1750-1850: Tuberculosis wreaks havoc

The industrial revolution swept across the civilized world from 1750-1850. New inventions improved agriculture, manufacturing, mining, transportation and technology, and this had a stunning effect on culture and economies.  The world was forever changed for the better, or so people suspected.

Yet while culture and economies improved, a vicious killer spread across this modern world.  No one knew what it was. No one knew where it came from.  No one knew what to do about it.  The killer was generally referred to as consumption, and if you got it you were probably doomed. 

Yet since people were ignorant about what it was, and what caused it, and how it was contacted, they didn't know that by getting together in poorly ventilated areas of mills and factories that they were breathing the contaminated air that was exhaled by people who had the disease.  They didn't know it was caused by a bacteria, and that the bacteria was transported through the air and was inhaled.  

They didn't know the disease was spread by sharing hanker chiefs, and by touching contaminated people.  They didn't know the disease was prevalent before the industrial revolution, but the disease was more of a random disease that occurred here and there by chance.

Yet with the beginning of the revolution, people gathered in small, poorly ventilated areas.  People moved to cities, right into the grasp of the killer.  They did this because they wanted to create a better life for themselves and their children, and they did this not knowing they were moving into the closed chambers of the rampant and killer beast that consumption was.

There were a variety of names for it. It was called scrofula (swollen lymph nodes), Pott's disease (TB of the bone, spine), the Great White plague (17th century Europe), consumption or phthisis (TB of the lung), lupis vulgaris (TB of the skin), Mesenteric disease (TB from non-pasteurized milk), white swelling (TB of bone), and King's Evil (TB of of lymph glands). Or sometimes it's simply referred to as "captain of the ship of death" or "captain of men and death. Later on it would become known as tuberculosis. (9) 

A plague swept through Europe in the 16th century, and during this time what Hippocrates referred to as phthsis was referred to as the Great White Plague. Yet it was usually described by scientists and physicians as either phthsis or consumption and sometimes even scrofula.
During the next 200 years thousands would be killed. Little was known about it other than it's symptoms. Usually, a patient was diagnosed by a physician only after the patient noticed he was coughing up blood. By this time the disease was near its later stages, and prognosis was grim.
Franciscus dele Bo Sylvius published a book in 1679 called the Opera Medica in which he made the association between nodules in the lungs with phthisis. Perhaps as a result, in the 17th and 18th centuries, there were many references to the disease being contagious, and many warnings about those infected with it. (3) 

Yet for the most part physicians thought it was hereditary, as which was no different from what Hippocrates thought way back in the 5th century B.C.

Giovanni Baptista Morgagni, an Italian anatomist who lived 1682-1771, wrote quite a bit about medicine in his later years. He warned that the condition might be an infection and he warned against doing autopsies on anyone infected with it. (1, page 2)

TB was called "White Plague"
in the 18th-19th centuries

Right around the turn of the 17th century a health edict in the Republic of Lucca in Italy warned:

"Henceforth, human health should no longer be endangered by objects remaining after the death of a consumptive. The names of the deceased should be reported to the authorities, and measures taken for disinfection.”(2)

English Physician Benjamin Martin published a book in 1720 called "A New Theory of Consumption."  He wrote that the disease was caused by "wonderfully minute little creatures." He believed these "creatures" enter the body and cause the symptoms.

Likewise, Martin believed that those in close proximity to the patient, particularly those talking to the person, should be careful.  He wrote:

It may be therefore very likely that by an habitual lying in the same bed with a consumptive patient, constantly eating and drinking with him, or by very frequently conversing so nearly as to draw in part of the breath he emits from the lungs, a consumption may be caught by a sound person... I imagine that slightly conversing with consumptive patients is seldom or never sufficient to catch the disease."

In 1793, Dr. Matthew Ballie published a book "Morbid Anatomy of Some of the Most Important Parts of the Human Body." (?check year and book) He provided a description of the lungs and many lung diseases. He wrote about consumption, and was among the first to note nodules in other organs other than the lungs.
In 1689 Richard Morton (1637-1698) used the term "tubercle" to describe lesions he saw in organs of those who died of consumption.

Rene Laennec was born in 1787 and contacted tuberculosis as a young adult. He became rapt in studying this disease during the course of his career as a physician. He is best known for his 1816 invention of the stethoscope.  He was also the first to master its use.  He was also the first to see tubercles in lung tissue of those patients?

In 1819 he published "A Treatise on Diseases of the Chest, and of Mediate Auscultation." He described how to use the stethoscope in assessing and diagnosing patients. He also discussed the pathology of many disease processes, including what was used it to describe symptoms during various stages of the condition.  He described the adventitious lung sounds heard in people infected with pulmonary diseases like consumption.

Laennec met his demise by the grips of tuberculosis in 1826 at the young age of 45.

Samuel George Morton (1637-1698) was a pupil of Laennec. In 1834 he published his own book titled "Pulmonary Consumption." This would be the first book on the subject published in the United States. (4, page 10). 

He recommended that the age old practice of bleeding patients who are coughing up blood was a "plan that has hurried thousands of patients to their graves by destroying the last remains of strength."

However, if the patient was of good strength with a good pulse, he recommended "ten or twelve ounces of blood, taken rapidly from a large orifice, may divert the current of the circulation and relieve the pulmonary congestion." (5, page 120).

He said this would work because the condition resulted in ulcers which dry and the blood becomes congested around these regions causing the ulcers to burst, and this is why these patients spit up blood. He believed bleeding prior to this happening would help prevent the congestion.
Other remedies may also help "promote absorption of the congested blood" Some of these include:

• Spirits of turpentine
• Elixir of vitriol
• Common salt
• Opium
• Sugar of lead
• Rest
• Diet of gum water and farinaceous food

He agreed with a Dr. Beddoes, who recommended a ride in the fresh air as treatment.  Morton quotes Beddoes:

"In haemoptysis and pulmonary hemorrhages, I never observed any bad consequence from traveling in a carriage: on the contrary, I have known these discharges to stop on a journey, though previously they had, for many days, occurred at least once in twenty-four hours."

Johan Lukas Schönlein (1793-1864) wrote relatively little during his life. However, he did write a doctoral thesis and two papers of 1 and 3 pages respectively.

Despite his lack of enthusiasm for writing, it was Schönlein who introduced the terms hemophilia and tuberculosis in 1839. The word "tuberculosis" was derived from "tubercle", a word introduced by Morton in 1689 to describe the characteristic lesions of consumption.

The mid 19th century was a time when many scientists and doctors were experimenting with microbes. In 1843 Dr. Klencke became the first to cause an animal to develop the condition by innoculating a rabit with "portions of miliary and infiltrating tubercles from a man. Klencke, after accomplilshing this result, did not continue his investigations, and they were consequently soon forgotten." (6)
Despite all the research that had been done prior to 1865, many physicians believed that each case of tuberculosis "rose spontaneously in predisposed people." (2) 

Yet it was in 1865 that a French military physician named Jean Antionne Villemin proved that tuberculosis was caused by an infecting organism.
He inoculated cattle with both human tuberculosis and bovine tuberculosis. (6)  He thus proved that the two diseases were of similar origin, and he proved that the disease could be transferred form a human to cattle and from cattle to rabbits.  (2)

Regardless of Villemin's work, the idea that tuberculosis was a spontaneous condition was ingrained in the minds of many medical experts who performed many experiments trying to prove Villemin wrong.  While it took several years, in the end Villemin's ideas won out.

