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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1750-1950: Methods of Manual Resuscitation

When the Humane Society was established in 1774 to help victims of drownings, various methods were used to breathe for those not breathing on their own.  There were success stories, and therefore the society was able to thrive.

Some of the methods used we might find laughable, because they had nothing at all to do with breathing, such as rubbing a feather on the nose, or blowing smoke up the anus.  Yet we must understand the limitations of knowledge at the time.  (You can read about the methods used by the Humane Society by clicking here)

For example, people from the year 2015 might read about how the American Red Cross once recommended mouth to mouth breathing and cringe, saying something like, "Ewe, they did that?"  As you can see by the history below, mouth to mouth breathing was once recommended by the Humane Society, but went out of fashion due to hygienic concerns.  By the 1960s it was back in vogue.  Mouth to mouth breathing would be debated once again in 2000, with many organizations no longer recommending it.  

And, who knows?  Like mouth to mouth breathing once made a come back, so too might any of these obsolete methods.

The general recommendation of the humane society and other similar organizations was to pull the victim away from danger first: out of the water, away from electric current, away from poisonous air, etc.

If the victim was not breathing, the airway should be cleared (such as of mucus and water), and one of the methods of manual resuscitation (artificial breathing) should be started right away.

As soon as possible a second person should notify (by word of mouth or by phone) a physician and/ or rescue team.  

During the 19th century, older methods of artificial resuscitation came under question, mainly due to the safety of performing, and on their effectiveness. Various physicians performed experiments on their own, and as the provided evidence that their method was more effective, the newer method was adapted.

Some of the more common methods of manual resuscitation are listed here:

1.  Simple methods to excite the breathing:  Simple methods come from the ancient world, and since never disproved to initiate breathing, were among the various recommendations of the original members of the Humane Society.  This can bee seen through the wrods of Frederick Killick in his 1893 article, "Resuscitation of the apparently drowned," in Dominion Illustrated Monthly:

Excite the nostrils with snuff, hartshorn and smelling salts, or tickle the throat with a feather, etc., if they are at hand. Rub the chest and face warm, and dash cold water, or cold and hot water alternately on them. If there be no success, lose not a moment, but instantly... (10, page 173)

Once these efforts have failed, it was time to move on to the preferred method of artificial respiration.  The authors in this case recommend the Marshall or the Howard method, both of which are described below. (10, page 173)

2.  Mouth to mouth method:  As noted in a booklet by the Lungmotor Company: 

As commonly practiced by Life Savers, the Rescuer grasps the victim's tongue between his teeth and blows into his mouth. This is too unsanitary to be considered, except to state that it is more likely to fill the victim's stomach with air than, it is to expand the lungs, and to call attention to the danger o£ transmission of dread diseases thereby, namely, Syphilis, Tuberculosis, etc., etc. (1, page 8)

Surely this method was used from time to time, although, because it was seen as unhygienic, it was not recommended. I would imagine this method, or a variation of it, was more likely to be used to save the life of a boy or girl, or a newborn infant, as opposed to a perfect stranger.

No. 2 —Dr. Hall's System of Artificial Expiration

3.  Dr. Marshall Hall's Method (postural method/ ready method):  (18, page 2) (17, page 74) Dr. Marshall Hall (1790-1857) was an English physician (10, page 171).who recommended a method of resuscitation in an 1856 article in The Lancet called "Asphyxia, it's rationale and its remedy."  (11, page 17)

His method was later recommended to the Humane Society.  (11, page 17)

In 1857 he published an article in the Lancet called "Prone and Postural Respiration in Drowning," whereby he criticized the methods used by the Humane Society in favor of his own method.  (17, page 74)

Mickey S. Eisenberg, in his 1997 book "Life in the Balance, explained that Hall "believed that too much valuable time was lost in transporting the victim; that restoratoin with warmth without artificial ventilation was dangerous and too time consuming; that exposure to fresh air was eneficial; and that in the supine position, the victim's tongue and larynx fell back and blocked the airway." (17, pages 74-75)

