History of Tracheotomy

The Evolution of the Tracheotomy
Although it may go unnoticed, the tracheotomy has become a live saving procedure for many patients. It consists of making an incision in the trachea, creating an immediate airway or a site for a tracheal tube to be inserted. This tracheal tube allows a person to breathe without the use of their nose or mouth. The tracheotomy is an ancient procedure that dates far back into the history of the world. Both the instruments and techniques used have evolved from a dreaded and fatal procedure into a universally accepted surgery of today.

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The History of the Tracheotomy

The procedure of a tracheotomy is one of the oldest in history. The word tracheotomy comes from two words meaning “I cut trachea” in Greek. However, it has been called various names such as, pharyngotomy, laryngotomy, bronchotomy, tracheostomy, and tracheotomy. Tracheotomies can be used to create a stoma, or hole, enabling a new airway for a person to breathe, or they are used to surgically place a tube in the trachea to allow respiration. When the tracheotomy was first practiced, it was referred to as a bronchotomy.^[1] It developed its name as tracheotomy in 1718 when it was first introduced by German surgeon Lorenz Heister. Although it is a well-known and highly successful procedure today, it was burdened with many complications throughout the centuries.^[2] In general the evolution and adaptation of the tracheostomy has evolved from five different stages: the period of legend, fear, drama, enthusiasm, and rationalization^[3].

The Period of Legend: The Tracheotomy from 1500BC to 1500AD

The first stage of the evolution of the procedure of the Tracheotomy occurred between 1500BC to 100AD and was known as the “period of legend”.^[4] It was first described in The Rig Veda, a Hindi text, around 2000BC as an incision in the windpipe that initiated immediate healing. It was first depicted on Egyptian artifacts in 3600BC. In 460BC Hippocrates discriminated against tracheotomies due to fear of carotid damage. Homer wrote of Alexander the Great saving a soldier from suffocating in 1000BC by making an incision with the tip of his sword in the man’s trachea. In 100 AD Antyllus depicted the first tracheotomy as a “horizontal incision between 2 tracheal rings to bypass upper airway obstruction”.^[5] Later, in 131 AD Galen clarified the anatomy of the trachea. He was the first man to discover that the larynx produces the voice.

The Period of Fear: The Tracheotomy from 460BC to 1500AD

In 460BC Hippocrates initiated the “period of fear” ranging from about 400AD to 1500AD by denouncing tracheotomies because he feared the risk of damaging the carotid artery.^[6] He was paranoid of the probability of death by lacerating the carotid vessels and so he promoted intubations instead. Additionally, because instruments were not well sterilized, infections following surgery produced numerous “complications, increased dyspnoea, cough, and death”.^[7] Despite the argument against them at the time, it is speculated that the first procedural tracheotomy was performed by Asclepiades of Bythinien who lived in Rome in 100AD.

Later, in 200AD Antyllus supported tracheotomy when treating oral diseases and refined the technique. His procedures were the similar to more modernized tracheotomy surgeries. The dated portrait above supports the idea that tracheotomies were performed long ago. The diagram below shows an instruction book used in the early hundreds to perform tracheotomies.

Around 600AD Dante said that a tracheotomy is a “suitable punishment for a sinner in the depths of the inferno.” By 700AD tracheotomies were well known in Indian and Arabian cultures although they were not commonly practiced on humans.^[8] During the European Renaissance, science and surgery improved dramatically. Although the tracheotomy was still a risky operation, surgeons were becoming more and more open to the idea of experimental surgery on the trachea. However, despite numerous suggestions made, there was little to no progress made on the success rate.^[9]

The Period of Drama: The Tracheotomy from 1500 to 1900

Following the “period of fear,” the first modern tracheotomy was performed, despite ethical hesitation from society, in 1546 on a patient suffering from tonsil complication and completely recovered.^[10] Pediatric tracheotomy was unheard of until 1620 when a boy tried to hide a bag of gold by swallowing it. It got stuck in his esophagus and blocked his trachea. The tracheotomy allowed the surgeon to manipulate the bag and it to pass through his system.^[11]

Above is an older depiction of the tracheotomy performed in the seventeenth century. This specific diagram was created in 1666. Sadly, from the period of 1500 to 1833 there are only twenty-eight reports of successful tracheotomies.^[12] Fortunately, although anatomist Heironymus Fabricius ab Aquapendente never actually performed a tracheotomy, his writings from 1537 to 1619 described a highly useful technique. He advised using a vertical cut and a straighter, short cannula that would help keep the tube from dropping too far into the trachea. He counseled that the operation be performed only as the last option.^[13]
Finally, during the “period of drama,” in the 1820s, the tracheotomy became more frequently used. Pierre Bretonneau gave the tracheotomy much of its fame when he credited his successful relief of diphtheria through the use of tracheotomy. After that an increasing amount of surgeons performed tracheotomies but still as their last resort. The issue with performing a tracheotomy at the last chance is that by that point a sufficient amount of damage has been inflicted on the body due to the lack of oxygen. Regardless of the potential of major damage, surgeons continued to postpone it until a tracheotomy was too late to be productive. In the 1850s, Dr. Trousseau, Bretonneay’s student, kept records of all the tracheotomies done at the Hopital des Enfans. Strangely enough, his mortality rate of a 73 percent was claimed to be “very satisfying”.^[14] At last, in 1880 Morrell Mackenzie wrote a book that discussed what symptoms indicate that a tracheotomy must be done and when it is absolutely necessary to perform.^[15] Sadly, even into the twentieth century surgeons debated on various aspects of the procedure. There were many techniques and methods used, along with many types and pieces of equipment. Many surgeons could not agree on where or how the incision should be made on the trachea. They argued whether the “high tracheotomy” or the “low tracheotomy” was more beneficial. Additionally, anesthesia made it even more dangerous and many people died from post-operative complications.

