The early history of ventilation.
Towards the end of the 19th century, improvements in anaesthesia and asepsis allowed surgeons to contemplate operations in previously inaccessible areas. Abdominal and pelvic surgery could be performed on spontaneously breathing patients under deep ether or high spinal anaesthesia--but operating within the chest remained problematic. Opening the chest in a spontaneously breathing patient led to lung collapse, making all but the shortest operations impracticable. As surgeons applied themselves to this problem, several creative solutions were devised.
Resuscitation with bellows had been popular in the late 18th century, but their use was discontinued after Leroy published a survey of resuscitation practices in 1827 which demonstrated an increase in traumatic lung injuries (1). In 1887, George Fell of Buffalo revived the technique, describing an apparatus to maintain artificial respiration via a tracheotomy or facemask (2). Joseph O'Dwyer, who had developed a series of laryngeal tubes for the treatment of diphtheria, modified this to create the Fell-O'Dwyer apparatus allowing ventilation with bellows via a tracheal tube, but did not use it for anaesthesia. In 1899, Rudolph Matas, a surgeon in New Orleans, reported the use of this apparatus for the successful removal of a chest wall tumour, stating "It is curious that surgeons should have failed to apply for so long a time the suggestions of the physiological laboratory, where the bellows and tracheal tubes have been in constant use from the days of Magendie to the present, in practising artificial respiration in animals" (3).
The O'Dwyer tubes were difficult to insert without considerable skill and practice. In 1896, Tuffier and Hallion reported some success in France with insufflation via a long copper tube into the trachea (4,5). Their method involved positive pressure ventilation with a bellows and expiration, via a series of flap valves, into a jar of water which provided positive end-expiratory pressure to keep the lungs inflated. In Kessel, the German surgeon Franz Kuhn investigated ways of intubating the trachea in corpses. He devised a flexible metallic endotracheal tube in 1900 (6) and described its clinical use the following year (7,8). Patients were intubated awake after topical cocaine and the tube was guided by an introducer and digital palpation of the epiglottis and arytenoid cartilages. He used these tubes for anaesthesia by attaching a Trendelenburg cone, suggesting that they could be used for resuscitation by connecting to an air pump. He worked with Drager, the equipment manufacturing company, to create an anaesthesia machine which applied positive pressure. Although he seems to have used the technique quite successfully, there are no accounts of others having adopted his methods (9).
In contrast, Sauerbruch's extraordinary negative pressure operating theatre became quite popular. Ernst Ferdinand Sauerbruch, working for Professor Johannes von Mikulicz in the University Hospital in Breslau, designed a negative pressure chamber for operations on the thoracic cavity of animals in 1904 (10). After many experiments, he constructed an airtight, negative pressure chamber for patients and a new operating theatre was built to accommodate it. Operating in the chamber, Mikulicz successfully removed the breastbone of a woman, while Sauerbruch operated later that year on a woman with cancer of the ribs. The patient's chest was sealed inside the chamber with the operating team. The head remained outside the chamber, with the lower body enclosed in a sealed bag also connected to the outside. The anaesthetist, seated at the patient's head, was able to administer anaesthesia outside the chamber, while the negative pressure inside prevented the lungs from collapsing.
In 1908, Sauerbruch demonstrated his chamber in Chicago. It is rumoured that he was unable to afford to take his chamber back to Germany, leaving it with Willy Meyer at the Rockefeller Institute in New York. Meyer developed both postive and negative pressure chambers, finally combining them in his 'Universal Negative Pressure Chamber'. This large chamber could accommodate seventeen people including the patient, with the anaesthetists inside a positive pressure chamber within the negative pressure room (11,12).
A colleague of Sauerbruch's, Brauer developed apparatus based on the opposite principle. He sealed the patient's head within an air-tight, pressurised box with sealed holes for the anaesthetist's hands. Anaesthesia was administered via a facemask from a Roth-Drager anaesthetic machine, the bag of which was sealed within another pressurised chamber. Windows were placed in the box to allow observation of the patient. Some automated machines were being developed at this time. Lawen and Sievers, in Trendelenberg's department in Leipzig, developed a double-pump apparatus for rhythmical ventilation of the lungs in 1910, but their technique required the use of a tracheotomy (13). Green and Janeway in New York City created a series of mechanical devices for positive pressure ventilation, their first attempt being modelled on the Brauer positive pressure head chamber. Janeway continued to experiment, introducing first an endotracheal cannula, then eventually a fully automated respirator that provided assistance to the patient's own respiration via a cuffed endotracheal tube. None of these inventions achieved widespread use. It seems that once individual surgeons had devised a way to operate, they began concentrating on their surgical techniques and their anaesthetic inventions were not carried forward (9).
