A Brief History of Tracheostomy and Tracheal Intubation, from the Bronze

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 intubation, from the Bronze Age to the Space Yehudah Roth Jeffrey Katz Age Y. R ot h the modern era of anesthesiology. 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 tracheal intubation 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 airway management 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 Anesthesia, 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- medicine 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 medical history with which ideas are lost and was first documented in written form. Egyptian physicians 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 bleeding 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, Hippocrates (460–380 BC) periodically for almost 4,000 years. (Fig. 1) described intubation of the trachea 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 throat 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 Andreas Vesalius (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 surgery” [9]. This chea to assist artificial breathing 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 Renaissance 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 Galen (129–199 AD) inflated the lungs 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 Human Body), revolutionizing the science of human on ventilation did not advance any further for centuries. anatomy. That same year Vesalius passed a reed into In the next triumph of airway experimentation, Muslim the trachea of a dying animal whose thorax had been philosopher and physician Avicenna (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 silver”. 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 tracheotomy. He published his account in 1546. The patient, 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 lung 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 tracheotomies 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 respiration. The condemned man managed to which patients, from a condition of almost suffocating conceal this ingenious preparation from his jailers, but to obstruction to respiration, suddenly regain consciousness, 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 resuscitation in 1754, severely compromised, but poultices did little to help”. the first endotracheal intubations were utilized for resus- One of the physicians present at the scene was aware of citation of drowning victims and for those suffering from tracheostomy but was disinclined to perform it, especially laryngeal diphtheria [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.

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