In intubation anesthesia, or tube anesthesia, as it might be called, the patient does not receive the anesthetic directly from a cone or mask. It is inhaled through a soft rubber tube which is introduced into the pharynx through the nostril or mouth. It is most successful in cases that do not require a very profound narcosis. It is indicated in operations on the head, enabling the anesthetist to be at a distance from the field of operation and out of the surgeon’s province.

An important preliminary is to give the patient morphine sulphate, gr. ¼, hypodermatically one half hour before anesthesia is begun, as much less of the anesthetic is then required.

The method is simple. The anesthesia is carried to the surgical degree in the ordinary way with anaesthol or chloroform. A soft rubber catheter with an opening at the end and side, and varying in diameter between ¼ and ? inch, is made smooth with sterile vaseline and then passed through the nostril down into the naso-pharynx for a distance of about 7¼ inches in the adult, to the vicinity of the larynx. If the respiratory air streams freely through the tube it is assumed to be at the proper level and the tube is anchored and held in place by making a single turn of zinc oxide adhesive plaster about it, near the nostril, and fastening the ends to the cheek. It is important that these straps adhere firmly and the skin should therefore be cleaned with a little ether or chloroform before they are attached. This naso-pharyngeal tube must now be connected with a second tube, the conducting tube, to which a perforated funnel covered with gauze is attached, or which is dipped into a tumbler containing loosely packed gauze; the conducting tube should lie by the side of the patient, beneath the sterile sheets and it should be so long that the anesthetist can sit at the foot of the operating table to administer the anesthetic.

Catheters, a piece of rubber tubing, some zinc oxide plaster, and a tumbler containing some gauze, are, therefore, all that one needs in order to improvise, in a few minutes, an adequate intubation apparatus. In practice, simplicity is frequently important.

Cocainization of the pharynx is an unnecessary procedure.

For operations on the mastoid or brain the pharynx need not be tamponed about the tubes. This is done only when blood is apt to flow down into the air passages, as in resecting the upper jaw, in Kocher’s excision of the tongue and various intrabuccal operations.

In such cases, the Roser mouth gag is inserted and the tongue drawn gently forward out of the way, while, aided by the index finger of the right or left hand, a piece of gauze tampon is placed snugly about the naso-pharyngeal tube or tubes. If a stream of expiratory air issues from the tube it is certain that the pharyngeal openings in the tube have not been plugged by the tampon or tenacious secretions. In certain operations on the nose where both nostrils are involved it becomes necessary to introduce the tubes through the mouth—oro-pharyngeal intubation.

The anesthetist need not be at sea, although he is at a considerable distance from the face and eyes, which he is accustomed to watch with such care during narcosis. In any case, the pupil is no longer a very useful guide because the patient has received morphine. There is access to the pulse at the wrist or the dorsal artery of the foot and its regularity and "Pulse" quality can be noted. A diffuse and weakening pulse wave is at once appreciated as a danger sign—too much chloroform—and the tube should be disconnected from the funnel to admit pure air, until the pulse has recovered its quality.

The color of the face can be observed; also the breathing movement of the chest and abdomen, and the respirations are readily heard through the tube. Any change in the character of the breathing or any hindrance in inspiration or expiration is readily detected. From time to time the funnel is disconnected and fluid which may have accumulated in the tube, as for instance condensed anesthetic, is allowed to flow out.

Secretions clogging the pharyngeal end of the tube are expelled by “milking” the tube, that is, forcing an occluded column of air through it by stroking it between the finger and thumb in a direction towards the patient, or allowing a gentle stream of oxygen to flow into its lumen.

As long as the breathing remains unembarrassed and regular, the pulse is of good quality and a general, passive condition maintained, the patient is in the normal plane of surgical anesthesia and any interference would be meddling.