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Home , General anaesthesia, Laryngoscopy, Robert Macintosh, Tracheal intubation, Tracheal tube, Tracheotomy

Intensive Care Med (2008) 34:222–228 DOI 10.1007/s00134-007-0931-5 REVIEW

Peter Szmuk A brief history of tracheostomy and tracheal Tiberiu Ezri Shmuel Evron , from the Bronze Age to the Space Yehudah Roth Jeffrey Katz Age

Y. R ot h the modern era of . Received: 29 January 2007 Wolfson Medical Center, Affiliated to Accepted: 9 October 2007 Data sources: Review of the liter- Published online: 13 November 2007 Tel Aviv University, Department of ature. Conclusions: The colorful © Springer-Verlag 2007 Otolaryngology, Holon, Israel and checkered past of tracheostomy and informs con- There is no conflict of interest. J. Katz temporary understanding of these University of Texas Medical School at procedures. Often, the decision P. Szmuk (u) Houston, Department of Anesthesiology, whether to perform a life-saving University of Texas Southwestern Medical Houston TX, USA School and Children’s Medical Center at tracheostomy or tracheal intubation Dallas, Department of Anesthesiology, has been as important as the technical 1935 Motor Street, Dallas 75235, TX, USA ability to perform it. The dawn of e-mail: [email protected]; modern owes its [email protected] existence to the historical develop- P. Szmuk · T. Ezri · S. Evron Abstract Objective: To present ment of increasingly effective airway Members Outcome Research Consortium, a concise history of tracheostomy devices and to regular contributions of Cleveland OH, USA and tracheal intubation for the ap- research into the pathophysiology of proximately forty centuries from their the upper airway. T.Ezri·S.Evron Wolfson Medical Center, Affiliated to earliest description around 2000 BC Tel Aviv University, Department of until the middle of the twentieth , century, at which time a proliferation Keywords Tracheal intubation · Holon, Israel of advances marked the beginning of Tracheostomy · History

Twentieth century Irish dramatist and social philosopher lowing the work of Imhotep (arguably a father of modern George Bernard Shaw is known for his scathing commen- as well as an architect, poet, priest, judge, and tary on the medical profession. In 1906 he satirized the prime minister), a technique resembling tracheostomy frequency in with which ideas are lost and was first documented in written form. Egyptian reinvented [1]. No finer illustration of that phenomenon were indeed pioneers in describing procedures such as exists than the history of tracheostomy and tracheal intu- cauterization to avoid excessive while operating, bation. While the originator of any specific airway man- drainage to cure purulent collections, and tracheostomy to agement technique or airway tool may be impossible to resolve upper respiratory obstructions [3]. identify, the techniques and tools themselves have recurred Much later in Greece, (460–380 BC) periodically for almost 4,000 years. (Fig. 1) described intubation of the of humans to One of the earliest suggestions of surgical trache- support ventilation. Alexander the Great (356–323 BC) ostomy can be inferred from a Bronze Age description of reportedly used his sword to cut open the trachea of the healing of a incision in Rig Veda, the ancient a soldier suffocating from an aspirated bone [2]. The Hindu book of medicine that appeared as oral tradition Talmud, a compendium of Judaic law, ethics, customs, around 2000 BC [2]. Five centuries later in Egypt, fol- and history promulgated between 200 BC and 400 AD, 223