Dr. Marshall was the first to recommend clearing the throat (clearing the airway) as the first step of artificial resuscitation. He thus recommended clearing the throat by placing the "patient on the floor or the ground with the face downward, and one of the arms under the forehead in which position all fluids will more readily escape by the mouth, and the tongue itself will fall forward leaving the entrance into the windpipe free.  Assist this operation by wiping and cleansing the mouth." (10, page 173)

A thorough description of what the method entailed can be found in the 1862 edition of the U.S. Army Medical Departments "Hand-book of Surgical Operations" by Stephen Smith, as noted here: (9, page 45)

"Turn the body gently, and completely, on the side and little beyond, and turn then on the face (prone); alternating; repeating these measures deliberately, efficiently, and perseveringly, fifteen times in a minute only (when the patient reposes on the thorax; this cavity is compressed by the weight of the body, and expiration takes place; when he is turned on the side, this pressure is removed and inspiration occurs).  When the prone position is resumed, make equitable but efficient pressure along the spine; removing it immediately before rotation on the side (the first pressure augments the expiration, the second commences inspiration)"  (9, page 45)(also see 10, page 173)(also see 15, page 347)

As noted by Killick:

By placing the patient on the chest the weight of the body forces the air out (expiration).  When turned on the side this pressure is removed and air enters the chest (inspiration). (10, page 173)

Eisenberg also explained that Dr. Hall referred to his method as the "ready method" because "no equipment or complicated training were required.  (17, page 75)

It is obvious the disadvantages to this method.  For one thing, it would entail more than one person to perform.  One, or possibly more, would be needed to turn the patient, and another to "attend solely to the movements of the head, and of the arm placed under it." (10, page 173)  It may also be noted that while this method was recommended by army physicians after an anesthetic was given, it would be next to impossible to perform any lengthy operation on such a patient.

Marshall's Method was among the main recommendations until the Sylvester method was introduced, and became obsolete after the Schaefer method was introduced.   

As a side note here, along with recommending clearing the airway, Dr. Marshall Hall was also the first to recommend cooling the patient as opposed to warming him.  Perhaps this is why, in the Army's "Hand-book of Surgical Operations," Smith noted that just after the anesthetic was given, and prior to initiating artificial respiration (Marshall,  Silvester, or Howard), to do the following: 

"...the patient's tongue was drawn forward with forceps or a tenaculum, fresh air admitted to the door or windows, or induced by a fan...  (9, page 45)

This was a notable recommendation by Marshall, because at that time the recommendation was to keep the patient warm, often by placing the victim by the fire. (11, page 17)  Once the patient wakes up, Smith recommends giving the patient brandy and ammonia. He then mentions a newer method introduced by Dr. Silvester. (9, page 45)

4.  1858: Dr. Henry R. Silvester's Method:   (Sometimes his name is spelled Sylvester) Silvester criticised Hall's method in favor of his own in an article published in The British Medical Journal in 1858 called "A NewMethod of Resuscitating Still-born Children, and of Restoring Persons Apparently Drowned orDead."

This entails laying the patient on his back and providing rhythmic traction on the patient's arms.  According to Smith, the method goes something like this:

Fig 59 — Artificial Respiration—Inspiration
These figures represent Silvester's method. (15, page 345)

It consists of laying the patient on his back, drawing the tongue forward, then carrying the arms slowly upward over the head, thus elevating the ribs by means of the pectoral muscles, and inducing respiration; the arms are then brought down to the side of the chest and slightly compressed against it; these movements are to be repeated slowly as by the other methods." (9, page 45)(also see 10, page 174)

When used on a drowned victim, the Lungmotor Company recommends that because this method does not remove water from the patient's lungs, water should be removed prior to its use. (1, page 7) When performed in a controlled setting,  Killick recommended the following:

Draw forward the patient's tongue, and keep it projecting beyond the lips; an elastic band over the tongue and under the chin will answer the purpose, or a piece of string or tape may be tied round them; or by raising the lower jaw, the teeth may be made to retain the tongue in that position (10, page 174)(also see 15, pages 345-6)

In his 1858 article, Silvester noted his method had many advantages, such as: (17, pae76)

1. It could be performed while victim was in a warm bath
2. It's easier to perform than Hall's method
3. It allows for more air to enter the lungs (17, page 76)

