Tracheal Tubes

In the 18th century, tubes were passed into the trachea during resuscitation from drowning, but these tubes were passed without direct visualization and were not for delivery of anesthetic agents. Similarly, the intubations of pediatrician Joseph O'Dwyer (1841–1898) in cases of diphtheria were performed with metal tubes passed blindly.^[402] The O'Dwyer metal tube was later attached to a bellows by George Fell (1850–1918) for the treatment of opioid respiratory depression. Placement of tracheal tubes was vigorously opposed by the influential Parisian surgeon Armand Trousseau (1801–1867), who quoted the failures experienced by M. Bouchut in attempting to pass metal tubes for airway obstruction.^[403] Bouchut had lost five of seven patients during his procedure, called le tubage du larynx, and the other two were rescued only by tracheotomy.^[403] Trousseau was the first to perform a tracheotomy in Paris and wrote a treatise promoting its use during airway compromise in 1851.^[403]

John Snow had accomplished administration of chloroform through tracheotomy tubes in animals, and Friedrich Trendelenburg (1844–1924) used the same technique in humans.^[406] Sir William Macewen (1848–1924) was the first physician to intubate the trachea orally for the sole purpose of administering anesthesia, and it was done to permit continued administration of chloroform during an operation in the mouth. On July 5, 1878, Macewen^[404] performed a blind oral intubation on an awake patient with an ulcerating epithelioma of the tongue. An extensive operation was performed, and the results were excellent. Subsequently, Macewen tracheally intubated three other patients, two for edema of the larynx, and a fourth for another surgical procedure in the mouth. In the fourth case, the pulse was suddenly lost after the chloroform was administered, and the patient died on the table.

The use of tracheal intubation was accelerated to meet the needs of surgeons operating on the face and in the thoracic cavity. To operate within the thoracic cavity, some means was required to avoid respiratory compromise, which followed the inevitable pneumothorax when the chest was opened. Ernst Ferdinand Sauerbruch^[407] (1875–1951) studied the problem as a young assistant to Johann von Mickulicz-Radecki (1850–1905) in Breslau, Germany, and his solution, the Sauerbruch Box, elevated him into a position of international prominence at a young age. The Sauerbruch Box was a cumbersome solution to the problem of pneumothorax and entailed placing the surgeon and the patient (below the neck) in a negative-pressure chamber, while the head of the patient and the anesthetist were outside the box at normal atmospheric pressure. The use of such an awkward construction indicates that the surgeons were determined to solve this problem at any cost. The modern solution, endotracheal intubation and controlled ventilation, as it unfolded was relatively simple, but it took several years to become established.

Franz Kuhn^[368] (1866–1929) perfected a metal, flexible tube and used blind oral or nasal intubation for anesthetic purposes when the surgeon operated in the mouth. Kuhn's first report was in 1905 and included extensive description of the technique that included carbon dioxide absorption cartridges and 20 illustrations. He proposed but did not use inflatable pharyngeal cuffs to prevent air leaks. Insertion of catheters directly into the trachea to insufflate anesthetic agents was begun in the first decades of the 20th century. With this method, gases were introduced under continuous pressure through catheters that allowed exhalation between the space between the catheter and the tracheal wall.

The use of to-and-fro respiration through one large-bore endotracheal tube is credited to Ivan W. McGill^[408] (1888–1986) ( Fig. 1-18A ) and Edgar S. Rowbotham^[409] (1890–1979) to meet the demands of the maxillofacial surgeon. Their technique of blind nasal intubation was to position patients as if they were "sniffing the morning air." Occasional failures of the blind intubation were solved with a special instrument designed by Magill to

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Figure 1-18 Prominent anesthesiologists of the 20th century. A, Sir Ivan Whiteside Magill (1888–1986) was born in Larne, Northern Ireland. He obtained a medical degree from Queen's University, Belfast, in 1913. During World War I, he served with the Irish Guards in the Medical Corps. After the war, he and Stanley Rowbotham (1890–1979) pioneered the use of large-bore endotracheal tubes to allow plastic surgeons to operate on the facial injuries of wounded soldiers. He designed many pieces of equipment for the anesthesiologist, some of which are still used today. Before his death at the age of 98 years, he received many awards, including a knighthood awarded personally by the Queen of England in 1960 and the Henry Hill Hickman Award. B, Ralph M. Waters was born in North Bloomfield, Ohio, and obtained his medical degree from Western Reserve University in Cleveland. He began his career in general practice in Sioux City, Iowa, and specialized in delivering anesthesia in 1916. Waters established the first academic program of anesthesiology in Madison, Wisconsin, in 1927. His contributions were many and included the carbon dioxide absorption method, endobronchial anesthesia for thoracic surgery, and introduction of cyclopropane. His chief legacy is the many residents he trained who then became the leaders within the specialty in the following generation. C, Sir Robert R. Macintosh (1897–1989) was born in New Zealand and was a prisoner of war during World War I. He finished medical training after the war in London and began the practice of anesthesia there. In 1937, he was appointed the first Nuffield Professor of Anaesthetics at Oxford University. He was primarily a clinician, and his innovative techniques of airway management were eventually accepted worldwide. He received honorary degrees from universities in several countries and was knighted in 1955. D, James T. Gwathmey was born in Roanoke, Virginia, in 1865 and graduated from the Vanderbilt School of Medicine in 1899. In 1903, he limited his practice to the administration of anesthetics, and he is considered one of the first full-time private practice physician anesthesiologists in the United States. He devised several new innovations for the delivery of anesthetic gases and introduced these machines to his European colleagues during World War I. He was an original member of the Long Island Society of Anesthetists, which eventually evolved into the American Society of Anesthesiologists. (Courtesy of the Wood-Library Museum of Anesthesiology, Park Ridge, IL.)

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