History of tracheal intubation
Encyclopedia
Tracheal intubation
(usually simply referred to as intubation), an invasive medical procedure
, is the placement of a flexible plastic catheter
into the trachea
. For millennia, tracheotomy
was considered the most reliable (and most risky) method of tracheal intubation. By the late 19th century, advances in the sciences of anatomy
and physiology
, as well as the beginnings of an appreciation of the germ theory of disease
, had reduced the morbidity and mortality
of this operation to a more acceptable rate. Also in the late 19th century, advances in endoscopic
instrumentation had improved to such a degree that direct laryngoscopy
had finally become a viable means to secure the airway
by the non-surgical orotracheal route. Nasotracheal intubation was not widely practiced until the early 20th century. The 20th century saw the transformation of the practices of tracheotomy, endoscopy and non-surgical tracheal intubation from rarely employed procedures to essential components of the practices of anesthesia
, critical care medicine, emergency medicine
, gastroenterology
, pulmonology
and surgery
.
The earliest known depiction of a tracheotomy is found on two Egypt
ian tablets
dating back to circa 3600 BC. The 110-page Ebers Papyrus
, an Egyptian medical papyrus which dates to circa 1550 BC, also makes reference to the tracheotomy. Tracheotomy was described in the Rigveda
, a Sanskrit
text of ayurvedic medicine
written circa 2000 BC in ancient India
. The text mentions "the bountiful one who, without a ligature, can cause the windpipe to re-unite when the cervical cartilages are cut across, provided they are not entirely severed." The Sushruta Samhita
(circa 400 BC) is another text from the Indian subcontinent
on ayurvedic medicine and surgery that mentions tracheotomy.
The Greek
physician Hippocrates
(ca. 460–ca. 370 BC) condemned the practice of tracheotomy. Warning against the unacceptable risk of death from inadvertent laceration of the carotid artery
during tracheotomy, Hippocrates also cautioned that "The most difficult fistula
s are those which occur in the cartilaginous areas." Because surgical instruments were not sterilized
at that time, infections following surgery also produced numerous and frequently fatal complications. Homerus of Byzantium
is said to have written of Alexander the Great (356–323 BC) saving a soldier from asphyxia
tion by making an incision with the tip of his sword in the man's trachea.
Despite the concerns of Hippocrates, Galen
of Pergamon
(129–199) and Aretaeus of Cappadocia
(both of whom lived in Rome
in the 2nd century AD) credit Asclepiades of Bithynia
(ca. 124–40 BC) as being the first physician to perform a non-emergency tracheotomy. However, Aretaeus warned against the performance of tracheotomy because he believed that incisions made into the tracheal cartilage
were prone to secondary wound infections and therefore would not heal. He wrote that that "The lips of the wound do not coalesce, for they are both cartilaginous and not of a nature to unite". Antyllus
, another Greek surgeon who lived in Rome in the 2nd century AD, was reported to have performed tracheotomy when treating oral diseases. He refined the technique to be more similar to that used in modern times, recommending that a transverse
incision be made between the third and fourth tracheal rings for the treatment of life-threatening airway obstruction. Antyllus wrote that tracheotomy was not effective however in cases of severe laryngotracheobronchitis
because the pathology
was distal to the operative site. Antyllus' original writings were lost, but they were preserved by Oribasius
(ca. 320–400) and Paul of Aegina
(ca. 625–690), both of whom were Greek physicians as well as historians. Galen clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice. Galen may have understood the importance of artificial ventilation, because in one of his experiments he used bellows to inflate the lungs of a dead animal.
During the Middle Ages
, scientific discoveries were few and far between in much of Europe. However, the scientific culture flourished in other parts of the world. By AD 700, the tracheotomy was well documented in India
n and Arabian
literature, although it was rarely practiced on humans. In 1000, Abu al-Qasim al-Zahrawi (936-1013), an Arab who lived in Al-Andalus
, published the 30-volume Kitab al-Tasrif
, the first illustrated work on surgery. He never performed a tracheotomy, but he did treat a slave girl who had cut her own throat in a suicide attempt. Al-Zahrawi (known to Europeans as Albucasis) sewed up the wound and the girl recovered, thereby proving that an incision in the larynx could heal. Circa 1020, Ibn Sīnā
(980–1037) described the use of tracheal intubation in The Canon of Medicine
to facilitate breathing
. In the 12th century medical textbook Al-Taisir, Ibn Zuhr
(1091–1161) of Al-Andalus (also known as Avenzoar) provided an anatomically correct description of the tracheotomy operation.
The Renaissance
saw significant advances in anatomy and surgery, and surgeons became increasingly open to surgery on the trachea. Despite this, the mortality rate failed to improve. From 1500 through 1832 there are only 28 known descriptions of successful tracheotomy in the literature. The first detailed descriptions on tracheal intubation and subsequent artificial respiration
of animals were from Andreas Vesalius (1514–1564) of Brussels. In his landmark book published in 1543, De humani corporis fabrica
, he described an experiment in which he passed a reed
into the trachea of a dying animal whose thorax
had been opened and maintained ventilation by blowing into the reed intermittently. Vesalius wrote that the technique could be life-saving. Antonio Musa Brassavola
(1490–1554) of Ferrara
treated a patient suffering from peritonsillar abscess
by tracheotomy after the patient had been refused by barber surgeon
s. The patient apparently made a complete recovery and Brassavola published his account in 1546. This operation has been identified as the first recorded successful tracheostomy, despite many ancient references to the trachea and possibly to its opening.
Towards the end of the 16th century, anatomist and surgeon Hieronymus Fabricius
(1533–1619) described a useful technique for tracheotomy in his writings, although he had never actually performed the operation himself. He advised using a vertical incision and was the first to introduce the idea of a tracheostomy tube. This was a straight, short cannula
that incorporated wings to prevent the tube from advancing too far into the trachea. He recommended the operation only as a last resort, to be used in cases of airway
obstruction by foreign bodies
or secretion
s. Fabricius' description of the tracheotomy procedure is similar to that used today. Julius Casserius (1561–1616) succeeded Fabricius as professor of anatomy at the University of Padua and published his own writings regarding technique and equipment for tracheotomy, recommending a curved silver tube with several holes in it. Marco Aurelio Severino
(1580–1656), a skillful surgeon and anatomist, performed multiple successful tracheotomies during a diphtheria
epidemic
in Naples
in 1610, using the vertical incision technique recommended by Fabricius. He also developed his own version of a trocar.
In 1620 the French surgeon Nicholas Habicot (1550–1624), surgeon of the Duke of Nemours
and anatomist, published a report of four successful "bronchotomies" which he had performed. One of these is the first recorded case of a tracheotomy for the removal of a foreign body, in this instance a blood clot in the larynx of a stabbing victim. He also described the first tracheotomy to be performed on a pediatric
patient. A 14-year-old boy swallowed a bag containing 9 gold coins in an attempt to prevent its theft by a highwayman
. The object became lodged in his esophagus
, obstructing his trachea. Habicot performed a tracheotomy, which allowed him to manipulate the bag so that it passed through the boy's alimentary tract, apparently with no further sequela
e. Habicot suggested that the operation might also be effective for patients suffering from inflammation of the larynx. He developed equipment for this surgical procedure which are similar in many ways to modern designs.
Sanctorius
(1561–1636) is believed to be the first to use a trocar in the operation; he recommended leaving the cannula in place for a few days following the operation. Early tracheostomy devices are illustrated in Habicot’s Question Chirurgicale and Julius Casserius' posthumous Tabulae anatomicae in 1627. Thomas Fienus (1567–1631), Professor of Medicine at the University of Louvain
, was the first to use the word "tracheotomy" in 1649, but this term was not commonly used until a century later. Georg Detharding (1671–1747), professor of anatomy at the University of Rostock
, treated a drowning victim with tracheostomy in 1714.
Fearful of complications, most surgeons delayed the potentially life-saving tracheotomy until a patient was moribund
, despite the knowledge that irreversible organ damage would have already occurred by that time. This began to change in the early 19th century, when the tracheotomy finally began to be recognized as a legitimate means of treating severe airway obstruction. In 1832, French physician Pierre Bretonneau
(1778–1862) employed tracheotomy as a last resort to treat a case of diphtheria
. In 1852, Bretonneau's student Armand Trousseau
(1801–1867) presented a series of 169 tracheotomies (158 of which were for croup
and 11 for "chronic maladies of the larynx"). In 1871, the German surgeon Friedrich Trendelenburg
(1844–1924) published a paper describing the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia. After the death of German Emperor Frederick III
from laryngeal cancer in 1888, Sir Morell Mackenzie
(1837–1892) and the other treating physicians collectively wrote a book discussing the then-current indications
for tracheotomy and when the operation is absolutely necessary.
