Dr. O'Dwyer was in everything the model of a Christian gentleman, and
an exemplary member of the great humanitarian profession whose
charitable opportunities he knew how to find and take advantage of at
every turn in life. The American medical profession has never had a
more worthy model of all that can be expected from physicians in their
philanthropic duties toward suffering humanity, nor a better exemplar
of what Christian manhood means in the widest sense of that expressive
term. With an inventive genius of a high order, that gave him a
prominent place in a great generation and that has stamped his name on
the roll of medical fame for all time, there were united the simple
faith, the earnest purpose, the clear-sighted judgment and the feeling
kindness--those supreme qualities of head and heart that will always
secure for him a prominent place in the small group of great medical
men.
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