The Strangling Angel of Children – Birth of Endotracheal Intubation

Up until the beginning of the 1920’s in the United States and contemporarily in many parts of the world, diphtheria has been a leading cause of death in children. Referred to as “the strangling angel of children,” large outbreaks occurred in Europe and in America in the 18th century, and more recently in the 1990’s in Russia and Eastern Europe. In the western frontier of the US in the 19th century, illnesses were common, and epidemics such as cholera, smallpox, and typhoid fever came recurrently. Diphtheria was second only to malaria in taking the lives of young children. The disease was awful, causing pain, swelling of the neck and lymph nodes, and eventually suffocation and death.

To allow a patient to breathe, tracheotomies were common. This technique, which was fatal in nearly a quarter of all cases, was gradually replaced with endotracheal intubation, or the act of inserting a breathing tube directly into the patient’s trachea through the mouth. This method was so effective that it is still practiced today, in generally the same form as almost 100 years ago.

Diphtheria and Its Victims

Early scientists discovered the bacteria that cause diphtheria in the 1880’s, and they had developed an antitoxin for the disease as early as the 1890’s. Although the development and administration of a vaccine against diphtheria significantly decreased the prominence of the disease, it remains a stealthy killer of young children. In the United States today, diphtheria is rare, with no reported cases since 2003, but it remains endemic to many places around the world.

Diphtheria is an infectious disease, caused by a contagious bacterium, Corynebacterium diphtheriae, which primarily affects the mucous membranes of the respiratory tract, as well as the skin, and other sensitive areas of the body, including ears, eyes, and genital areas.

The symptoms of respiratory diphtheria include sore throat, fever, lethargy, difficulty swallowing, and difficulty breathing, and usually appear after a two to five day incubation period. As the disease worsens, a pseudomembrane often develops over the tonsils and nasopharynx. In other words, the bacterium collects and coagulates into a film, which covers the lining of the throat, causing swelling of the neck and difficulty breathing.

As the pseudomembrane gets larger, swelling worsens and lymph nodes become enlarged, giving the neck a “bull-neck” appearance. In untreated cases, this pseudomembrane will become large enough to obstruct the larynx and the trachea, slowly cutting off the airway, causing suffocation and death.

Unfortunately, diphtheria often affected the youngest of children, who were weaker and harder to treat. The pseudomembrane resulting from the infection would make it impossible for the patient to swallow, speak, and later, breathe. Early surgeons had made use of the tracheotomy, which was a small incision at the base of the throat. This allowed for a curved hollow tube to be inserted into the airway to allow the patient to breathe.

Tracheotomies bypassed the swelling of the pseudomembrane in the neck and opened an airway to allow the patient to breathe. They were, however, difficult, painful, and due to the risk of infection, often fatal.

From Tracheotomy to Intubation

Because it was a childhood disease, it is fitting that a pediatrician invented a better method of allowing young diphtheria patients to breathe. In 1858, Eugene Bouchut developed the method of endotracheal intubation, which bypassed the diphtheria pseudomembrane and opened the airway. This method was less invasive than the tracheotomy, and often resulted in a higher survival rate. Bouchut’s first experiment with intubation was by insertion of a small metal tube into the larynx, and simply leaving it in the airway until the pseudomembrane had resolved.

Bouchut’s invention did wonders for the medical world. Although it was at first negatively received, its use in medical procedures other than treating childhood cases of diphtheria was soon obvious. In 1878, endotracheal intubation was used in a surgery to remove vocal cord polyps, and later in treating patients with glottic edema.

After the turn of the century, intubation was used not only in patients requiring an airway, but as a way of administering general anesthesia. In 1919, Ivan Magill was the first to use endotracheal intubation, using a rubber tube rather than a metal pipe, to pass anesthetic gas directly into a patient’s lungs. Perhaps humorously, this was more than an easy way to administer anesthesia. Before intubation, gas anesthesia pipes were prone to leak, and surgeons, leaning close to anesthetic gas for hours at a time, would often fall asleep on top of their patients.

Endotracheal intubation was also used to administer drugs directly into the patient’s lungs. Mercury, for example, was administered in the form of a vapor, and was used as a treatment for membranous croup and ulcers of the mouth and throat, as well as for diphtheria.

Sometimes, good things come from bad, as in the case of diphtheria. An awful disease, which still causes hundreds, if not thousands, of deaths each year, led to the invention of a valuable piece of technology. Endotracheal intubation is now a common procedure in emergency rooms and operating rooms throughout the world. It is used in nearly all major surgeries and is a basic form of emergent care, and diphtheria, no longer the “strangling angel of children,” has now receded to an afterthought of the American way of life.


Bethard, Wayne. Lotions, Potions and Deadly Elixirs: Frontier Medicine in America. Lanhan, MD: Taylor Trade Publications, 2004.

Dary, David. Frontier Medicine: From the Atlantic to the Pacific, 1492-1941. New York: Alfred A. Knopf, 2008.

Hollingham, Richard. Blood and Guts: A History of Surgery. New York: St Martin’s Press, 2008.

Schwartz, MD, Seymour I. Gifted Hands: America’s Most Significant Contributions to History. New York: Prometheus Books, 2009.

Elizabeth Roberts, MA, CPC

Elizabeth Roberts, MA, CPC, holds a Bachelor of Arts in History and Philosophy, and a Master of Arts in Curriculum and Instruction. She is a freelance writer who enjoys sharing her love of history with others. She also enjoys writing as a way to get out of the boring gray cubicle that she occupies in her full time day job. She spends what time she has left with her two daughters and husband, family, and friends, cooking, reading, and creating just about anything with her hands. She also hopes to one day get her PhD in History, and finish one of the many books that she has been writing. Elizabeth has recently been credentialed as a Certified Professional Coder (CPC) by the American Academy of Professional Coders.
See All Posts By The Author