In the early 20th century, physicians began to use the tracheotomy in the treatment of patients afflicted with paralytic poliomyelitis
who required mechanical ventilation. The currently used surgical tracheotomy technique was described in 1909 by Chevalier Jackson
(1865–1958), a professor of laryngology at Jefferson Medical College in Philadelphia. However, surgeons continued to debate various aspects of the tracheotomy well into the 20th century. Many techniques were employed, along with many different surgical instruments and tracheal tubes. Surgeons could not seem to reach a consensus on where or how the tracheal incision should be made, arguing whether the "high tracheotomy" or the "low tracheotomy" was more beneficial. Ironically, the newly developed inhalational anesthetic agents
and techniques of general anesthesia actually seemed to increase the risks, with many patients suffering fatal postoperative complications. Jackson emphasised the importance of postoperative care, which dramatically reduced the mortality rate. By 1965, the surgical anatomy was thoroughly and widely understood, antibiotic
s were widely available and useful for treating postoperative infections and other major complications of tracheotomy had also become more manageable.
. Many new optical instrument
s with medical applications were invented during the 19th century. In 1805, a German army surgeon named Philipp von Bozzini
(1773–1809) invented a device he called the lichtleiter (or light-guiding instrument). This instrument, the ancestor of the modern endoscope, was used to examine the urethra
, the human urinary bladder
, rectum
, oropharynx and nasopharynx. The instrument consisted of a candle within a metal chimney; a mirror on the inside reflected light from the candle through attachments into the relevant body cavity. The practice of gastric endoscopy in humans was pioneered by United States Army surgeon William Beaumont
(1785–1853) in 1822 with the cooperation of his patient Alexis St. Martin
(1794–1880), a victim of an accidental gunshot wound to the stomach. In 1853, Antoine Jean Desormeaux (1815–1882) of Paris modified Bozzini's lichtleiter such that a mirror would reflect light from a kerosene lamp
through a long metal channel. Referring to this instrument as an endoscope
(he is credited with coining this term), Desormeaux employed it to examine the urinary bladder. However, like Bozzini's lichtleiter, Desormeaux's endoscope was of limited utility due to its propensity to become very hot during use. In 1868, Adolph Kussmaul
(1822–1902) of Germany performed the first esophagogastroduodenoscopy
(a diagnostic
procedure in which an endoscope is used to visualize the esophagus, stomach and duodenum
) on a living human. The subject was a sword-swallower
, who swallowed a metal tube with a length of 47 centimeters and a diameter of 13 millimeters. On 2 October 1877, Berlin
urologist
Maximilian Carl-Friedrich Nitze
(1848–1906) and Viennese
instrument maker Josef Leiter (1830–1892) introduced the first practical cystourethroscope
with an electric light source. The instrument's biggest drawback was the tungsten
filament incandescent light bulb
(invented by Alexander Lodygin
, 1847–1923), which became very hot and required a complicated water cooling system. In 1881, Polish physician Jan Mikulicz-Radecki
(1850–1905) created the first rigid gastroscope for practical applications.
In 1932, Rudolph Schindler (1888–1968) of Germany introduced the first semi-flexible gastroscope. This device had numerous lenses
positioned throughout the tube and a miniature light bulb at the distal tip. The tube of this device was 75 centimeters in length and 11 millimeters in diameter, and the distal portion was capable of a certain degree of flexion. Between 1945 and 1952, optical engineers
(particularly Karl Storz (1911–1996) of Germany, Harold Hopkins
(1918–1995) of England and Mutsuo Sugiura of the Japanese Olympus Corporation
) built upon this early work, leading to the development of the first "gastrocamera". In 1964, Fernando Alves Martins (born 17 June 1927) of Portugal applied optical fiber
technology to one of these early gastrocameras to produce the first gastrocamera with a flexible fiberscope. Initially used in esophagogastroduodenoscopy, newer devices were developed in the late 1960s for use in bronchoscopy
, rhinoscopy
and laryngoscopy. The concept of using a fiberoptic endoscope for tracheal intubation was introduced by Peter Murphy, an English anesthetist, in 1967. By the mid-1980s, the flexible fiberoptic bronchoscope had become an indispensable instrument within the pulmonology
and anesthesia communities.
In 1854, a Spanish vocal pedagogist
named Manuel García
(1805–1906) became the first man to view the functioning glottis in a living human. García developed a tool that used two mirrors for which the Sun served as an external light source. Using this device, he was able to observe the function of his own glottic apparatus and the uppermost portion of his trachea. He presented his observations at the Royal Society of London
in 1855.
In 1858, Eugène Bouchut
(1818–1891), a pediatrician
from Paris, developed a new technique for non-surgical orotracheal intubation to bypass laryngeal obstruction resulting from a diphtheria-related pseudomembrane. His method involved introducing a small straight metal tube into the larynx, securing it by means of a silk thread and leaving it there for a few days until the pseudomembrane and airway obstruction had resolved sufficiently. Bouchut presented this experimental technique along with the results he had achieved in the first seven cases at the French Academy of Sciences
conference on 18 September 1858. The members of the Academy rejected Bouchut's ideas, largely as a result of highly critical and negative remarks made by the influential Armand Trousseau. Undaunted, Bouchut later introduced a set of tubes ("Bouchut's tubes") for intubation of the trachea, as an alternative to tracheotomy in cases of diphtheria.
In March 1878, Wilhelm Hack of Freiburg published a paper describing the use of non-surgical orotracheal intubation in the removal of vocal cord polyps
. In November of that year, he published another study, this time on the use of orotracheal intubation to secure the airway of a patient with acute glottic edema
, progressively introducing sizes 3 through 11 of "Schrotter's graduated triangular vulcanite
bougies" into the larynx. In 1880, the Scottish
surgeon William Macewen
(1848–1924) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well as in the setting of general anesthesia with chloroform
. All previous observations of the glottis and larynx (including those of García, Hack and Macewen) had been performed under indirect vision (using mirrors) until 23 April 1895, when Alfred Kirstein (1863–1922) of Germany first described direct visualization of the vocal cords. Kirstein performed the first direct laryngoscopy in Berlin, using an esophagoscope he had modified for this purpose; he called this device an autoscope. The death in 1888 of Emperor Frederick III may have motivated Kirstein to develop the autoscope.
Until 1913, oral and maxillofacial surgery
was performed by mask inhalation anesthesia
, topical application of local anesthetic
s to the mucosa
, rectal anesthesia, or intravenous
anesthesia. While otherwise effective, these techniques did not protect the airway from obstruction and also exposed patients to the risk of pulmonary aspiration of blood and mucus
into the tracheobronchial tree. In 1913, Chevalier Jackson was the first to report a high rate of success for the use of direct laryngoscopy as a means to intubate the trachea. Jackson introduced a new laryngoscope blade that had a light source at the distal tip, rather than the proximal light source used by Kirstein. This new blade incorporated a component that the operator could slide out to allow room for passage of an endotracheal tube or bronchoscope.
That same year, Henry H. Janeway (1873–1921) published results he had achieved using a laryngoscope he had recently developed. An American anesthesiologist practicing at Bellevue Hospital
in New York City
, Janeway was of the opinion that direct intratracheal insufflation
of volatile anesthetics would provide improved conditions for otolaryngologic
surgery. With this in mind, he developed a laryngoscope designed for the sole purpose of tracheal intubation. Similar to Jackson's device, Janeway's instrument incorporated a distal light source. Unique however was the inclusion of batteries
within the handle, a central notch in the blade for maintaining the tracheal tube in the midline of the oropharynx during intubation and a slight curve to the distal tip of the blade to help guide the tube through the glottis. The success of this design led to its subsequent use in other types of surgery. Janeway was thus instrumental in popularizing the widespread use of direct laryngoscopy and tracheal intubation in the practice of anesthesiology.
After World War I
, further advances were made in the field of intratracheal anesthesia. Among these were those made by Sir Ivan Whiteside Magill
(1888–1986). Working at the Queen's Hospital for Facial and Jaw Injuries
in Sidcup
with plastic surgeon Sir Harold Gillies
(1882–1960) and anesthetist E. Stanley Rowbotham (1890–1979), Magill developed the technique of awake blind nasotracheal intubation. Magill devised a new type of angulated forceps (the Magill forceps) that are still used today to facilitate nasotracheal intubation in a manner that is little changed from Magill's original technique. Other devices invented by Magill include the Magill laryngoscope blade, as well as several apparati for the administration of volatile anesthetic agents. The Magill curve of an endotracheal tube is also named for Magill.
Sir Robert Reynolds Macintosh
(1897–1989) also achieved significant advances in techniques for tracheal intubation when he introduced his new curved laryngoscope blade in 1943. The Macintosh blade remains to this day the most widely used laryngoscope blade for orotracheal intubation. In 1949, Macintosh published a case report describing the novel use of a gum elastic urinary catheter as an endotracheal tube introducer to facilitate difficult tracheal intubation. Inspired by Macintosh's report, P. Hex Venn (who was at that time the anesthetic advisor to the British firm Eschmann Brothers & Walsh, Ltd.) set about developing an endotracheal tube introducer based on this concept. Venn's design was accepted in March 1973, and what became known as the Eschmann endotracheal tube introducer went into production later that year. The material of Venn's design was different from that of a gum elastic bougie in that it had two layers: a core of tube woven from polyester
threads and an outer resin
layer. This provided more stiffness but maintained the flexibility and the slippery surface. Other differences were the length (the new introducer was 60 cm (23.6 in), which is much longer than the gum elastic bougie) and the presence of a 35° curved tip, permitting it to be steered around obstacles. The concept of using a stylet for replacing or exchanging orotracheal tubes was introduced by Finucane and Kupshik in 1978, using a central venous catheter
.