Fig. 1 Hippocrates of Kos (460–380 BC) (engraving by Peter Paul Fig. 2 (1514–1564) (portrait from the Fabrica) Rubens, 1638; courtesy of the National Library of Medicine) contains descriptions of inserting a reed through the tra- a “semi-slaughter and a scandal of ” [9]. This chea to assist artificial for newborn humans [4]. description would certainly explain the contemporaneous The Greek physicians Aesculapius and Aretaeus and the demise of its use. Roman anatomist Gallenus documented similar opera- It was not until the height of the that tions. By around 100 BC, tracheostomy may have been tracheostomy reappeared as a viable medical solution, routine [5]. when, in parallel with the arts and other sciences, medicine Air movement and the means by which it was achieved too began to flourish. Efforts to manage the human air- were often perceived as curiosities and have thus con- way regained prominence, and many descriptions of tributed to Mr. Shaw’s thesis as being “discovered” at tracheostomy can be found. In 1543, for example, at the various times throughout history. In a famous experiment, same time Copernicus was challenging Church doctrine (129–199 AD) inflated the of dead animals by claiming that the earth revolved around the sun, the via the trachea with a bellows and concluded that air Flemish anatomist Andreas Vesalius (Fig. 2) in Padua movement caused chest “arises”. The full significance of published De Humani Corporis Fabrica (On the Fabric of that finding was not appreciated, however, and research the ), revolutionizing the science of human on ventilation did not advance any further for centuries. . That same year Vesalius passed a reed into In the next triumph of airway experimentation, Muslim the trachea of a dying animal whose had been philosopher and (980–1037 AD) opened, and maintained ventilation by blowing into the described intubation of the trachea using “a cannula of reed intermittently [10]. This activity, he wrote, caused gold or ”. the lungs to expand and the heart to recover its normal For the ensuing centuries of the Middle Ages, history pulsation: “But that life may in a manner of speaking be is for the most part silent on the airway procedure. In a rare restored to the animal, an opening must be attempted in mention in the thirteenth century, tracheostomy is termed the trunk of the trachea, into which a tube or reed or cane 224

Fig. 3 Antonio Musa Brasavola (1490–1554), an Italian physician, performed the first documented case of a successful . He published his account in 1546. The , who suffered from a laryngeal abscess, recovered from the surgical procedure (courtesy of the National Library of Medicine)

Fig. 4 Engraving, Armamentarium chirurgicum bipartitum, 1666 (courtesy of the National Library of Medicine). The first five images should be put; you will then blow into this, so that the shown in this engraving depict the tracheotomy procedure. Between may rise again and the animal take in air”. 1500 and 1833, there are reports of only 28 successful Shortly thereafter, in 1546, the Italian physician Antonio Brasavola (Fig. 3) reintroduced tracheostomy in humans [2] by performing the first documented case of a successful tracheostomy (Fig. 4) in a patient with tonsil- recounts a case of a 14-year-old patient who swallowed lar obstruction. a bag of gold coins to prevent their theft. The bag caused These instances did not stand alone. Other Renais- upper airway obstruction, which was resolved by prompt sance medical personalities emphasized the importance tracheotomy. Another heroic account in Habicot’s book of “opening the airway” in saving victims’ lives [11, 12]. describes a boy who was pronounced dead from stab Fabricius of Aquapendente (1537–1619), an Italian wounds to the neck. Following emergent tracheotomy and anatomist, wrote this historic statement: “Of all the release of a tracheal blood clot, the boy was fully resus- surgical operations which are performed in man ... the citated. In possibly the most dramatic story, a convicted foremost [is] that by which man is recalled from a quick thief sentenced to be hanged hired a surgeon to perform death to a sudden repossession of life ... the operation a pre-gallows tracheostomy and to insert an elongated is the opening of the aspera arteria [“artery of air”], by tube for . The condemned man managed to which , from a condition of almost suffocating conceal this ingenious preparation from his jailers, but to obstruction to respiration, suddenly regain , no avail. Notwithstanding the tracheostomy’s potential for and draw that vital ether, the air, so necessary to life, protecting the man from suffocation, it could not save him and again resume an existence which had been all but from a broken neck. annihilated”. In October 1667, tracheostomy, “discovered” yet again, In 1620, as the Mayflower was landing the Pilgrims was performed on a dog at a Royal Society meeting by on Plymouth Rock in America, a book on tracheotomy Robert Hooke (1635–1703), who preserved the canine’s was published by Parisian Nicholas Habicot. In it, Habicot life by breathing for it by means of a bellows. Hooke even 225