Criticism of this method was that it was hard to perform and there were stories of victims who survived but had broken ribs and ruptured livers.  It was also hard to keep the tongue from blocking the airway, and depth of breaths (tital volume) were less than ideal, or so later physicians like Dr. E.A. Schaefer proved. (12, page 754)

The position of the patient and operator as well as the modus operandi,
are well depicted in figure 14  It consists of producing contraction of
the thorax by means of the operator's knee.  (19, page 75)  As usual,
there were probably more than one versions of this method.  Perhaps
a safer method would be so simply apply pressure to the chest by
placing the hands on the chest and applying pressure by force of
the upper body.  Either way, this method would be close in design
to modern chest compressoin. 

5.  1869:  Dr. Benjamin Howard's Method (Direct Method): (17, pages 78-79)  Dr. Howard was an American physician (10, page 171) who recommended  in 1871 (18, page 15) a method that entailed the following, as noted by Dr. Edward Schaefer in a 1904 report (Schaefer would later perfect Dr. Howard's method):

The only method of artificial respiration which is perfectly simple to apply, and which effects a sufficient exchange of air per minute, is that of intermittent pressure upon the lower part of the thorax. The introduction of this system, although it had been suggested by Erichsen and others, is due to Dr. Howard (1869). By Howard's method the patient in a case of drowning is first turned face downwards and the back is pressed upon two or three times to force out water from the lungs, after which he is turned face upwards. The operator is then directed to grasp the lower part of the chest and to press gradually forward with all his weight for three seconds, then with a push to jerk himself back and wait three seconds, repeating this eight to ten times a minute.

This method is simple, can be performed by one operator, and is fairly efficient so far as air-exchange is concerned. The drawbacks are (1) that the tongue is the face-up position tends to fall back and block the passage of air through the pharynx; (2) that there is risk of rupturing the liver (which is enormously swollen in asphyxia); (3) that there is risk of breaking the ribs if the operator is heavy and powerful, and if the patient be advanced in years. (12, page 754)(also see 15, pages 346-7)

He initially recommended his procedure in an 1869 five page pamphlet "Plain Rules for theRestoratoin of Persons Apparently Dead from Drowning."  The pamphlet set for some simple rules for performing artificial respiration, including: (17, pages 78-79)

1. Set patient on his back
2. Open the airway
3. Kneel astride the patient and perform his procedure to breathe for victim
4. His method should be continued for up to two hours (17, page 78-79)

So that was the Howard method.  It was modified by Dr. Schaefer. First, however, Dr. Schaefer noted the following regarding the drawbacks of the Howard method:

These drawbacks are avoided by keeping the patient in the face-down (or prone) position during the whole operation. The tongue then tends to fall forwards, and the weight of the operator's body being communicated through his hands, which are placed over the lower part of the back (lowest ribs), compresses the thorax and abdomen in such a way that the pressure is diffused over a considerable area, and is less localised than by the method described by Howard. This produces greater efficiency and reduces the risk if injury to ribs or viscera to a minimum. The muscular exertion required is only that needed to swing the upper part of the body backwards and forwards on the hands about twelve or thirteen times a minute, the operator kneeling by the side of or across the patient. The pressure is gradually applied and gradually released. The amount of air exchanged by this method per minute is greater than that yielded by any other which has been tried, and may even exceed the ordinary rate of exchange of the individual. It is perfectly simple and easy of application by boy, woman, or man.  (12, page 754)

Eisenberg quotes Howard from an 1877 article in The Lancet, in an article titled "The more usual methods of artificial respiratoin. With demonstrations of the 'direct method' of the author": "This method is called the 'direct method' because byit the few things neded to be done are, simply, done.  The tongue needs holding forward -- it is held; the ribs, pressing -- they are pressed.  It is so simple tht a Harbour policeman, after a single lesson, has done it as well as I.. can do it.  Adjunctive measures as friction, electricity, insufflation, or even tracheotomy, can be used simultaneously." (17, pages 80-81, 275)

This method was generally not accepted due risks of broken ribs and ruptured liver, which may explain why this author can find only a few descriptions nor pictures of the procedurs. (18, page 2)