, gastroenterology
, pulmonology and surgery. The "digital revolution"
of the 21st century has brought newer technology to the art and science of tracheal intubation. Several manufacturers have developed video laryngoscopes which employ digital technology such as the CMOS
active pixel sensor
(CMOS APS) to generate a view of the glottis so that the trachea may be intubated. The Glidescope video laryngoscope is one example of such a device.
Tracheal intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs...
(usually simply referred to as intubation), an invasive medical procedure
Invasiveness of surgical procedures
There are three main categories which describe the invasiveness of surgical procedures. These are: non-invasive procedures, minimally invasive procedures, and invasive procedures ....
, is the placement of a flexible plastic catheter
Catheter
In medicine, a catheter is a tube that can be inserted into a body cavity, duct, or vessel. Catheters thereby allow drainage, administration of fluids or gases, or access by surgical instruments. The process of inserting a catheter is catheterization...
into the trachea
Vertebrate trachea
In tetrapod anatomy the trachea, or windpipe, is a tube that connects the pharynx or larynx to the lungs, allowing the passage of air. It is lined with pseudostratified ciliated columnar epithelium cells with goblet cells that produce mucus...
. For millennia, tracheotomy
Tracheotomy
Among the oldest described surgical procedures, tracheotomy consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea...
was considered the most reliable (and most risky) method of tracheal intubation. By the late 19th century, advances in the sciences of anatomy
Anatomy
Anatomy is a branch of biology and medicine that is the consideration of the structure of living things. It is a general term that includes human anatomy, animal anatomy , and plant anatomy...
and physiology
Physiology
Physiology is the science of the function of living systems. This includes how organisms, organ systems, organs, cells, and bio-molecules carry out the chemical or physical functions that exist in a living system. The highest honor awarded in physiology is the Nobel Prize in Physiology or...
, as well as the beginnings of an appreciation of the germ theory of disease
Germ theory of disease
The germ theory of disease, also called the pathogenic theory of medicine, is a theory that proposes that microorganisms are the cause of many diseases...
, had reduced the morbidity and mortality
Mortality rate
Mortality rate is a measure of the number of deaths in a population, scaled to the size of that population, per unit time...
of this operation to a more acceptable rate. Also in the late 19th century, advances in endoscopic
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
instrumentation had improved to such a degree that direct laryngoscopy
Laryngoscopy
Laryngoscopy is a medical procedure that is used to obtain a view of the vocal folds and the glottis. Laryngoscopy may be performed to facilitate tracheal intubation during general anesthesia or cardiopulmonary resuscitation or for procedures on the larynx or other parts of the upper...
had finally become a viable means to secure the airway
Airway
The pulmonary airway comprises those parts of the respiratory system through which air flows, conceptually beginning at the nose and mouth, and terminating in the alveoli...
by the non-surgical orotracheal route. Nasotracheal intubation was not widely practiced until the early 20th century. The 20th century saw the transformation of the practices of tracheotomy, endoscopy and non-surgical tracheal intubation from rarely employed procedures to essential components of the practices of anesthesia
Anesthesia
Anesthesia, or anaesthesia , traditionally meant the condition of having sensation blocked or temporarily taken away...
, critical care medicine, emergency medicine
Emergency medicine
Emergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
, gastroenterology
Gastroenterology
Gastroenterology is the branch of medicine whereby the digestive system and its disorders are studied. The name is a combination of three Ancient Greek words gaster , enteron , and logos...
, pulmonology
Pulmonology
In medicine, pulmonology is the specialty that deals with diseases of the respiratory tract and respiratory disease. It is called chest medicine and respiratory medicine in some countries and areas...
and surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
.
Tracheotomy
Egypt
Egypt , officially the Arab Republic of Egypt, Arabic: , is a country mainly in North Africa, with the Sinai Peninsula forming a land bridge in Southwest Asia. Egypt is thus a transcontinental country, and a major power in Africa, the Mediterranean Basin, the Middle East and the Muslim world...
ian tablets
Clay tablet
In the Ancient Near East, clay tablets were used as a writing medium, especially for writing in cuneiform, throughout the Bronze Age and well into the Iron Age....
dating back to circa 3600 BC. The 110-page Ebers Papyrus
Ebers papyrus
The Ebers Papyrus, also known as Papyrus Ebers, is an Egyptian medical papyrus dating to circa 1550 BC. Among the oldest and most important medical papyri of ancient Egypt, it was purchased at Luxor, in the winter of 1873–74 by Georg Ebers...
, an Egyptian medical papyrus which dates to circa 1550 BC, also makes reference to the tracheotomy. Tracheotomy was described in the Rigveda
Rigveda
The Rigveda is an ancient Indian sacred collection of Vedic Sanskrit hymns...
, a Sanskrit
Sanskrit
Sanskrit , is a historical Indo-Aryan language and the primary liturgical language of Hinduism, Jainism and Buddhism.Buddhism: besides Pali, see Buddhist Hybrid Sanskrit Today, it is listed as one of the 22 scheduled languages of India and is an official language of the state of Uttarakhand...
text of ayurvedic medicine
Ayurveda
Ayurveda or ayurvedic medicine is a system of traditional medicine native to India and a form of alternative medicine. In Sanskrit, words , meaning "longevity", and , meaning "knowledge" or "science". The earliest literature on Indian medical practice appeared during the Vedic period in India,...
written circa 2000 BC in ancient India
Indus Valley Civilization
The Indus Valley Civilization was a Bronze Age civilization that was located in the northwestern region of the Indian subcontinent, consisting of what is now mainly modern-day Pakistan and northwest India...
. The text mentions "the bountiful one who, without a ligature, can cause the windpipe to re-unite when the cervical cartilages are cut across, provided they are not entirely severed." The Sushruta Samhita
Sushruta Samhita
The Sushruta Samhita is a Sanskrit text, attributed to one Sushruta, foundational to Ayurvedic medicine , with innovative chapters on surgery....
(circa 400 BC) is another text from the Indian subcontinent
Indian subcontinent
The Indian subcontinent, also Indian Subcontinent, Indo-Pak Subcontinent or South Asian Subcontinent is a region of the Asian continent on the Indian tectonic plate from the Hindu Kush or Hindu Koh, Himalayas and including the Kuen Lun and Karakoram ranges, forming a land mass which extends...
on ayurvedic medicine and surgery that mentions tracheotomy.
The Greek
Greeks
The Greeks, also known as the Hellenes , are a nation and ethnic group native to Greece, Cyprus and neighboring regions. They also form a significant diaspora, with Greek communities established around the world....
physician Hippocrates
Hippocrates
Hippocrates of Cos or Hippokrates of Kos was an ancient Greek physician of the Age of Pericles , and is considered one of the most outstanding figures in the history of medicine...
(ca. 460–ca. 370 BC) condemned the practice of tracheotomy. Warning against the unacceptable risk of death from inadvertent laceration of the carotid artery
Common carotid artery
In human anatomy, the common carotid artery is an artery that supplies the head and neck with oxygenated blood; it divides in the neck to form the external and internal carotid arteries. - Structure :...
during tracheotomy, Hippocrates also cautioned that "The most difficult fistula
Fistula
In medicine, a fistula is an abnormal connection or passageway between two epithelium-lined organs or vessels that normally do not connect. It is generally a disease condition, but a fistula may be surgically created for therapeutic reasons.-Locations:Fistulas can develop in various parts of the...
s are those which occur in the cartilaginous areas." Because surgical instruments were not sterilized
Sterilization (microbiology)
Sterilization is a term referring to any process that eliminates or kills all forms of microbial life, including transmissible agents present on a surface, contained in a fluid, in medication, or in a compound such as biological culture media...
at that time, infections following surgery also produced numerous and frequently fatal complications. Homerus of Byzantium
Homerus of Byzantium
Homerus from Byzantium was an ancient Greek grammarian and tragic poet. He was also called ho Neoteros , to distinguish him from the older Homerus ....
is said to have written of Alexander the Great (356–323 BC) saving a soldier from asphyxia
Asphyxia
Asphyxia or asphyxiation is a condition of severely deficient supply of oxygen to the body that arises from being unable to breathe normally. An example of asphyxia is choking. Asphyxia causes generalized hypoxia, which primarily affects the tissues and organs...
tion by making an incision with the tip of his sword in the man's trachea.
