A Study of the Principal Ob 
jectionable Features of 
Intubation. 
BY 
OHAELES E. SAJOUS, M.D., 
LECTURER ON LARYNGOLOGY IN THE SPRING COURSE OF 
JEFFERSON MEDICAL COLLEGE, PHILA- 
DELPHIA, ETC. 
EKPRINTED FROM 
Efye WeiD STorfc l&rOical Journal 
for July 23, 1887. Reprinted from the New York Medical Journal 
for July S3, 1887. 
A STUDY OF THE 
PRINCIPAL OBJECTIONABLE FEATURES 
OF INTUBATION* 
CHARLES E. SAJOHS, M. D., 
LECTURER ON LARYNGOLOGY IN THE SPRING COURSE OP JEFFERSON MEDICAL 
COLLEGE, PHILADELPHIA, ETC. 
As tliG literatme of intubation increases, a firm believer 
in its many advantages can not but behold with regret the. 
statistical evidence which, although numerically increasing 
daily, does not improve its relative position as regards its 
powerful opponent, tracheotomy. This is certainly a source 
of sorrow to the physician who has had repeatedly to wit- 
ness the mental agony of fond parents, for he hailed intuba- 
tion as at least a substitute to the ever-dreaded knife a 
substitute entailing less physical suffering upon the patient, 
less mental suffering upon the relatives. These advantages 
not only implied greater liberty of action, but less hesita- 
tion, less delay, not uncommon causes of a fatal issue. 
The proportion of recoveries after tracheotomy, accord- 
ing to Agnew, who based his calculations upon ten thousand 
cases, is about 30 per cent. In intubation, a list of three 
hundred and fifteen cases, computed by myself, showed that 
Read before the American Laryngological Association at its ninth 
annual congress. 2 
A STUDY OF THE PRINCIPAL 
only per cent, were successful—a difference of 
per cent, in favor of tracheotomy. It does not compete 
with the latter, therefore, hut stands second to it, to be re- 
sorted to when the former is not permitted. This second- 
ary position it has about held for the past year, and since, 
as time advances, there does not seem to be an increase in 
the proportionate number of recoveries, the profession is 
gradually becoming accustomed to intubation in the light 
of an easier, but less promising, operation than tracheotomy. 
O’Dwyer’s contribution to practical medicine is worthy 
of a higher standard. Its inherent qualities are too numer- 
ous not to raise it ultimately to the first rank. Had Bou- 
chut been able to present even the bare 25 per cent, of re- 
coveries, and “tubage” received since then the attention 
that tracheotomy has received, and consequently reached 
the perfection that the latter has, the question of comparison 
would not to-day present itself. Tracheotomy would not 
only be secondary to intubation in the sense here under- 
stood, but it would be limited entirely to different classes of 
cases. As it stands to-day, intubation is encumbered in its 
progress by not a few real defects. Analyzing these, and 
studying their cause, will, I am sure, lead to their early cor- 
rection, and soon annul the dangers resulting from them. 
In presenting this paper I merely wish to record the result of 
a little thinking, and in doing so it is my humble desire 
merely to suggest a plan of action that will, in my opinion, 
soonest bring about the desired result. In this I feel that 
I am morally supported by Dr. O’Dwyer; and, if I differ 
with him in several emitted opinions and herein present 
them without reserve, he will, I hope, bear in mind that I 
am one of his warmest admirers. 
I am confident of the ultimate success and of the greater 
ultimate comparative value of intubation over tracheotomy, 
because I am of the opinion that the difficulties militating OBJECTIONABLE FEATURES OF INTUBATION. 
3 
against the former are purely mechanical; while a close 
study of these mechanical defects has led me to believe 
that they are in turn due to erroneous conclusions as to the 
relative action of several prominent factors in the general 
plan of procedure. 
Taking the principal objections to intubation, and ar- 
ranging them according to the degree of danger attending 
them, we have: 
1. Obstruction of the tube by fragments of membrane. 
2. Crowding down of loose membrane during introduc- 
tion of the tube. 
3. Passage of food through the tube into the trachea, 
and consequent inability to feed sufficiently through the 
mouth. 