6.  Ventilation (insuflation) with bellows:  It must be noted here that inflating lungs using bellows or other similar devices was referred to as insuflation prior to the term positive pressure being used in the 1950s.  Dudley Wilmon Buxton, in the 4th edition of his book "Anaesthetics, their uses and administration," explains the following: (16, page 347)

Professor H. C. Wood regards all the methods of artificial respiration mentioned as imperfect and inferior to  the following plan: A pair of bellows has a length of India rubber tubing attached to it. A face mask and two intubation tubes of different sizes are also in readiness. In the tubing "there should also be set a double tube, with an opening similar to that commonly found in the trachea cannula of the physiological laboratory, so that the operator can allow the escape of any excess of air thrown in by the bellows." Professor Wood gives the following directions for employing the apparatus: "In using this apparatus, the mask should be first tried, care being exercised to see that the tongue is well drawn forward and held in place by a thread through it, and that the epiglottis is kept open." If the face-piece does not succeed, intubation should be at once performed. In the use of either the face-piece or of intubation, the lungs should be slowly but thoroughly expanded by each stroke of the bellows. Care must be taken that only sufficient force is used to expand, not to rupture, the air-vesicles. The use of oxygen as the perflating gas greatly enhances the value of the method. The patient's body temperature should be maintained. Forced respiration is of especial value for persons with rigid chests. (15, page 347)

Buxton says that mouth to mouth breathing can also be used.  A method he does not describe is "infuflation" using a tracheostomy, although this technique is mentioned by others.

Gradually, this method, or variations of it, would become the preferred method of artificial respiration in the controlled setting, such as by caregivers in hospitals, ambulances, etc. Gradually the bellows were replaced with one of mechanical resuscitators (such as the Lungmotor or Pulmotor), and ultimately devices like the bag-valve mask AMBU-bag, and intermittent positive pressure breathing and mechanical ventilators of the 1950s and 1960s.

Fig. 1. This illustration shows Schaefer method first movement (inspiration)  

7.  The Edward A. Schaefer (Shafer) Method (Prone-Pressure Method): A committee was formed in 1899 by the Royal Medical Chirurgical Society and in 1903 Professor Edward A. Schaefer provided a report where he recommended a new method of resuscitation which was basically just a modification of the Howard Method.  (18, page 2)

The "new method" was introduced to the American Medical Society in 1908 by Professor Schaefer, and he referred to it as the Prone-Pressure Method. (1, page 7)(3, page 11) (4, page 53) The Schaefer method was recommended by two commissions in the United States.  In 1909 it was recommended by the Royal Society of Medicine.   Regardless, the Royal Humane Society, among others, continued to recommend Silvester's Method. (17, page 2)

Fig 2 -This illustration shows Schaefer method second movement (expiration)

The advantage over Howard's method is that the patient is prone, so that the tongue falls out of the way of the airway.  (17, page 3)  Another advantage was the this new method, when compared with other methods of manual respiration, provided the best tidal volumes, as per studies performed by Schaefer on conscious human beings. Although later studies by others on apneic (not breathing) human beings refuted the evidence, claiming that the Schaefer method resulted in the same tidal volumes, if not less, than the other methods. .  (15, page 4)

The Prone Pressure Method entailed the following as described in an August, 1913, entry in The Colliery Engineer:  (4, page 53)

1. Pulling the patient away from danger
2. Laying the victim on his stomach (prone position)
3. Place victims arms above his head
4. Turn victim's face to one side so the mouth and nose are not blocked by the ground
5. Operator then kneels, straddling the victim and facing the victim's head (figure 1)
6. Operator finds the landmarks of floating ribs (lowest ribs) and pelvis
7. Operator places hands over lowest ribs (but not over pelvis)
8. With arms straight, the operator swings forward slowly so that the weight of the body is gradually brought to bear upon the subject as shown in figure 2.  This produces expiration.  
9. Immediately swing backward to remove pressure, but leave hands in place (as is shown in figure 1).  Through their elasticity, the chest walls expand, and the lungs are thus supplied with fresh air (inspiration)
10. After 2 seconds, swing forward again.  Thus repeat deliberately 12-15 times a minute the double movement of compression and release -- a complete respiration in 4-5 seconds, the operator following the rate of his own deep breathing -- swinging forward with each expiration, and backward with each inspiration.  (4, page 53)(also see 15, pages 344-345)