Despite the concerns of Hippocrates, Galen
Galen
Aelius Galenus or Claudius Galenus , better known as Galen of Pergamon , was a prominent Roman physician, surgeon and philosopher...
of Pergamon
Pergamon
Pergamon , or Pergamum, was an ancient Greek city in modern-day Turkey, in Mysia, today located from the Aegean Sea on a promontory on the north side of the river Caicus , that became the capital of the Kingdom of Pergamon during the Hellenistic period, under the Attalid dynasty, 281–133 BC...
(129–199) and Aretaeus of Cappadocia
Cappadocia
Cappadocia is a historical region in Central Anatolia, largely in Nevşehir Province.In the time of Herodotus, the Cappadocians were reported as occupying the whole region from Mount Taurus to the vicinity of the Euxine...
(both of whom lived in Rome
Ancient Rome
Ancient Rome was a thriving civilization that grew on the Italian Peninsula as early as the 8th century BC. Located along the Mediterranean Sea and centered on the city of Rome, it expanded to one of the largest empires in the ancient world....
in the 2nd century AD) credit Asclepiades of Bithynia
Asclepiades of Bithynia
Asclepiades was a Greek physician born at Prusa in Bithynia in Asia Minor and flourished at Rome, where he established Greek medicine near the end of the 2nd century BCE. He attempted to build a new theory of disease, based on the flow of atoms through pores in the body...
(ca. 124–40 BC) as being the first physician to perform a non-emergency tracheotomy. However, Aretaeus warned against the performance of tracheotomy because he believed that incisions made into the tracheal cartilage
Cartilage
Cartilage is a flexible connective tissue found in many areas in the bodies of humans and other animals, including the joints between bones, the rib cage, the ear, the nose, the elbow, the knee, the ankle, the bronchial tubes and the intervertebral discs...
were prone to secondary wound infections and therefore would not heal. He wrote that that "The lips of the wound do not coalesce, for they are both cartilaginous and not of a nature to unite". Antyllus
Antyllus
For the son of Mark Antony, see Marcus Antonius AntyllusAntyllus was a Greek surgeon, who lived in the 2nd century AD in Rome. He is most notable for his method of treatment of aneurysms...
, another Greek surgeon who lived in Rome in the 2nd century AD, was reported to have performed tracheotomy when treating oral diseases. He refined the technique to be more similar to that used in modern times, recommending that a transverse
Transverse plane
The transverse plane is an imaginary plane that divides the body into superior and inferior parts. It is perpendicular to the coronal and sagittal planes....
incision be made between the third and fourth tracheal rings for the treatment of life-threatening airway obstruction. Antyllus wrote that tracheotomy was not effective however in cases of severe laryngotracheobronchitis
Croup
Croup is a respiratory condition that is usually triggered by an acute viral infection of the upper airway. The infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, and hoarseness...
because the pathology
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....
was distal to the operative site. Antyllus' original writings were lost, but they were preserved by Oribasius
Oribasius
Oribasius or Oreibasius was a Greek medical writer and the personal physician of the Roman emperor Julian the Apostate. He studied at Alexandria under physician Zeno of Cyprus before joining Julian's retinue. He was involved in Julian's coronation in 361, and remained with the emperor until...
(ca. 320–400) and Paul of Aegina
Paul of Aegina
Paul of Aegina or Paulus Aegineta was a 7th-century Byzantine Greek physician best known for writing the medical encyclopedia Medical Compendium in Seven Books...
(ca. 625–690), both of whom were Greek physicians as well as historians. Galen clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice. Galen may have understood the importance of artificial ventilation, because in one of his experiments he used bellows to inflate the lungs of a dead animal.
During the Middle Ages
Middle Ages
The Middle Ages is a periodization of European history from the 5th century to the 15th century. The Middle Ages follows the fall of the Western Roman Empire in 476 and precedes the Early Modern Era. It is the middle period of a three-period division of Western history: Classic, Medieval and Modern...
, scientific discoveries were few and far between in much of Europe. However, the scientific culture flourished in other parts of the world. By AD 700, the tracheotomy was well documented in India
India
India , officially the Republic of India , is a country in South Asia. It is the seventh-largest country by geographical area, the second-most populous country with over 1.2 billion people, and the most populous democracy in the world...
n and Arabian
Arab world
The Arab world refers to Arabic-speaking states, territories and populations in North Africa, Western Asia and elsewhere.The standard definition of the Arab world comprises the 22 states and territories of the Arab League stretching from the Atlantic Ocean in the west to the Arabian Sea in the...
literature, although it was rarely practiced on humans. In 1000, Abu al-Qasim al-Zahrawi (936-1013), an Arab who lived in Al-Andalus
Al-Andalus
Al-Andalus was the Arabic name given to a nation and territorial region also commonly referred to as Moorish Iberia. The name describes parts of the Iberian Peninsula and Septimania governed by Muslims , at various times in the period between 711 and 1492, although the territorial boundaries...
, published the 30-volume Kitab al-Tasrif
Al-Tasrif
The Kitab al-Tasrif was an Arabic encyclopedia on medicine and surgery, written near the year 1000 by Abu al-Qasim al-Zahrawi...
, the first illustrated work on surgery. He never performed a tracheotomy, but he did treat a slave girl who had cut her own throat in a suicide attempt. Al-Zahrawi (known to Europeans as Albucasis) sewed up the wound and the girl recovered, thereby proving that an incision in the larynx could heal. Circa 1020, Ibn Sīnā
Avicenna
Abū ʿAlī al-Ḥusayn ibn ʿAbd Allāh ibn Sīnā , commonly known as Ibn Sīnā or by his Latinized name Avicenna, was a Persian polymath, who wrote almost 450 treatises on a wide range of subjects, of which around 240 have survived...
(980–1037) described the use of tracheal intubation in The Canon of Medicine
The Canon of Medicine
The Canon of Medicine is an encyclopedia of Galenic medicine in five books compiled by Ibn Sīnā and completed in 1025. It presents a clear and organized summary of all the medical knowledge of the time...
to facilitate breathing
Breathing
Breathing is the process that moves air in and out of the lungs. Aerobic organisms require oxygen to release energy via respiration, in the form of the metabolism of energy-rich molecules such as glucose. Breathing is only one process that delivers oxygen to where it is needed in the body and...
. In the 12th century medical textbook Al-Taisir, Ibn Zuhr
Ibn Zuhr
Abū Merwān ’Abdal-Malik ibn Zuhr was a Muslim physician, surgeon and teacher in Al-Andalus.He was born at Seville...
(1091–1161) of Al-Andalus (also known as Avenzoar) provided an anatomically correct description of the tracheotomy operation.
The Renaissance
Renaissance
The Renaissance was a cultural movement that spanned roughly the 14th to the 17th century, beginning in Italy in the Late Middle Ages and later spreading to the rest of Europe. The term is also used more loosely to refer to the historical era, but since the changes of the Renaissance were not...
saw significant advances in anatomy and surgery, and surgeons became increasingly open to surgery on the trachea. Despite this, the mortality rate failed to improve. From 1500 through 1832 there are only 28 known descriptions of successful tracheotomy in the literature. The first detailed descriptions on tracheal intubation and subsequent artificial respiration
Artificial respiration
Artificial respiration is the act of assisting or stimulating respiration, a metabolic process referring to the overall exchange of gases in the body by pulmonary ventilation, external respiration, and internal respiration...
of animals were from Andreas Vesalius (1514–1564) of Brussels. In his landmark book published in 1543, De humani corporis fabrica
De humani corporis fabrica
De humani corporis fabrica libri septem is a textbook of human anatomy written by Andreas Vesalius in 1543....
, he described an experiment in which he passed a reed
Reed (plant)
Reed is a generic polyphyletic botanical term used to describe numerous tall, grass-like plants of wet places, which are the namesake vegetation of reed beds...
into the trachea of a dying animal whose thorax
Thorax
The thorax is a division of an animal's body that lies between the head and the abdomen.-In tetrapods:...
had been opened and maintained ventilation by blowing into the reed intermittently. Vesalius wrote that the technique could be life-saving. Antonio Musa Brassavola
Antonio Musa Brassavola
Antonio Musa Brassavola was an Italian physician and one of the most famous of his time. He studied under Niccolò Leoniceno and Manardi. He was the friend and physician of Ercolo II, the prince of Este...
(1490–1554) of Ferrara
Ferrara
Ferrara is a city and comune in Emilia-Romagna, northern Italy, capital city of the Province of Ferrara. It is situated 50 km north-northeast of Bologna, on the Po di Volano, a branch channel of the main stream of the Po River, located 5 km north...
treated a patient suffering from peritonsillar abscess
Peritonsillar abscess
Peritonsillar abscess , also called a quinsy or abbreviated as PTA is a recognised complication of tonsillitis and consists of a collection of pus beside the tonsil .-Symptoms and signs:...
by tracheotomy after the patient had been refused by barber surgeon
Barber surgeon
The barber surgeon was one of the most common medical practitioners of medieval Europe - generally charged with looking after soldiers during or after a battle...
s. The patient apparently made a complete recovery and Brassavola published his account in 1546. This operation has been identified as the first recorded successful tracheostomy, despite many ancient references to the trachea and possibly to its opening.
