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A brief history of tracheostomy and tracheal

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Article in Intensive Care Medicine · March 2008

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Intensive Care Med (2008) 34:222–228
DOI 10.1007/s00134-007-0931-5 REVIEW

Peter Szmuk
Tiberiu Ezri
A brief history of tracheostomy and tracheal
Shmuel Evron intubation, from the Bronze Age to the Space
Yehudah Roth
Jeffrey Katz Age

Y. Roth the modern era of anesthesiology.

Received: 29 January 2007
Accepted: 9 October 2007
Published online: 13 November 2007
© Springer-Verlag 2007
There is no conflict of interest.
P. Szmuk (u)
University of Texas Southwestern Medical
School and Children’s Medical Center at
Dallas, Department of Anesthesiology,
1935 Motor Street, Dallas 75235, TX, USA
e-mail: pszmuk@gmail.com;
Peter.Szmuk@UTSouthwestern.edu
P. Szmuk · T. Ezri · S. Evron
Members Outcome Research Consortium,
Cleveland OH, USA
T. Ezri · S. Evron
Wolfson Medical Center, Affiliated to
Tel Aviv University, Department of
Anesthesia,
Holon, Israel
Wolfson Medical Center, Affiliated to
Data sources: Review of the liter-
Tel Aviv University, Department of
Otolaryngology, ature. Conclusions: The colorful
and checkered past of tracheostomy
Holon, Israel
and tracheal intubation informs con-
J. Katz temporary understanding of these
University of Texas Medical School at procedures. Often, the decision
Houston, Department of Anesthesiology,
Houston TX, USA
whether to perform a life-saving
tracheostomy or tracheal intubation
has been as important as the technical
ability to perform it. The dawn of
modern airway management owes its
existence to the historical develop-
Abstract Objective: To present ment of increasingly effective airway
a concise history of tracheostomy devices and to regular contributions of
and tracheal intubation for the ap- research into the pathophysiology of
proximately forty centuries from their the upper airway.
earliest description around 2000 BC
until the middle of the twentieth
century, at which time a proliferation Keywords Tracheal intubation ·
of advances marked the beginning of Tracheostomy · History

Twentieth century Irish dramatist and social philosopher
George Bernard Shaw is known for his scathing commen-
tary on the medical profession. In 1906 he satirized the
frequency in medical history with which ideas are lost and
reinvented [1]. No finer illustration of that phenomenon
exists than the history of tracheostomy and tracheal intu-
bation. While the originator of any specific airway man-
agement technique or airway tool may be impossible to
identify, the techniques and tools themselves have recurred
periodically for almost 4,000 years.
One of the earliest suggestions of surgical trache-
ostomy can be inferred from a Bronze Age description of
the healing of a throat incision in Rig Veda, the ancient
Hindu book of medicine that appeared as oral tradition
around 2000 BC [2]. Five centuries later in Egypt, fol-
lowing the work of Imhotep (arguably a father of modern
medicine as well as an architect, poet, priest, judge, and
prime minister), a technique resembling tracheostomy
was first documented in written form. Egyptian physicians
were indeed pioneers in describing procedures such as
cauterization to avoid excessive bleeding while operating,
drainage to cure purulent collections, and tracheostomy to
resolve upper respiratory obstructions [3].
Much later in Greece, Hippocrates (460–380 BC)
(Fig. 1) described intubation of the trachea of humans to
support ventilation. Alexander the Great (356–323 BC)
reportedly used his sword to cut open the trachea of
a soldier suffocating from an aspirated bone [2]. The
Talmud, a compendium of Judaic law, ethics, customs,
and history promulgated between 200 BC and 400 AD,