removed the thoracic cage and demonstrated that a con- Virginia, December 1799, as three physicians gathered tinuous stream of blood-altering “fresh air,” and not mere around a dying man. The man kept shifting his position as movement of the lungs as had been supposed, was essential he gasped for air. The physicians gave the man sage tea to life [9]. with vinegar to gargle, but it nearly caused the patient to Although Benjamin Pugh, an English obstetrician, choke to death. It was obvious the patient’s airway was described an air-pipe for neonatal in 1754, severely compromised, but poultices did little to help”. the first endotracheal were utilized for resus- One of the physicians present at the scene was aware of citation of victims and for those suffering from tracheostomy but was disinclined to perform it, especially laryngeal [13]. Great advances in resuscitation on such an important personage, because he believed the were made by societies created in Amsterdam, Paris, procedure to be futile. As a result, George Washington London, Venice, and Philadelphia to rescue drowning died from fully preventable suffocation due to an upper victims from the water. In 1760 Buchan described the airway obstruction caused by bacterial . first use of an opening in the patient’s “windpipe” during In support of reluctant practitioners of the age, it is true resuscitation [2]. Cullen suggested the use of tracheal that airway management and ventilation techniques had intubation and ventilation with bellows for reviving the been subject to criticism. For example, although positive apparently dead [2]. Subsequently, Curry developed pressure ventilation using bellows was first used for intralaryngeal cannulae for resuscitation [2]. drowning victims in the 1700s, concerns soon arose that In 1788 Charles Kite first used endotracheal tubes in re- such therapy could in fact be harmful to the lungs [22]. suscitation of drowned persons and described their use by In 1827 Leroy demonstrated that vigorous bellows ven- either the oral or nasal route [14]. Kite wrote: “If any diffi- tilation of drowned dogs could cause emphysema and culty should arise in distending the lungs ...we shall gen- fatal [23–25]. The French Academy erally remedy the inconvenience by bringing the quickly abandoned the technique of bellows ventilation, forwards, which being connected to the by in- and the Royal Humane Society soon followed [26]. Posi- elastic ligaments, must of course be elevated. Should any tive pressure ventilation was thus banned from common further impediment however occur, the crooked tube, bent use, and would not seriously emerge as a contender to like a male ...should be introduced into the glot- other techniques for more than a hundred years. Despite tis, through the or one nostril; the end should be this considerable setback, tracheostomy and tracheal connected to a blow pipe ...”. intubation continued to be performed and their techniques On 18 April l774, Cogan and Harwes founded a Lon- improved in the following decades, especially for acute don rescue society with the somewhat unwieldy name of airway management. “The Institution for Affording Immediate Relief to Per- In 1833, the Frenchman Trousseau routinely performed sons Apparently Dead from Drowning” which was later tracheostomy when required, and thereby saved the lives of chartered as the Royal Humane Society. Cogan and Hawes 200 individuals suffering from diphtheria [5]. At that time, emphasized that tracheal intubation was more efficient for tracheostomy was otherwise done in emergency settings survival than mouth-to-mouth ventilation [9]. only. In view of Trousseau’s achievements 170 years ago, In the late 1700s, Chaussier (1746–1828), a gynecolo- it is remarkable that patients still die today because of the gist working in a maternity in Paris, performed failure to take steps to open an obstructed airway. translaryngeal intubation with self-made tubes in neonates Throughout this history, or possibly despite it, the with obstructed airways [15] and was the first to administer practice of anesthesia continued to mature. It is widely to newborns. held that general anesthesia was first employed by Craw- Working in the same field in the first half of the nine- ford Long in Georgia on 30 March 1842. An account of teenth century, John Snow (1813–1858) of resus- the achievement, however, was not published until 1849. citated a baby with a tracheal catheter [16]. Snow holds In the intervening years, on 30 September 1846, William the dubious distinction of being the first to employ tra- Morton gave the first successful public demonstration cheostomy to give anesthesia to a rabbit. He performed the of ether as an at Massachusetts same experiment described by Vesalius (l543) and Hooke General Hospital [18]. Because the ether anesthesia was (1667), except for the addition of the anesthetic agent. light and preserved the patient’s and Regardless of “discoveries” and advances made in reflexes, Morton reported no concern with taking care of airway management through the ages, implementation by the airway. practitioners was erratic. The decision whether or not to Applying the techniques of tracheostomy developed undertake a procedure such as tracheostomy or tracheal by John Snow in animals, the German Trendelenburg intubation was often as critical as the technical ability to (1844–1924) manufactured the first cuffed tracheostomy perform it successfully. In Virginia in December 1799, tube in 1869, and administered the first endotracheal for example, the first President of the United States of anesthesia in man in early 1871 [15]. In 1901 this first America, only 3 years after his retirement, lay struggling tracheostomy tube cuff was dubbed “Trendelenburg’s to breathe [17]: “It was a frigid afternoon that day in tampon” [18]. 226