Towards the end of the 16th century, anatomist and surgeon Hieronymus Fabricius
Hieronymus Fabricius
Hieronymus Fabricius or Girolamo Fabrizio or by his Latin name Fabricus ab Aquapendende also Girolamo Fabrizi d'Acquapendente was a pioneering anatomist and surgeon known in medical science as "The Father of Embryology."...
(1533–1619) described a useful technique for tracheotomy in his writings, although he had never actually performed the operation himself. He advised using a vertical incision and was the first to introduce the idea of a tracheostomy tube. This was a straight, short cannula
Cannula
A cannula or canula is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of data...
that incorporated wings to prevent the tube from advancing too far into the trachea. He recommended the operation only as a last resort, to be used in cases of airway
Airway
The pulmonary airway comprises those parts of the respiratory system through which air flows, conceptually beginning at the nose and mouth, and terminating in the alveoli...
obstruction by foreign bodies
Foreign body
A foreign body is any object originating outside the body. In machinery, it can mean any unwanted intruding object.Most references to foreign bodies involve propulsion through natural orifices into hollow organs....
or secretion
Secretion
Secretion is the process of elaborating, releasing, and oozing chemicals, or a secreted chemical substance from a cell or gland. In contrast to excretion, the substance may have a certain function, rather than being a waste product...
s. Fabricius' description of the tracheotomy procedure is similar to that used today. Julius Casserius (1561–1616) succeeded Fabricius as professor of anatomy at the University of Padua and published his own writings regarding technique and equipment for tracheotomy, recommending a curved silver tube with several holes in it. Marco Aurelio Severino
Marco Aurelio Severino
Marco Aurelio Severino was an Italian surgeon and anatomist.-Biography:Severino was born in Tarsia , of Giovanni Jacopo Severino, a lawyer. He died of plague in 1656....
(1580–1656), a skillful surgeon and anatomist, performed multiple successful tracheotomies during a diphtheria
Diphtheria
Diphtheria is an upper respiratory tract illness caused by Corynebacterium diphtheriae, a facultative anaerobic, Gram-positive bacterium. It is characterized by sore throat, low fever, and an adherent membrane on the tonsils, pharynx, and/or nasal cavity...
epidemic
Epidemic
In epidemiology, an epidemic , occurs when new cases of a certain disease, in a given human population, and during a given period, substantially exceed what is expected based on recent experience...
in Naples
Naples
Naples is a city in Southern Italy, situated on the country's west coast by the Gulf of Naples. Lying between two notable volcanic regions, Mount Vesuvius and the Phlegraean Fields, it is the capital of the region of Campania and of the province of Naples...
in 1610, using the vertical incision technique recommended by Fabricius. He also developed his own version of a trocar.
In 1620 the French surgeon Nicholas Habicot (1550–1624), surgeon of the Duke of Nemours
Duke of Nemours
In the 12th and 13th centuries the Lordship of Nemours, in the Gatinais, France, was in possession of the house of Villebeon, a member of which, Gautier, was marshal of France in the middle of the 13th century...
and anatomist, published a report of four successful "bronchotomies" which he had performed. One of these is the first recorded case of a tracheotomy for the removal of a foreign body, in this instance a blood clot in the larynx of a stabbing victim. He also described the first tracheotomy to be performed on a pediatric
Pediatrics
Pediatrics or paediatrics is the branch of medicine that deals with the medical care of infants, children, and adolescents. A medical practitioner who specializes in this area is known as a pediatrician or paediatrician...
patient. A 14-year-old boy swallowed a bag containing 9 gold coins in an attempt to prevent its theft by a highwayman
Highwayman
A highwayman was a thief and brigand who preyed on travellers. This type of outlaw, usually, travelled and robbed by horse, as compared to a footpad who traveled and robbed on foot. Mounted robbers were widely considered to be socially superior to footpads...
. The object became lodged in his esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
, obstructing his trachea. Habicot performed a tracheotomy, which allowed him to manipulate the bag so that it passed through the boy's alimentary tract, apparently with no further sequela
Sequela
A sequela) is a pathological condition resulting from a disease, injury, or other trauma.Chronic kidney disease, for example, is sometimes a sequela of diabetes, and neck pain is a common sequela of whiplash or other trauma to the cervical vertebrae. Post-traumatic stress disorder may be a...
e. Habicot suggested that the operation might also be effective for patients suffering from inflammation of the larynx. He developed equipment for this surgical procedure which are similar in many ways to modern designs.
Sanctorius
Sanctorius
Santorio Santorio , also called Santorio Santorii, Sanctorius of Padua, and various combinations of these names, was an Italian physiologist, physician, and professor. From 1611 to 1624 he was a professor at Padua where he performed experiments in temperature, respiration and weight...
(1561–1636) is believed to be the first to use a trocar in the operation; he recommended leaving the cannula in place for a few days following the operation. Early tracheostomy devices are illustrated in Habicot’s Question Chirurgicale and Julius Casserius' posthumous Tabulae anatomicae in 1627. Thomas Fienus (1567–1631), Professor of Medicine at the University of Louvain
Old University of Leuven
The Old University of Leuven is the name historians give to the university, or studium generale, founded in Leuven, Brabant , in 1425, and closed in 1797, a week after the cession to the French Republic of the Austrian Netherlands and the principality of Liège by the Treaty of Campo Formio.When...
, was the first to use the word "tracheotomy" in 1649, but this term was not commonly used until a century later. Georg Detharding (1671–1747), professor of anatomy at the University of Rostock
University of Rostock
The University of Rostock is the university of the city Rostock, in the German state of Mecklenburg-Vorpommern.Founded in 1419, it is the oldest and largest university in continental northern Europe and the Baltic Sea area...
, treated a drowning victim with tracheostomy in 1714.
Fearful of complications, most surgeons delayed the potentially life-saving tracheotomy until a patient was moribund
Moribund
Moribund refers to a literal or figurative state of near-death.Moribund may also refer to:* "Le Moribond", a song by Jacques Brel which became better known for its rewritten English-language version, "Seasons in the Sun"...
, despite the knowledge that irreversible organ damage would have already occurred by that time. This began to change in the early 19th century, when the tracheotomy finally began to be recognized as a legitimate means of treating severe airway obstruction. In 1832, French physician Pierre Bretonneau
Pierre Bretonneau
- Biography :Born at Saint-Georges-sur-Cher, in the Loir-et-Cher département. His father was a surgeon. He studied with his uncle, the vicar at Chenonceaux department along with the children of the Chenonceau château...
(1778–1862) employed tracheotomy as a last resort to treat a case of diphtheria
Diphtheria
Diphtheria is an upper respiratory tract illness caused by Corynebacterium diphtheriae, a facultative anaerobic, Gram-positive bacterium. It is characterized by sore throat, low fever, and an adherent membrane on the tonsils, pharynx, and/or nasal cavity...
. In 1852, Bretonneau's student Armand Trousseau
Armand Trousseau
Armand Trousseau was a French internist. His contributions to medicine include Trousseau sign of malignancy, Trousseau sign of latent tetany, Trousseau-Lallemand bodies , and the truism, "use new drugs quickly, while they still work."-Biography:A native of Tours, Indre-et-Loire, Armand Trousseau...
(1801–1867) presented a series of 169 tracheotomies (158 of which were for croup
Croup
Croup is a respiratory condition that is usually triggered by an acute viral infection of the upper airway. The infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, and hoarseness...
and 11 for "chronic maladies of the larynx"). In 1871, the German surgeon Friedrich Trendelenburg
Friedrich Trendelenburg
Friedrich Trendelenburg was a German surgeon. He was son of the philosopher Friedrich Adolf Trendelenburg, father of the pharmacologist Paul Trendelenburg and grandfather of the pharmacologist Ullrich Georg Trendelenburg.Trendelenburg was born in Berlin and studied medicine at the University of...
(1844–1924) published a paper describing the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia. After the death of German Emperor Frederick III
Frederick III, German Emperor
Frederick III was German Emperor and King of Prussia for 99 days in 1888, the Year of the Three Emperors. Friedrich Wilhelm Nikolaus Karl known informally as Fritz, was the only son of Emperor William I and was raised in his family's tradition of military service...
from laryngeal cancer in 1888, Sir Morell Mackenzie
Morell Mackenzie
Sir Morell Mackenzie was a British physician, one of the pioneers of laryngology in the United Kingdom.-Biography:...
(1837–1892) and the other treating physicians collectively wrote a book discussing the then-current indications
Indication (medicine)
In medicine, an indication is a valid reason to use a certain test, medication, procedure, or surgery. The opposite of indication is contraindication.-Drugs:...
for tracheotomy and when the operation is absolutely necessary.