This method was shown by various experiments to be superior to the Silvester Method due to the following reasons: (3, page 11)

• Greater simplicity and ease of performance
• Absence of trouble from the tongue falling back and blocking the air passages.
• Little danger of injuries the liver or breaking the ribs if pressure be gradually -- not roughly -- applied
• Larger ventilation of the lungs (3, page 11)

During the first 20 years of the 20th century various mechanical resuscitators were introduced to the market, such as the Bratt's Apparatus and the Lungmotor.  In 1907 the first mechanical ventilator was introduced to the Pulmotor, and quickly gained fame through stories reported by the media.  Rescue crews were equipped with one or more of these mechanical resuscitators.  Once on the scene, manual resuscitation was stopped and mechanical resuscitation started.  Of course the mechanical device was generally credited with saving the patient, regardless of whether this was true or not.

However, B.L. Wilson, who was responsible for the Pulmotor crew in Baltimore in 1922, noted the following:  (2, page 258)

Every policeman should be taught the "prone method" of resuscitation, so that while waiting for the pulmonator he could do his part in helping to bring some poor person back to life. The police are usually the first on the scene, and if they were equipped with pulmonators more lives could be saved in Baltimore than at present." (2, page 258)

The prone pressure method remained the most recommended method of manual resuscitation in the years that followed.  This, and all similar methods, were phased out in favor of mouth to mouth breathing, as a new method called cardiopulmonary resuscitation, gained favor during the 1950s and 1960s.  (14, page 539)

8.  Horseback riding on victim's chest:  This was never a recommended method of resuscitation, although I found it interesting that it was even brought up.  I'll leave a description of it to S. J. Meltzer:

Several years ago in a conversation which we had in London, Professor Schafer remarked that "if he were now confronted with the task of resuscitation he would kneel astride over the subject and perform the simple motions of horseback riding without employing his hands and arms at all." (17, page 3)

There is no further data that this technique was ever used. It is, however, comical that a respected physician would make such a comment, if that's all it was.

9.  1909:  Mouth to mouth breathing:  Yes, once again a physicians toyed with the idea that the best method of breathing was mouth to mouth breathing.  This time it was Dr. Robert H. Woods, an Irish throat surgeon.  He noted that this method was simple to do and could be started immediately upon finding the victim.  However, because the Schaefer and Silvester methods were so well thought of at the time, his "voice was stifled," according to Eisenberg. (17, page 82)

The Holger Nielson method became the most commonly recommended
method during the 1940s and 1950s until CPR was invented. Posters
like this were commonplace around water or other such places of danger.
They were also seen where artificial resuscitation training took place.

10.  1932:  The Holger Louis Nielson Method (back pressure-arm lift method):  Colnel Holger Louis Nielson (1866-1955) was a Danish army officer (16) (17, page 83) who devised a technique that was a combination of the Silvester and the Schafer methods. According to Mickey S. Eisenberg in his 1997 book "Life in the Balance:"

His original plan was to have two rescuers -- one to perform prone pressure on the lower back to cause exhalation while the other lifted the arms above the victim to facilitate inhalation.  But this method was rejected by the Danish Red Cross in 1930 because it required two rescuers Back to the drawing board.

Nielson's breakthrough came when he visited a masseur for relief from rheumatic pains in his shoulders and noticed that when the masseur pressed down on his shoulder blades, he experienced a forceful expiration.  This experience led him to suggest one rescuer positioned at the head of the victim, who alternates pressure on the upper back for expiration and lifts the arms for inhalation.  Nielson described his prone back-pressure arm lift methods in 1932, and presented physiological data to support the superiority of the method. Tidal volumes of 450 to 1750 milliliters were measured in relaxed, hyperventilated subjects, much better performance than other methods of artificial ventilation. (17, page 82)

By 1953 his method was the preferred method of the International Red Cross.  Of course use of the method was short lived, as by the end of the 1950s a better method was devised called Cardiopulmonary Resuscitation (CPR).  (17, page 82)

11.  1942: Emerson Method:  During WWII Jack Emerson joined V. Ray Bennett and Forrest Bird in the quest to invent a device that allowed pilots to fly higher and out of harms way. What he ended up inventing was a better method of artificial resuscitation, replacing the Shafer method.  Richard Branson described this method. (20, page 568)

This technique placed the patient in the prone position and alternately raised and lowered the patient's hips. The hipbones were grasped and lifted upward to create inspiration and drainage of fluid out of the lungs. When the hips were lowered, exhalation occurred. (20, page 568)

This method replaced the Shafer technique, and was commonly used until the mid 1940s when mouth to mouth breathing was preferred.

