Sunday, August 23, 2015

1774-1829: Humane Society used intubation, bellows

Figure 3 -This is an 1823 version of an airway box.
 It was often referred to simply
as a Case of Resuscitating Instruments.
 Contained inside was all the equipment
necessary to breathe for a victim.
  Such cases were stored at Receiving Houses.
Rarely were they at the scene when needed,
so other means of inflating lungs were attempted.
(12, page liii) (14, page46)
One of the recommendations by the Royal Humane Society was to breathe for victims by using fireside bellows.

The use of mouth to mouth breathing was initially on the list of recommended methods.  However, due to epidisodes of disease, people developed a fear of this method, and it was ultimately scratched from the list of recommendations.

Surely there was other equipment that could have been used to provide breaths, although since fireside bellows were readily available in nearly every household, they became the preferred equipment.

In the case a drowning victim was pulled from the water, a rescuer was supposed to carry the victim to a warm shelter.  Perhaps in most instances, this shelter would be a home or business.  The victim was stripped of his wet clothing, dried with warm towels, and placed on a warm bed.  The fire should be stoked to warm the victim, and the fireside bellows should be used to provide artificial breaths.

An old depiction of bellows being used to breathe for a victim.
The more recommended recommendation was to insert the bellows
into one nostril, and then to block the nose and mouth.
Another recommendation was to also apply cricoid pressure,
a method of pressing in on the trachea to occlude the esophagus.
All these techniques were required to prevent air from insufflation
from leaking out so that more air could get into the lungs.
However, lacking a 2nd or 3rd rescuer, the above technique
would probably be the only recourse left. 
The use of fireside bellows to provide artificial breaths was not new.  Galen described using them to provide breaths to animals, and most certainly he was not the only one. Yet considering it was considered sacrosanct to interfere with the process of death in the ancient world, most who made such efforts would most certainly keep it to himself.

In 1530 Paracelsus, and again in 1665 Robert Hooke, used double chambered fireside bellows to breathe for animals through a tracheostomy. Back then, when breaths were given by mechanical means, it was referred to as insuflation.

Dr. Monro secundus played on this idea and constructed double chambered fireside bellows to insuflate vicitms, but his bellows were too big and were rejected by the society. (15, page 2)

In 1776 British anatomist John Hunter used his own double chambered fireside bellows to insuflate lungs. His work made bellows the preferred method of artificial respiration. (5, page 102) (15, page 2)

The creators of the Amsterdam Life Saving Society recognized the significance of bellows, as these were among the apparatus included at rescue stations at "intervals along Amsterdam's canal." (8)

Figure 4 - Photo of the apparatus
used by the society in 1823,
and contained in the cases
like the one in figure 3.
Can you guess what the above
instruments are? The answers
can be found at the end of the
post.   (12, page lii)
The Humane Society was based on a similar model, likewise endorsing the use of bellows:
"Receiving Houses, which are established in the most convenient and appropriate situations along the shores of the Thames, near the banks of canals, in the immediate neighborhood of dangerous pieces of water, and in various parts of the metropolis and its vicinity. And to ensure the due and prompt application of the processes and means of the Society, respectable Professional Gentlemen residing near the Receiving Houses are appointed Medical Assistants." (12, page xi)
In this House (which may be considered as the Society’s model) every thing necessary for the application of the resuscitating process is provided, and kept in constant readiness. A bed is fitted up—a warm bath and electrifying machine, in case it should be found necessary, are in a state of preparation for instant use—apparatus and medicine, of every kind, necessary in a case of Suspended Animation, are deposited there, and during the bathing season in summer, and the frosts in winter, a medical gentleman attends for the purpose of rendering immediate and effectual assistance on the occurrence of accidents. (12, page xii)
On the outside of the other Receiving-Houses of the Society are placed large and conspicuous boards, announcing their object. These Houses are furnished with drags, poles, and other necessary apparatus, all of which are under the constant superintendance of the Society’s Surveyor, and are thus kept in a state of repair and readiness for immediate use in case of accident. (12, page xii)
This is an engraving of the Receiving House in Hyde Park. (12, page xiv)
However, while Hunter proved the significance of bellows, and even though he was the director of the Humane Society, the bellows adapted by the Society were those made by Charles Kite (Kyte), which had a capacity of 500 cubic centimeters. "