Fig. 1 Hippocrates of Kos (460–380 BC) (engraving by Peter Paul Fig. 2 Andreas Vesalius (1514–1564) (portrait from the Fabrica)
Rubens, 1638; courtesy of the National Library of Medicine)
contains descriptions of inserting a reed through the tra-
chea to assist artificial breathing for newborn humans [4].
The Greek physicians Aesculapius and Aretaeus and the
Roman anatomist Gallenus documented similar opera-
tions. By around 100 BC, tracheostomy may have been
routine [5].
Air movement and the means by which it was achieved
were often perceived as curiosities and have thus con-
tributed to Mr. Shaw’s thesis as being “discovered” at
various times throughout history. In a famous experiment,
Galen (129–199 AD) inflated the lungs of dead animals
via the trachea with a bellows and concluded that air
movement caused chest “arises”. The full significance of
that finding was not appreciated, however, and research
on ventilation did not advance any further for centuries.
In the next triumph of airway experimentation, Muslim
philosopher and physician Avicenna (980–1037 AD)
described intubation of the trachea using “a cannula of
gold or silver”.
For the ensuing centuries of the Middle Ages, history
is for the most part silent on the airway procedure. In a rare
mention in the thirteenth century, tracheostomy is termed
223
a “semi-slaughter and a scandal of surgery” [9]. This
description would certainly explain the contemporaneous
demise of its use.
It was not until the height of the Renaissance that
tracheostomy reappeared as a viable medical solution,
when, in parallel with the arts and other sciences, medicine
too began to flourish. Efforts to manage the human air-
way regained prominence, and many descriptions of
tracheostomy can be found. In 1543, for example, at the
same time Copernicus was challenging Church doctrine
by claiming that the earth revolved around the sun, the
Flemish anatomist Andreas Vesalius (Fig. 2) in Padua
published De Humani Corporis Fabrica (On the Fabric of
the Human Body), revolutionizing the science of human
anatomy. That same year Vesalius passed a reed into
the trachea of a dying animal whose thorax had been
opened, and maintained ventilation by blowing into the
reed intermittently [10]. This activity, he wrote, caused
the lungs to expand and the heart to recover its normal
pulsation: “But that life may in a manner of speaking be
restored to the animal, an opening must be attempted in
the trunk of the trachea, into which a tube or reed or cane
224

Fig. 3 Antonio Musa Brasavola (1490–1554), an Italian physician,

performed the first documented case of a successful tracheotomy.
He published his account in 1546. The patient, who suffered from
a laryngeal abscess, recovered from the surgical procedure (courtesy
of the National Library of Medicine)

Fig. 4 Engraving, Armamentarium chirurgicum bipartitum, 1666

should be put; you will then blow into this, so that the lung shown in this engraving depict the tracheotomy procedure. Between
may rise again and the animal take in air”.
Shortly thereafter, in 1546, the Italian physician
Antonio Brasavola (Fig. 3) reintroduced tracheostomy in
humans [2] by performing the first documented case of
a successful tracheostomy (Fig. 4) in a patient with tonsil-
lar obstruction.
These instances did not stand alone. Other Renais-
sance medical personalities emphasized the importance
of “opening the airway” in saving victims’ lives [11, 12].
Fabricius of Aquapendente (1537–1619), an Italian
anatomist, wrote this historic statement: “Of all the
surgical operations which are performed in man . . . the
foremost [is] that by which man is recalled from a quick
death to a sudden repossession of life . . . the operation
is the opening of the aspera arteria [“artery of air”], by
which patients, from a condition of almost suffocating
obstruction to respiration, suddenly regain consciousness,
and draw that vital ether, the air, so necessary to life,
and again resume an existence which had been all but
annihilated”.
In 1620, as the Mayflower was landing the Pilgrims
on Plymouth Rock in America, a book on tracheotomy
was published by Parisian Nicholas Habicot. In it, Habicot
(courtesy of the National Library of Medicine). The first five images
1500 and 1833, there are reports of only 28 successful tracheotomies
recounts a case of a 14-year-old patient who swallowed
a bag of gold coins to prevent their theft. The bag caused
upper airway obstruction, which was resolved by prompt
tracheotomy. Another heroic account in Habicot’s book
describes a boy who was pronounced dead from stab
wounds to the neck. Following emergent tracheotomy and
release of a tracheal blood clot, the boy was fully resus-
citated. In possibly the most dramatic story, a convicted
thief sentenced to be hanged hired a surgeon to perform
a pre-gallows tracheostomy and to insert an elongated
tube for respiration. The condemned man managed to
conceal this ingenious preparation from his jailers, but to
no avail. Notwithstanding the tracheostomy’s potential for
protecting the man from suffocation, it could not save him
from a broken neck.
In October 1667, tracheostomy, “discovered” yet again,
was performed on a dog at a Royal Society meeting by
Robert Hooke (1635–1703), who preserved the canine’s
life by breathing for it by means of a bellows. Hooke even