Tracheal intubation was greatly helped by the works tube “lies better” and leaves the mouth clear of impedi- of the Scottish surgeon William Macewen and Joseph ments to operation. Kuhn was the first to realize that an O’Dwyer in the second part of the nineteenth century [10]. unblunted surgical stimulus may easily lead to spasm of Along with many accomplishments in the surgical field, the . He believed that “cocainization” of the larynx Macewen is credited with the first elective use of endo- was a helpful adjunct to intubation, and he frequently used tracheal intubation for an anesthetic [10, 16]. In 1878, it. This technique was further developed by Magill in Eng- preparing for the resection of an oral tumor, Macewen land [10, 14]. Kuhn’s efforts were probably the first histor- performed an awake, digital, blind intubation under ical steps toward awake tracheal intubation under topical anesthesia [3]. His apparent goals were to anesthesia, a technique frequently used today in patients provide an uninterrupted smooth supply of anesthetic, with difficult airways. and to avoid aspiration of blood into the airways [6, 10]. In other innovations of the same era, the Americans Macewen was also the first to introduce packing of the Guedel and Waters were among the first to attach an inflat- superior aperture of the larynx to avoid contamination able cuff to a [18, 19]. In 1909, Meltzer and of the airway with blood, , and debris from the Auer in Germany described insufflation anesthesia in ani- surgical site. mals, and Kelly applied the technique to humans in Eng- In 1885, after witnessing the mutilating effect of hasty land in 1912 [10, 14]. tracheostomies, Joseph O’Dwyer, an American pediatri- Sir Ivan Whiteside Magill (1888–1986), mentioned cian and obstetrician, developed a series of metal tracheal above, realized that reconstructive performed tubes he inserted orally between the in patients on mutilated soldiers were more successful under general who had diphtheria and needed surgery [10] (Fig. 5). The anesthesia with the airway secured by endotracheal tubes were also of value in stenosis of the larynx caused tubes. In consequence, during World War I, Magill and by various other , such as syphilis, and to stric- Rowbotham performed several endotracheal intubations tures of the larynx, especially the consequence of burns and administered endotracheal anesthesia for patients or scalds. His intubation method, also called the O’Dwyer suffering from severe facial [20, 21]. They also method, was first published in the New York Medical Jour- developed a forceps useful for nasal intubation (the “Mag- nal as “Intubation of the Larynx” in 1888. In the same year, ill forceps”) and, in 1928, introduced the term “blind” O’Dwyer successfully intubated and artificially ventilated intubation by performing nasal intubation with rubber patients undergoing thoracic surgery [15]. tubes, following cocainization of the airway [10, 14]. At the end of the nineteenth century, the German sur- These various innovations marked Magill as one of the geon Franz Kuhn constructed metal tubes that he inserted pioneers of modern endotracheal anesthesia and helped orally with a digital, blind technique [10]. Kuhn described to transform anesthesia into the independent medical the use of a curved tube introducer. He preferred packing specialty it is today. the hypopharynx with gauze instead of using cuffed tubes The next giant step in the progress of airway manage- for prevention of aspiration [10]. Kuhn also published the ment was the relatively recent discovery of the importance first paper on nasal intubation [10]. He felt that a nasal of lung isolation. It was not until 1930 – a year that saw

