19th century pioneering of intensive therapy in North America. Part 3: the Fell-O'Dwyer apparatus and William P Northrup.

Two previous articles in this series have described the reintroduction of forced respiration for ventilatory difficulties, particularly in opiate poisoning (by George Fell), and successful use of intralaryngeal tubes designed for treating airway obstruction in diphtheritic acute laryngitis (by Joseph O'Dwyer). In 1891, O'Dwyer extended the applications of Fell's system, introducing a longer orolaryngeal tube, replacing Fell's methods of inflating the lungs, which had been with a somewhat unsatisfactory facemask or through a tracheotomy tube. The combined system became known as the "Fell-O'Dwyer apparatus". Use of the apparatus widened, to include treating apnoea from intracranial disasters (by William P Northrup, especially) and, on the initiative of Rudolph Matas, in delivering anaesthesia and maintaining lung inflation to enable intrathoracic surgery (by FW Parham). Although the apparatus was used beyond New York (eg, in New Orleans by J D Bloom, especially for neonatal apnoea), it is difficult to find other than nonspecific references. Matas and Bloom improved O'Dwyer's original system, but after the clinical success of Charles Elsberg's continuous insufflation anaesthesia for thoracic surgery, 1909, American anaesthetists came to prefer that.

Early artificial ventilation: the mystery of "Truehead of Galveston"--was he Dr Charles William Trueheart?

It seems strange that the medical literature from the United States has only a single original source of reference for a device (from circa 1870) for artificial ventilation in neonatal resuscitation. The invention is attributed to "Dr Truehead of Galveston, Texas". I argue that this mystery arises from two separate misspellings of the inventor's name, and propose that the correct name is Dr Charles William Trueheart (1837-1914), also of Galveston.

19th century pioneers of intensive therapy in North America. Part 2: Joseph O'Dwyer.

Dr Joseph O'Dwyer's principal distinction lies in his dedication and achievements in battling laryngeal diphtheria among children at the New York Foundling Asylum, where he was a physician from 1872. He was also active at the Presbyterian Hospital of New York and in private practice. Some of his pioneering work anticipated methods of intensive care medicine. His achievements included: * Introduction of a practical system of intralaryngeal intubation, including designs of tubes and a technique for inserting them, after many years of careful study and experimentation - always "without borrowed inspiration". * Use of his tubes in children with diphtheritic pseudomembranes in the larynx, to substantially increase their survival chances at a time when tracheotomy for this problem still had a high failure rate. The first intubated patient recovered, November 1882, only after change to prolonged wearing of a tracheotomy tube, so O'Dwyer did not date his first intubation success until 21 May 1884. * Introduction of his tubes into the Fell method of forced respiration, with the resultant Fell-O'Dwyer apparatus supplying practical instrumentation for intermittent positive pressure ventilation. * Demonstration that this apparatus, primarily used for saving lives after acute opiate poisoning, was also useful with some intracranial disasters, 1894. * Provision of a system, which others then applied, enabling surgeons to overcome the great "pneumothorax problem" of intrathoracic operations, and thereby conduct safe surgery inside the chest, 1898. * Development of an intubating method using successive short-term dilatations for treating chronic laryngeal stenosis, usually syphilitic, in adults, 1885. Throughout his medical lifetime, O'Dwyer was held in the highest regard as an altruistic, compassionate person of "sincere simplicity and frank goodness of character".

On the very first, successful, long-term, large-scale use of IPPV. Albert Bower and V Ray Bennett: Los Angeles, 1948-1949.