removed the thoracic cage and demonstrated that a con-
tinuous stream of blood-altering “fresh air,” and not mere
movement of the lungs as had been supposed, was essential
to life [9].
Although Benjamin Pugh, an English obstetrician,
described an air-pipe for neonatal resuscitation in 1754,
the first endotracheal intubations were utilized for resus-
citation of drowning victims and for those suffering from
laryngeal diphtheria [13]. Great advances in resuscitation
were made by societies created in Amsterdam, Paris,
London, Venice, and Philadelphia to rescue drowning
victims from the water. In 1760 Buchan described the
first use of an opening in the patient’s “windpipe” during
resuscitation [2]. Cullen suggested the use of tracheal
intubation and ventilation with bellows for reviving the
apparently dead [2]. Subsequently, Curry developed
intralaryngeal cannulae for resuscitation [2].
In 1788 Charles Kite first used endotracheal tubes in re-
suscitation of drowned persons and described their use by
either the oral or nasal route [14]. Kite wrote: “If any diffi-
culty should arise in distending the lungs . . . we shall gen-
erally remedy the inconvenience by bringing the tongue
forwards, which being connected to the epiglottis by in-
elastic ligaments, must of course be elevated. Should any
further impediment however occur, the crooked tube, bent
like a male catheter . . . should be introduced into the glot-
tis, through the mouth or one nostril; the end should be
connected to a blow pipe . . .”.
On 18 April l774, Cogan and Harwes founded a Lon-
don rescue society with the somewhat unwieldy name of
“The Institution for Affording Immediate Relief to Per-
sons Apparently Dead from Drowning” which was later
chartered as the Royal Humane Society. Cogan and Hawes
emphasized that tracheal intubation was more efficient for
survival than mouth-to-mouth ventilation [9].
In the late 1700s, Chaussier (1746–1828), a gynecolo-
gist working in a maternity hospital in Paris, performed
translaryngeal intubation with self-made tubes in neonates
with obstructed airways [15] and was the first to administer
oxygen to newborns.
Working in the same field in the first half of the nine-
teenth century, John Snow (1813–1858) of England resus-
citated a baby with a tracheal catheter [16]. Snow holds
the dubious distinction of being the first to employ tra-
cheostomy to give anesthesia to a rabbit. He performed the
same experiment described by Vesalius (l543) and Hooke
(1667), except for the addition of the anesthetic agent.
Regardless of “discoveries” and advances made in
airway management through the ages, implementation by
practitioners was erratic. The decision whether or not to
undertake a procedure such as tracheostomy or tracheal
intubation was often as critical as the technical ability to
perform it successfully. In Virginia in December 1799,
for example, the first President of the United States of
America, only 3 years after his retirement, lay struggling
to breathe [17]: “It was a frigid afternoon that day in
225
Virginia, December 1799, as three physicians gathered
around a dying man. The man kept shifting his position as
he gasped for air. The physicians gave the man sage tea
with vinegar to gargle, but it nearly caused the patient to
choke to death. It was obvious the patient’s airway was
severely compromised, but poultices did little to help”.
One of the physicians present at the scene was aware of
tracheostomy but was disinclined to perform it, especially
on such an important personage, because he believed the
procedure to be futile. As a result, George Washington
died from fully preventable suffocation due to an upper
airway obstruction caused by bacterial epiglottitis.
In support of reluctant practitioners of the age, it is true
that airway management and ventilation techniques had
been subject to criticism. For example, although positive
pressure ventilation using bellows was first used for
drowning victims in the 1700s, concerns soon arose that
such therapy could in fact be harmful to the lungs [22].
In 1827 Leroy demonstrated that vigorous bellows ven-
tilation of drowned dogs could cause emphysema and
fatal pneumothorax [23–25]. The French Academy
quickly abandoned the technique of bellows ventilation,
and the Royal Humane Society soon followed [26]. Posi-
tive pressure ventilation was thus banned from common
use, and would not seriously emerge as a contender to
other techniques for more than a hundred years. Despite
this considerable setback, tracheostomy and tracheal
intubation continued to be performed and their techniques
improved in the following decades, especially for acute
airway management.
In 1833, the Frenchman Trousseau routinely performed
tracheostomy when required, and thereby saved the lives of
200 individuals suffering from diphtheria [5]. At that time,
tracheostomy was otherwise done in emergency settings
only. In view of Trousseau’s achievements 170 years ago,
it is remarkable that patients still die today because of the