Tracheotomy Established in World of Medicine Today

Entering the 1900s, Chevalier Jackson bettered the procedure by emphasizing post-operative care and dramatically reduced the death rate. In 1909, entering in the “period of enthusiasm,” the uses of tracheotomy expanded to treat paralysis requiring artificial ventilation. Eventually, in 1965 the “period of rationalization” began and the major complications were controlled and tracheotomy became a common and vital procedure in many cases. Recently, the mortality rate has dropped to one to three percent. The surgery has become less complicated to the extent where Intensive Care Units can perform a tracheotomy.^[16]

Tools Utilized for Tracheotomy in the Nineteenth Century and Today

Similar to any other surgery the difficulty of a tracheotomy varies on a case by case basis. Because adults have bigger necks and tracheas it is much simpler to perform a tracheotomy on an adult than a child. Difficulties such as a short neck and bigger thyroid glands make the trachea hard to open.^[17] People with irregular necks, those who are obese, or have “large goiters,” an enlargement of the thyroid gland, should not undergo this procedure. There many problems that can occur with a tracheotomy which include “hemorrhage, loss of airway, subcutaneous emphysema…wound infections, stomal cellulites, fracture of tracheal rings, poor placement of the tracheotomy tube…bronchospasm, and death".^[18] Luckily, the tracheotomy had been greatly simplified and mastered by the 1800s that it could be performed with few instruments. The main tools used were:

“Two small scalpels, on short grooved director, a tenaculum, two aneurism needles which may be used as retractors, one pair of artery forceps, haemostatic forceps, two pairs of dissecting forceps, a pair of scissors, a sharp-pointed tenotome, a pair of tracheal forceps, a tracheal dilator, tracheotomy tubes, ligatures, sponges, a flexible catheter, and feathers”.^[19] Haemostatic forceps were used to control bleeding from separated vessels that were not ligatured due to the urgency of the operation. Generally, they were used to expose the trachea by clamping the isthmus thyroid gland on both sides. To physically open the trachea, a sharp-pointed tentome allowed the surgeon to easily place the ends into the opening of the trachea. The thin points permitted the doctor a better view of his incision. Tracheal dilators, such as the “Golding Bird”, were placed through the opening and then expanded by “turning the screw to which they are attached.” Tracheal forceps, as displayed on the right , were commonly used to extract foreign bodies from the larynx. The optimum tracheal tube at the time caused very little damage to the trachea and “mucus membrane”.^[20]

The best position for a tracheotomy was and still is one that forces the neck into the biggest prominence. Usually, the patient was laid on his back on a table with a cushion placed under his shoulders to prop him up. The arms were restrained to ensure they would not get in the way later.^[21] The tools and techniques used today in tracheotomies have come a long way. The tracheotomy tube placed into the incision through the windpipe comes in various sizes, thus allowing a more comfortable fit and the ability to remove the tube in and out of the throat without disrupting support from a breathing machine. In today’s world general anesthesia is used when performing these surgeries, which makes it much more tolerable for the patient. Special tubes have always been created to assist people in their speech. With these unique speaking tubes, people can breathe and talk through these tubes. When they exhale the air passes through the tube and vocal cords, producing sound. ^[22]
As a whole, the procedure for tracheotomies improved significantly. It is one of the oldest procedures known to man, dating back as far as 1500BC. The concept of the tracheotomy suffered centuries of denial and rejection as well as much failure. Finally, in recent decades, it improved into a commonly accepted practice. Regardless of its age, it is a crucial and successful surgery that has saved the lives of hundreds of thousands of patients and will save many more that are yet to come.

References

Bibliography

• Conley, John J. "Tracheotomy." The American Journal of Nursing 52.9 (1952): 1078-81.
• Cullen, James H.. "An Evaluation of Tracheostomy in Pulmonary Emphysema." Annals of Internal Medicine 58(1963): 953-58.
• Ferlito, Alfio. "Percutaneous Tracheotomy." Acta Oto-Laryngologica 123(2003): 1008-12.
• Holinger, Paul H. "Cancer of the Larynx." The American Journal of Nursing 57.6 (1957): 738-43.
• Holmquist, Emily W. "Nursing the Adult Tracheotomized Patient." The American Journal of Nursing 47.5 (1947): 310-4.
• Lawless, Carolyn A. "Helping Patients with Endotracheal and Tracheostomy Tubes Communicate." The American Journal of Nursing * 75.12 (1975): 2151-3.
• Rajesh, Orl. "Historical Review Of Tracheostomy." Internet Journal of Ophthalmology & Visual Science 4,22006 1-5. 17 Oct 2007
• Wharton, Henry R. Minor Surgery and Bandaging. 3. New York: Lea Brothers & Co., 1896.