Dr. Jordan Francke, a CA-2 resident at UCLA, was born in Kentucky and raised in Maine. He is an avid marathoner, hiker, and lover of history.
October 4, 1928
Arthur Guedel MD (Beverly Hills, CA) to Ralph Waters MD (Madison, WI)
“It was my first case at St. Vincents Hospital, the young wife of one of our (Los Angeles) X ray men… She died within three minutes after the anesthesia was started, and before the operation was begun. I don’t know what happened… Some cyanosis, and I felt the pulse to be indefinite. Seemed feeble, but still passable. As cyanosis increased I inflated with Oxygen. No pink. More Oxygen. No pink. No Pulses. I put a catheter into her larynx… and conducted artificial respiration by inhaling my own lungs full of oxygen and blowing it into her lungs through the catheter. I dont know and you dont know. After all medicine some times seems damned futile.” 1
If the above attempt to resuscitate an apneic patient were performed by a contemporary anesthesiologist, it would likely be considered malpractice. However, less than a century ago, this effort might have been considered sophisticated, using a groundbreaking innovation that had yet to be popularized: the endotracheal tube.
The invention of the modern cuffed endotracheal tube can be traced to when two leaders in the field met during anesthesia meetings in the American Midwest during the 1920s.2-3 Dr. Arthur Guedel was a physician in Indianapolis. Having served in World War I, Guedel had witnessed countless soldiers aspirating on gastric contents and blood during surgeries.2-3 Dr. Ralph Waters was an anesthesiologist at the University of Wisconsin in Madison who had spent several years developing a soda lime apparatus to remove carbon dioxide (CO2) from the air exhaled by patients. Upon meeting, Drs. Guedel and Waters found themselves with much in common: Midwestern roots and humor, a love for four-legged companions, and a dream of creating a closed anesthetic system capable of preventing aspiration.
In the 1920s, anesthesia was typically administered using either a mask with spontaneous respiration, or an uncuffed catheter for “intratracheal insufflation.”3 Both required large volumes of oxygen and exposed not only the patient but also everyone in the operating room to anesthetic gas.2 Guedel began experimenting with various materials to create an inflatable cuff that could seal the trachea. He opened a lab in his basement and studied lamb tracheas purchased by his wife at a local butcher shop.3 Guedel trialed his first cuffed endotracheal catheter using fingers from a rubber glove; his second iteration used a rubber condom.2 A flexible rubber tube “long enough to extend conveniently well out of the mouth” was then connected to the cuff, inflated using a graduated syringe, and closed with a metal surgical clamp.4
This prototype was subsequently tested in two human patients.4 The patients were anesthetized with combinations of nitrous oxide and either ether or ethylene. The catheter was inserted under direct laryngoscopy, and the cuff was inflated. To demonstrate the tube’s efficacy in preventing aspiration, both patients’ mouths and noses were filled with water, and no air bubbles were observed to escape from the airway.
It is likely Guedel’s third patient who gained the most notoriety for successful intubation with an early cuffed endotracheal tube on May 8, 1928.2 This “patient” was the newest member of Guedel’s own family – his pet dog “Airway.” The twenty-pound dog was anesthetized with ethylene and morphine, and then intubated with a cuffed endotracheal catheter.4 He was then inverted, submerged in an aquarium, and ventilated for an hour using an apparatus connected to Dr. Water’s soda lime CO2 absorber. At the end of the hour, the dog “awakened and sat up in the tank… the catheter was removed and the dog [was] placed on the floor, where he stood up, shook the water off, and lay down for a nap.”4
After three successful intubations and an article in Current Researches in Anesthesia and Analgesia, the main physician anesthesiology journal of the time, word traveled quickly of a remarkable endotracheal catheter and closed ventilatory system.3 Arthur Guedel moved to Los Angeles and gifted his “dunked dog” Airway to Dr. Waters, who remained in Wisconsin.2-3 Airway lived with the Waters family, happily “hunting rabbits” for two years before disappearing; Waters was convinced someone had dognapped him.2
Correspondence between Guedel and Waters continued after Guedel established himself in Southern California. As interest in cuffed endotracheal tubes intensified, the two collaborators enlisted the assistance of Dr. E.I. McKesson, President of Toledo Technical Appliance Company (Toledo, OH) in the production of catheters.5 The tubes made by Toledo Technical were expensive and time-consuming to manufacture, and therefore were reused between patients after being sanitized through boiling.5 The exchange below captures the excitement that these novel endotracheal tubes generated:
March 19, 1929
Ralph Waters MD (Madison, WI) to Arthur Guedel MD (Beverly Hills, CA)
“The balloon which you enclosed in your last letter looks like a dinger; I think you said I could keep it, at any rate I have it. You are certainly an artist at making the things. Sise and Woodbridge of the Lahey Clinic are very much interested in the idea and want some catheters and balloons as soon as they are available… They are pestering me for the name of the manufacturer, as is Lundy in Rochester.”5
These early cuffed endotracheal catheters served as the archetype upon which every modern endotracheal tube is based. In a 1928 letter to Waters, Dr. Guedel lamented that the practice of medicine sometimes seemed futile.1 Indeed, even with the use of an early cuffed endotracheal tube, the patient he described had expired without a clear cause.1 However, as its practice and design were refined and perfected, Guedel’s cuffed endotracheal tube prevented countless other patients from facing similar demises. It enabled the modern-day anesthesiologist to protect patients more reliably from aspiration, provide positive-pressure ventilation, ventilate a single lung at a time, and reduce operating room staff’s exposure to anesthetics. Dr. Guedel’s cuffed endotracheal tube has endowed the field with a powerful tool to provide higher quality, safer care to patients, and has ultimately made the practice of anesthesia less futile.
(1). Guedel AE. Letter to Ralph Waters, October 4, 1928. Ralph Water Papers. Arthur E. Guedel Memorial Anesthesia Center, San Francisco, CA. Accessed on 8 January 2022 at https://calisphere.org/collections/27436/?q=&sort=a&facet_decade=1920s.
(2). Calmes SH. Two men and their dog: Ralph Waters, Arthur Guedel, and the Dunked Dog “Airway.” Proceedings the Ralph M. Waters Symposium on Professionalism in Anesthesiology Madison, Wisconsin 2002. Wood Library - Museum of Anesthesiology. 37-42. Accessed on 8 January 2022 at https://www.csahq.org/docs/default-source/history-of-anesthesia-articles/history-articles/calmes-two-men-and-their-dog-2004.pdf?sfvrsn=9f1ec146_2.
(3). Calmes SH. Dr. Arthur Guedel’s Contributions to Airway Management. American Society of Anesthesiologists. Newsletter 72(9): 14-16. Accessed on 8 January 2022 athttps://pubs.asahq.org/monitor/article-abstract/72/9/14/4233/Dr-Arthur-Guedel-s-Contributions-to-Airway?redirectedFrom=fulltext.
(4). Guedel AE, Waters RM. A new intratracheal catheter. Anesthesia and Analgesia; July-August 1928. 238-239. Accessed on 8 January 2022 at https://journals.lww.com/anesthesiaanalgesia/Citation/1928/07000/A_New_Intratracheal_Catheter__.21.aspx.
(5). Waters R. Letter to Arthur Guedel, March 19, 1929. Ralph Water Papers. Arthur E. Guedel Memorial Anesthesia Center, San Francisco, CA. Accessed on 8 January 2022 at https://calisphere.org/collections/27436/?q=&sort=a&facet_decade=1920s.