failure to take steps to open an obstructed airway.
Throughout this history, or possibly despite it, the
practice of anesthesia continued to mature. It is widely
held that general anesthesia was first employed by Craw-
ford Long in Georgia on 30 March 1842. An account of
the achievement, however, was not published until 1849.
In the intervening years, on 30 September 1846, William
Morton gave the first successful public demonstration
of ether as an inhalation anesthetic at Massachusetts
General Hospital [18]. Because the ether anesthesia was
light and preserved the patient’s cough and swallowing
reflexes, Morton reported no concern with taking care of
the airway.
Applying the techniques of tracheostomy developed
by John Snow in animals, the German Trendelenburg
(1844–1924) manufactured the first cuffed tracheostomy
tube in 1869, and administered the first endotracheal
anesthesia in man in early 1871 [15]. In 1901 this first
tracheostomy tube cuff was dubbed “Trendelenburg’s
tampon” [18].
226
Tracheal intubation was greatly helped by the works
of the Scottish surgeon William Macewen and Joseph
O’Dwyer in the second part of the nineteenth century [10].
Along with many accomplishments in the surgical field,
Macewen is credited with the first elective use of endo-
tracheal intubation for an anesthetic [10, 16]. In 1878,
preparing for the resection of an oral tumor, Macewen
performed an awake, digital, blind intubation under
chloroform anesthesia [3]. His apparent goals were to
provide an uninterrupted smooth supply of anesthetic,
and to avoid aspiration of blood into the airways [6, 10].
Macewen was also the first to introduce packing of the
superior aperture of the larynx to avoid contamination
of the airway with blood, secretions, and debris from the
surgical site.
In 1885, after witnessing the mutilating effect of hasty
tracheostomies, Joseph O’Dwyer, an American pediatri-
cian and obstetrician, developed a series of metal tracheal
tubes he inserted orally between the vocal cords in patients
who had diphtheria and needed surgery [10] (Fig. 5). The
tubes were also of value in stenosis of the larynx caused
by various other diseases, such as syphilis, and to stric-
tures of the larynx, especially the consequence of burns
or scalds. His intubation method, also called the O’Dwyer
method, was first published in the New York Medical Jour-
nal as “Intubation of the Larynx” in 1888. In the same year,
O’Dwyer successfully intubated and artificially ventilated
patients undergoing thoracic surgery [15].
At the end of the nineteenth century, the German sur-
geon Franz Kuhn constructed metal tubes that he inserted
orally with a digital, blind technique [10]. Kuhn described
the use of a curved tube introducer. He preferred packing
the hypopharynx with gauze instead of using cuffed tubes
for prevention of aspiration [10]. Kuhn also published the
first paper on nasal intubation [10]. He felt that a nasal
Fig. 5 Craig Gelfand, “Dr. Joseph
O’Dwyer (1841–1898) and his
intubation tube”, Caduceus 1987;
3,2:1–35. a O’Dwyer performing
a tracheostomy. b A series of
metal tracheal tubes developed by
O’Dwyer for use in patients who
had diphtheria
tube “lies better” and leaves the mouth clear of impedi-
ments to operation. Kuhn was the first to realize that an
unblunted surgical stimulus may easily lead to spasm of
the larynx. He believed that “cocainization” of the larynx
was a helpful adjunct to intubation, and he frequently used
it. This technique was further developed by Magill in Eng-
land [10, 14]. Kuhn’s efforts were probably the first histor-
ical steps toward awake tracheal intubation under topical
anesthesia, a technique frequently used today in patients
with difficult airways.
In other innovations of the same era, the Americans
Guedel and Waters were among the first to attach an inflat-
able cuff to a tracheal tube [18, 19]. In 1909, Meltzer and
Auer in Germany described insufflation anesthesia in ani-
mals, and Kelly applied the technique to humans in Eng-
land in 1912 [10, 14].
Sir Ivan Whiteside Magill (1888–1986), mentioned
above, realized that reconstructive surgeries performed
on mutilated soldiers were more successful under general
anesthesia with the airway secured by endotracheal
tubes. In consequence, during World War I, Magill and
Rowbotham performed several endotracheal intubations
and administered endotracheal anesthesia for patients
suffering from severe facial injuries [20, 21]. They also
developed a forceps useful for nasal intubation (the “Mag-
ill forceps”) and, in 1928, introduced the term “blind”
intubation by performing nasal intubation with rubber
tubes, following cocainization of the airway [10, 14].
These various innovations marked Magill as one of the
pioneers of modern endotracheal anesthesia and helped
to transform anesthesia into the independent medical
specialty it is today.
The next giant step in the progress of airway manage-
ment was the relatively recent discovery of the importance
of lung isolation. It was not until 1930 – a year that saw
 227