Robert Koch (1843-1910) was the next to perform many experiments on tissue from tuberculosis victims to see if he could learn more about it and come up with a cure.  He invented a staining method that allowed him to see the tubercle bacillus.

Through "artificial cultivation" he was able to grow the bacillus.  He then proceeded to reproduce the characteristics of tuberculosis in animals.  He also identified different forms of the disease in various animals.

Slowly, as the deadliest disease in the history of mankind continued to wreak havoc, the civilized world was learning more about it.  It would remain one of the top causes of death in the United States and Europe until the 1930s, when all this wisdom would result in control of the beast.

References:

1. Norris, Charles Camblos, "Gynecological and Obstetrical Tuberculosis," 1921, New York, London
2. Koehler, Christopher W., "Consumption, the great killer," http://pubs.acs.org/subscribe/archive/mdd/v05/i02/html/02timeline.html
3. "History of TB," New Jersey Medical School, Global Tuberculosis Institute, http://www.umdnj.edu/ntbc/tbhistory.htm
4. Klebs, Arnold Carl, "Tuberculosis," 1909, New York
5. Morton, Samuel, "Pulmonary Consumption," 1834, Philadelphia
6. Flenner, Simon, , "Immunity in Tuberculosis," Annual report of the Smithonian Institution, 1907, New York, page 627 
7. "Captain of the Men of Death," Ulster Med J. 1989; 58(Suppl): 7–9.
8. Sigeris, Henry E, "A History of Medicine," volume I, "Primitive and Archaic Medicine," Second Edition, 1955, New York, Oxford University Press, page 53
9. Seth, Vimlesh, SK Kabra, Rachna Seth, "Essentials of Tuberculosis,"  Third ed., Jaypee Brothers Medical Publishing, 2006, page 3-4
10. Jones, Greta, "Ca;ptain of All These Men of Death," 2001, New York
11. Prioreschi, Plinio, "A History of Medicine," 1991, volume I, "Primitive and Ancient Medicine," Edwin Mellen Press, Chapter VII, "biblical Medicine," page 514
12. Landau, Elaine, "Tuberculosis," 1995, New York, Chicago, London, Sydney, Franklin Watts, pages 13-32

Photos:

• 1.  from  http://www.grantvillegazette.com/articles/The_White_Plague

Further reading:

• Essentials of tuberculosisi in children
• Johnson, H.A., "Consumption in the Northwestern States," The Chicago Medical Journal and Examiner, Volume 37, William M. Syford, et al, editors, 1878, pages 133-143

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1930s-1990s?: Alcohol aerosolization for pulmonary edema

Although I have never seen it, I am aware that alcohol was once used as a treatment for foaming pulmonary edema. It was nebulized as a breathing treatment, forced into the airway by IPPB, or inserted into the ETT. I have heard stories of Vodka being used, although Ethanol Alcohol (ETOH) may also have been an option.

The most common cause of foaming pulmonary edema is heart failure. The dyspnea felt is usually so bad that it causes orthopnea, meaning that the person has to sit up to breathe. Usually the patient has a feeling of impending doom, and will cry out for help. That's my experience with it anyway.

So, what is it? For most of history it was diagnosed as asthma. However, after William Harvey convinced the medical community that blood circulates through the body, this inspired Raymond Vieussens to study the heart. He became the first physician to describe dyspnea caused by a failing heart as separate from dyspnea caused by the lungs. This was during the 1670s.

In 1669, Giorgio Baglivi was the first to describe pulmonary edema (or at least that's what he appeared to describe). He referred to it as "suffocative catarrh."

In 1830 Dr. James Hope was a cardiologist who wrote a book called "A treaties on the diseases of the heart and great vessels."  In it he described how an overworked heart becomes enlarged, as any overworked muscle would.  When this happens it becomes a weak heart. When it poops out it becomes too weak to pump blood through the heart and lungs, and this causes blood to become backed up (congested) all the way back to the capillaries in the lungs, where it seeps out, thus causing pulmonary edema.

Now we know it's a little more than that, and can be caused by other things too, such as fluid overload and kidney failure. It is more likely to occur in the elderly and the sick more so than in the young, although I have seen it in a 26-years-old female.

As blood seeps into the lungs it increases the pulmonary vascular resistance, otherwise known as the blood pressure in the lungs. As this happens, blood will seep out of the blood vessels and into the lungs, causing increased fluid build up in the lungs called pulmonary edema. It's referred as foaming pulmonary edema because it is pink and frothy. This is because it is a mixture of airway secretions and blood.

This results in severe dyspnea and orthopnea. It means that immediate medical treatment is necessary or the person will probably die. It can result from a disease like heart failure or kidney failure, although it may also may be caused when a person is given too much fluid. It can happen slowly over time, and when this happens it may also cause fluid to build up in the lower legs and ankles. It can also happen in a short period of time, and in this case it's often referred to as flash pulmonary edema.

This would explain why some ancient physicians found that diuretics worked to treat asthma. This was because diuretics cause fluid to be drained from the body, from the lungs, from the legs, etc. It caused the person to pee. The more a person pees the more relief will be felt. Today the most common diuretics are Lasix and Bumex. These are given through the IV, and usually work pretty fast.

In the past, however, when there was no effective treatment, the patient's lungs would become so full of foaming pulmonary edema that it would start to come out of the patients mouth and nose. I saw this happen on my first day as a respiratory therapist, and the patient refused treatment, and was dead within five minutes. So it's an impending emergency.

Back in the 1930s, there were no truly effective diuretics, and it was known that Vodka seemed to sooth the foam. So it was often given to these patients. It seemed to stabilize the foaming bubbles which results in rapid dispersion of the bubbles. (1, page 417)

I have been told that it worked really well. In some cases it calmed the foaming bubbles right down and made breathing easier. The theory was it reduced surface tension of the fluid to reduce resistance in the alveoli. This made breathing easier.

I'm told Vodka was used. One therapist told me the pharmacist would sometimes have to make trips to the store to get Vodka. The 1991 edition of "Respiratory Care: A Guide to Clinical Practice," said the dose was 3-5ml of 30-50% ethanol alcohol.  (2, page 417)

Apparently, studies performed in the late 40s or early 50s showed it to be both effective and safe. It was discussed in the 1950 edition of the New England Journal of Medicine (Gootnick, et al).

Inhalation of certain volatile substances decreases the amount of foam in the respiratory passages and may be helpful in acute pulmonary edema. Experiments with several agents were performed in animals with different types of acute edema of the lungs. The best results were obtained with ethyl alcohol, which decreased the severity of the edema and prolonged the survival of the animals. Alcohol, while acting as an antifoaming agent, has no untoward side effects and is well tolerated. This method of therapy is now undergoing clinical tests. (3)

It was also discussed in a 1952 edition of Circulation (Aldo, et al). The authors reviewed a study where alcohol was given by aerosol or with pressure therapy (probably IPPB). They list some of the other options for treating foaming pulmonary edema of various causes. These include:

• Morphine
• Phenobarbital
• Oxygen
• Positive Pressure
• Venesection 

Some patients already received an initial dose of medicine by rescue crews prior to being admitted to the hospital, the authors note. They said, "If, a suitable interval having elapsed, the attack continued unabated in spite of the above procedures, then alcohol inhalation was started. This plan was adopted in order to avoid the objection that life-saving procedures and drug therapy had been omitted to the possible detriment of the patients. (4, page 368)

I really don't know when it was stopped. I learned about it when I was a respiratory student in 1995, so chances are it was long phased out by then. It 4was probably phased out during the 1960s and 70s after the diuretic furosimide (Lasix) was introduced to the market and discovered to be both safe and effective.