Peter Safar asked doll maker Asmund Laerdal (1913-1981) to make  a training
manikin to be useful for training people his new method.  Laerdal wanted to
make the manikin look like an unconscious person, although he didn't want
it to be scary.  At a relative's house he saw a death mask of a lady named
Annie who drowned herself.  Impressed by her "enigmatic yet peaceful gaze,"
he made the face of the manikin in he image.  Laerdal amply named the manikin
"Resusci-Annie."  Laerdal said he did not name the manikin after the person
he modeled the face after, but the first line of successful dolls that he made:
The Annie Dolls. (17, page 102)

12. 1954:  Mouth-toMouth breathing (expired-air resuscitation):  Back again, and it quickly becomes popular this time around.  In 1949 Anesthesiologist James Elam (1918-1995) attempted to use mouth to mouth breathing to save the life of a young boy, and it worked.  He learned about this method while reading "historical accounts of newborns."   (9)

Subsequent experiments by Dr. Elam in 1954 and Safer in 1958 proved that none of the previously used methods of artificial breathing (listed above) provided a deep enough  breath to be effective.  (6, page 590-591)

He also proved by his experiments that all of the previous methods of artificial respiration barely provided respiration at all, and they all also provided a very low amount of inspired oxygen to the patient.  As there is 21% oxygen in inspired air, there is only 16% in expired air.  Both the Schafer, Silvester and Nielson methods generated far less than 16 percent  (17, page 92).

By the 1950s there was a device that could measure the amount of inhaled oxygen that was absorbed into the blood and bound onto a hemoglobin molecule.  A normal human arterial oxygen saturation was shown to be about 98%. During experiments Elam performed in 1952 he proved that "total arterial oxygen saturatoin could be maintained at 100 percent. During experiments with the Schafer and Nielson methods, the oxygen saturation fell to 70 percent. (17, page 92)

Slowly but surely the various organizations in America and Europe accepted expired-air resuscitation as the preferred method of artificial respiration.  The organization that was slowest to adapt it was the American Red Cross.  However, due to the "ever growing body of scientific data," in 1958 the American Medical Association approved of the method, followed shortly thereafter by the American Red Cross.  (17, page 93, 101-102)

Expired-air respiration would ultimately gain "worldwide recognition and application (after the) publication, in 1959, of the National Academy of Sciences - National Research Council 'Statement on Emergency Artificial Respiration Without Adjunct Equipment'," according to Dr. Peter Safar (1924-2003) in 1966. (7, page 155)

Safar continued to work on mechanisms to deal with the various concerns regarding mouth to mouth breathing, mainly:

•  Preventing the tongue from falling back and blocking the airway
• The issue of poor hygiene and the fact that most people considered it to be gross

To deal with the former, he invented what was referred to as a Safar S-Tube that was inserted through the oral opening into the pharynx.  On the opposite end (the end sticking out of the mouth) was a mouthpiece, whereby the rescuer would provide breaths.  The S-Tube, thereby, acted as both an oral airway and as a means of providing ventilations.  (6, page 590-591)

Considering most bystanders wouldn't have such a device, he created a method called the chin lift jaw thrust, whereby the chin was lifted, and the jaw thrust forward.  The simple technique is still used to this day.

During the course of the 1950s a technique called CPR would be devised, and the only of the above methods to survive was, ironically, mouth to mouth breathing.  It's ironic how mouth to mouth breathing has come full circle. In the early 2000s it would once again come into question.

