Friday, January 8, 2016

1500-1900: Physicians experiment with protecting the airway

Antonio Brasavola (1500-1555)
Every once in a while I have to have a post that lists a bunch of information all at once, and this is one of those posts. Basically, I just want to give a brief synopsis of the evolution of tracheotomies and intubation -- two methods of creating an artificial airway -- from the Renaissance to the turn of the 20th century.

Tracheal openings, creating an airway by making an incision in the throat, were used in the ancient world by physicians who wanted to keep animals alive while doing experiments on them.  (1, page 269-280)  

So over time certain physicians became quite adept at creating them, which probably came in handy the few times they were needed for upper airway obstruction (probably due to some disease that caused inflammation in the throat, like diptheria).

Aound 400 B.C., Hippocrates described preventing asphyxiation by inserting a tube into the airway. He wrote in "Treatise on Air," that "One should introduce a cannula into the trachea along the jawbone so that air can be drawn into the lungs." While it was probably used before earlier, this is the first known description of endotracheal intubation. (

Andreas Vesalius, (1514-1564)  the same person who proved that Galen wasn't a know all about medicine, described in his 1543 book, De humani corporis fabrica ("On the Fabric of the Human Body"), how he could provide breaths to animals by blowing into a reed inserted into their necks through a tracheal opening. (2, page 67)(x3, page 5-7)  

In 1546 Antonio Brasavola of Italy performed a tracheostomy on a patient with tonsilar obstruction, and through Vesalius, Brasavola and other physicians during the Renaissance  reintroduced the world to tracheotomies and there ability to save lives. (9, page 224)

In 1667 Robert Hooke (1635-1703) took the trachea of a dog and connected it to a "pair of bellows, and the ribs and diaphragm were removed; the dog was seized with convulsions and appeared to be dying, but revived when air was blown into the lungs. Small punctures were then made into various parts of the lungs, and by means of two pairs of bellows the lungs were kept fully distended with fresh air; the dog remained quiet and its heart beat regularly. The circulation continued although there was no alternate expansion and collapse of the lungs; moreover, a further experiment showed that even when the lungs were allowed to collapse the blood continued to circulate for some time." (4, page 474)

By his experiment, Hooke also proved that "by blowing a bellows briskly over the open thorax of a dog, that artificial respiration can keep the animal alive without any movements of either chest or lungs." (5, page 267)

In 1714 Dethharding recommended using mouth to mouth breathing to resuscitate near drowning and other such victims.   In 1732 a Scottish surgeon named Dr. William Tossack successfully used mouth to mouth breathing to revive a coal minor who stopped breathing due to suffocation, and as a result rescue breathing became common by the 1840s. (1, page 269-280)

However, once the germ theory was established this was deemed as harmful to the rescuer and bellows were used.  Many suspected this too was harmful to victims because it might blow out a lung, so physicians refused to do it.  (6)

While a cannula through the stoma created by the tracheotomy was used to maintain the airway for quite a few years already, George Martin was the first to use a double cannula in 1730 "on the suggestion of one of his friends." (11, page 48.

"This valuable suggestion was, however, soon forgotten" by the medical community in general.  (10, page 522)

In 1754 Benjamin Pugh of England inserted an "air pipe" into newborn infants who were not breathing, and soon thereafter intubation became common for near drowning victims.  Aware of the benefits of creating an airway, a physician by the name of Curry developed an "intralaryngeal cannulae" to use for resuscitation efforts.  (7) 

In 1783 De Poiteau recommended the use of tracheas when administering positive pressure breaths to drowning victims in order to let water out and warm air in and out by using a tube.  Tracheotomy tubes were further refined as the century came to a close.  Use of tracheotomies ultimately waned in favor of intubation (placing a tube or cannula into the airway to the trachea). (2, page 67-72)  

Lorenz Heister (1683-1758)
As noted earlier, Lorenz Heister (1683-1758) was the first to refer to the procedure as tracheotomy, as prior to this it was simply referred to as bronchotomy. (10, page 520)

Overall, most accounts of the procedure of tracheotostomy mention physicians "look upon it with great distrust" until the 18th century when Antoine Louis published articles on 'bronchotomy'  (8, page 198-199)

By the 1830s there were enough positive experiences with tracheotomies, by others and himself, that resulted in Armand Trousseau (1801-1867) becoming an ardent proponent of the procedure, recommending it to his colleagues. (10, page 523)