I have seen some discussions among healthcare communities where it has been theorized alcohol inhalations were stopped due to harsh side effects. One nurse stated that, since the alcohol was delivered directly into the blood stream through the lungs, it would have resulted in a good drunk, followed by a nasty hangover the next day.

However, Gootnick et all notes that this is not true. Among all the patients who participated in the experiments, "The concentration of alcohol detected in the blood was small; it's general effects were negligible." (4, page 364)

If you have stories about alcohol aerosols or droplets used to treat foaming pulmonary edema, please share in the comments below. If I learn more I will be sure to do the same.
References:

1. Burton, George G, John Elliot Hodgkin, Jeffrey J. Ward, "Respiratory Care: a guide to clinical practice," 1991, Lippincott
2. Lough, Marvin D., Robert L. Chatburn, W. Arlen Schrock, "Handbook of Respiratory Care," 1983, Year Book Medical Publishers
3. Gootnick, Abraham, Henry I Lipson, Joseph Turbin, " "Inhalation of ethyl alcohol for pulmonary edema." New England Journal of Medicine, November 29, 1951, 245: 842-843
4. Aldo, et al, "Alcohol Vapor by Inhalation in the Treatment of Acute Pulmonary Edema," Circulation, 1952, Volume 5, pages 363-369

1743: Hales invents first mechanical ventilator

Stephen Hales (1677-1761)
 (1, page 328)

Stephen Hales was among the great men of science who lived during the 17th century. Among other achievements, he was the first to accurately measure blood pressure, and he invented an artificial ventilator used to purify air for people living in enclosed quarters such as prisons, ships, and granaries.

He was born in 1677 into the world of Isaac Newton (1643-1727), the man who inspired the scientific revolution.  When Hales was only a boy of ten-years-old, Newton was at the peek of his career, publishing his book Philosophiæ Naturalis Principia Mathematica (Mathematical Principals of Natural Philosophy). It was in this book Newton published his laws of motion and laws of universal gravitation. Such wisdom, when he learned about it in school, must have inspired the young Hales. (4, page 66)

A young Hales would also have been influenced by Robert Boyle and John Mayow.  Boyle's was a great chemist (some say alchemist) who was best known for his use of the scientific method and creating Boyle's law, which states the inverse relationship between absolute pressure and the volume of gas.  Mayow was such a great mind that, had he not died prematurely at the young age of 35, might have been the first to discover oxygen and carbon dioxide.  (4, page 66-67)

As those great men set a path for men like Hales, he would do the same for those who followed in his tracks, such as Joseph Black, who discovered carbon dioxide, Joseph Priestly, who discovered oxygen, Carl Scheele, who also discovered oxygen, Lavoisier, who also discovered oxygen and gave it a name, and Henry Cavendish, who discovered hydrogen.

Hales entered Corpus Christi College, Cambridge, in 1696, and studied science, botany, and chemistry.  He was ordained in 1703, and he began his work on chemistry at the laboratory at Trinity College.  In 1709 he was appointed as minister to the Parish of Teddington, where he would spend the rest of his life. He was married in 1719, although his wife died in 1721.  He died at the age of 83 in 1761.  (4, page 65)(5)

His main contributions to science and physiology came in his Statical Essays that were published in two parts: Vegetable Statics, published in 1727 (the same year that Newton died), and Haemastaticks, published in 1733.

In Vegetable Statics he discussed plant physiology and chemistry.  Yet his most significant contributions to our history come from his later work Haemastaticks, which is described by britannica.com as the most significant contribution to the physiology of blood circulation since the works of William Harvey. (5)

In this book he described an experiment where he inserted a tube into a blood vessel and allowed blood to rise up the tube.  In this way he became the first person to "quantitatively measure blood pressure." (5)

He also described measuring the capacity of the left ventricle of the heart, the output of the heart per minute, and the speed and resistance to flow of blood in the vessels.  (5)

He became very interested in the spread of disease, and was aware that people in close quarters were more likely to catch diseases because they were all breathing the same stale air. Infections were easily spreading from one person to another.  (2, pages 241-243)

Of course in his day, once you caught a disease such as tuberculosis, you were at the whim of God, meaning that there was little you could do but pray that you got better.

So he set out to invent something that could be installed at these places to ventilate air from the outside in order to freshen the air inside.  What he ended up inventing was the first artificial mechanical ventilator which he introduced to the public in 1743.

He published his invention and opinions in his 1758 book "Treaties on Ventilators."

Sir John Simon wrote about "English Sanitary Institutions" in 1897, and explained how the invention of Stephen Hales benefited people who spent time in prisons, military barracks, military hospitals, and aboard ships.  He said:

Dr. Hales's "lungs"... seem to have been often advantageously used in ships, prisons and hospitals (the military was) ordered by the Lords of the Admiralty to adapt his "fire-pipes" to His Majesty's Navy 4 Readers of the present day who may find it hard to imagine the " putrid " quality of the atmospheres which in those days the inmates of prisons and ships and barracks and hospitals had to breathe, can well assist their imagination by referring to the pages of Hales and other contemporary reformers. (3, page 119)

John Pringle (1707-1782)
(1, page 374)

The invention was helped along by John Pringle, who was a surgeon general of the British Army from 1742-1758, and considered the father of modern military medicine. (1, page 373)

He studied the spread of disease among the military, particularly fevers.  He observed, along with others, that the more people were in a confined space, the greater likelihood the spread of fevers would be.  (2, pages 241-3)

Attributing it to the stale air inhaled, he championed to have the mechanical ventilator described by Hales installed in hospital wards.  (2, pages 241-3)

He discussed the importance of military sanitation, especially the importance of the mechanical ventilator, in his 1752 book "Observations on the Diseases of the Army." He also wrote about the importance of antiseptics to prevent the spread of disease. (1, page 373)

The problem with the ventilator was electricity hadn't been invented yet, and so the machine had to be man powered.  So, not only was the machine itself expensive, it was expensive to work and maintain. (1, pages 241-3)

So many military hospital wards resorted the difficult task of maintaining wards in well ventilated places such as "barns, churches, or ruinous houses.  Of  course the simplest and least expensive solution was simply to keep patients in the same poorly ventilated wards they were already in.   (1, pages 241-3)

When this was the case, many such institutions worked hard to install as many windows as they could into such places.  When new places were built, as many windows as possible were installed.  Windows, therefore, were the least expensive option to improve ventilation, and by the late 1750s most hospitals had plenty of windows.  (1, pages 241-3)(2, pages 241-243)

Of course, Pringle also said there was an increased effort to try to keep patients separated.  This, along with better ventilation from open windows, seemed to help allay the problem, at least to a certain degree.  (2, pages 241-3)

It got to the point that there are stories of patients who were lying sick in bed looking up through the holes in the ceiling at the stars and moon in the night sky, or feeling the hot sun upon their bodies during the day.  This must have been a nice, refreshing atmosphere to get healthy in.

However, when the weather wasn't so friendly, such a venue must have posed a problem, especially when the rain or snow was falling.

