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Insufflation anaesthesia and the Shipway apparatus.

Robert Hook, Curator of the Royal Society, was the first to describe respiration by insufflation in 1667. His experiment involved opening a dog's thorax and attaching the trachea directly to a tube through which a constant stream of air was blown. The air was allowed to escape through a number of puncture wounds in the surface of the lungs. By this means he was able to keep the dog alive for an hour; "his eyes being all the time very quick and his heart beating very regularly" (1). Cessation of the air flow resulted in the dog developing "dying convulsive fits", but renewal of the air flow restored the animal to life (1,2). In 1900, German physiologist W. Nagel reported the maintenance of life in curarised pigeons by blowing a continuous stream of air through the humerus. In birds, the humerus is connected to the air sacs and in this case, the exit of air was via the trachea (2-4).

These experiments led Meltzer and Auer to their experiments in dogs and rabbits, using a tracheal tube of smaller diameter than the trachea so the air stream was able to exit around the tube and via the trachea, nose and mouth (2-5). They also used curare to paralyse the animals and physostigmine to reverse the curarisation (3). The continuous flow of air was generated by a foot bellows and passed through an ether bottle and a humidifying bottle.

Others had preceded Meltzer and Auer, but used intermittent positive pressure rather than a continuous stream of air. In 1907, Barthelemy and Dufour introduced a urethral catheter into the trachea during head and facial surgery. After connecting it to a Vernon Harcourt chloroform inhaler, they used a hand bellows to blow a stream of air, timed with the patient's inspiratory effort (4). Volhard also described a rhythmic inflation method in 1908. In his ingenious device, a constant air flow was intermittently interrupted by the pendulum motion of a reservoir of mercury around the exit tube (4).

Charles Elsberg, having been convinced by Meltzer and Auer to try the method on humans, experimented on animals, coworkers and himself. He devised an apparatus using an electric compressor, where the air stream passed through a filter, an ether bottle and hot water (3,6).

Other similar devices were developed, including the Kelly-Mott machine (5). Although the air stream was passed through a humidifying bottle (sometimes heated), the warming effect was probably limited by the high air flows used (up to 30 l/minute) and patients invariably became hypothermic during long operations (3). The same was true when ether was administered by means of a wire frame mask, such as the Schimmelbusch, the routine method of anaesthesia.

In 1908, Francis Shipway (later Sir Francis) was appointed to the anaesthesia staff of Guy's Hospital in London. Having obtained his MA at Christ's College, Cambridge, in 1901, he gained his medical degrees (MB, BCh) in 1902. He conducted postgraduate research in Vienna and gained his doctorate in 1907 (7).

Shipway noted that when patients were required to breathe from a mask, it became coated with frost from the expired air. He set about devising an apparatus to deliver warmed ether vapour to the patient. James Gwathmey in New York similarly advocated warming ether vapour, and Karl Connell described an apparatus in 1913 whereby the ether was vaporised by dropping it into a warm chamber (8,9).

Shipway's original warmed ether apparatus was relatively simple. A hand bellows was used to pump air to a control tap that diverted the gas stream to either an ether or Junkers type chloroform bottle and thence to a 'U-tube' immersed in a thermos flask with water at 116[degrees]F. The air and vapour was then delivered to either a closed mask with a valve, to a cloth covered mask or to a pharyngeal tube (10). A subsequent modification allowed the air to bypass both of the vaporising bottles, more suitable for use with a cloth covered mask.

Having observed Kelly's insufflation device in 1912, Shipway developed his own intratracheal device using an electric blower as the gas supply. Ether was drip fed into a warmed vaporising chamber and the gas was delivered to an intratracheal catheter at a pressure of 10-20 mmHg, measured by a mercury containing tube in the circuit (10,11).

In 1916, Shipway, together with physiologist Marcus Pembrey, showed that using the standard method of administration, the temperature under the domette cover of a Schimmelbusch mask dropped to between 48-79[degrees]F. They demonstrated that the administration of a flow of warmed ether and air would maintain the internal mask temperature at around 96[degrees]F (12).

