Part 25

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

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

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

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

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

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

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

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

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

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

Later, however, we find the report:

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

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

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

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

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

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"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.