In the early 20th century, physicians began to use the tracheotomy in the treatment of patients afflicted with paralytic poliomyelitis
Poliomyelitis
Poliomyelitis, often called polio or infantile paralysis, is an acute viral infectious disease spread from person to person, primarily via the fecal-oral route...
who required mechanical ventilation. The currently used surgical tracheotomy technique was described in 1909 by Chevalier Jackson
Chevalier Jackson
Chevalier Jackson was a laryngologist.Jackson was born in Pittsburgh, Pennsylvania. He went to school at the Western University of Pennsylvania from 1879 to 1883, and received his MD from Jefferson Medical College. He also studied laryngology in England.His work reduced the risks involved in a...
(1865–1958), a professor of laryngology at Jefferson Medical College in Philadelphia. However, surgeons continued to debate various aspects of the tracheotomy well into the 20th century. Many techniques were employed, along with many different surgical instruments and tracheal tubes. Surgeons could not seem to reach a consensus on where or how the tracheal incision should be made, arguing whether the "high tracheotomy" or the "low tracheotomy" was more beneficial. Ironically, the newly developed inhalational anesthetic agents
Inhalational anaesthetic
An inhalational anaesthetic is a chemical compound possessing general anaesthetic properties that can be delivered via inhalation. They are administered by anaesthetists through an anaesthesia mask, laryngeal mask airway or tracheal tube connected to some type of anaesthetic vaporiser and an...
and techniques of general anesthesia actually seemed to increase the risks, with many patients suffering fatal postoperative complications. Jackson emphasised the importance of postoperative care, which dramatically reduced the mortality rate. By 1965, the surgical anatomy was thoroughly and widely understood, antibiotic
Antibiotic
An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...
s were widely available and useful for treating postoperative infections and other major complications of tracheotomy had also become more manageable.
Endoscopy
While all these surgical advances were taking place, many important developments were also taking place in the science of opticsOptics
Optics is the branch of physics which involves the behavior and properties of light, including its interactions with matter and the construction of instruments that use or detect it. Optics usually describes the behavior of visible, ultraviolet, and infrared light...
. Many new optical instrument
Optical instrument
An optical instrument either processes light waves to enhance an image for viewing, or analyzes light waves to determine one of a number of characteristic properties.-Image enhancement:...
s with medical applications were invented during the 19th century. In 1805, a German army surgeon named Philipp von Bozzini
Philipp Bozzini
Philipp Bozzini was born in Mainz, Germany. On June 12, 1797 he was awarded the degree of doctor of medicine. From 1804 onwards, Bozzini devoted himself virtually completely to develop his instrument, Lichtleiter or "Light Conductor", a primitive endoscope to allow for inspecting the ear, urethra,...
(1773–1809) invented a device he called the lichtleiter (or light-guiding instrument). This instrument, the ancestor of the modern endoscope, was used to examine the urethra
Urethra
In anatomy, the urethra is a tube that connects the urinary bladder to the genitals for the removal of fluids out of the body. In males, the urethra travels through the penis, and carries semen as well as urine...
, the human urinary bladder
Urinary bladder
The urinary bladder is the organ that collects urine excreted by the kidneys before disposal by urination. A hollow muscular, and distensible organ, the bladder sits on the pelvic floor...
, rectum
Rectum
The rectum is the final straight portion of the large intestine in some mammals, and the gut in others, terminating in the anus. The human rectum is about 12 cm long...
, oropharynx and nasopharynx. The instrument consisted of a candle within a metal chimney; a mirror on the inside reflected light from the candle through attachments into the relevant body cavity. The practice of gastric endoscopy in humans was pioneered by United States Army surgeon William Beaumont
William Beaumont
William Beaumont was a surgeon in the U.S. Army who became known as the "Father of Gastric Physiology" following his research on human digestion.-Early life:...
(1785–1853) in 1822 with the cooperation of his patient Alexis St. Martin
Alexis St. Martin
Alexis St. Martin was a Canadian voyageur who is known for his part in experiments on digestion in humans, conducted by the American physician William Beaumont between 1822 and 1833.- Work with Beaumont :...
(1794–1880), a victim of an accidental gunshot wound to the stomach. In 1853, Antoine Jean Desormeaux (1815–1882) of Paris modified Bozzini's lichtleiter such that a mirror would reflect light from a kerosene lamp
Kerosene lamp
The kerosene lamp is a type of lighting device that uses kerosene as a fuel. This article refers to kerosene lamps that have a wick and a tall glass chimney. Kerosene lanterns that have a wick and a glass globe are related to kerosene lamps and are included here as well...
through a long metal channel. Referring to this instrument as an endoscope
Endoscopy
Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...
(he is credited with coining this term), Desormeaux employed it to examine the urinary bladder. However, like Bozzini's lichtleiter, Desormeaux's endoscope was of limited utility due to its propensity to become very hot during use. In 1868, Adolph Kussmaul
Adolph Kussmaul
Adolph Kussmaul was a German physician and a leading clinician of his time. He was born as the son and grandson of physicians at Graben near Karlsruhe and studied at Heidelberg. He entered the army after graduation and spent two years as an army surgeon...
(1822–1902) of Germany performed the first esophagogastroduodenoscopy
Esophagogastroduodenoscopy
For other expansions of the initialism "OGD", see the disambiguation page.In medicine , esophagogastroduodenoscopy is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum...
(a diagnostic
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
procedure in which an endoscope is used to visualize the esophagus, stomach and duodenum
Duodenum
The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms anterior intestine or proximal intestine may be used instead of duodenum...
) on a living human. The subject was a sword-swallower
Sword swallowing
Sword swallowing is an ancient performance art in which the performer passes a sword through the mouth and down the esophagus towards the stomach...
, who swallowed a metal tube with a length of 47 centimeters and a diameter of 13 millimeters. On 2 October 1877, Berlin
Berlin
Berlin is the capital city of Germany and is one of the 16 states of Germany. With a population of 3.45 million people, Berlin is Germany's largest city. It is the second most populous city proper and the seventh most populous urban area in the European Union...
urologist
Urology
Urology is the medical and surgical specialty that focuses on the urinary tracts of males and females, and on the reproductive system of males. Medical professionals specializing in the field of urology are called urologists and are trained to diagnose, treat, and manage patients with urological...
Maximilian Carl-Friedrich Nitze
Maximilian Nitze
Maximilian Carl-Friedrich Nitze was a German urologist who was born in Berlin. He studied medicine at the Universities of Heidelberg, Würzburg and Leipzig. In 1874 he earned his doctorate, and subsequently became a medical assistant at the city hospital in Dresden. During the 1880s, Nitze founded...
(1848–1906) and Viennese
Vienna
Vienna is the capital and largest city of the Republic of Austria and one of the nine states of Austria. Vienna is Austria's primary city, with a population of about 1.723 million , and is by far the largest city in Austria, as well as its cultural, economic, and political centre...
instrument maker Josef Leiter (1830–1892) introduced the first practical cystourethroscope
Cystoscopy
Cystoscopy is endoscopy of the urinary bladder via the urethra. It is carried out with a cystoscope.Diagnostic cystoscopy is usually carried out with local anaesthesia...
with an electric light source. The instrument's biggest drawback was the tungsten
Tungsten
Tungsten , also known as wolfram , is a chemical element with the chemical symbol W and atomic number 74.A hard, rare metal under standard conditions when uncombined, tungsten is found naturally on Earth only in chemical compounds. It was identified as a new element in 1781, and first isolated as...
filament incandescent light bulb
Incandescent light bulb
The incandescent light bulb, incandescent lamp or incandescent light globe makes light by heating a metal filament wire to a high temperature until it glows. The hot filament is protected from air by a glass bulb that is filled with inert gas or evacuated. In a halogen lamp, a chemical process...
(invented by Alexander Lodygin
Alexander Lodygin
Alexander Nikolayevich Lodygin was a Russian electrical engineer and inventor, one of inventors of the Incandescent light bulb....
, 1847–1923), which became very hot and required a complicated water cooling system. In 1881, Polish physician Jan Mikulicz-Radecki
Jan Mikulicz-Radecki
Jan Mikulicz-Radecki was a Polish-Austrian surgeon. He was born May 16, 1850 in Czernowitz in the Austrian Empire and died June 4, 1905 in Breslau, German Empire .While his mother Freiin von Damnitz was Austrian, his parental ancestors of the Mikulicz...
(1850–1905) created the first rigid gastroscope for practical applications.
In 1932, Rudolph Schindler (1888–1968) of Germany introduced the first semi-flexible gastroscope. This device had numerous lenses
Lens (optics)
A lens is an optical device with perfect or approximate axial symmetry which transmits and refracts light, converging or diverging the beam. A simple lens consists of a single optical element...
positioned throughout the tube and a miniature light bulb at the distal tip. The tube of this device was 75 centimeters in length and 11 millimeters in diameter, and the distal portion was capable of a certain degree of flexion. Between 1945 and 1952, optical engineers
Optical engineering
Optical engineering is the field of study that focuses on applications of optics. Optical engineers design components of optical instruments such as lenses, microscopes, telescopes, and other equipment that utilizes the properties of light. Other devices include optical sensors and measurement...