Although John Snow, when designing his vaporiser, bad been well aware of the importance of the latent heat of vaporisation, few subsequent anaesthetists gave the phenomenon much thought. Shipway was careful to acknowledge the work of Lawson Tait, who devised an apparatus in 1883 to administer ether at a temperature of 33[degrees]C (16). Shipway also noted that warmed ether was less irritating, and that breathing was calmer and mucus production decreased (13).

Pembrey and Shipway commented in their original paper,

"A normal man reacts to external cold by diminishing his loss and increasing his production of heat; the anaesthetized man, paralysed for sensation and movement, has lost this control, and the level of the chemical changes, which are a measure of vital activity, can also be maintained only by external warmth ... A great practical advantage of the warm ether is that it enables the surgeon to operate in a cooler theatre; the ideal must be to keep the patient warm without exposing the staff to the depressing effect of high temperatures. Apart from the diminished efficiency and endurance, a warm and moist atmosphere introduces the danger of the sweat of the surgeon undoing the elaborate precautions taken to preserve aseptic conditions. With an operation table warmed by an electric heater or some other safe method, it should be possible to operate in a theatre of moderate warmth" (12).

Shipway was twice elected President of the Royal Society of Medicine (in 1926 and 1932), introduced Avertin to British practice and was knighted in 1929 after having anaesthetised King George V twice for rib resection and drainage of empyemas (14). He invented a cuffed pharyngeal airway for intranasal surgery in 1935, subsequently reinvented as the cuffed oropharyngeal airway in the 1990s (15,16).

Sir Francis Shipway retired in 1938 and died at the age of 92 in 1968 (7).

Caption: Shipway's warmed ether apparatus. Early version on left. Later insufflation version on right. Reproduced from Silk JFW. Modern Anaesthetics, 2nd ed. London: Edward Arnold 1920.

References

(1.) Hook R. Phil Trans Roy Soc 1667; 2:539.

(2.) Meltzer SJ, Auer J. Continuous respiration without respiratory movements. J Exp Med 1909; 11:622-625.

(3.) Boulton TB, Cole PV, Hewer CL. A reassessment of anaesthesia by endotracheal insufflation. Anaesthesia 1965; 20:442-460.

(4.) Mushin WW, Rendell-Baker L. The Principles of Thoracic Anaesthesia, Past and Present. Oxford: Blackwell Scientific Publications 1953.

(5.) Ball C, Westhorpe RN. Insufflation anaesthesia and the Kelly-Mott machine. Anaesth Intensive Care 2013; 41:147-148.

(6.) Elsberg CA. The value of continuous intratracheal insufflations of air (Meltzer) in thoracic surgery. Med Rec 1910; 77:493.

(7.) Obituary. Sir Francis Shipway, KCVO. MA, MD, FFARCS.

(8.) Minnitt RJ, Gillies J. Textbook of Anaesthetics. 7th ed. Edinburgh: E & S Livingstone 1948.

(9.) Gwathmey JT. Anaesthesia. New York: D Appleton and Company 1914.

(10.) Silk JFW. Modern Anaesthetics, 2nd ed. London: Edward Arnold 1920.

(11.) Hewer CL. Recent Advances in Anaesthesia and Analgesia. London: J & A Churchill 1932.

(12.) Pembrey MS, Shipway FE. Observations on the influence of anaesthetics on the temperature of the body. Proceedings of the Royal Soc Med. Section of Anaesthetics 1916; 14 April:1-7.

(13.) Shipway FE. Anaesthesia by warmed ether. Br Med J 1917; 1:826.

(14.) Thornton JL. Royal patients and the popularisation of anaesthesia. Anaesthesia 1953; 8:146-150.

(15.) Hewer CL. Recent Advances in Anaesthesia and Analgesia. 2nd ed. London: J & A Churchill 1937.

(16.) Rendell-Baker L. From something old something new. Anesthesiology 2000; 92:913-918.

R. N. WESTHORPE, C. BALL

Melbourne, Victoria
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Title Annotation:Cover Note
Author:Westhorpe, R.N.; Ball, C.
Publication:Anaesthesia and Intensive Care
Article Type:Cover story
Geographic Code:8AUST
Date:May 1, 2013
Words:1367
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