The history of tracheotomy Garret Choby, MD, and David Goldenberg, MD, FACS Dr. Choby (AΩA, Pennsylvania State University, 2010) is racheotomy is one of the oldest known surgical a resident in Otolaryngology—Head and Neck Surgery at procedures,datingbacktoancientEgyptandIndia. the University of Pittsburgh Medical Center. Dr. Goldenberg Throughout its history, utilization of the operation (AΩA, Pennsylvania State University, 2009) is associate has wavered between widespread acceptance and extensive professor of Surgery and Oncology at the Pennsylvania rejection both because of controversy over its safety, neces- State University. sity,andtechniqueselection,andbecausetheindicationsand methods for tracheotomy have changed and expanded over time.Today,advancesinintensivecaremedicineandthewide- spreaduseofmechanicalventilationhavemadetracheotomy From Armamentarium chirurgicum bipartitum, plate 34, oppo. page 71. Courtesy of the National Library of Medicine. T 34 The Pharos/Summer2011 oneofthemostcommonlyperformedsurgicalprocedures. Tracheotomy is derived from two Greek words meaning Thehistoricaldevelopmentoftracheotomycanbedivided incisionoropeningofthetracheaandcarriesnoimplication The history of tracheotomy intofiveperiods:1 ofpermanence.Ontheotherhand,tracheostomyisthesurgi- 1. ThePeriodofLegend(2000BCto1546AD). calcreationofanopeningintothetracheathroughtheneck, 2. ThePeriodofFear(1546to1833),duringwhichtheop- withthetrachealmucosabeingbroughtintocontinuitywith erationwasperformedonlybyabravefew,oftenattheriskof theskin.2Thisprocedureisoften,butnotalways,permanent. theirreputations. Despite animated discussion about the correct usage of the 3. ThePeriodofDramatization(1833to1932),duringwhich twoterms,authorscontinuetousetheminterchangeably.For tracheotomywasperformedonlyinemergencysituationson the sake of correctness, tracheotomy is used throughout this acutelyobstructedairways. manuscript. 4. ThePeriodofEnthusiasm(1932to1965),duringwhich the saying, “if you think of tracheotomy—do it!”1 became The Period of Legend (2000 BC–1546 AD) popular. ThePeriodofLegendstretchesfromthefirstmentionof 5. ThePeriodofRationalization(1965tothepresent),dur- tracheotomyintheBCerauntil1500AD.1Althoughitisdif- ingwhichthemeritsoftracheotomyversusintubationremain ficulttotellforsurewhentheearliesttracheotomyprocedure atopicofdebate. was performed, two ancient Egyptian hieroglyph slabs from The Pharos/Summer2011 35 The history of tracheotomy about3100BCshowimagesstronglysuggestiveoftracheotomy oftracheotomytobypassanobstructionoftheairway.Earlyin procedures.3 hiscareer,hewrote“Theterrifiedsurgeonsofourtimeshave Thefirstwrittendocumentationoftracheotomyappearsin not dared to exercise this surgery (tracheotomy) and I also theRig Veda,asacredbookofHindumedicinewrittenbetween haveneverperformedit. .itiscalledascandal.”4Sometime 2000and1000BC.3,4Itdescribes“thebountifulone,whocan later,however,Fabriciussuccessfullyperformedtracheotomies causethewindpipetoreunitewhenthecervicalcartilagesare to relieve laryngeal foreign body obstruction. His version of cutacross,providedthattheyarenotentirelysevered.”1 thetracheotomyusedaverticalincisiontoallowinsertionof Homer, writing in the eighth century BC, referred to the acannulawithflanges.Followingthisseriesofoperations,his operationtorelievechokingpersonsbycuttingthetrachea.3–5 pupilCasseriusintroducedthecurvedcannulawithstaytapes ThenextrecordedmentionisinthefourthcenturyBCwhen to hold it in position. This improvement in tube shape was AlexandertheGreatissaidtohavesavedthelifeofasoldier quicklyforgottenbytherestofthemedicalworld;thestraight choking from a bone lodged in his throat by puncturing his tracheotomytuberemainedinuseformanyyears.3 tracheawiththepointofhissword.3–5 Bytheearlytomid1600s,tracheotomybegantobeconsid- In100BC,AsclepiadesofBithyniaiscreditedasbeingthe eredacceptableforacuteupperairwayobstructioncausedby first man to perform an elective tracheotomy.2–4 Described foreignbodyingestionoraspiration.4Thisadvancewasstimu- over200yearslaterbytherenownedphysicianClaudiusGalen latedinpartbyTheophilusBonetus,arenownedsurgicalpa- in 131 AD, who is also credited with the description of the thologist,whoin1650recommendedtheuseofatracheotomy structuresoftheheadandneck,Galenincludedcharacteriza- foraseven-year-oldchildwhohadaspiratedapieceofbone. tion of the laryngeal muscles, cartilages, and trachea. Galen This suggestion was rejected by the internist, in accordance alsotaughtthatthevoicewasproducedbythevocalcordsand withthetimes,andthechildsubsequentlydied.3 not,asbelievedatthetime,bytheheart.4 Another interesting case was that of noted Parisian sur- In 340 AD, Antyllus of Rome described a patient whose geon Nicholas Habicot, who performed a tracheotomy on difficult breathing was relieved by a transverse incision