Top: Incision for inferior tracheotomy

Bottom: Tracheal anatomy and surrounding structures

In diphtheria patients with a significant formation of leathery pseudo-membrane, providing a way to breathe is paramount. Since the putrid pus that hardened into the membrane would be pushed into the bronchi if regular intubation was used, a technique that allowed air in below the upper pharynx (where most of the membrane formed) was needed. The concept of the tracheotomy has been around for hundreds of years, but it wasn’t until the 18th century that more than a handful of patients survived the procedure when it came to diphtheria and other membranous croups. Well, if you consider 25% to be “more than a handful”.

By the point a patient would need a tracheotomy, the procedure would need to be done quickly and accurately, but because of the relative size of veins, arteries, nerves, and tendons surrounding a child’s trachea, it would be incredibly difficult to do this successfully. However, once the medical schools began teaching this as a standard procedure in the mid-1800s, the success rate (meaning the survival of the patient, not just the procedure being done correctly) increased to around 45%. Given how sick someone with advanced pseudo-membranous laryngeal diphtheria is, that’s not bad at all.

Atlas and Epitome of Operative Surgery. Otto Zuckerkandel, translated by J. Chalmers DaCosta, 1902.

A Treatise on Diphtheria including Croup, Tracheotomy, and Intubation. Henry Z. Gill, 1887.