Fig. 5 Craig Gelfand, “Dr. Joseph O’Dwyer (1841–1898) and his intubation tube”, Caduceus 1987; 3,2:1–35. a O’Dwyer performing a tracheostomy. b Aseriesof metal tracheal tubes developed by O’Dwyer for use in patients who had diphtheria 227

the completion of New York’s Empire State Building Endotracheal intubation came into routine use after the and the success of Hollywood’s All Quiet on the Western introduction of muscle relaxants into anesthesia practice. Front – that techniques and devices for lung isolation and artificial ventilation were first employed in emerged. American Ralph Waters is credited with devel- animal treatment and experimentation by Sir Benjamin oping one-lung intubation to facilitate thoracic surgery. Brodie in England as early as 18l1. More than 100 years Initially it was performed with double-cuffed, single- later, Canadian anesthetist Harold Griffith used curare tubes invented by Gale, Waters and Guedel [5, 19]. for the first time in human anesthesia in 1942. Griffith Both Gebauer in 1939 [28] and Eric Carlens in Sweden in intubated the trachea in 25 patients, providing abdominal 1948 [29] proposed similar designs for early double-lumen relaxation for surgery [33]. bronchial tubes for separation of the lungs. Only in 1962 In the final important breakthrough that set the stage did Robertshaw develop the first double-lumen tubes of for the modern era, Kensuke Ikeda of Japan introduced the modern era [30]. flexible fiberoptic into medical practice in While lung isolation was a significant breakthrough, 1968 [34]. Fiberoptic bronchoscopy has since taken its possibly the biggest aids to successful endotracheal intu- place in the standard anesthetic arsenal as an adjuvant for bation were the development of and the con- management of difficult endotracheal intubations. tinuous improvement of laryngoscopes. Their foundations As we have seen, the roots of airway management span had existed in primitive form for some time. The first tools almost 4,000 years of human history. During that time, used for visualization of the oral cavity were based either the development of increasingly effective airway devices, on a reflective metallic spatula (Leveret in 1743) or an ex- along with a better understanding of the pathophysiology ternal light source, such as sunlight or a candle [31]. In- of the upper airway, have formed the cornerstones of direct laryngoscopy was first described in 1855 by Garcia, modern practice. Today’s appreciation of the value of a singing teacher in England [9]. By using sunlight and tracheostomy and tracheal intubation was prefaced by two two mirrors, Garcia was able to see his own moving vocal millennia of the intermittent rise and fall of their vogue. cords. Advances made from antiquity until the middle of the Direct laryngoscopy was first performed in 1895 by twentieth century underpin the decrease in anesthetic mor- Alfred Kirstein [16, 32]. His “autoscope” had an external tality linked to failed airway management; and they form electrical light source. In 1913, Chevalier Jackson [10] of the foundation for modern management of the normal and Philadelphia designed a laryngoscope that was later modi- difficult airway. Perhaps, with full knowledge of these fied by Magill, Miller and Macintosh [16, 30]. Jackson was dramatic strides, even Mr. Shaw might soften the irony the first to describe tracheal intubation under direct laryn- of his observation, “We have not lost faith, but we have goscopy [32]. transferred it from God to the medical profession.” [35]. Thus the genesis of direct laryngoscopy is attributed primarily to surgeons. Among anesthesiologists, direct Acknowledgements. We would like to thank Dr. David Zuck, MB, laryngoscopy was popularized by Henry Harrington ChB, FRCA, DA, DHMSA, retired consultant anesthetist, past Presi- Janeway in New York in 1913 [32]. He designed a battery- dent of the British History of Anaesthesia Society, and an honorary powered laryngoscope, solely dedicated for tracheal member of the Association of Anaesthetists of Great Britain and Ire- land; and Dr. Henry Hadad, Chief of Anesthesia at the English Hos- intubation. Sir (1897–1989) introduced pital, Nazareth, Israel, for the invaluable information they provided the eponymous Macintosh curved laryngoscopic blade to help us write this brief review. We also thank Camille Lloyd, PhD, that has been in use since 1943 [16]. and Liza Farrow-Gillespie for editorial assistance.

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