An "unprecedented respirator patient load at Los Angeles County Hospital [LACH] in 1948 (294 respirator cases)" arose from a seasonal increase in poliomyelitis cases to nearepidemic proportions. A finding by physician Albert Bower and his team that respiratory acidosis was frequent in patients receiving intermittent negative pressure ventilation (INPV), together with their awareness of a previous high mortality rate due to the standard treatment of polio ventilatory failure with Drinker-Collins respirators, led to multiple advances in equipment technology for LACH. Most important was biomedical engineer V Ray Bennett's positive pressure respirator attachment, in use after September 1948, which converted an INPV machine, the Drinker, into one capable of supplying "intratracheal" intermittent positive pressure ventilation (IPPV), supplementary to its NPV. Together with their teams, Bower and Bennett used this attachment for 73 of 1949's 130 "respirator cases", to establish the first-ever large-scale long-term success of IPPV for respiratory failure in acute polio. In 1949, they demonstrated the superiority of (supplemental) IPPV over INPV alone, achieving a survival rate of 83.7% (108/129) -- compared with the 21.1% survival rate in 1946 among the 38 patients ventilated that year. A complete system of respiratory care was developed for polio victims at LACH, setting levels of treatment and expertise distinctly higher, by 1950, than was current at other known polio respiration units, and preceding the well known developments in Copenhagen in the early 1950s. Extensive experience was obtained by a consistent medical staff, working as a team, in one hospital. Bower and Bennett deserve greater recognition of their pioneering merit than they currently receive in the written history of intensive care medicine.

History of mouth-to-mouth ventilation. Part 3: the 19th to mid-20th centuries and "rediscovery".

The start of the 19th century saw the enthusiasm of the previous one for mouth-to-mouth ventilation (MMV) dissipated. To inflate the lungs of the asphyxiated, the Royal Humane Society in the United Kingdom had recommended bellows since 1782. Principal determinants for change were aesthetic distaste for mouth-to-mouth contact and the perceived danger of using expired air, although MMV survived in the practice of some midwives. Following the 1826-9 investigations of Jean-Jacques Leroy d'Etiolles then François Magendie, all positive pressure ventilation methods were generally abandoned, after 1829 in France, and 1832 in the UK; but not chest compressions. During the next quarter century, rescuers lost understanding of the primary need for "artificial respiration", apart from researchers such as John Snow and John Erichsen, until Marshall Hall's "Ready Method" heralded the second half-century's various methods of negative pressure ventilation. Some of those methods continued in use until the 1940s. Sporadic anecdotal cases of MMV rescues were documented throughout. In the 20th century, inadequate mechanical inhalators were also tried from 1908, while obstetricians devised indirect methods of expired air ventilation (EAV). Anaesthetists in the 1940s, such as Ralph Waters, Robert Dripps, and the pair, Robert Macintosh and William Mushin, described the usefulness of MMV, and James Elam was "re-discovering" it. Following World War II, "Cold War" concerns stimulated research at the Edgewood Medical Laboratories in Maryland in the United States into the possibilities of MMV, and Elam et al confirmed and expanded on brief experiments at Oxford (United Kingdom) on the efficacy of mouth-to-tube EAV. Studies, 1957-9, by Archer Gordon, Elam and especially Peter Safar resulted in the resolution of previous airway problems, established the primacy of MMV, and incorporated it into an integrated system for basic cardiopulmonary resuscitation. Ready adoption of MMV in the US was followed by worldwide spread, especially after endorsement from the 1962 international symposium at Stavanger in Norway. However, already there were occasional rumblings of reluctance to perform MMV. In this article, I consider MMV also in the context of other ventilatory modes for resuscitation.

Nomenclature for two intravenous solutions.

May I comment on the names applied to two solutions commonly used in critical care practice, 0.9% sodium chloride (NaCl) and 5.0% glucose? I am highly aware that the pinpricking remarks following are trifling in the context of the clinical importance of the articles referred to; I am simply trying to write about scientifically correct and/or consistent use of expressions.

19th century pioneers of intensive therapy in North America. Part 1: George Edward Fell.

