2. History of Tracheostomy

As mentioned above tracheostomy happens to be a old surgical procedure. Description of this procedure could be seen in old Egyptian tablets dating back to 3600 BC. Asclepiades of Persia has been credited with the first tracheostomy way back in 100 BC. The famous warrior Alexander is known to have performed tracheostomy on his soldier in order to save his life. This happened during one of the drinking binges following a victory. A soldier had aspirated a mutton piece following which started chocking. Alexander the great famously used his sword to open up the neck so that he could start breathing again. Mention about tracheostomy procedure could be found in ancient Hindu texts written in 2000 BC.

Hippocrates (460-377 BC) knew pretty well the disastrous effects of carotid artery injury. He hence criticized the procedure to be too dangerous to be practiced. Aretaeus of Cappadocia (today’s Turkey) condemned this procedure because the infection that followed the procedure was nearly always fatal.

The first properly documented tracheotomy was performed by Antonio Musa Brasavola of Italy in 1546. Ir was performed successfully on a patient who was suffering from laryngeal abscess.

George Martin of Scotland was the first Briton to carry out this procedure successfully. He also recommended the use of double lumen tube. He also documented that the wound closed normally and spontaneously when the tracheostomy tube as withdrawn.

The first tracheostomy in a child was first performed by Caron in 1766. He performed this procedure to remove a foreign body (I.e a bean) from the child’s airway. His pupil Trousseau had performed nearly 200 tracheotomies on children with diphtheria. It was Trousseau who brought legitimacy to this procedure as a life saving one. He was also the first to design a retractor to open up the soft tissue before trachea could be exposed. This dilator is known as Trousseau’s dilator.

This procedure became rather common during the latter half of 19th century. It was usually performed at a high level. This gave rise to may complications like subglottic stenosis etc. It was Jackson in 1921 who standardized the procedure with clear cut documented indications for the surgery.

Lots of literature in 20th century was generated on this topic which centered around recognition of clinical signs of laryngeal obstruction, development of safe surgical technique and after care of the patient.

Galloway 1943 proposed another use for tracheostomy – To clear the airway off its secretions. He commonly performed this surgery on patients with Bulbar polio who suffered from aspiration of their own oral secretions. This turned out to be an eye opener for almost all surgeons. He has identified another use for this procedure.

Carter and Giuseffi advocated this life saving procedure for patients with badly crushed chest. Many patients owe their lives to them because it really tilted the balance of survival in favor of the patient. Many a life could have been saved during the second world war if only this procedure was commonly performed.

Another indication for tracheostomy got evolved fairly late in Scandinavia. In 1952 – 53 there was a polio epidemic there. Bulbar polio was nearly fatal because of respiratory arrest. Tracheostomy was performed in these patients to take control of their airway. Positive pressure ventilation via tracheostome was practiced those days. Norlander advocated early tracheostomy in these patients so that air way could be maintained better and more effectively.

The entire history of tracheostomy could be summarized under three headings:

1. Ancient period – The procedure fraught with many risks. Many surgeons did not undertake this procedure because of sheer fear of losing the patient in the process. This phase covered nearly 3000 years (1500 BC to 1500 AD). Tracheostomy was performed in Greece way back in 3600 BC as evidenced by neck wounds in Egyptian mummies. Rig Veda the Hindu text describes spontaneous healing of tracheostomy wound. Despite the warnings of Hippocrates Antyllus advocated tracheostomy in children with adeno tonsillar hypertrophy (second century AD). He was also the one who suggested that this procedure is best performed between the second and third rings of trachea. 20 years later Galen described the anatomy of larynx in detail.

2. Period of Acceptance – During this phase the entire procedure gained acceptance as a life saving procedure. It was accepted as a last life saving method in certain conditions. It was George Martin who developed a double cannula tracheostomy tube. He suggested that the inner tube can be safely removed and cleaned and reinserted.

3. Period of rationalization – This period started from 1965. The entire procedure got standardized with clear cut indications, ideal surgical procedure to be followed and post operative care that should be provided. It was during this phase that the entire procedure was considered to be an acceptable risk and many surgeons practiced it without hesitation.

    Antonio Musa Brasavola