4. Momentary arrest of respiration during introduction, 
and shock resulting therefrom. 
5. Liability of the tube to be coughed out, and slipping 
of the tube into the trachea. 
1. Obstruction of the Tube by Fragments of Membrane. 
—This defect I believe to be due (1) to the limited diame- 
ter of the interior of the tube; (2) to its internal conforma- 
tion. 
As to the first defect, Dr. O’Dwyer considers a limited 
diameter of the tube necessary to preserve the expulsive 
force of cough in the expulsion of detached pseudo-mem- 
brane. To use his words: “ Cough, to have its full expul- 
sive power, requires a full inspiration, complete closure of 
the glottis, and then a violent expiratory effort, which com- 
presses the air in the lungs, and forces it through the 
small space between the still contracted vocal cord. Cough- 
ing through a tube, on the contrary, whether in the larynx 
or trachea, means inability to close the glottis, with little 
power of compressing the air, and, consequently, little ex- 
pulsive power. Therefore, the smaller the tube, compatible 4 
A STUDY OF THE PRINCIPAL 
with free respiration, the better, as there will be more power 
to expectorate, and less accumulation of secretions in the 
air-passages, which predisposes to the development of bron- 
chial catarrh and broncho-pneumonia.” I can not agree 
with him in this opinion. The tube hanging loosely in the 
cavity of the trachea, and the head only closing the laryngeal 
aperture by its weight, it seems to me that the smaller the 
interior of the tube, the smaller the tube proper, and the 
more chance for the expulsive air-current of the cough to 
force itself out around the tube, between tissues too much 
swollen to render respiration between them possible, but 
still not resisting enough not to separate under the pressure 
of the air-column. The force exerted upon the membrane 
choking the tube depends, therefore, upon the amount of 
resistance the tissues surrounding the tube present to the 
passage of the air-current; if that resistance is great, and 
the membrane not too tightly wedged in the cavity, the 
fragment will be coughed out; if the surrounding tissues and 
the impacted membrane present more resistance than the 
air-current is able to overcome, the tube will be coughed 
out, if the latter is held loosely; if, on the contrary, the 
tube is too tightly held to be coughed out, asphyxia ensues. 
Here a defect becomes a virtue, and I do not think that I am 
mistaken in saying that loose tubes have saved many lives. 
Close apposition of the vocal bands is only necessary 
to the expulsion of very small masses. We all know the 
power of the voiceless “hem” to bring up even quite small 
quantities of mucus, and the violence with which this move- 
ment sometimes causes small particles of mucus to fly out 
through the mouth. In the execution of this movement 
the vocal bands remain quite a distance apart. Bouchut 
states that in one of his cases great cyanosis existed, and 
that this was relieved by the ejection of false membrane 
through his tube. In a second case, the introduction of OBJECTIONABLE FEATURES OF INTUBATION. 
5 
the tube was followed by the expulsion, at two different 
times, of casts of the primary bronchus. Bouchut’s tubes 
were large. Have we not here practical evidence that a 
narrow aperture is not necessary for the proper expulsion of 
the pseudo-membrane ? 
For the proper expulsion of loose membrane from any 
part of the trachea, the power of the air-current must exert 
itself equally upon all parts of the cavity, in order that 
every part of it be impinged upon by the mechanical press- 
ure that the air-current affords. In order to obtain the 
greatest advantage from this force, the upper opening of 
the trachea must approximate as much as possible its gen- 
eral diameter, including that of the portion immediately 
above the bifurcation. If the upper orifice is constricted, 
the expulsive force centers itself there, and exerts no influ- 
ence upon the pseudo-membrane. At the same time, only 
a part of the air-current passes out, while a part recoils, to 
counteract, to a degree, the expulsive force. A natural in- 
dication resulting from this argument would be to use a 
laryngeal tube approaching as nearly as possible the diam- 
eter of the normal larynx. I can not agree, therefore, with 
Dr. O’Dwyer, who says : “ The smaller the tube compatible 
with free respiration, the better, as there will be more power 
to expectorate and less accumulation in the air-passages, 
which predisposes to bronchial catarrh and broncho-pneu- 
monia.” 