the completion of New York’s Empire State Building
and the success of Hollywood’s All Quiet on the Western
Front – that techniques and devices for lung isolation
emerged. American Ralph Waters is credited with devel-
oping one-lung intubation to facilitate thoracic surgery.
Initially it was performed with double-cuffed, single-
lumen tubes invented by Gale, Waters and Guedel [5, 19].
Both Gebauer in 1939 [28] and Eric Carlens in Sweden in
1948 [29] proposed similar designs for early double-lumen
bronchial tubes for separation of the lungs. Only in 1962
did Robertshaw develop the first double-lumen tubes of
the modern era [30].
While lung isolation was a significant breakthrough,
possibly the biggest aids to successful endotracheal intu-
bation were the development of laryngoscopy and the con-
tinuous improvement of laryngoscopes. Their foundations
had existed in primitive form for some time. The first tools
used for visualization of the oral cavity were based either
on a reflective metallic spatula (Leveret in 1743) or an ex-
ternal light source, such as sunlight or a candle [31]. In-
direct laryngoscopy was first described in 1855 by Garcia,
a singing teacher in England [9]. By using sunlight and
two mirrors, Garcia was able to see his own moving vocal
cords.
Direct laryngoscopy was first performed in 1895 by
Alfred Kirstein [16, 32]. His “autoscope” had an external
electrical light source. In 1913, Chevalier Jackson [10] of
Philadelphia designed a laryngoscope that was later modi-
fied by Magill, Miller and Macintosh [16, 30]. Jackson was
the first to describe tracheal intubation under direct laryn-
goscopy [32].
Thus the genesis of direct laryngoscopy is attributed
primarily to surgeons. Among anesthesiologists, direct
laryngoscopy was popularized by Henry Harrington
Janeway in New York in 1913 [32]. He designed a battery-
powered laryngoscope, solely dedicated for tracheal
intubation. Sir Robert Macintosh (1897–1989) introduced
the eponymous Macintosh curved laryngoscopic blade
that has been in use since 1943 [16].
Endotracheal intubation came into routine use after the
introduction of muscle relaxants into anesthesia practice.
Curare and artificial ventilation were first employed in
animal treatment and experimentation by Sir Benjamin
Brodie in England as early as 18l1. More than 100 years
later, Canadian anesthetist Harold Griffith used curare
for the first time in human anesthesia in 1942. Griffith
intubated the trachea in 25 patients, providing abdominal
relaxation for surgery [33].
In the final important breakthrough that set the stage
for the modern era, Kensuke Ikeda of Japan introduced
flexible fiberoptic bronchoscopy into medical practice in
1968 [34]. Fiberoptic bronchoscopy has since taken its
place in the standard anesthetic arsenal as an adjuvant for
management of difficult endotracheal intubations.
As we have seen, the roots of airway management span
almost 4,000 years of human history. During that time,
the development of increasingly effective airway devices,
along with a better understanding of the pathophysiology
of the upper airway, have formed the cornerstones of
modern practice. Today’s appreciation of the value of
tracheostomy and tracheal intubation was prefaced by two
millennia of the intermittent rise and fall of their vogue.
Advances made from antiquity until the middle of the
twentieth century underpin the decrease in anesthetic mor-
tality linked to failed airway management; and they form
the foundation for modern management of the normal and
difficult airway. Perhaps, with full knowledge of these
dramatic strides, even Mr. Shaw might soften the irony
of his observation, “We have not lost faith, but we have
transferred it from God to the medical profession.” [35].
Acknowledgements. We would like to thank Dr. David Zuck, MB,
ChB, FRCA, DA, DHMSA, retired consultant anesthetist, past Presi-
dent of the British History of Anaesthesia Society, and an honorary
member of the Association of Anaesthetists of Great Britain and Ire-
land; and Dr. Henry Hadad, Chief of Anesthesia at the English Hos-
pital, Nazareth, Israel, for the invaluable information they provided
to help us write this brief review. We also thank Camille Lloyd, PhD,
and Liza Farrow-Gillespie for editorial assistance.

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