Monday, July 20, 2015

1-1619: Jews, Arabs and Latins practice tracheotomies (and mouth to mouth breathing)

Chances are early tracheotomies were performed with no anaesthetics.  I write this not that I know this for sure, although I would imagine the procedure was generally performed as a last ditch effort to try to save a life of a person who was otherwise suffocating and was probably going to die if nothing was done.

There were, however, medicines that could have taken the edge off, such as opium.  Opium is an opiate that is one of the oldest known medicines known to man.  It is described in some of the earliest writings shared among the medical community.  So if the opportunity presented itself, this or some other medicine could have been taken to ease pain and suffering.

The ancient Jews, after the birth of Christ (around the years 1-650 A.D.) were known to perform surgeries when prayer, magic and natural remedies did not work.  When they did resort to surgeries, they did have certain herbs that were perhaps mixed into a drink that was used as a sleeping draught. (1, page 62)

The Jews were nomads, which means they traveled to many places in search of a home.  They spent time among the ancient Mesopotamians and Egyptians, and in the process they picked up a lot of knowledge about medicine.  Perhaps among the medical procedures they learned about from either of these places was the operation later to be called tracheotomy by the Greeks.  As they traveled they may also have educated other civilizations of the procedure.  This was one of the ways medical knowledge traveled through time.

Renouard explains that "the Arabs, and the Latins of the Middle Ages, had so little anatomical knowledge that they very much exaggerated the dangers of the operation, and, without condemning it absolutely in theory, abstained from its practice." (2, page 449)

Although this was not always the case.

Paulus Aegineta (625-690), as was noted earlier, performed the procedure with regularity, and described the procedure pretty much as Antyllus had several hundred years earlier.  (5, page 521) The operation was not regularly practiced until the 16th century, yet most of what was written was a reproduction of what Antyllus wrote on the subject.

Rhazes (865-925), Mesue (777-857), and Avicenna (980-1037) do not mention the methods of the procedure, but recommend it as a last option in cases of "angina strangulans." (3, page 199)  Avecenna did, however, describe "intubating the trachea using 'a cannula of gold or silver.'" (4pages 222-228) 

In the 12th century Arabian physicians Avenzoar and Albacasis were among the few physicians who dared to perform tracheotomies, although prior to them the procedure was rarely performed. Avenzoar (Ibn Zuhr), who was the most renowned physician and surgeon after Avicenna,  noted experiments of the procedure on goats, although he recommended it not be done unless the physician had knowledge of anatomy.  (3, page 198)  (6, pages 70-71)

Of course anatomical knowledge was rarely obtained by physicians mainly because autopsies were rarely performed, and when they were it must have been an unwholesome event.  Historian Fielding Hudson Garrison, in his 1922 history of medicine, explains that bodies were probably stolen, and both the grave robber and the autopsy performer would have risked an untimely death if caught.  There were a few books describing anatomy, although chances were good the descriptions were from animal dissections: pigs, dogs, apes, etc. (1, page 415)

The Surgeon Lanfranchi of Milan (1250-1306), Garrison explains,  was a surgeon at the School of Salerno in Northern Italy who may have been the first physician to mention intubation.  He became involved in the "squabbles of Guelphs and Ghibellines and was exiled.  He arrived in Paris in 1295, where he introduced the French to Italian medicine.  So it's highly likely the French also had knowledge to the technique of intubation.  (1, page 144)

Renouard continues:  "Anthony Benivieni, a physician of Florence, who lived at the end of the fifteenth century, saved the life of a patient by opening the trachea, and giving issue to the pus of an abscess that was formed within it. This is the first account we have of a tracheotomy, after an interruption of twelve hundred years; but its author does not state the manner in which he performed it, and it does not appear that he employed this method in other cases." (2, page 449)

Along with tracheostomies, mouth to mouth breathing also is mentioned in the fifteenth century.  It was documented to have been performed in Italy to revive newborn infants stunned at birth and not breathing on their own. This would have been a major effort on the part of the caregivers to save the life of a newborn infant stunned at birth who otherwise would have had no chance at life.  (5 need reference)

Fabricius d’Aquapendente (1537-1619), Renouard said, "is the first among moderns who gives a detailed description of this operation. He proves that it may be executed without injury to any other important organ; and that by it, we may often save a patient from impending death. The invention of the canula has been attributed to him, which has usually been left for some time in the artificial opening thus made. (2, pages 448-449)

In 1596 Sanatorius became the first to use a trocar to insert a cannula into the stoma, "and left a canula in the opening for three days."  Fabricius ab Aquapendente, in order to prevent the cannula from falling into the airway, added a cannula with wings.  Later later his pupil, Casserius, "made a very important improvement in introducing a canula with a curve corresponding to the arc of the quadrant, and he also tied in position the canula with tape.  The improvement in the shape of the instrument, however, was soon lost sight of, and the straight tube long remained in use." (5, page 521)

So knowledge of how to create an airway made it's way through the dark ages of medicine in the west, and the bright ages of medicine in the east.  Now it would make it's way to the Renaissance, where improved anatomical wisdom would help speed up the advancement of medical wisdom.

Note:  Spelling within quotes is that of the original author

  1. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, Philadelphia, W.B. Saunders Company
  2. Renouard, Pierre-Vincent, "History of medicine: from its origin to the nineteenth century,"
  3. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company,  pages 193-203  (referenced to page 198-9)
  4. Szmuk, Peter, eet al, "A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age," Intensive Care Medicine, 2008, 34, pages 222-228
  5. Mackenzie, Morrell, "Diseases of the throat and nose, Volume I, 1880, Philadelphia, Presley Blakiston
  6. Bradford, Thomas Lindsley, writer, Robert Ray Roth, editor, “Quiz questions on the history of medicine from the lectures of Thomas Lindley Bradford M.D.,” 1898, Philadelphia, Hohn Joseph McVey

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