References:

1. "Drowning: Historical-Statistical Methods of Resuscitation," no author nor editor listed, Published by Lungmotor Company, Boston, Massachusetts, 1920
2. "Pulmotor advertises gas company," Gas Age, volume 29, 1922, New York, Robbins Publishing Company Inc. 
3. Cannon, Walter Bradford, George Washington Crile, Joseph Erlanger, Yandell Henderson, "Report of the Committee on Resuscitation from Mine Gases," Technical paper number 77, Department of Interior, Bureau of Mines, Joseph A. Holmes, Director, 1914, Washington, Government Printing Office
4. "Schaefer Method of Resuscitation," The Colliery Engineer, August, 1913, Volume XXXIV, August 1913 to July 1914, Scranton, PA, International Textbook Co., page 53 (no author or editor listed)
5. 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)."
6. Agasti, T.K. "Textbook of Anesthesia for Postgraduates," 2011, New Delhi, Jaypee Brothers Medical Publishers, page 590
7. Safar, Peter, "Exhaled air ventilation and cardiopulmonary resuscitation," published in the following: Gordon, Archer S, editor, "Cardiopulmonary Resuscitation: Conference Proceedings," May 23, 1966, Washington D.C., National Research Council, pages 35-45
8. Donahue, Mary, "History of Lifesaving," DeAnza Collegge, http://faculty.deanza.edu/donahuemary/Historyoflifesaving, accessed 8/10/13
9. Smith, Stephen, "Hand-Book of Surgical Operations," 1862, New York, U.S. Army Medical Department, republished in 1990 in "The American Civil War Surgery Series, No. 8," U.S., Norman Publishing 
10. Killick, Frederick H., "Resuscitation of the apparently drowned," The Dominion Illustrated Monthly, February, 1893, Montreal and Toronto, Vol. II, NO. 1, pages 171- 175 *Once the patient's natural breathing has been restored, the author recommends a variety or methods of warming the patient, such as "hot flannels, bottles, or bladders of hot water, heated bricks, etc... on restoration of life, a teaspoon of warm water should be given.  And then, if the if the power of swallowing have returned, small quantities of wine, warm brandy-and water, or coffee should be administered. The patient should be kept in bed, and a disposition to sleep encouraged." These passages can be found on pages 174-175 in the section "Treatment after natural breathing has been restored."
11. O'Connor, W.J., "Founders of British Physiology: A biographical dictionary, 1820-1885,"  Chapter 2: Physicians, 1820-1835, 1988, U.K., Manchester University Press
12. Schafer, E.A., "On the methods of artificial respiration," "Report of the seventy forth meeting of the British association for the advancement of science held at Cambridge in August 1904," 1905, London, John Murray,  page 754-755
13. Gordon, Archer S., "History and Evolution of Modern Resuscitation Techniques,"  published in the following: Gordon, Archer S, editor, "Cardiopulmonary Resuscitation: Conference Proceedings," May 23, 1966, Washington D.C., National Research Council, pages 7-31
14. Howarth, Glennys, Oliver Eaman, editors, "Encyclopedia of Death and Dying," 2001, New York, Routledge, page 539
15. Buxton, Dudley Wilmot, "Anaesthetics, their uses and administration," 4th edition, 1907, Philadelphia, P. Blakiston's Sons and Co. 
16. "Holger Nielson Method," Merriam Dictionary, merriamdictionary.com, http://www.merriam-webster.com/medical/holger%20nielsen%20method, accessed 8/19/2013
17. Eisenberg, Mickey S., "Life in the Balance: Emergency Methods and the Quest to Reverse Sudden Death," 1997, New York, Oxford University Press
18. 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; Thomas L. Stedman, editor, Medical Record, Volume 92, July 17, 1917 - December 29, 1917, New York, William Wood and Compay
19. Guilford, Simeon.Hayden., "Nitrous oxide; it's properties method of administration, and effects," 1887, Philadelphia, Spangler and Davis, Printers
20. Branson, Richard,  Branson, Richard D, "Jack Emerson:  Notes on his life and contributions to Respiratory Care," Respiratory Care, July 1998, vol. 43, no. 7, pages 567-71

Furhter reading:

1. Knott, Arthur Reynolds, "Lie Saving and Artificial Respiration," 2nd edition, 1915, no city or publisher noted in book

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