To the Editor:—

Sir, may we contribute a small historical addendum to the correspondence from Adnet et al.  1concerning the correct positioning for laryngoscopy and tracheal intubation? The authors state that it is Chevalier Jackson who is credited with observing that alignment of oral, pharyngeal, and laryngeal axes is necessary for successful visualisation of the larynx and subsequent tracheal intubation; a description of his technique was published in the literature in 1913 and helped to popularize routine laryngoscopy. However, the principles of laryngoscopy had been laid some 18 yr before by Alfred Kirstein, a Berlin physician who invented the laryngoscope. 2In his publication about direct laryngoscopy, 3Kirstein reported that

… the body must be placed in such a position that an imaginary continuation of the laryngotracheal tube would fall within the opening of the mouth … . When the military position is assumed, the continuation of the windpipe would strike somewhere in the neighbourhood of the root of the nose; when the head is bent comfortably backward, as in looking aloft, it would about strike the chin … . The position adopted for autoscopy (laryngoscopy) must therefore be somewhere between the two positions just mentioned

… . [fig. 1]

Fig. 1. Kirstein’s suggested position (dotted lines) for laryngoscopy. Reprinted with permission. 2 

Fig. 1. Kirstein’s suggested position (dotted lines) for laryngoscopy. Reprinted with permission. 2 

Kirstein was therefore almost certainly the first to describe what subsequently became called the “sniffing the morning air” position.

His practical conduct of laryngoscopy (fig. 2)

Fig. 2. Line engraving of Kirstein performing laryngoscopy. Reprinted with permission. 2 

Fig. 2. Line engraving of Kirstein performing laryngoscopy. Reprinted with permission. 2 

clearly shows that he was also aware of the importance of rotation at the atlantooccipital joint.

1.
Adnet F, Borron SW, Lapostolle F, Lapandry C: The three axis alignment theory and the “sniffing position”: Perpetuation of an anatomic myth? A nesthesiology 1999; 91: 1964–5
2.
Hirsch NP, Smith GB, Hirsch PO: Alfred Kirstein: Pioneer of direct laryngoscopy. Anaesthesia 1986; 41: 42–5
3.
Kirstein A: Autoskopie des Larynx und der Trachea. Archiv für Laryngologie und Rhinologie 1895; 3: 156–64