The first truly automated ventilator to become popular was the Drager Pulmotor, which was developed as a rescue device. It was designed in 1907 by Heinrich Drager, the company founder, who was motivated by a desire to provide resuscitation equipment for people who had been exposed to poisonous gases, such as in mining disasters (14). The machine had to be simple and portable. The original patented design was not a commercial product but a concept. It created alternating positive and negative airway pressure, powered by compressed oxygen from from a cylinder. The ventilation was time-cycled, as one would expect from a skilled watchmaker like Heinrich. He left it to his son, Bernhard, and an engineer, Hans Schroder to redesign the original machine to make it commercially marketable. They divided the breathing system to minimise the inhalation of expired gases, while the mechanism of ventilation was changed to pressure cycling which was easier to achieve. In later models, a bag was added to the tube system which expanded under pressure and activated the control system which switched between the positive and negative phases. By 1913, 3000 Pulmotors were in use and Drager collected information about successful resuscitations to publish in Drager magazines. The ventilator was used with a simple facemask and did not require any special airway equipment. Although never used in hospitals, or for anaesthesia, it was the beginning of a concept that was to transform medicine.
(1.) Leroy J. Recherches sur l'asphyxie. J Physiol Exp Pathol 1827; 7:45-65.
(2.) Mushin WW, Rendell-Baker L. The Origins of Thoracic Anaesthesia. Reprint (original 1951) ed. Park Ridge, Illinois: Wood Library-Museum of Anesthesiology 1991.
(3.) Matas R. I. On the management of acute traumatic pneumothorax. Ann Surg 1899; 29:409-434.
(4.) Tuffier T, Hallion L. On the regulation of intrabronchial pressure and anesthesia in artificial respiration by insufflation. Compt Rend Soc de Biol, Paris 1896; 10:1086-1088.
(5.) Tuffier T, Hallion L. Intrathoracic operations with artificial respiration by insufflation. Compt Rend Soc de Biol, Paris 1896; 48:951.
(6.) Kuhn F. Der Metallschlauch in der Tubage und als Trachealkancile. Wien Klin Rdsch 1900; 28:554.
(7.) Kuhn F. Die perorale Intubation. Zentralbl Chir 1901; 28:1281-1285.
(8.) Thierbach A. Franz Kuhn, his contribution to anaesthesia and emergency medicine. Resuscitation 2001; 48:193-197.
(9.) Mushin WW, Rendell-Baker L, Thompson PW, Mapleson WW. Automatic Ventilation of the Lungs. 2nd ed. Oxford and Edinburgh: Blackwell Scientific Publications; 1961.
(10.) Cherian SM, Nicks R, Lord RS. Ernst Ferdinand Sauerbruch: rise and fall of the pioneer of thoracic surgery. World J Surg 2001; 25:1012-1020.
(11.) Miscall L, Founding of the American Association for Thoracic Surgery. AATS, Beverly, Massachusetts 1967.
(12.) Comroe JH, Retrospectroscope. Inflation-1904 model. Am Rev Respir Dis 1975; 112:713-716.
(13.) Lawen A, Sievers R. Zur praktischen Anwendung der instrumentellen kunstlichen Respiration am Menschen. Munch med Wchnschr 1910; 57:2221.
(14.) Bahns E. It began with the Pulmotor. One Hundred Years of Artificial Ventilation. Dragerwerk, Lubeck 2011.
C. BALL, R. N. WESTHORPE
Geoffrey Kaye Museum of Anaesthetic History
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|Title Annotation:||COVER NOTE|
|Author:||Ball, C.; Westhorpe, R.N.|
|Publication:||Anaesthesia and Intensive Care|
|Date:||Jan 1, 2012|
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