To sum up the contributions of Hales I will quote Dr. Garrison:

Stephen Hales (was) an English clergyman of inventive genius, who enriched practical science in many ways, particularly as the originator of artificial ventilation."  (1, page 328) 

References:

1. Garrison, Fielding Hudson, "Introduciton to the history of medicine," 1922, London, W.B. Saunders Company
2. Hudson, George L, "British Military and Naval Medicine, 1600-1830," 2007, Amsterdam, New York, Editions Rodopi B.V.
3. Simon, John, "English Sanitary Institutions," 1897, 2nd edition, London, John Murray
4. Darwin, Francis, edited by Francis Wall Oliver, "Makers of British Botany," 1913, London, Cambridge University Press
5. "Stephen Hales," britannica.com, http://www.britannica.com/EBchecked/topic/252340/Stephen-Hales, accessed 7/11/14

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1700-1970: Evolution of intubation

How procedure was performed circa 1891 (23, page 20)

Curious physicians started investigating the human body during the course of the 18th century, and they learned a ton about human anatomy. Near the end of the century physicians used this improved wisdom to discover and invent better methods of saving lives, such as intubation and bag mask ventilation.
Such inventions were crude back then, and the methods of performing them must have been traumatic for the patients receiving them, yet they gave physicians something to work with in order to help their patients. The more these physicians struggled, the better they got. The more they tinkered, the better their equipment got.
Here is a pithy progression of some of the results that transpired due to the hard work, and crafty thinking, of a few admirable physicians.

1500:  A paralytic discovered for modern world:   Curare (Succicholine) was one of the most famous native American poison, as the Indians often placed it on the tips of their arrows in order to paralyze their prey. (18, page 4, 177-178) Sir Walter Raleigh first reported the paralytic when he discovered that the South American Tupi Indians used the poison on the tips of their hunting darts. (19, page 1674)

1773:  First resuscitation of near drowning victim:  According to a 1920 publication by the Lungmotor Company, "Drowning: Historical-Statistical Methods of Resuscitation:"

The first reliable history of a resuscitation from drowning was that performed by M. Reamer in Switzerland. This was reported to the French Academy of Sciences and translated into English by Dr. Crogan in 1773. About this time Dr. Fothergill published his "Physical Dissertation on Drowning," which was read before the Royal Society in England. In 1773, the first society for the rescue of those apparently drowned was instituted at Amsterdam, Holland. (20, page 3) (22, page 1)

1774:  Humane Society used bellows to help drowning victims: Members of the society recommended the use of bellows to breathe for victims of accidents (mainly drownings). They recommended that the end of the bellows be placed in one nostril, while the other nostril and mouth were occluded by a second operator. One problem that often occurred was air entering the stomach. Another problem was the tongue blocking the airway. Goodwin ultimately recommended a catheter be inserted into the other nostril into the esophagus to prevent air from getting into the stomach and to keep the tongue from blocking the airway. (22, page 2) (18, page 50-52)

1780:  Bag Mask Ventilation:  In this year a reservoir bag was attached to a mask and used to give breaths to infants who were not breathing at birth. The device was invented by Chaussier. He also invented a cannula (or catheter) that could be inserted into the airway by blind insertion through the mouth into the larynx. His reservoir bag could then be inserted to the cannula to provide positive pressure breaths. (1) He was also the first to provide oxygen breaths to newborns. (2)

1788:  Endotracheal tube:  The first endotracheal tube was invented in 1788 by Charles Kite (Kyte).  He was a surgeon who wrote an essay titled, "The Recovery of the Apparently Dead," in which he described inserting a tube he referred to as a catheter through one of the nares or the mouth to the lungs whereby the operator could either provide positive pressure breaths either by placing his mouth over a mouthpiece or by using bellows.(1)(23, page 50-52)

To cause expiration, Kite recommended pushing in on the abdomen.  Various bellow-type systems were available for providing positive pressure breaths. He also recommended a catheter that was inserted into the esophagus to prevent the tongue from blocking the airway. (1)(23, page 50-52)

On the catheter was an ivory sliding piece that was slid down with a finger into the gullet in order to block the esophagus and prevent air from entering the stomach. Kite's equipment was included in the Case of Resuscitating Instruments that was kept at the various Receiving Houses (Rescue Stations)(1)(23, page 50-52)

1826:  Bellows fall out of favor:  In 1826 by Leroy d'Etiolles performed experiments using bellows and noted in a report that "bellows could kill an animal by suddenly inflating the lungs." (23, page 2) This was among the first reports that showed that over inflating the lungs with too much positive pressure could cause the lungs to collapse.  Due to this report, bellows were no longer recommended by the Humane Society.  (23, page 2)

However, in 1888, "experiments by Leroy were performed that proved that a collapsed lung only occurred when the pressure forced into the lungs was too high, such as greater than 20-80 mm of mercury in the lungs of infants.  As a result of his experiments, he "invented a safety bellows to obviate these effects.  The bellows had a scale graduated in ages attached to the handles to limit the volume of air delivered." (1)  

Experimenters in the succeeding years attempted to create a system of bellows, or methods of fusing them, that were safer to the patient.  

1793:  Intubation to treat diseased patients:  Prior to this time, artificial respiration was generally used to treat near drowning patients or for some other purpose.  Yet near the end of the 18th century artificial respiration was thought to benefit people with diseases or conditions that resulted in dyspnea or asphyxia.  (3, pages 2-4)

This was a time when a tube was sought to be kept inside the airway long-term as opposed to temporary.  Xavier Bichat, a pupil of French surgeon Desault, described how Desault decided to insert a catheter into the larynx of a patient in impending respiratory failure as opposed to a tracheotomy. Desault is considered the first to apply artificial respiration for dyspnea. (3, pages 2-4)

In many cases the patient's breathing became easier, and in one case the patient's breathing became easier and was extubated 24 hours later. Desaults cather "was a large gum-sized elastic catheter, with two large eyes and an opening inferiorly, and he introduced it through one of the nasal fossa rather than the mouth."  (3, pages 2-4)

Catheterization became a common procedure in France, although later fell into disuse.  (3, pages2-4)

1800?:  A paralytic discovered for modern world:   Curare was one of the most famous native American poisons, as the Indians often placed it on the tips of their arrows in order to paralyze their prey. American physicians discovered this poison early on in the 19th century (exact date unknown). Physicians tried to find a safe dose for using it as a paralytic, which was hard to do. They also experimented with various diseases to see if it had beneficial effects. The poison would become an important medicine used by physicians, although it would be a few years before it was proved useful as an anesthetic. (18, page 4, 177-178)

1807:  Method of making Curare discovered:  After Curare was mentioned by Sir Walter Raleigh, many people believed it was made from "poison dart frogs." Alexander von Humboldt discovered that this was not true, that the poison was derived from various vines in the rain forest.  (19, page 1674)

The stems, roots and leaves were crushed and boiled into a paste, which was sometimes mixed with frog and snake venom. A thick black paste was placed on the tips of darts. As they pierced through the skin, the poison would enter the blood stream causing the animal to become paralyzed. (19, page 1674)

Breathing would cease, and the animal was turned into easy prey. This would be a major breakthrough for modern medicine, because it would allow physicians an opportunity to experiment with it on animals, and ultimately on patients of various types. (19, page 1674)

1814:  First use of experiments with muscle relaxants:  Benjamin Brodie (1783-1862) was an English surgeon who performed experiments using Curare (Succicholine) on a donkey, and he proved that so long as the animal was provided with artificial breaths, it could be kept alive during an operation. (2, page 227)(17, page 25)

Charles Waterton gave the Curare while "Brodie supplied the experimental idea." Bellows were used to breathe for the animal for two hours. The animal lived another 25 years. (17, page 25) 

1839:  Intubation fails  Dieffenbach of Berlin tried to catheterize the larynx of a patient inflicted with croup caused by diphtheria and failed. (8)

Figure 1(23, page 6)

1837:  Artificial breathing condemned:  In 1837 Leroy d'Etoille was concerned about the use of such artificial breathing because he suspected it caused emphysema and would collapse the lungs (pneumothorax). (7)
This simply provided another excuse not to perform the procedure, because after the germ theory was established in the late 19th century all methods of performing artificial breaths (positive pressure breathing) was banned for the next 100 years before it's value would be re-established in the later half of the 19th century.  (7)

1845:  Oxygen breaths: A man named Erichson invented the first device that provided positive pressure breaths with oxygen through a cannula inserted through a pipe inserted into one of the nostrils. He recommended ten breaths a minute.

