"DAVID AND GOLIATH"
By George B. Sanders, M.D.
(By invitation, Eugene H. Conner, M.D. to comment upon the development of the endotracheal tube and positive pressure ventilation for open chest since George Sanders, M.D. is confining his remarks to the development of the cumbersome negative pressure chamber).
"Development of the Endotracheal Tube and Positive
In 1928, Ralph M. Waters, M.D. [b. 1883] and Arthur E. Guede1, M.D., pioneers of anesthesia in the United States, introduced what they then believed to be a new type of endotracheal tube with an inflatable rubber cuff that could make a gas and water tight fit in the trachea when inflated. (1, 2) Several years later Dr. Waters was invited to report on the historical developments related to endotracheal anesthetic administration. On this occasion, Dr. Waters assigned three main causes for the development of endotracheal anesthesia. (3) They were:
1. The treatment of respiratory obstruction and resuscitation by artificial respiration.
2. Protection of the tracheobronchial tree from contamination by debris in surgery of the mouth and nose.
3. Control of intra-pulmonary pressure in thoracic surgery.
These three most important causes for the development of endotracheal anesthesia remain the same today. Hopefully the intervening "40" years since Dr. Waters’ address may have provided us a better perspective.
Tracheostomy and Resuscitation - 16th Century
The earliest use of this operation was for demonstrating alterations of the beat of the heart produced by inflation of the lungs in the experimental animal - either dog or pig. This application by the famous surgeon-anatomist, Andreas Vesa1ius [1514-1564] is described as follows:
That life may in a manner of speaking be restored to the animal an opening must be attempted in the trunk of the trachea, into which a tube of reed or cane should be put: you will then blow into this, so that the lung may rise again and the animal take in air. Indeed with a slight breath in the case of this living animal the lung will swell to the full extent of the thoracic cavity, and the heart becomes strong and exhibit a wondrous variety of motions. ...For when the lung, long f1accid, has collapsed the beat of the heart and arteries appears wavy, creepy, twisting, but when the lung is inflated, it becomes strong again and swift and displays wonderous variations...
And as I do this, and take care that the lungs is inflated at intervals, the motion of the heart and arteries does not stop. (4)
This is clearly resuscitation and a demonstration, in an animal, that life could be sustained by rhythmically inflating the lungs even with an open thorax. Practical anesthesia is yet nearly 300 years away and antisepsis still another generation after that.
Mechanical Ventilation – Tracheostomy & Resuscitation - 17th Century
The Royal Society since its beginning has been witness to many new physiological concepts and demonstrations of such discoveries are yet a part of their regular meetings. It was before this Royal Society in 1667 that the Curator 0f Experiments, Robert Hooke [1635-1703] performed tracheostomy on a dog and preserved its life by breathing for it by means of a bellows. He even removed the thoracic cage and demonstrated that movement of the lungs was not essential to life but rather a continuous stream of “fresh air” was essential. (5) This was in October 1667.
Here in the 17th century we have clearly established a mechanical means of ventilation - the hand operated bellows. The operation of tracheostomy is performed again for establishing a clear airway.
Man’s Concern for His Fellow Man – 18th Century
Nearly a century passes before man's inventiveness is again aroused and directed to resuscitation, but in this 18th century there appears another important development in our civilization. It is a concern of man for his fellow man which was manifested in such ways as the establishing of foundling homes and hospitals and the institution of prison reforms. Our particular attention this evening is the resuscitation of the apparently dead or drowned.
On 18 April l774, Dr. T. Cogan (known mainly as the translator of a Dutch handbook on resuscitation) and Dr. William Hawes formed what was later to be chartered as the Royal Humane Society. (6) These enthusiasts sought the advices of John Hunter, surgeon [1728-93] on methods of restoring life to the drowned. Hunter obliged the Society by recounting his experiments of 1755 in which dogs whose chest walls had been excised had been kept alive by artificial respiration, using a double-chambered bellows. He had designed the apparatus so that one chamber filled the lungs and the other chamber exhausted them [positive-negative ventilation]. Hunter recommended a similar application of his double-chambered bellows in resuscitation of the drowned. His recommendations were confirmed by the professor of Physic at Edinburgh, Dr. William Cullen [1712-1790], in independent observations made with Alexander Monro, Secundus [1733-1817] bellows.
In this excitement of interest in resuscitation, we should mention the work of Edmund Goodwyn who published a monograph of his experiments with submersion, strangulation and asphyxia in animals and his means of curing them. (8) He devised a piston pump which was adapted to a tube “inserted into the nose, larynx, or trachea.” (9) We should also mention the studies of James Curry.