2. Crowding down of Detached False Membrane during 
the Introduction of the Tube.—This accident has occurred a 
sufficient number of times to render it worthy of a promi- 
nent position in the list of dangers accompanying the 
operation. I believe it to be due principally to the length 
of the tubes. “ The object of having them so long,” says 
Dr. O’Dwyer, “ is to retain the pseudo-membrane in situ as 
it becomes detached from the tracheal walls until macera- 6 
A STUDY OF THE PRINCIPAL 
tion takes place.” lam inclined to consider this as a dan- 
gerous measure ; it seems to me contrary to all teachings 
to mechanically retain over their seat of formation masses 
of an infections product that serves but to add to the 
general toxaemia, both through the blood and through 
the inspired air. As prompt a deliverance of all pseudo- 
membrane as possible would seem to me more compati- 
ble with our efforts to prevent extension to the lungs 
proper. 
This reason, therefore, does not appear to me to hold 
good in accounting for the inordinate length of the tubes. 
Their action in crowding down membrane needs no ex- 
planation, The deeper the instrument sinks, the more 
opportunity it has of meeting detached portions which, un- 
touched, would have remained innocuous. This danger, 
therefore, is proportionate to the length of the tube em- 
ployed. 
3. Passage of Food through the Tube into the Trachea. 
—ln considering this drawback, an important question pre- 
sents itself. Is there not, in the occasional passage of food 
into the trachea, a prolific cause of broncho-pneumonia, 
corresponding, at least, with the setiological position of 
tracheotomy in relation to that complication ? Waxham, 
of Chicago, one of intubation’s warmest advocates, who has 
probably had more experience than any man living in the 
performance of that operation, stated at a meeting of the 
Chicago Medical Society, held on February 7th last, that, 
“besides the difficulty of swallowing, food and fluids ran 
into the bronchial tubes through the cannula, and that it 
was true that many patients died from broncho-pneumonia 
from this source,” * presenting at the same time an in- 
genious attachment of his invention to overcome the diffi- 
culty. Again, to quote his words: “lie (the physician) 
* “Jour, of the Am. Med. Assoc.,” March 12, 1887, p. 291. OBJECTIONABLE FEATURES OF INTUBATION. 
7 
may tell the people to feed it bread and milk, or semi- 
solids, and, if he investigate the matter, he will find that 
they are giving it half a teaspoonful of milk with a little 
bread, and the milk trickles into the trachea and the bread 
is rejected. If they are told to make a custard, they make 
it so soft and fluid that it will trickle into the tracheal * 
Imagine a custard and milk rolling down into the trachea! 
And still I have not the least doubt that Dr. Waxham was 
perfectly right. 
In a list of seventeen observers, it is a rather obvious 
fact that those who report the greatest number of cases 
characterized by marked difficulty in swallowing, report at 
the same time the greatest number of deaths from broncho- 
pneumonia. This may be a mere coincidence, but lam in- 
clined to believe that it is not. 
Fletcher Ingals, in the proceedings of March 7th of the 
Chicago Medical Society, stated that, in the cases in which 
he had introduced the tube for other physicians, “ those that 
recovered, he had insisted that they should drink absolutely 
nothing.” In the last case he insisted upon this so strongly 
that “he cautioned the parents that if they gave the child a 
teaspoonful of water they would kill it.” 
That impediment to proper deglutition is an important 
defect of the operation is demonstrated by the fact that fif- 
teen of the seventeen writers above alluded to mention it 
in connection with their cases in a more or less emphatic 
manner. 
Dr. O’Dwyer believes this defect to depend principally 
upon the state of the epiglottis, the mobility of which may 
be very much crippled by inflammatory thickening. I 
doubt whether this is the case, as the proportion of cases 
in which the epiglottis is involved in the inflammatory pro- 
cess sufficiently to paralyze its functions is not to he com- 
* “Cincinnati Lancet-Clinic,” March 26, 1887. 8 
A STUDY OF THE PRINCIPAL 
pared with the number of cases in which deglutition be- 
comes difficult. Again, difficulty in swallowing is men- 
tioned as occurring only after the introduction of the tube 
in all the cases reported, a fact demonstrating that the 
difficulty is due to the presence of the tube. 
