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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. ==Tracheotomy== The earliest known depiction of a tracheotomy is found on two Egyptian tablets dating back to circa 3600 BC.〔 The 110-page Ebers Papyrus, an Egyptian medical papyrus that dates to around 1550 BC, also refers to the tracheotomy.〔〔 Tracheotomy was described in an ancient Indian scripture, the Rigveda: 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 fistulas are those that 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 asphyxiation 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 Indian 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 surgeons. 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 in cases of airway obstruction by foreign bodies or secretions.〔 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" 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 known tracheotomy 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 sequelae.〔 Habicot suggested that the operation might also be effective for patients suffering from inflammation of the larynx. He developed equipment for this surgical procedure that 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 performed to administer 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, antibiotics were widely available and useful for treating postoperative infections and other major complications of tracheotomy had also become more manageable. 抄文引用元・出典: フリー百科事典『 ウィキペディア（Wikipedia）』 ■ウィキペディアで「History of tracheal intubation」の詳細全文を読む スポンサード リンク
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