into ayouthwho,toprotecthispossessionsfromrobbers,swal- thetracheabetweenthethirdandfourthcartilaginousrings, lowedabagofcoins.Thebagbecamelodgedinhisesopha- whichwasthensuturedtogetherafterthepatientwasbreath- gus.Habicotperformedanemergencytracheotomytorelieve ingmoreeasily.3 theobstructionandmanuallymanipulatedthecoinsintothe Although these cases of successful tracheotomy received boy’sstomach.Followingthissuccess,Habicotalsosuggested some attention, not all medical practitioners of the time as- that the operation be used for inflammatory conditions of cribed to the procedure. Aretaeus, in his book entitled The thelarynx.3-4 Therapeutics of Acute Diseases,confirmedtheideaofelective Thewidespreadfearoftracheotomyextendedacrossthe tracheotomydonebyAsclepiadesofBithynia,butcondemned Atlantic into the New World. When Dr. Elisha Dick sug- itonthegroundsthatcartilagewoundsdonotheal.3Similarly, gested a tracheotomy for his most famous patient, George CoeliasAurelinianisinthefifthcenturyADcondemnedboth Washington,Drs.JamesCraigandGustavusBrownrejected theoperationandAsclepiades,writingthatitwasa“futileand the idea, instead suggesting treatment with bloodletting to irresponsibleidea.”3 release “evil humors.”7 Washington, under their care for sepsis and hemorrhagic shock, subsequently developed a The Period of Fear (1546–1833) peritonsillarabscessthatacutelyworsenedhisbreathing.On TheDarkAgeseclipsedtheworldofscienceandmedicine. December 14, 1799, the first President of the United States Littlewasheardofanytypeofsurgeryuntilthefifteenthcen- died of an acute upper airway obstruction secondary to a tury.Thisperiodbetween1546and1833markstheso-called peritonsillarabscess.3 PeriodofFear.Manyoftheauthorsofthisperioddescribed AnotherimportantdevelopmentduringthePeriodofFear tracheotomyingreatdetail,butdeniedperformingtheopera- wasthemodificationoftheterminologyusedtodescribethe tionthemselves.Althoughmanyreferencesweremadetotra- procedure. Up until this time, the operation was known as a cheotomy,theoperationwasofficiallyconsideredbothuseless “laryngotomy.”In1707,PierreDioniswrotethat“laryngotomy” anddangerous.Duringthistime,onlytwenty-eightsuccessful wasbeingusedincorrectlyandthattheprocedureshouldbe tracheotomieswererecordedintheliterature.6 called“bronchotomy.”3-4However,in1718,LorenzHeisterwrote In1546AntonioMusaBrasavolaisquotedassaying“When intheprestigiousChirurgie thattheoperationshouldbecalled thereisnootherpossibility,inangina,ofadmittingairtothe tracheotomyandthatallothernamesshouldbediscarded.3By heart,wemustincisethelarynxbelowtheabscess.”4Thisac- thenineteenthcentury,thistermbecamewidelyaccepted. count describes the use of tracheotomy to attain emergency airway in the case of a submental-submandibular space ab- The Period of Dramatization (1833–1932) scess,commonlyreferredtoasLudwig’sAngina. During this stage, the tracheotomy was considered an Fabricius ab Aquapendente (1537–1619) described the use operationoflifeordeath.Acommondebateamongsurgeons 36 The Pharos/Summer2011 was whether or not the symptoms of the patient were se- vere enough to justify tracheotomy.3 Armand Trousseau reported experiencing great satisfaction that, of more than two hundred tracheotomies, one-fourth were successful.8 These outcomes were considered satisfactory compared to theaveragesoftheday. Itwasalsoduringthisperiodthattracheotomy’shighpa- tientmorbidityratesbegantobeaddressed.In1909,Chevalier Jackson analyzed the operative technique3,9 and defined the factors leading to complications such as a high incision, use ofanimpropercannula,poorpostoperativecare,andsplitting the cricoid. Through Jackson’s groundbreaking analysis and teachings,thecomplicationandmortalityrateoftracheotomy fellsignificantly.Thustracheotomycametobeusedwithin- creasingfrequencytobypassupperairwayobstructioncaused byforeignbodiesandinfections. When,earlyinthetwentiethcentury,diphtheriabegantobe controlledbyimmunizationandthediscoveryofsulfonamides helped curb other bacterial upper respiratory infections, the need for emergency tracheotomy for infections waned. The PeriodofDramatizationbegantocometoanend. The Period of Enthusiasm (1932–1965) MedicalRF.com/Corbis. Duringthefourthstageinthehistoryoftracheotomy,in- dicationswereactivelysoughtandthemedicalworldlargely becameproponentsoftracheotomy. In 1932, J. L. Wilson made the landmark suggestion that fifty-fivepercentwereperformedtoassistinmechanicalventi- tracheotomybeusedtoprevent impendingpulmonaryinfec- lationandfourpercentwereperformedasanadjuncttohead tion in poliomyelitis,10 the first time that tracheotomy was and neck procedures.13 With the invention of the fiberoptic consideredappropriateforavertingpulmonarydistressbefore endoscopeinthemid-1960s,itbegantobeclearthatoralor itactuallyhappened.Suddenly,tracheotomybegantobeadvo-