The prevailing opinion respecting the cause of this 
objectionable feature is that it is due to the impediment 
offered by the head of the tube to the free action of the 
epiglottis, by preventing its close apposition to the upper 
portion of the larynx. That this is but a small part of the 
faulty mechanism is shown by the following words of Dr. 
O’Dwyer: “ The heads of my first tubes were made very 
small, to permit them to sink well down in the larynx, so 
that the epiglottis could perform its function more per- 
fectly. . . . Notwithstanding that I have quadrupled their 
size, I can see no difference in the ability to swallow fluids.” 
There must, therefore, be another cause. That cause lam 
inclined to believe to be the weight of the tube. Elevation 
of the larynx during the act of deglutition is as important 
a feature of the proper execution of that act as the contrac- 
tion of the constrictors. The muscles presiding over this 
elevation are not strong; their duty being a fixed one, their 
power is proportionate to the weight that they are calcu- 
lated to lift. There is, perhaps, a certain amount of latent 
force in them, to serve in case of necessity, but that latent 
force can be at its best only during health, and the general 
stiffness that pervades the entire throat during severe local 
inflammatory infiltration can but counteract it, to say the 
least. If we add weight to the burden, the exact power 
necessary will either be present or absent, according to the 
inherent strength of the muscles and to the degree of their 
involvement in the inflammatory process. It must not be 
forgotten that in swallowing the larynx ascends more 
toward the epiglottis than the epiglottis descends to the OBJECTIONABLE FEATURES OF INTUBATION. 
9 
larynx. If, therefore, the ascent of the former is checked 
by only one sixteenth of an inch, there will be an aperture 
left quite sufficient to allow a considerable quantity of fluid 
to enter. 
4. Momentary Arrest of Respiration during the Intro- 
duction of the Tube.—Dr. L. L. Palmer, of Toronto, in an 
interesting article on intubation,* relates a case in which 
the introduction of the tube was followed by an increase in 
the pulse-rate of from fifteen to twenty heats, which con- 
tinued until death. He recommends a short first attempt, 
with special effort, to render it successful. He is inclined 
to consider momentary asphyxias as greatly aggravating 
causes, and is considering whether in his case these did not 
cause extension of the local manifestations. 
Although seldom alluded to, this feature of the opera- 
tion must certainly carry along with it a pernicious effect 
upon the already semi-asphyxiated patient. Needless to 
say that it is due to the presence of the obturator, which 
blocks up the cavity of the tube from the time the tip enters 
the larynx until it is well in place. 
5. Liability of the Tube to be Coughed Out.—This occurs 
in almost every case, and is due, in my opinion, to the con- 
formation of the tube, which exposes it to the action of the 
air-current during cough, and causes it to be influenced by 
it as if it were a foreign body. 
The principal mechanical defect in this case is again the 
limited diameter of the interior of the tube, which is out of 
proportion to that of the column of air. The pressure is, 
therefore, exerted around the instrument with sudden vio- 
lence, assisting the suddenly narrowed portion of the air- 
current which passes through the tube, in lifting it bodily. 
6. Slipping of the Tube into the Trachea.—Slipping of 
the tube into the trachea during efforts at withdrawal is 
* “ Canadian Practitioner,” January, 188 V. 10 
A STUDY OF THE PRINCIPAL 
probably due to narrowness of the head, the descent being 
also assisted by the weight of the instrument. Independ- 
ently of these mechanical features, however, the accident 
principally depends upon the selection of an instrument too 
small for the cavity that it is to occupy. 
Recapitulating, we have then: Obstruction of the tube 
by detached membrane, due to the limited diameter of its 
interior. 
Crowding down of loose membrane during the introduc- 
tion of the tube, due to its inordinate length. 
Passage of food through the tube into the trachea, due 
principally to its weight. 
Momentary arrest of respiration during the introduction 
of the tube, due to the presence of the obturator. 
Liability of the tube to be coughed out, due principally 
to the limited diameter of the interior. 
Slipping of the tube into the trachea, due to its weight 
and to the conformation of its head. 
We have now considered the principal defects of intu- 
bation, and I have given you what to me seemed to be their 
origin. I may be right, I may be wrong in my conclusions. 
