From Andreas Vesalius To Endotracheal Anesthesia

The safe anaesthetic management requires diligent efforts in maintaining an intact functional airway. Endotracheal intubation has been one of the best ways of achieving this goal. Intubation of the trachea for the purpose of resuscitation is three centuries older than anaesthesia itself.  Andreas Vesalius in 1543 reported the first tracheal intubation in an animal (1). In his landmark book published in 1543, De humani corporis fabrica, he described an experiment in which he passed a reed into the trachea of a dying animal whose thorax had been opened and maintained ventilation by blowing into the reed intermittently (2,3). Vesalius wrote that the technique could be life saving.

Human endotracheal intubation was first done by Curry in 1792 (4). At that time, no laryngoscope was invented and intubation was done by tactile method. Frederich Trendelenburg in 1868 manufactured the first cuffed tracheostomy tube (“Trendelenburg’s tampon”) and in 1871 performed the first endotracheal anaesthetic in humans via tracheostomy (1). In 1880, William Macewen, Scottish orthopaedic surgeon started placing metal tubes inside the trachea orally in conscious patients by digital palpation and saw the advantage of this “orotracheal intubation” over tracheostomy. In his paper entitled "clinical observations on the introduction of tracheal tubes by the mouth instead of performing tracheotomy or laryngotomy', he describes in addition two cases of endotracheal intubation lasting at least 36 h. He can, therefore, be said also to have performed the first long-time intubation (5). In 1887, an American paediatrician, Joseph O'Dwyer, described a method of oral tracheal intubation and published a detailed account of 50 patients with croup treated by intubation, 12 (24%) of whom survived (6).

Ivan Magill and Stanley Rowbotham together, they laid the foundations of tracheal anaesthesia (7). In 1922 at the Queen Hospital for Facial and Jaw Injuries in the UK, Ivan Magill and Stanley Rowbotham were working on development of techniques to administer anaesthesia to patients with facial injuries. At the time, the best available method for general anaesthesia in facial surgery was by endotracheal insufflation through the mouth or nose. This involved the use of a gum elastic catheter placed into the pharynx, through which air was driven by a motorised pump with the addition of vaporised ether from Shipway Apparatus heated in hot water (8).

During an extensive surgery on a deformed jaw of a soldier, a catheter had been passed through the nose. However, the deformity and contracture of the lower jaw prevented adequate expiration and the patient's breathing became laboured. Magill passed a second tube through the patient's nose which entered the trachea alongside the catheter which was followed by immediate relief in respiration. These findings later contributed to use of endotracheal intubation during anaesthesia (9).

Blind nasal intubation was first developed and described by Magill in 1928, with a demonstration given to the Society of Anaesthetics (Liverpool) in 1932 (9). Great achievement was recorded in the field on endotracheal anaesthesia during the First World War and post war period. The contribution of Ivan Magill and Stanley Rowbotham was the hallmark of endotracheal anaesthesia since 1934.

References:

1. Ezri T, Evron S, Hadad H, Roth Y. Tracheostomy and endotracheal intubation: a short history. Harefuah. 2005 Dec; 144(12): p. 891-3.
2. Baker AB. Artificial respiration, the history of an idea. Med Hist. 1971 Oct; 15(4): p. 336–351.
3. Garrison DH., Hast MH. The Fabric of the Human Body,An Annotated Translation of the 1543 and 1555 Editions of “De Humani Corporis Fabrica”: Northwestern University; 2003.
4. Paul AK. Essentials of Anaesthesiology. 7th ed.: Jaypee Brothers; 2006.
5. Brandt L, Pokar H, Schütte H. 100 years of intubation anesthesia. William Macewen, a pioneer of endotracheal intubation. Anaesthesist. 1983 May; 32(5): p. 200-4.
6. Opinel A, Gachelin G. French 19th century contributions to the development of treatments for diphtheria. J R Soc Med. 2011 Apr; 104(4): p. 173–178.
7. Condon H, Gilchrist E. Stanley Rowbotham. Twentieth century pioneer anaesthetist. Anaesthesia. 1986 Jan; 41(1): p. 46-52.
8. Magill I. Blind nasal intubation. Anaesthesia. 1975 Jul; 30(4): p. 476-9.
9. McLachlan G. Sir Ivan Magill KCVO, DSc, MB, BCh, BAO, FRCS, FFARCS (Hon), FFARCSI (Hon), DA, (1888-1986). Ulster Med J. 2008 Sep; 77(3): p. 146–152.