(particularly Karl Storz (1911–1996) of Germany, Harold Hopkins
Harold Hopkins
Harold Horace Hopkins FRS was a renowned British physicist. His Wave Theory of Aberrations, , is central to all modern optical design and provides the mathematical analysis which enables the use of computers to create the wealth of high quality lenses available today...
(1918–1995) of England and Mutsuo Sugiura of the Japanese Olympus Corporation
Olympus Corporation
is a Japan-based manufacturer of optics and reprography products. Olympus was established on 12 October 1919, initially specializing in microscope and thermometer businesses. Its global headquarters are in Shinjuku, Tokyo, Japan, while its USA operations are based in Center Valley, Pennsylvania,...
) built upon this early work, leading to the development of the first "gastrocamera". In 1964, Fernando Alves Martins (born 17 June 1927) of Portugal applied optical fiber
Optical fiber
An optical fiber is a flexible, transparent fiber made of a pure glass not much wider than a human hair. It functions as a waveguide, or "light pipe", to transmit light between the two ends of the fiber. The field of applied science and engineering concerned with the design and application of...
technology to one of these early gastrocameras to produce the first gastrocamera with a flexible fiberscope. Initially used in esophagogastroduodenoscopy, newer devices were developed in the late 1960s for use in bronchoscopy
Bronchoscopy
Bronchoscopy is a technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy. This allows the practitioner to examine the patient's airways for...
, rhinoscopy
Rhinoscope
A rhinoscope is a thin, tube-like instrument used to examine the inside of the nose. A rhinoscope has a light and a lens for viewing and may have a tool to remove tissue.- External links :...
and laryngoscopy. The concept of using a fiberoptic endoscope for tracheal intubation was introduced by Peter Murphy, an English anesthetist, in 1967. By the mid-1980s, the flexible fiberoptic bronchoscope had become an indispensable instrument within the pulmonology
Pulmonology
In medicine, pulmonology is the specialty that deals with diseases of the respiratory tract and respiratory disease. It is called chest medicine and respiratory medicine in some countries and areas...
and anesthesia communities.
Laryngoscopy and non-surgical tracheal intubation
Vocal pedagogy
Vocal pedagogy is the study of the art and science of voice instruction. It is used in the teaching of singing and assists in defining what singing is, how singing works, and how proper singing technique is accomplished....
named Manuel García
Manuel Patricio Rodríguez García
Manuel Patricio Rodríguez García , was a Spanish singer, music educator, and vocal pedagogue.-Biography:García was born on 17 March 1805 in the town of Zafra in Badajoz Province, Spain. His father was singer and teacher Manuel del Pópulo Vicente Rodriguez García...
(1805–1906) became the first man to view the functioning glottis in a living human. García developed a tool that used two mirrors for which the Sun served as an external light source. Using this device, he was able to observe the function of his own glottic apparatus and the uppermost portion of his trachea. He presented his observations at the Royal Society of London
Royal Society
The Royal Society of London for Improving Natural Knowledge, known simply as the Royal Society, is a learned society for science, and is possibly the oldest such society in existence. Founded in November 1660, it was granted a Royal Charter by King Charles II as the "Royal Society of London"...
in 1855.
In 1858, Eugène Bouchut
Eugène Bouchut
Eugène Bouchut was a French physician born in Paris. He made significant contributions in several medical fields, including pediatrics, laryngology, neurology and ophthalmology.-Career:...
(1818–1891), a pediatrician
Pediatrics
Pediatrics or paediatrics is the branch of medicine that deals with the medical care of infants, children, and adolescents. A medical practitioner who specializes in this area is known as a pediatrician or paediatrician...
from Paris, developed a new technique for non-surgical orotracheal intubation to bypass laryngeal obstruction resulting from a diphtheria-related pseudomembrane. His method involved introducing a small straight metal tube into the larynx, securing it by means of a silk thread and leaving it there for a few days until the pseudomembrane and airway obstruction had resolved sufficiently. Bouchut presented this experimental technique along with the results he had achieved in the first seven cases at the French Academy of Sciences
French Academy of Sciences
The French Academy of Sciences is a learned society, founded in 1666 by Louis XIV at the suggestion of Jean-Baptiste Colbert, to encourage and protect the spirit of French scientific research...
conference on 18 September 1858. The members of the Academy rejected Bouchut's ideas, largely as a result of highly critical and negative remarks made by the influential Armand Trousseau. Undaunted, Bouchut later introduced a set of tubes ("Bouchut's tubes") for intubation of the trachea, as an alternative to tracheotomy in cases of diphtheria.
In March 1878, Wilhelm Hack of Freiburg published a paper describing the use of non-surgical orotracheal intubation in the removal of vocal cord polyps
Vocal fold nodule
A vocal cord nodule is a mass of tissue that grows on the vocal folds . Typically, this mass will appear on the junction of the anterior and middle two-thirds of the vocal fold, where contact is most forceful....
. In November of that year, he published another study, this time on the use of orotracheal intubation to secure the airway of a patient with acute glottic edema
Epiglottitis
Epiglottitis is an inflammation of the epiglottis - the flap that sits at the base of the tongue, which keeps food from going into the trachea . Due to its place in the airway, swelling of this structure can interfere with breathing and constitutes a medical emergency...
, progressively introducing sizes 3 through 11 of "Schrotter's graduated triangular vulcanite
Vulcanization
Vulcanization or vulcanisation is a chemical process for converting rubber or related polymers into more durable materials via the addition of sulfur or other equivalent "curatives." These additives modify the polymer by forming crosslinks between individual polymer chains. Vulcanized material is...
bougies" into the larynx. In 1880, the Scottish
Scottish people
The Scottish people , or Scots, are a nation and ethnic group native to Scotland. Historically they emerged from an amalgamation of the Picts and Gaels, incorporating neighbouring Britons to the south as well as invading Germanic peoples such as the Anglo-Saxons and the Norse.In modern use,...
surgeon William Macewen
William Macewen
Sir William Macewen, CB, FRS, was a Scottish surgeon. He was a pioneer in modern brain surgery and contributed to the development of bone graft surgery, the surgical treatment of hernia and of pneumonectomy .-Career:Macewen was born near Port Bannatyne, Isle of Bute, Scotland in 1848 and studied...
(1848–1924) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well as in the setting of general anesthesia with chloroform
Chloroform
Chloroform is an organic compound with formula CHCl3. It is one of the four chloromethanes. The colorless, sweet-smelling, dense liquid is a trihalomethane, and is considered somewhat hazardous...
. All previous observations of the glottis and larynx (including those of García, Hack and Macewen) had been performed under indirect vision (using mirrors) until 23 April 1895, when Alfred Kirstein (1863–1922) of Germany first described direct visualization of the vocal cords. Kirstein performed the first direct laryngoscopy in Berlin, using an esophagoscope he had modified for this purpose; he called this device an autoscope. The death in 1888 of Emperor Frederick III may have motivated Kirstein to develop the autoscope.
Until 1913, oral and maxillofacial surgery
Oral and maxillofacial surgery
Oral and maxillofacial surgery is surgery to correct a wide spectrum of diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region. It is an internationally recognized surgical specialty...
was performed by mask inhalation anesthesia
Inhalational anaesthetic
An inhalational anaesthetic is a chemical compound possessing general anaesthetic properties that can be delivered via inhalation. They are administered by anaesthetists through an anaesthesia mask, laryngeal mask airway or tracheal tube connected to some type of anaesthetic vaporiser and an...
, topical application of local anesthetic
Local anesthetic
A local anesthetic is a drug that causes reversible local anesthesia, generally for the aim of having local analgesic effect, that is, inducing absence of pain sensation, although other local senses are often affected as well...
s to the mucosa
Mucous membrane
The mucous membranes are linings of mostly endodermal origin, covered in epithelium, which are involved in absorption and secretion. They line cavities that are exposed to the external environment and internal organs...
, rectal anesthesia, or intravenous
Intravenous therapy
Intravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. The word intravenous simply means "within a vein". Therapies administered intravenously are often called specialty pharmaceuticals...
anesthesia. While otherwise effective, these techniques did not protect the airway from obstruction and also exposed patients to the risk of pulmonary aspiration of blood and mucus
Mucus
In vertebrates, mucus is a slippery secretion produced by, and covering, mucous membranes. Mucous fluid is typically produced from mucous cells found in mucous glands. Mucous cells secrete products that are rich in glycoproteins and water. Mucous fluid may also originate from mixed glands, which...
into the tracheobronchial tree. In 1913, Chevalier Jackson was the first to report a high rate of success for the use of direct laryngoscopy as a means to intubate the trachea. Jackson introduced a new laryngoscope blade that had a light source at the distal tip, rather than the proximal light source used by Kirstein. This new blade incorporated a component that the operator could slide out to allow room for passage of an endotracheal tube or bronchoscope.