1850:  Jaw-Thrust technique recommended:  One of the problems that must have ensued when a patient was anaesthetised during surgery was asphyxia (or increased risk of it) due to upper airway obstruction. To resolve this problem, anaesthesiologist Joseph Clover (1825-1882) performed the "jaw thrust- chin lift" procedure." (10, page xxi)(9, page 7)

The physician used chloroform as an anesthetic in over 7,000 operations without a single fatality, so other physicians must have been eager to copy his successful techniques.(10, page xxi)(9, page 7)

Due to side effects, and the death of a little girl as a result, the use of chloroform started to wane by 1864, and by WWI was essentially replaced with better, safer anaesthetics (which included both explosive gases and injection through the hypodermic needle that was invented in 1855 by Alexander wood.) (10, page xxi)(9, page 7)

1855: Intubation fails:  Pediatricians become concerned about the large number of children with diphtheria who die despite emergency tracheotomies.  Reybard in Lyon tried to catheterize the larynx of a patient inflicted with croup caused by diphtheria, and failed.  Weinlechner in Vienna tried to catheterize the laryx of a similar patient, and he too failed.  (8)

(26, page 13)

1858:  Bouchut's Intubation Tube is rejected:  In this year French pediatrician Bouchut became the first to describe insertion of a tube into the airway as opposed to a catheter in a case of dyspnea.

The tube he used was a rounded silver tube narrower at the end to be inserted as you can see in Figure 1 It was 1.5 to 2 cm long and 7 cm in diameter. Interestingly, a silk thread was attached to the distal end of the tube that was "brought out to the mouth, and was intended to prevent the tube from going down the trachea or esophagus; and to allow it to be taken out when necessary."

He later "insisted on the distinction between his method and catheterism." However, of the seven cases he cited to the French Academy of medicine, only two lived and both required tracheotomy.

Yet he proved the procedure could be done. Various other physicians described success with this or similar procedures between 1858 and 1880 when the Joseph O'Dwyer introduced his tube (see below) (3, page 5)

Some speculate the reason Bouchut's intubation tube (tubage de la glotte), which "set in the glottic space for a few days" was doomed to be rejected due to a bias created by Dr. Armand Trousseau, who was an ardent supporter of the operation of tracheotomy. Trousseau had previously convinced his fellow physicians that tracheotomy was the best method of creating an airway when suffocation was imminent, even with the low success rate. (12)

The main problem with Bouchut's "small tubes" was that they "did not adapt to the anatomy of the larynx and their sharp edges were a very traumatic cause of lesions to the mucosa and of intense pain." (12) (also see 26,page 13) 

Also of note, since the tube was short, it was barely positioned below the glottis (this would have allowed for air to leak around the tube resulting in diminished lung volumes). (26, page 13)

In the end, "Bouchut and his operation were so bitterly criticised that he became discouraged and abandoned it altogether. So effectually was it crushed out that no further investigations were made in this direction for nearly a quarter of a century." (26, page 13)

Richardson's (21)

1867:  Richardson's Double Acting Rubber Bellows:  Benjamin Ward Richardson created a bellow system similar to Hunter's Bellows (although he may not have known of Hunter's Bellows). The original system took up a lot of room, so he invented the double acting bellows, which "consists of two rubber bulbs terminating in common tube that was called the nostril-tube." One bellow supplied inspiration, the other expiration.

1869: First intubation during operation:  Performed by German physician Friedrich Trendelenburg (1844-1924) to prevent aspiration of blood and mucus during oral operations. 13, page 91)

He is the same person the position "trendelenberg" comes from. This is a position where the patients lies supine (flat on his back) and his feet are set higher than his head.  This is generally done for therapeutic purposes. According to merriam-webster.com, he recommended it in an 1890 paper to provide better access during abdominal surgeries.

Today the position is frequently used in emergency situations when blood pressure is critically low in order to stimulate blood flow to the brain.  It's also often used as one of the various position used to stimulate secretion clearance in diseases that result in thick secretions, such as cystic fibrosis.   

Trendelenburg position

1875:  Blake cures poison victim: Using a device similar to Richardson's Bellows, Blake connected a reservoir of condensed oxygen to it and treated a case of acute poisoning with success. Before this time artificial respiration (often referred to as insufflation) was used mainly to treat neonatal asphyxia, but now the focus was also on treating adults. The nozzle of the device was inserted into the nostril. (1)

1878: The first elective intubation: William Macewan was a Scottish surgeon who, on July 5, 1878, performed the first elective intubation on a patient "with a flexible metal tube" who was not anesthetized. (9, page 7)

"Once the tube was properly positioned, an assistant provided chloroform-air anesthetic via the tube. Once anesthetized, the patient soon stopped coughing." (9, page 7)

The physician lost confidence in his technique when a tube became dislodged and the patient expired. (9, page 7)
His success and failures would become learning points for future surgeons or physicians attempting intubation. (9, page 7)

It also should be noted here that, along with patient anticipation and fear, there was a lot of anxiety among physicians regarding this procedure.  Surely they wanted to help their patients, but they also didn't want to cause further harm by their experimentation.  Macewan, for example, practiced on cadavers prior to intubating any actual living patients.  (9, page 7)

O'Dwyer's Intubation Tube for a child 2-3 years old (23

1880:  The first effective endotracheal tube:  Dr. Joseph O'Dwyer (a pediatrician), and his fellow physicians at the New York Foundling Asylum, observed problems with trachetomy. Once again this occurred during an epidemic of diphtheria where too many children were dying due to suffocation from croup. (3, page 9-18)

Tracheotomy was a viable option as an emergency airway, but it was painful and bloody for children, and the end results were not always positive.  He decided another means of breathing for these children was necessary.   (3, page 9-18)

He at first trialed flexible catheters into the nasal passages, yet this didn't meet his satisfaction.  So he devised a tube to be placed into the larynx where it would remain.  In this way, he picked up where Bouchut left off.  By trial and error he tinkered with the device until it met his satisfaction.   (3, page 9-18)

O'Dwyer's set of five Tubes (26, page 19)

The device was made with a bivalve tube with a narrow transverse diameter, and about an inch long."  A shoulder on the upper end prevented the tube from slipping down (perhaps learned from Macewan's error).  By trial and error the tube transformed so the tube was a "plain tube of elliptical form about an inch in length.  (3, page 9-18)

He then played with longer tubes until he found the desired length.  The final tube used was made of brass and lined with gold, and was accepted by the medical community.  (See figures 2 and 3.)   (3, page 9-18)(also see 26, pages 18-21)

A complete set was included in a box, that included sizes for different aged children, an obturator, an introducer, an extractor, and a gag.   The length of the tubes in inches were 1.5, 1 3/4, 2, 2.25 and 2.5. (3, page 9-18)(also see 26, pages 18-21)

The obturator of the physicians choice is connected to the end of the introducer, and this is used to insert the tube.  If necessary a small thread could be inserted and tied to a hole on the outer edge of the tube to prevent it from going down the traches, and to facilitate removal. (3, page 9-18)(also see 26, pages 18-21)

The kit also came with a scale (see figure  5) which helped the physician determined appropriate depth of the tube according to age.  The scale was used like this:

The smallest tube reaches line 1, and is intended for children about one year and under. The next reaches line 2, and is for children between one and two years. The third size, marked 34 on the scale, should be used between two and four years. The fourth, marked 5-7, is for the next three years, and the largest tube is for children from eight to twelve.

