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)

References:

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," freewebs.com, Scientific Anti-Vivisectionism,  http://www.freewebs.com/scientific_anti_vivisectionism4/resuscitation.htm, 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

Further reading: 

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124-200 A.D.: Roman physicians describe tracheotomies

Knowledg of mouth to mouth breathing and the operation of tracheotomy was carried from ancient Greece to ancient Rome by the physician Asclepiades of Bythinia. (124-40 B.C.).

Prior to Asclepiades the Romans had a negative view of the harsh medicine of the Greeks, although Asclepiades was able to convince the Romans that Greek medicine could be useful for saving lives and soothing the minds of the sick.

Once again I quote Renouard:

Asclepiades of Bythinia, had the idea of opening a passage for the air, by making an incission into the larynx or trachea; but the authors who report this fact do not describe the operation he adopted. After him, no one dared attempt tracheotomy until Antyllus, who practiced it several times, and described his mode of operating.  (1, pages 448-449)

Antyllus, a Greek physician who lived in Rome sometime between the birth of Jesus and the 4th century (and probably in the 2nd century), had a fragment of his writings preserved by Paulus Aegineta (625-690), some of which provides one of our first accounts of the surgical procedure:  

"The incision should be made in the trachea, under the larynx, about the third or fourth ring. This situation is most eligible, because it is not covered by any muscles, and no vessels are near it. The patient's head must be kept back, in order that the trachea may project more forward. A transverse cut is to be made between two of the rings, so as not to wound the cartilage, only the membrane." (2)(3)(also see 5, page 521)

The GrecoRoman physician Galen (120-200 A.D.) stated that Aesculapius (around 100 A.D.) was the first to recommend tracheotomy, so we may speculate Galen also used it.   Both Aeretaeus (130-200 A.D) and Caelius-Aurelianus (5th century) mention the recommendation by Aesculapius, although Aeretaeus condemned the procedure out of fear the cartilage would not heal, and Caelius talked of it as a rash procedure never put into practice.  (2)(5, page 521)

Galen also described tracheostomies, and described inflating lungs with bellows through a hole in the trachea.  (4) 

Chances are Galen performed his experiments on animals, probably pigs, dogs or apes.  Yet even if he never performed it on a human, his efforts may have been the first mechanical breaths. 

So, like ancient Greek physicains, ancient Roman physicians were knowledgeable of the operation of tracheotomy, and performed experiments that would be picked up by later physicians who would have had better knowledge of anatomy.   

References:

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. 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)
3. "Biographical Dictionary of the society for the diffusion of useful knowledge," Longman, Brown, Green and Longmans, volume III, 1843, A. Spottingwood, London, page 124-5
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

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800-400 B.C.: Greeks define tracheotomy

Knowledge of mouth to mouth breathing and the surgical procedure of tracheotomy would have made it's way from ancient Egypt to ancient Greece. There were many Greek philosophers who studied medicine at one of Egypts fine schools, probably at Heliopolis early on and Alexandria later. The procedure more than likely made it's way to Greece by this means. 

So this knowledge must have appeared via a dream to a priest at the Asclepion at Cos, who must have used it successfully at some point early in Greek's history. Details of the procedure and the diagnosis it was used for would have been surreptitiously etched onto a stone slab that was kept at the temple for future reference. The slabs may also have been used as early medical texts, as such temples also served as schools. 

Sometime around 450 B.C. a boy by the name of Hippocrates (460-370 B.C.) sat with his father, a physician, at the temple, learning as much as he could about medicine, perhaps using the stone slabs as texts. Hippocrates grew to become the greatest physician of the ancient world, and would become the first to write about the procedure in his Hippocratic Corpuus.  He wrote:

"A tube should be inserted into the throat, along the jaws, so that the air may be attracted to the lungs."  (1) 

The procedure is perhaps best detailed by historian Pierre Victor Renouard in his 1867 history of medicine:

When the air passage is stopped by any obstacle, the anguish is extreme, the suffocation iminent, and the patient speedily dies, unless promptly succored. This accident has sometimes occurred in a violent quinsey, but more frequently in the fibrinous effusion in children, called croup. The Hippocratic works indicate as the only resource in this extremity, to pass a leek leaf, or any elastic tube, into the throat of the patient; but this agent is very diflicult of application, and I doubt whether it was ever done advantageously.(2, pages 448-449)

The ancient Greeks would have referred to this procedure as a tracheotomy.  The term, according to dictionary.com, comes from a combination of the Greek terms for "windpipe" (arterios trakheia) and "to cut into" (tom).  It means to cut into the trachea.

Another term, tracheostomy, comes from the combination of the Greek terms for "windpipe" (arterios trakheia) and "mouth, opening, or orifice" (stoma).  It is the creation of an opening in the trachea.  The opening is often referred to as a stoma, which comes from the Greek term for mouth, opening, orifice.  It is the opening created in the trachea or, simply, the hole in the trachea.

However, it should be understood here that, according to Dr. Morrell Mackenzie in his 1880 book "Disease of the nose and throat," the term tracheotomy was first used by Lorenz Heister (1683-1758).  Prior to him the procedure was actually called a bronchotomy.  Mackenzie defined bronchotomy as "the various operations by which the air-passages are laid open."  (3, pages 520,522)

For simplicities sake, I will simply refer to the procedure as a tracheotomy for the purposes of this history.

So while the ancient Greeks definitely didn't invent the procedure, they gave it a name and an identity.

References:

1. 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) 
2. 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 
3. Mackenzie, Morrell, "Diseases of the throat and nose, Volume I, 1880, Philadelphia, Presley Blakiston

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