That same year, Henry H. Janeway (1873–1921) published results he had achieved using a laryngoscope he had recently developed. An American anesthesiologist practicing at Bellevue Hospital
Bellevue Hospital Center
Bellevue Hospital Center, most often referred to as "Bellevue", was founded on March 31, 1736 and is the oldest public hospital in the United States. Located on First Avenue in the Kips Bay neighborhood of Manhattan, New York City, Bellevue is famous from many literary, film and television...
in New York City
New York City
New York is the most populous city in the United States and the center of the New York Metropolitan Area, one of the most populous metropolitan areas in the world. New York exerts a significant impact upon global commerce, finance, media, art, fashion, research, technology, education, and...
, Janeway was of the opinion that direct intratracheal insufflation
Insufflation (medicine)
Insufflation is the practice of inhaling a substance. Insufflation has limited medical use, but is a common route of administration with many respiratory drugs used to treat conditions in the lungs and paranasal sinus .The technique is common for many recreational drugs and is also used for some...
of volatile anesthetics would provide improved conditions for otolaryngologic
Otolaryngology
Otolaryngology or ENT is the branch of medicine and surgery that specializes in the diagnosis and treatment of ear, nose, throat, and head and neck disorders....
surgery. With this in mind, he developed a laryngoscope designed for the sole purpose of tracheal intubation. Similar to Jackson's device, Janeway's instrument incorporated a distal light source. Unique however was the inclusion of batteries
Battery (electricity)
An electrical battery is one or more electrochemical cells that convert stored chemical energy into electrical energy. Since the invention of the first battery in 1800 by Alessandro Volta and especially since the technically improved Daniell cell in 1836, batteries have become a common power...
within the handle, a central notch in the blade for maintaining the tracheal tube in the midline of the oropharynx during intubation and a slight curve to the distal tip of the blade to help guide the tube through the glottis. The success of this design led to its subsequent use in other types of surgery. Janeway was thus instrumental in popularizing the widespread use of direct laryngoscopy and tracheal intubation in the practice of anesthesiology.
After World War I
World War I
World War I , which was predominantly called the World War or the Great War from its occurrence until 1939, and the First World War or World War I thereafter, was a major war centred in Europe that began on 28 July 1914 and lasted until 11 November 1918...
, further advances were made in the field of intratracheal anesthesia. Among these were those made by Sir Ivan Whiteside Magill
Ivan Magill
Sir Ivan Whiteside Magill was an Irish born anaesthetist who is famous for his involvement in much of the innovation and development in modern anaesthesia....
(1888–1986). Working at the Queen's Hospital for Facial and Jaw Injuries
Frognal House
Frognal House, in Foots Cray near Sidcup, Greater London, England, was built in the early 18th century.-History:Frognal House was purchased by Thomas Townshend in 1752 and became the residence of his son, Thomas Townshend, 1st Viscount Sydney, after whom Sydney, Australia was named...
in Sidcup
Sidcup
Sidcup is a district in South East London in the London Borough of Bexley and small parts of the district in the London Borough of Greenwich.Located south east of Charing Cross, Sidcup is bordered by the London Boroughs of Greenwich and Bromley and Kent County Council, and whilst now part of...
with plastic surgeon Sir Harold Gillies
Harold Gillies
Sir Harold Delf Gillies was a New Zealand-born, and later London based, otolaryngologist who is widely considered as the father of plastic surgery.-Personal life:Gillies was born in Dunedin, New Zealand...
(1882–1960) and anesthetist E. Stanley Rowbotham (1890–1979), Magill developed the technique of awake blind nasotracheal intubation. Magill devised a new type of angulated forceps (the Magill forceps) that are still used today to facilitate nasotracheal intubation in a manner that is little changed from Magill's original technique. Other devices invented by Magill include the Magill laryngoscope blade, as well as several apparati for the administration of volatile anesthetic agents. The Magill curve of an endotracheal tube is also named for Magill.
Sir Robert Reynolds Macintosh
Robert Reynolds Macintosh
Sir Robert Reynolds Macintosh was a New Zealand-born anaesthetist. He was the first Professor of Anaesthetics outside United States.-Early life:...
(1897–1989) also achieved significant advances in techniques for tracheal intubation when he introduced his new curved laryngoscope blade in 1943. The Macintosh blade remains to this day the most widely used laryngoscope blade for orotracheal intubation. In 1949, Macintosh published a case report describing the novel use of a gum elastic urinary catheter as an endotracheal tube introducer to facilitate difficult tracheal intubation. Inspired by Macintosh's report, P. Hex Venn (who was at that time the anesthetic advisor to the British firm Eschmann Brothers & Walsh, Ltd.) set about developing an endotracheal tube introducer based on this concept. Venn's design was accepted in March 1973, and what became known as the Eschmann endotracheal tube introducer went into production later that year. The material of Venn's design was different from that of a gum elastic bougie in that it had two layers: a core of tube woven from polyester
Polyester
Polyester is a category of polymers which contain the ester functional group in their main chain. Although there are many polyesters, the term "polyester" as a specific material most commonly refers to polyethylene terephthalate...
threads and an outer resin
Resin
Resin in the most specific use of the term is a hydrocarbon secretion of many plants, particularly coniferous trees. Resins are valued for their chemical properties and associated uses, such as the production of varnishes, adhesives, and food glazing agents; as an important source of raw materials...
layer. This provided more stiffness but maintained the flexibility and the slippery surface. Other differences were the length (the new introducer was 60 cm (23.6 in), which is much longer than the gum elastic bougie) and the presence of a 35° curved tip, permitting it to be steered around obstacles. The concept of using a stylet for replacing or exchanging orotracheal tubes was introduced by Finucane and Kupshik in 1978, using a central venous catheter
Central venous catheter
In medicine, a central venous catheter is a catheter placed into a large vein in the neck , chest or groin...
.
21st century
The 20th century saw the transformation of the practices of tracheotomy, endoscopy and non-surgical tracheal intubation from rarely employed procedures to essential components of the practices of anesthesia, critical care medicine, emergency medicineEmergency medicine
Emergency medicine is a medical specialty in which physicians care for patients with acute illnesses or injuries which require immediate medical attention. While not usually providing long-term or continuing care, emergency medicine physicians diagnose a variety of illnesses and undertake acute...
, gastroenterology
Gastroenterology
Gastroenterology is the branch of medicine whereby the digestive system and its disorders are studied. The name is a combination of three Ancient Greek words gaster , enteron , and logos...
, pulmonology and surgery. The "digital revolution"
Information Age
The Information Age, also commonly known as the Computer Age or Digital Age, is an idea that the current age will be characterized by the ability of individuals to transfer information freely, and to have instant access to knowledge that would have been difficult or impossible to find previously...
of the 21st century has brought newer technology to the art and science of tracheal intubation. Several manufacturers have developed video laryngoscopes which employ digital technology such as the CMOS
CMOS
Complementary metal–oxide–semiconductor is a technology for constructing integrated circuits. CMOS technology is used in microprocessors, microcontrollers, static RAM, and other digital logic circuits...
active pixel sensor
Active pixel sensor
An active-pixel sensor is an image sensor consisting of an integrated circuit containing an array of pixel sensors, each pixel containing a photodetector and an active amplifier. There are many types of active pixel sensors including the CMOS APS used most commonly in cell phone cameras, web...
(CMOS APS) to generate a view of the glottis so that the trachea may be intubated. The Glidescope video laryngoscope is one example of such a device.
See also
- History of anatomyHistory of anatomyThe development of anatomy as a science extends from the earliest examinations of sacrificial victims to the sophisticated analyses of the body performed by modern scientists. It has been characterized, over time, by a continually developing understanding of the functions of organs and structures...
- History of general anesthesiaHistory of general anesthesiaAttempts at producing a state of general anesthesia can be traced throughout recorded history in the writings of the ancient Sumerians, Babylonians, Assyrians, Egyptians, Greeks, Romans, Indians, and Chinese...
- History of medicineHistory of medicineAll human societies have medical beliefs that provide explanations for birth, death, and disease. Throughout history, illness has been attributed to witchcraft, demons, astral influence, or the will of the gods...
- History of surgeryHistory of surgerySurgery is the branch of medicine that deals with the physical manipulation of a bodily structure to diagnose, prevent, or cure an ailment. Ambroise Paré, a 16th century French surgeon, stated that there were to perform surgery: "To eliminate that which is superfluous, restore that which has been...
External links
- Videos of direct laryngoscopy recorded with the Airway Cam (TM) imaging system
- Examples of some devices for facilitation of tracheal intubation
- Diagram of performance of the Sellick maneuver
- The CRIC™ Cricothyrotomy System from Pyng Medical Corporation
- The Rüsch QuickTrach® from Teleflex Medical Corporation
- The Portex® Cricothyroidotomy Kit (PCK)
- The Melker Emergency Cricothyrotomy Catheter Tray