For three decades after Marshall Hall's 1856 strictures against "forcing methods" and bellows for artificial ventilation (AV), human "forced respiration" (equivalent to intermittent positive pressure ventilation) was virtually abandoned. Various arm-chest manoeuvres often proved inadequate to save life. After doctor and engineer George Fell, of Buffalo (New York) (1849-1918), failed to save the life of an opiate-poisoned patient using Silvester's popular method, he resolved to try his animal laboratory AV method (bellows and tracheotomy). Following his first success in a landmark case (1887), he better adapted the apparatus for human use and soon succeeded with further difficult cases, but was unable to raise enthusiasm for his "Fell method" of AV. His reports of successful rescues to prestigious Washington Congresses met derision (1887) and indifference (1893), although by then they detailed 28 "human lives saved", mostly after opiate poisoning, and a switch from tracheotomies to face masks (simpler, but with a few complications). Continuing with rescues throughout the 1890s, Fell personally achieved recoveries after AV for as long as 73.5 hours (1896), and over 78 hours (1899). He argued for his method repeatedly with many talks, much documentation, and pleas for its use in other ventilatory crises. Despite his endeavours and successes, Fell was unable to secure widespread uptake of forced respiration, but others adopted his principles. Joseph O'Dwyer modified Fell's face mask-tracheotomy system by incorporating an intralaryngeal tube, and this "Fell-O'Dwyer apparatus" was used for neurosurgical cases (1894), also revolutionising intrathoracic surgery (1899).

Notable Australian contributions to the management of ventilatory failure of acute poliomyelitis: with special reference to the Both respirator and Dr. John A. Forbes.

When Australia's 1937 epidemic of poliomyelitis created an urgent need for extra ventilating machines to compensate for respiratory paralysis, Edward Both, an innovative Adelaide biomedical engineer, invented a wooden-cabinet respirator capable of being made relatively quickly in sufficient quantity. His device, here called "the Both", alleviated the problem at Adelaide's Northfield Infectious Diseases Hospital and others, and in late 1938 was introduced into England when Both was visiting there. Appreciating its merits, Lord Nuffield financed assembly-line production at the Morris motor works in Cowley, Oxford. Then, through the Nuffield Department of Anaesthetics in Oxford's Radcliffe Infirmary, he had the Both distributed Commonwealth-wide, as a gift for treating ventilatory failure in polio - especially in children. For the 1937 epidemic in Victoria, and to the design of Melbourne University's Professor of Engineering, Aubrey Burstall, nearly 200 of another wooden-cabinet respirator were ultimately built. Some were installed at the Acute Respiratory Unit of the Infectious Diseases Hospital at Fairfield, then others "all over Australia". However, by the early 1950s, the Both had replaced Fairfield Hospital's "Burstall", which had functioned as Victoria's favoured respirator since 1937. Dr John Forbes at Fairfield became the foremost Australian clinician for expertise with the Both. Before the advent of intermittent positive pressure ventilation, the Both's usefulness had seen it tried for ventilatory failure in some non-polio conditions, but uptake of that application was limited. Nonetheless, Nuffield's philanthropy with the (Nuffield-)Both ultimately furthered progress along the 20th century pathway to intensive care medicine.

History of mouth-to-mouth rescue breathing. Part 2: the 18th century.

In Britain, the great boost to performing mouth-to-mouth resuscitation for the "suddenly apparently dead" came from William Tossach's 1744 documentation of his own successful case, and then from promotion by John Fothergill and other enthusiasts. Some civic authorities on the Continent were exhorting citizens to employ it from as early as the mid-18th century. The first humane society was founded in Amsterdam in 1767 and initially promoted expired air ventilation (EAV) by the mouth-to-mouth method. Other humane societies were soon established throughout Europe, especially in maritime cities with frequent drownings. The founding of London's humane society in 1774, initially known as "The Institute," was followed by earnest efforts to promote mouth-to-mouth EAV in England, and soon after in Scotland, but not until the 1780s in North America. Disenchantment with the mouth-to-mouth method as less desirable (for various reasons) led to decline in its general use. In 1782, what later became The Royal Humane Society in London changed its expressed preference for artificial ventilation by mouth-to-mouth to manual artificial ventilation using inflating bellows, although mouth-to-mouth was a method of resuscitation which could be attempted by any rescuer. The need to apply artificial ventilation immediately was not really recognised before John Hunter's recommendation to London's Humane Society in 1776. Charles Kite spelt out clearly the principles of resuscitation in 1787-8, though he gave some priority to warming. It seems that only in the latter part of the 18th century was the importance of airway obstruction recognised, largely due to Edmund Goodwyn.