I give them to you for what they are worth—food for 
thought. Let me say, however, as an encouragement, that 
by eliminating from the statistics in my possession the 
cases of death that I thought might have been avoided, had 
the instruments reached the degree of perfection that they 
will some day reach, the proportion of recoveries, instead of 
25 per cent., became 43 per cent. This is, of course, a mere 
estimate, imbued with a certain amount of guessing, but I 
feel confident that the time is not far distant when this rec- 
ord, at least, will stand to the credit of intubation. Then, 
even more than now, will O’Dwyer’s patience and perse- 
verance be appreciated. How many thousands of lives will 
it have saved! OBJECTIONABLE FEATURES OF INTUBATION. 
11 
In conclusion, I will show you a set of instruments that 
I have had constructed in which I have tried to incorporate 
the qualities that an intubation set should possess in accord- 
ance with the ideas set forth above. Their value will de- 
pend, of course, upon the correctness of my views. In de- 
vising them I based myself upon the principle that the 
natural conformation of the larynx should as much as pos- 
sible be followed, in order to preserve for the patient, to 
the greatest degree possible, the natural physiological func- 
tions of the surrounding parts. They are more calculated 
to supply the larynx with a metallic coating to preserve its 
perviousness than with a tube, properly speaking. To con- 
struct the throat-piece, I took a plaster cast of a larynx, and 
this, in turn, served to sink a die, which was used to transfer 
its shape to thin sheets of metal (due attention being paid to 
strength). Each side being taken separately, two plates were 
obtained which, united on the sides, formed an accurate mold 
of the internal aspect of the laryngeal cavity from the ary- 
epiglottic folds down to below the vocal bands. You will 
notice, however, that the lower portion of the instrument 
extends on an average one inch below the bands. The two 
side-pieces are united immediately above the middle, and 
in doing so the edges are bent so as to prevent close apposi- 
tion of the joints to the parts adjoining them. In this 
manner neither the anterior commissure nor the inter-ary- 
tenoid space is touched by the instrument. The two 
pieces work freely around the pins holding them together, 
the upper portions becoming approximated when the lower 
separate, and vice versa. When the latter is the case, the 
instrument assumes the shape of a sharp Y. When it is in- 
troduced into the larynx it assumes the shape of a capital A, 
with a funnel at the top. In this position the separated 
lower branches are in the trachea, the narrow portion of the 
funnel is at the vocal cords, and the edge of the broad por- 12 
A STUDY OF THE PRINCIPAL 
tion of the funnel is just below the ary-epiglottic folds, its 
shape being such as to avoid any interference with the epi- 
glottis. The mold presented on each side, near the top, 
two rounded protuberances corresponding with the ven- 
tricles of the larynx. Reproduced in the instrument, these 
protuberances form a convenient supporting point, resting 
as they do on the vocal bands below and within the ven- 
tricles above, the edge of the ventricular band resting in 
turn in the recess formed by the protuberance and the lower 
portion of the funnel on each side. It is thus held securely, 
the vocal band preventing its descent and the ventricular 
band its ascent. The internal portions of the protuber- 
ances serve for the hooks of the forceps. The general ap- 
pearance of the instrument is that of a bivalve speculum. 
Dr. O’Dwyer’s first idea was to use such an instrument. 
After experimenting a few times with one, he abandoned it 
to resort to tubes. The defect was that the mucous mem- 
brane of the inter-arytenoid space and adjoining parts 
“pressed forward between the edges of the separated valves 
and the dyspnoea returned.” * The mechanical error in 
this case was that the valves were united near the top, so 
that, when they were separated by the action of the spring, 
a gap occurred opposite the inter-arytenoid space and ad- 
joining parts below, and also opposite the anterior commis- 
sure, thus enabling the swollen membrane to invaginate it- 
self into the interior of the instrument. In the instrument 
now shown the point of union is nearly half an inch below 
the level of the vocal band, so that when the instrument is 
in position a complete tube is formed extending from the 
top of the inter-arytenoid space to almost half an inch 
below the vocal bands. Although not fitting tightly within 
the larynx, the adjustment is such that, like a well-fitting 
shoe, it can not produce irritation in any particular spot. 