O'Dwyer also designed larger tubes and equipment for adult intubation. (3, page 9-18)

1880:  The Fell-O'dwyer Apparatus:  Once O'dwyer intubated his patient's, he needed a mechanism to breathe for them.  This task fell into the hands of George Fell, who invented a t-piece.  One end of the t-piece was connected to the tracheal tube, and the other to bellows.  The bellows were used to provide positive pressure breaths.  Of course the problem here was it took a lot of manual labor to provide breaths for such patients.  Still, the technique provided physicians an opportunity to help their patients, both when a physician needed to create an emergency airway, and when surgeons needed to perform more invasive operations.  (9, page 7) 

O'Dwyer's introducer connected to obturator (23, page 16)

1887-1888:  George Fell's Apparatus (Hand Operated Bellows): In 1887 Dr. George Fell invented a system of bellows whereby the operator would use his hands to provide positive pressure breaths.  He connected the bellows to either a tracheotomy or face mask. He became the first to perform this procedure on a human in a case of poisoning. (6, page 283)  (22, page 3)

In order to connect the apparatus to the airway, Fell invented a t-piece.  One end of the t-piece was connected to a tracheal tube or mask, and the other to the bellows.  (9, page 7)

Figure 5

1889: The first rubber endotrachal tube:  Thomas Annandale devised a tube made of Indian rubber that was connected from the tracheostomy to (a cap is attached to the trach for just this purpose) to a small tumbler filled with "a piece of absorbent wool at the bottom, upon which chloroform or ether was from time to time sprinkled."  This was significant because a similar material would be used by a later physician to create an endotracheal tube that would be commonly used for over 40 years. (27, pages 261, 838)

1891: The Fell-O'Dwyer Apparatus (Foot operated Bellows):  Once O'dwyer intubated his patient's, he needed a mechanism to breathe for them. George Fell's apparatus must have worked, yet it needed to be fine tuned for ease of use. O'dwyer revised Fell's system so that breaths were provided by pressing down on a lever with his foot. O'Dwyer preferred to connect his bellow system to an endotracheal tube. O'Dwyer was concerned about over-distention of the lungs due not allowing enough time for expiration, and therefore recommended giving slow breaths, or 10-12 per minute. (6, page 283)
1891:  Concerns of Intubation:  By the late 19th century many of the same concerns physicians have today about intubation were considered.  One such concern being the ulceration of tissue due to pressure of the tube set upon it for a long period of time.  Tubes were generally taken out after six days with success, although in some cases were left in 12 days or longer. Dr. Rank, a German physician, ultimately recommended removal of the tube after 10 days, and if necessary, the physician should consider tracheotomy. Some physicians recommended extubation after the 5th day, which would be in line with modern protocols.  Feeding the patient was also a concern, and was either done with soft foods or liquids, or by nasalgastric tube.  It was recommended that if the tube was accidentally spit up that the nurse take advantage of the moment to try feeding the patient prior to re-introducing the tube (if the tube was still needed). (3, page 29-20)

O'Dwyer intubation kit as advertised to physicians in 1901.  (16, page 228)

1892: Dr. O'Dwyer makes pitch for intubation:  In 1892, and according to the New York Academy of Medicine,  Dr. O'Dwyer gave a presentation where he explained that poor statistics shouldn't discourage physicians from performing the procedure, as most studies are performed by "hospital staff, who did not remain on duty long enough to obtain the skill necessary to perform intubation successfully." (14, page 557)

He said:

"The operation of intubation is a difficult one, because it must be done very rapidly.  A period of ten seconds is not safe in some cases, and fifteen seconds would certainly produce apnea in many instances.  The necessary touch and skill require much practice, and this should be acquired on the cadaver until the tube can be inserted in different subjects in about five seconds. It is much easier to perform intubation in some subjects than it is in others.  After such prolonged practice, the operation may be done with comparative safety... No great amount of surgical skill is required to perform tracheotomy, but good nursing is a necessity.  Intubation, therefore, calls for a trained operator, and tracheotomy for a trained nurse."(14, page 557)

Here is another picture of O'Dwyer's Intubation kit. (26, page 27)

He noted that regardless of the challenges, "intubation has supplanted tracheotomy to a very considerable extent, especially in this country (the U.S.)." O'Dwyer further noted that with his new improved equipment, he never found a case in which he found it impossible to insert the tube. (14, page 557)

1892:  Dr. Gay makes pitch for intubation: Another physician, Dr. George S. Gay of Boston, said that...

...intubation is by no means perfect, but it possesses sufficient advantages to give it a permanent place in the treatment of acute laryngeal stenosis (narrowed upper airway caused by croup secondary to diphtheria).  Although it will never entirely displace tracheotomy, the former has some important advantages over the latter.  No anesthetic is required; there is no hemorrhage.  Unless one's early experience with intubation has been particularly favorable, he is likely to prefer tracheotomy.  The strongest advocates of intubation will be found among those who have had the largest experience with it.  The consent of the parents to perform intubation is more easily obtained, and the operation can be resorted to earlier. (14, page 557-558)

This shows the proper position of operator and assistant. 

The assistant holds the head "securely and slightly backward."

The gag should be introduced in the left angle of the mouth,

 well back between the teeth, and widely opened. The operator

 should then quickly seize the introducing instrument with the

 tube attached, hook the loop over the little finger of the left hand,

 and introduce the index finger of the same hand, closely followed

 by the tube" The tube should sit in the larynx. (26, pages 38-40)

1892: Dr. Jacobi makes pitch for intubation: According to the Medical News, Dr. Abraham Jacobi said he performed many tracheotomies (between 600 and 700), but around 1887 he listened to a discussion at the New York Academy of Medicine in which he was "converted from trachheotomy to intubation." (14, page 558)

He warned that, as noted by the Medical News: (14, page 558)

It is very easy to get the parents consent to perform intubation, but it is very difficult to get their consent to perform tracheotomy.  For this reason in many cases the latter operation is performed to late."  (14, page 558)

He said that despite improvements in aseptic techniques, it was still impossible to prevent dying due to sepsis infection of the blood. The Medical News also said that...