Because of his "unabound enthusiasm... his immense industry, and careful attention to detail, not only before, but during and after the operation, (he) soon established the position of tracheotomy in modern surgery." (10, page 523)

Trousseau is now considered the father of tracheotomy. (12)

Despite Trousseau's improvements of the tracheotomy technique, and the fact more physicians were willing to perform the procedure for croup caused by diphtheria, the inflammation was so severe in many such patients, especially small children, that other methods of creating an airway were experimented with. This lead to the first attempts at creating an airway by using a tube inserted from the mouth or nose into the lungs. (12)

Attempts were made to catheterize the larynx in 1839 by Dieffenbach of Berlin, and in 1855 by Reybard in Lyon and Weinlechner in Vienna, although none succeeded. (12)

Eugene Bouchut (1818-1891)
In 1858 Eugene Bouchut succeeded in two of seven cases, yet his tube was made of wood and caused so much trauma to the patient, that the entire idea was criticized as "harmful and traumatic" by the well respected Trousseau, who said the operation of tracheotomy, despite its low success rate, was much more tolerable. (12)

Discouraged when his idea was rejected, Bouchut set aside his attempts at finding a better method of creating an airway in favor of research in other areas.  (12)

Joseph P. O'Dwyer (1841-1898)
The idea was not taken up again until 1885, when Joseph P. O'Dwyer, himself a pediatrician, picked up where Bouchut left off, and made a few small adjustments to make the procedure more comfortable for the patient. (12)

Still, for the time being, the tracheotomy was the main method of creating an airway for patients who were in an imminent threat to suffocating due to inflammation of the throat, regardless of the cause. Although, for those who wanted to risk it, there was a viable endotracheal tube.

In 1858 Roget came up with the idea of connecting the "tube to it's shield by means of a collar permitting movement between the two parts." (10, page 523)

Since then various other improvements to the tracheostomy have been made by various physicains, including Sales-Cohen, who also invented an early inhaler/ nebulizer.

Through most of history tracheotomies were mostly performed when the patient was suffocating due to severe airway obstruction.  During the 18th century the procedure was still recommended for foreign body obstruction of the larynx (i.e., choking due to large chunk of steak stuck in throat), although physicians started experimenting with the procedure for specific disease processes or symptoms, such as inflammation of throat tissue, severe inflammation of the tongue, mumps, diphtheria, near drowning, drowning, large nasal and pharyngeal polypi, severely swollen tonsils, and croup.   (10, page 522-523)

However, despite all the experiments and recommendations made during the 18th century, it wouldn't be until the 19th century that tracheotomy and intubation would be recommended and practiced with regularity. (8, page 198-199)

  1. Lee, W.L., A.S. Stutsky, "Ventilator-induced lung injury and recommendations for mechanical ventilation of patients with ARDS," Semin. Respit. Critical Care Medicine, 2001, June, 22, 3, pages 269-280
  2. Price, J.L., "The Evolution of Breathing Machines,Medical History, 1962, January, 6(1), pages 67-72; Price references The Bible, Kings, 4: 34 
  3. Tan, S.Y, et al, "Medicine in Stamps:  Paracelsus (1493-1541): The man who dared," Singapore Medical Journal,  2003, vol. 44 (1), pages 5-7
  4. Hill, Leonard, Benjamin Moore, Arthur Phillip Beddard, John James Rickard, etc., editors, "Recent Advances in Physiology and bio-chemistry," 1908, London, Edward Arnold
  5. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, Philadelphia, W.B. Saunders Company
  6. "Resuscitation and Artificial Respiration,", Scientific Anti-Vivisectionism,, accessed March 1, 2012 (see also reference 1 above)
  7. Ball, James B, "Intubation of the Larynx," 1891, London, H.K. Lewis
  8. 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)
  9. 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
  10. Mackenzie, Morrell, "Diseases of the athroat and nose, Volume I, 1880, Philadelphia, Presley Blakiston
  11. Cohen, J. Solis, "Croup, in its relation to tracheotomy," 1874, Philadelphia, Lindsay and Blakiston
  12. Sperati, G., Felisati, D., "Bouchut, O'Dwyer and laryngeal intubation in patients with croup," Acta Otorhinolaryngol Ital, 2007, 27 (6), 320-323
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