* Northrup, New York “Medical Record,” Dec. 11, 1886. OBJECTIONABLE FEATURES OF INTUBATION. 
13 
Its movements are automatic, the vocal bands opening and 
closing the valves, according to the relative position they 
occupy with them. When they are introduced, closed be- 
low, and pushed downward, the moment the point of junc- 
tion is reached, the valves open below and close above, 
forming the tube. When the instrument is withdrawn it 
remains closed above until the joint is reached, when it 
suddenly opens, the lower portions closing. This arrange- 
ment renders introduction and withdrawal exceedingly 
easy. This mechanical arrangement should obtain the fol- 
lowing advantages: 
Ist. We have almost the same breathing space as in the 
normal larynx, thus preventing as much as possible ob- 
struction by detached membrane. 
2d. The comparative shortness of the instrument and 
the early separation of the lower portions of the valves re- 
duce greatly the danger of crowding down loose pseudo- 
membrane. 
3d. The light weight of the instrument and the shape of 
the head avoid interference with the act of deglutition. 
4th. Separation of the valves a short distance above 
their tips, when closed, enables the patient to breathe freely 
while the instrument is being introduced. 
sth, The fact that the force of the air-current is exerted 
in the center of the instrument and has sufficient space to 
pass freely, renders ejection during cough almost impos- 
sible. 
6th. The breadth of the head, the facility with which it 
can be grasped by the forceps, combined with the lightness 
of the instrument, make it impossible to force it into the 
trachea without fracturing the thyreoid cartilage. 
As to the forceps, it only differs from ordinary instru- 
ments of that class in having a side-hook at each tip to 
penetrate the ventricular cavities of the speculum and hold 14 
A STUDY OF THE PRINCIPAL 
the instrument fast. The tips can be extended so as to 
render the instrument applicable to all ages and depths of 
larynges. To engage the speculum in the grasp of the for- 
ceps, the tips of the latter are passed into thp funnel-shaped 
cavity and then allowed to open. When the speculum is in 
the larynx this procedure, prior to extraction, is extremely 
simple. The forceps acting automatically, their tips have 
merely to be passed behind the epiglottis and depressed un- 
til an obstruction (the bottom of the funnel) prevents fur- 
ther progress. Allowing the forceps to open, they grasp 
the speculum firmly, when slight traction will suffice to 
withdraw it. This has been tried repeatedly upon the ca- 
daver. The manipulation of introduction is that recom- 
mended by Dr. O’Dwyer for his instrument. 
I wish also to show you an instrument devised for the 
purpose of withdrawing detached membrane from any part 
of the trachea, from the bifurcation up. It consists, as you 
can see, of a spiral tube, which, pushed out through the 
shaft of the body of the instrument, can be lengthened at 
will from the handle. A small blunt forceps is mounted on 
the end of the spiral tube, which forceps opens while on 
the descent and closes as soon as the spiral tube is drawn 
home. This instrument can be used with the speculum in 
situ, and is so constructed as to not interfere with respira- 
tion. For the extraction of foreign bodies from the trachea 
it will also, I think, render valuable services. I have already 
had occasion to use it, with gratifying results. 
You will pardon me for introducing the laryngeal spec- 
ula to you before having tried them upon the living subject, 
the crucial test—the only one, in fact, that can render them 
worthy of your attention. You will kindly remember that 
they are merely brought before you to illustrate the ideas 
set forth in ray paper, and that eighteen months will proba- 
bly elapse before we meet again, and therefore eighteen OBJECTIONABLE FEATURES OF INTUBATION. 
15 
months before I have an opportunity of showing them to 
yon. My future plan of procedure with them will he to try 
them in a number of cases, and when found satisfactory in 16 THE OBJECTIONABLE FEATURES OF INTUBATION. 
my bands, I will place a number of sets at the disposal of 
as many general practitioners and request them to study the 
defects that they may present in their hands (naturally not 
so accustomed to the manipulation of laryngeal instruments 
as mine), and, these defects once corrected to their and my 
satisfaction, I shall again have the pleasure of bringing them 
before you, but in a more mature form.