...Dr. Jacobi said that, although he is in favor of intubation, and always recommends it, he has never performed the operation personally.  Thirty years ago he was a professed tracheotomist, and on one occasion he was told that he was a good enough man, but that he cut too many throats. (14, page 558)

1893: Cuffed Endotracheal Tube:  It must have also been discovered early on that air was leaking around the tubes, instead of inflating the lungs.  Likewise, some patients must have vomited when the tube was inserted past the gag reflex, and this would have caused aspiration pneumonia, which would spell doom for most patients back then.  Physicians must have sought some means of securing the airway around the tube.  (13, page 91)

According to the 55th anniversary publication of the German Society of Anaesthesiology and Intensive care, Victor Eisenmenger became the first to use an endotracheal tube that had a cuff on the distal end of the tube that was connected by a pilot line to a pilot balloon. Air was inserted with a syringe into the pilot line, and both cuffs would become inflated. The physician would know the distal cuff was inflated when the pilot cuff was inflated. Such a system was soon adapted by other physicians.  (13, page 91)

This is a picture representing insertion of O'Dwyer's tube.
The dotted lines represent the outline of the operator's forefinger.
Back then a finger was used to assist the endotracheal tube to
the desired location in the airway.  The proper tube should be
selected, attached to the introducer, and then introduced to the airwa.
 It was inserted under the tip of the epiglottis, and into the larynx
You  knew the tube entered the larynx when the patient coughs and
the breathing becomes easier.  If it enters the esophagus, breathing
will not become easier.  Once the tube is inside the larynx, the
tube should be disconnected from the introduces.  The tube
should then be pressed forward until it is positioned in the pharynx
Physicians were further warned that "no force should be used,
no anesthetic is required, and the operator should not require
longer than five to ten seconds.
The risk, as you might imagine, was getting bitten by the patient,
and inhaling the same air as the patient, and then getting
the same disease.  Some physicians sacrificed
their lives by attempting to save the lives of their
patients by this procedure.  (26, page 40-42)

1895: First use of laryngoscope:  A laryngoscope was invented to visualize the back of the airway, and was first used by Kirsetein in Germany (15, page 372)

1896: The Fell-O'Dwyer Apparatus modified:  Dr. Northrup recommended the Fell-O'Dwyer apparatus, and it was later modified by Tuller and Hallion of France, and later by Doyan. Doyan's "apparatus consisted of 'duplex' bellows (for insuflation and suction) attached to an intralaryngeal cannula. (22, page 3)

1900:  Cuffed Endotracheal Tubes and laryngoscopes:  Around the turn of the century cuffed endotracheal tubes (ETT) were used with increased frequency.  A larygoscope was first described in 1855 using sunlight to see the vocal cords, and by 1913 a battery powered laryngoscope with an external light was invented.  This was refined so it had a handle with a battery and a light bulb at the end of the scope for easy visualization of the vocal cords.   (2)

1900: Oral intubation becomes popular: Initially the procedure of oral intubation must have been as nerve wracking to the physician as the patient and the patient and the patient's family. However, as with anything, the more it was performed the more confident and competent the physician became in both recommending and performing the procedure. According to a 1911 edition of the New York Medical Journal there must have been enough successes with the intubation by the mouth (per os) by 1900 that it had "found many followers."  (12, page 760)


1900:  Indications for intubation: As more and more physicians became comfortable with laryngeal intubation, they began experimenting with the procedure both on cadavers and on real live patients. The ultimate goal, of course, was to help patients survive diseases that otherwise would have taken their lives. By 1911 some of the indications for the procedure were mentioned in the New York Medical Journal: (12, page 760)

• Narcosis
• Operations (of the mouth, nose, throat and thorax) (12, page 760)

1900-1912:  Intubation technique improved: Frank Kuhn, a German physician, published a series of papers where he "described the techniques of oral and nasal intubation that he performed with flexible metal tubes composed of coiled tubing similar to those now used for the spout of metal gasoline cans." (11, page 7)

The tubes were of his own design. (13, page 91)

As a local anaesthetic to prevent the gag reflex he used cocaine.  He introduced the tube into the airway with a metal stylet.  He used the index finger of his left hand to lift the tongue and the glottic tissue, and used his right hand to insert the tube through the vocal cords.  While cuffs were used by other physicians to seal the airway.  He preferred to have it sealed by "positioning a supralaryngeal flange near the tube's tip before packing the pharynx with gauze."  (11, page 7)  (13, page 91)(also see 22, page 3) 

To see a very good picture of Kuhn's procedure check out this link.  

1902: O'Dwyer apparatus modified again:  This modification was made by R. Matas who 'Constructed an apparatus in which a modified O'Dwyer tube was connected with an automatically acting pump.  The pump contained originally two independent metal cylinders for inspiration and aspiration.  However, the first experiment made on a dog convinced Matas that the suction force, exercised by the aspiration cylinder, does damage to the lungs, and he eliminated that part of the apparatus. (22, page 3)

1913:  Modern laryngoscope invented:  A better laryngoscope was invented by Jackson, and it was later improved by Miller and Mackintosh (see below) (14, page 372)

1914-1918: Magil invents blind intubation:  During WWI Dr. Magill performed a variety of facial reconstruction surgeries. He discovered that in order to do such surgeries the patient had to be intubated.  Along with Stanley Rowbotham, he developed a method of tracheal intubation.  He blindly inserted one tube of gum elastic design into one nostril.  In this way he coined the term "blind intubation."  (24, pages 8, 753)

There were two problems with this system.  One was that anesthetic gas was escaping the tube, and the operating physician was inhaling this gas. Obviously, this affected his work.   The other was that blood and other debris from the operation would fall into the airway when the tube was pulled.  Obviously, this was detrimental to the patient.  So a two-tube system was developed.  One tube was blindly inserted into a nostril to the larynx to breathe and to apply the anesthetic, and the other through the mouth into the pharynx to provide for the escape of gases.     (24, pages 8, 753)

He became so proficient at his method that students from all over came to watch and learn his method. While he taught his method, other physicians continued to have trouble inserting the tubes due to patient agitation, while Magill did not. Magill had a secret that he refused to tell the students: that he applied cocaine as a local anesthetic to the throat. (25, page 110)
The rubber endotracheal tubes used by Magill were standard for the next 40 years until being replaced with plastic tubes. (24, page 8)

1920: Magill Forceps introduced:   In order to guide the nasal tube into the airway, Magill used forceps that still bear his name (Magill Forceps) (15, page 372)(24, page 8)

1926: Guedel experiments with cuffed endotracheal tubes:  Noting the need to protect the lower airway from secretions and surgical debris, Arthur Guedel (1883-1956) performed experiments with using a cuffed endotracheal tube.  His cuff was made out of rubber. His experiments also determined that the best place to position and inflate the cuff was just below the vocal cords.  This, he found, was the best way of protecting the airway during intubation.  Once this task was accomplished, he aimed to encourage stubborn American physicians of the benefits of intubation.  (24, page 8)

1926: Guedel inspires American physicians to intubate:  While European physicians intubated on a regular basis during operations, American surgeons used other means.  Noting the benefits of intubation, Arthur Guedel put on a show where he went around the country with his dog named Airway.  He would anesthetize and intubate his dog, and then submerge it under water.  Just as the audience suspected the dog was dead, he would pull it from the water, extubate it, and the dog would shake off the water and run off.  These shows became known as the Dunking Dog Shows, and proved that intubation not only allowed the physician to breathe for the dog, but the inflated cuff prevented water from getting into the dog's lungs.  These efforts worked, as American physicians soon became proficient in the procedure of intubation. (25, page 111)

1930:  Oral Airway Introduced:  Ralph Waters (1883-1979) introduced the flattened oral airway, and it was later modified by Guedel by fitting the oral airway with a "rubber envelope in an attempt to reduce mucosal trauma." (24, page 753)

1932:  One lung intubation introduced:  Ralph Waters accidentally allowed an endotracheal tube to slip all the way into a patient's lungs, and he inflated the cuff. In this way he learned that one lung could be intubated with a long endotracheal tube while the other was operated on. This made it possible to do lung operations. (24, page 8)(25, page 111)

1942:  Anesthesia during intubation: By the 1880s intubation was being increasingly used for children with airway stenosis secondary to croup secondary to diphtheria.  As a physician observed that the patient was going to suffocate to death unless he did something, the choice was offered to the parents: intubation or tracheotomy?  (2, page 227) (19, page 1674)