From 1782 onward bellows were recommended by the Royal Humane Society as the best means for artificial respiration." (15, page 2)

The bellows, if they were available, were used in one of a variety of ways. One method (the preferred method) was to insert the bellow into one nostril, while the other nostril and mouth were occluded by a second rescuer in order to prevent insuflated air from entering the stomach and to prevent air from leaking out. (12, page 6)

Figure 5 -  A. This is a flexible tube that is inserted beyond the windpipe and gullet.
 An ivory sliding piece can be pushed with the hand as far as possible
in order to plug up the opening of the gullet, and thereby preventing
any air from getting into the stomach. The tube is inserted by the rescuer
inserting the forefinger of his left hand as far as he can into the victim's airway,
and then guides the tube along his finger into place.
B. This is a silver cannula inserted beyond the windpipe into the trachea.
 This cannula is inserted in the same way as inserting the flexible tube.
Bellows are connected to this cannula.  While an assistant holds the
tubes in place, and occludes the nostrils, the bellows are used to
provide artificial breaths to the victim. If this method did not work,
then the rescuers would use the scalpel in the kit to perform a tracheosomy.
A tube would be inserted into the trachea that the bellows were connected to.
(14, plates between pages 204 and 205)(14, page 50-52)
The bellows could also be inserted into the mouth, although a problem that ensued here was that the tongue sometimes blocked the airway. So this may have lead to the recommendation to use the nose. It also lead to the recommendation by Goodwin to insert a catheter into the esophagus to keep the tongue out of the way and keep the airway open. The catheter also came with an ivory sliding piece that could be pushed down into the gullet (the esophagus) to prevent air from entering the stomach. (15, page 2) (14, page 50-52)

The bellows generally came in a case with a variety of other apparatus and gadgets, which could be rigged in a variety of ways depending on the needs of the victim. A blade was usually among the kid if the need to arose to perform the operation of tracheostomy (what was then called bronchotomy). A tube could be inserted into the stoma, and the bellows could be attached to this tube. (12, page vii)

However, the recommendation to use bellows changed in "1829 when Leroy d'Etiolles stated in a memoir that it was possible to kill an animal by suddenly inflating its lungs."

This alarmed the members of the Royal Humane Society, and bellows quickly fell out of favor, no longer being listed as a recommendation for artificial respiration. During the "abeyance" of bellows, the chief methods of reanimation was warming the patient, "with treatment commencing with the immersion of a patient in a bath of about 100° F." (15, page 2)

However, in review of the date, the following was learned:
The following data, taken from one of Kieth's tables, present us with a bewildering illustration.  From 1795-1811, when warmth and insuflation (bellows) were used, there were as many as 54.8 per cent. unsuccessful cases; from 1832-1851, when warmth and friction were used, there were only 10 per cent. unsuccessful cases. Is this striking contrast merely an outcome of the familiar unreliableness of information derived from statistical data, or is it due to the fact that inflation of the lungs by bellows is indeed a very dangerous procedure. (16, page 2)
This was the first ever study that confirmed the fact that inflating too much air into a person to fast could cause damage to the victim's lungs.  The idea that better training, and gentler breaths, must not have occurred to the gentlemen of the society, because as of 1829 bellows were no longer recommended, and fell into rapid disuse.  They would make a comeback, but that wouldn't occur until later in the century.

Figure 3.  Here is a brief description of the apparatus shown in this photo:  1,2 & 3 are fireside bellows;4 is a flexible tube to convey air into the lungs, and 5-9 are pieces that go to this tube;10 is a tube to be inserted into the trachea which the bellows could be connected to; 11 is an elastic bottle for injecting fluid into the stomach; 12 is a flexible tube to inserted into esophagus to convey spirits into the stomach; 13 & 14 are clyster pipes for administering enemas;15 is a scalpel for administering the surgery of tracheotomy. The rest of the objects simply gadgets for joining one part to another.  So, did you guess right? (12, page lii)

 References:  See post "1774:  The birth of the Royal Humane Society"

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