Intubation must have presented as the best option in many cases, as the procedure would avoid a cut of the throat.  A problem that continued was the procedure caused quite a bit of anxiety on the part of the patient, as you might imagine.  If the child fought the efforts of the physician, this could make the procedure very difficult to perform. (2, page 227) (19, page 1674)

Cocaine was occasionally used as a local anesthetic to prevent the gag reflex, and general anesthetics were occasionally used to paralyze the patient, although these were only used if the physician was familiar with them and comfortable with their use.  (2, page 227) (19, page 1674)

In 1942, Harold Griffith, A Canadian anesthesiologist, made a major breakthrough in this regard on January 23, 1942, when he and his assistant, Dr. Enid Johnson (also an anesthesiologist) used Curare to paralyze a patient prior to intubation. He used it as an anesthetic in 23 operations, and wrote a report on his successes with it. (2, page 227) (19, page 1674)

This was a major breakthrough because it allowed the surgeons to sedate and ventilate patients during the operation.  (2, page 227) (19, page 1674)

WWII:  Intubations proficiency increases worldwide:  In preparation for the traumas generally associated with battle wounds, anesthesiologists practiced and became very proficient at performing the procedure of intubation.  The methods learned became standard practice, and over time intubation training became a regular part of a physician's training.  (25, page 753)

1964: Plastic endotracheal tubes introduced: They were actually made of polyvinylchloride (PVC) with an inflatable cuff. Rubber tubes tend to harden when exposed to body temperature.  PVC tends to soften at body temperature, and is therefore less likely tocause damage to tissues of the airway.  The tubes are also clear and opaque.  They come with markers so caregivers know how far down the tube is inserted.

1970:  High volume, low pressure cuffs introduced:  Previously, cuffs were low volume high pressure.  When inflated, these cuffs came into contact with very little area of the trachea, and created a great seal.  However, due to the high pressure, risk of cutting off circulation and causing necrosis was high.  High volume, low pressure cuffs would come into contact with more tracheal tissue, although the lower pressure was less traumatic.  Surely the cuff pressure would have to be minimized, and the cuff may need to be rotated up or down 1-2 cm on a regular basis to minimize tissue damage, yet this was a much better set up than the older cuffs. The drawback is the seal is not ideal.

Conclusion:  So you can see that physicians were slow to begin using intubation, although experiments by the few, in an attempt to help their patients, resulted in both an improvement in the technique used and the equipment available.  By the 1940s intubation during surgery became standard practice, and by the 1950s it became standard across the medical spectrum, including on the scene of an accident and emergency rooms.

While fireside bellows remained the preferred method of providing breaths through the endotracheal tube, the quest was ongoing to find a mechanical device that would provide breaths in a fashion that was less laborious for the provider, and safer for the patient.

References:

1. Price, J.L., "The Evolution of Breathing Machines," Medical History, 1962, January, 6(1), pages 67-72; Price references The Bible, Kings, 4: 34 
2. Szmuk, Peter, eet al, "A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age," Intensive Care Medicine, 2008, 34, pages 222-228
3. Ball, James B, "Intubation of the Larynx," 1891, London, H.K. Lewis
4. Woollam, C.H.M., "The development of apparatus for intermittent positive pressure respiration," Anaesthesia, 1976, volume 31, pages 537-147
5. Previtera, Joseph, "Negative Pressure Ventilation: Operating Procedure (Iron Lung)," Tufts Medical Center, Respirator Care Programs, http://160.109.101.132/respcare/npv.htm, and http://160.109.101.132/respcare/ironlung.htm, accessed February 27, 2012
6. Tissler, Paul Louis Alexandre, "Pneumotherapy: Including Aerotherapy and inhalation...," 1903, Philadelphia, Blakiston's sons and Company, page 284,5
7. Lee, W.L., A.S. Stutsky, "Ventilator-induced lung injury and recommendations for mechanical ventilation of patients with ARDS," Semin. Respit. Critical Care Medicine, 2001, June, 22, 3, pages 269-280
8. Sperati, G., Felisati, D., "Bouchut, O'Dwyer and laryngeal intubation in patients with croup," Acta Otorhinolaryngol Ital, 2007, 27 (6), 320-323
9. Barash, Paul G, Bruce F. Cullen, Robert K. Stoelting, Michael Cahalan, M. Christine Stock, editors, "Clinical Anesthesia," 6th edition, 2009, China, Lippincot Williams and Wilkins
10. Subramaniam, Rajeshwari, "A primer of anesthesia," 2008, MO, Jaypee Brothers Medical Publishers
11. Barash, Paul G., Bruce F. Cullen, robert K. Stoelting, Michael k. Cahalan, M. Christine Stock, "Clinical Anaesthesia," 6th edition, 2009, Philadelphia, Lippincott
12. Foster, Frank P., editor, "Book Notices," New York Medical Journal, volume 94, New York, A.R. Elliott Publishing Co.
13. Schuttler, Jürgen, editor, "55 years: German Society of Anaesthesiology and Intensive Care Medicine," 2012, Germany, Springer
14. Gould, George M., editor, "Society Proceedings: New York Academy of Medicine: Stated Meeting, Thursday Evening, October 20, 1892," The Medical News, A Weekly Medical Journal," July-December, 1892, Vlolume LXI, Philadelphia, Lea Brothers and Co., pages 557-558
15. Hagberg, Carin A., "Benumof's Airway Management," 2007, Philadelphia, Mosby
16. "Blees-Moore Instrument Company: surgical instraments," 1901, St. Louis, MO, Burton and Skinner Print
17. Miller, Ronald D., editor, "Miller's Anesthesia," 7th edition, volume 1, 2010, Philadelphia, Churchill Livingstone Elsevier
18. Vogel, Virgil J., "American Indian Medicine," 1970, London, Oklahoma University Press
19. Wheeler, Derek S., Hector R. Wong, Thomas P. Shanley, editors, "Pediatric Critical Care Medicine: Basic Science and Clinical Evidence," 2007, London, Springer
20. "Drowning: Historical-Statistical Methods of Resuscitation," no author nor editor listed, Published by Lungmotor Company, Boston, Massachusetts, 1920
21. Hughes, Martin, Roland Black, "Advanced Respiratory Critical Care,"  2011, New York, Oxford University Press; material from section 3.1: "Invasive Ventilation Basics: Development of Invasive Ventilation (history)."
22. Meltzer, S. J., "History and analysis of the methods of resuscitation," Medical Record: A Weekly Journal of Medicine and Surgery, July 7, 1917, Volume 92, Number 1, New York, 
23. The Forty Ninth Annual Report of the Royal Humane Society, For the Recovery of  Persons Apparently Drowned or Dead," 1823, London, 
24. Barash, Paul G. Bruce F. Cullen, Rober, "Clinical Anesthesia," 2009, Philadelphia, Lippincott
25. Friedman, Meyer, Gerald W. Friedman, "Medicine's 10 Greatest Discoveries," 1998, Yale University
26. Waxham, F.E., "Intubation of the Larynx," 1888, Chicago, published by Charles Traux (Waxham was an early proponent of intubation for diptheria and croup. 
27. Gould, George M, "American Year-book of Medicine and Surgery," 1899, Philadelphia, W.B. Saunders
28. Curry, James, "Observations on Apparent Death from drowning, hanging, suffocation by noxious vapours, fainting-fits, intoxication, lightning, exposure to cold, & etc., and an account of the means to be employed for recovery. To which are added the treatment proper in cases of poison, with caution and suggestions respecting various circumstances of sudden danger," 2nd edition, 1815, London (the 1st edition was published in 1792)

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