Tracheotomy without the 
Cannula. 
THOMAS ADDIS EMMET, M. D., 
SURGEON TO THE WOMAN’S HOSPITAL. 
BY 
REPRINTED FROM 
Nrto ¥ortt ptettica! Journal 
for June 2, 188 S. Reprinted from the New YorTc Medical Journal 
for fine 2, 1888. 
TRACHEOTOMY WITHOUT THE CANNULA. 
By THOMAS ADDIS EMMET, M. D., 
SURGEON TO THE WOMAN’S HOSPITAL. 
The patient would be spared great discomfort after the 
operation of tracheotomy if the use of the tube could be 
dispensed with; moreover, a source of irritation would be 
removed which by its presence retards the healing process 
and increases the danger from blood-poisoning. 
My thoughts have been recently directed into an old 
channel by reading the medical reports issued from time to 
time on the condition of the Emperor of Germany. It has 
been evident that the instrument in his case has been a 
constant cause of discomfort while in place, and the usual 
difficulty attending its insertion or change has been expe- 
rienced. 
This subject has not come within the scope of the line 
of practice with which the greater part of my life has been 
identified, but in earlier years my experience with the opera- 
tion of tracheotomy was unusually great. One of my first 
literary contributions to the profession was an article on 
“ (Edema Glottidis resulting from Typhus Fever,” which 
was published in the “American Journal of the Medical 
Sciences,” July, 1856. I was directly or indirectly the 
means of saving the lives of some twenty persons by per- TRACHEOTOMY WITHOUT THE CANNULA. 
forming tracheotomy where passive oedema of the glottis 
had taken place. 
At a later period I saved the lives of two children, now 
grown, on whom I operated for membranous croup. One of 
the first difficulties I experienced was in the management of 
the cannula. In the treatment of some of the adult patients 
I dispensed with the use of the tube entirely, and kept the 
wound open by means of a thick lead wire passing around 
the neck. This could be bent to avoid pressure on the 
vessels, and, through a hole in each end of the wire, a silk 
suture was secured, which had been passed through the skin 
and edge of the tracheal wound on each side, and thus the 
opening was kept patulous. 
With both children I used a long silver wire, passed 
through the skin and trachea, which was so adjusted and 
twisted sufficiently as to turn the edges of the skin over 
into close contact with the edge of the opening in the 
trachea. To avoid making pressure on the vessels, I placed 
on each side of the neck two corks into which 1 had made 
deep cuts to imbed the wire, and, after making the neces- 
sary traction to separate the sides of the wound, the ends 
of the wires were twisted together behind the neck. 
A great improvement has doubtless been made in the 
cannula since the treatment of these cases, but the instru- 
ment can never be so perfected that its presence in the tra- 
chea will cause no irritation. 
The strip of muscular tissue which is inserted, as it were, 
in the posterior wall along the line of the long axis of the 
trachea and between the ends of the cartilaginous rings, is 
exceedingly sensitive to the touch of a foreign body. Mus- 
cular contraction can be excited, and often a paroxysm of 
coughing brought on by the pressure of a probe. AVhen 
this contraction is brought about, the diameter of the trachea 
must be proportionately diminished, Through the action TRACHEOTOMY WITHOUT THE CANNULA. 
3 
of the reflex system the irritation must be transmitted to 
the minutest bronchi, so that the capacity of the air-passages 
becomes greatly lessened as a consequence. Until the wound 
has healed, it is impossible to prevent the discharges from 
its surface entering the trachea. The healing process is 
retarded and the discharge is greatly increased from the 
irritation of the tube, while its introduction is always at- 
tended with difficulty, and with more or less damage to the 
soft parts. 
I believe that it will prove good surgery and a compara- 
tively easy matter to obtain early union between the edges 
of the skin and the lining membrane of the trachea, and at 
the same time to preserve the necessary opening into the 
air-passage. This assertion is based upon my experience 
in treating diseases of the bladder and urethra in the female, 
where it is now easy to establish a permanent opening for 
drainage in chronic cystitis, and in making the “ button- 
hole ” opening in the urethra, by uniting with interrupted 
sutures the mucous membrane of the bladder or of the ure- 
thra with the mucous membrane of the vagina. If an early 
union can be obtained in such friable tissue, so prone to in- 
flammatory action, and with a constant stream of urine 
flowing over the parts, we may infer that the skin can be 
made to unite around the opening in the trachea with even 
less difficulty. An oval opening should be made in the 
trachea by removing a small portion of tissue on each side, 
and this can be readily done by the aid of a tenaculum and 
a pair of curved scissors. A fine needle, about half an inch 
in length—such a one as I employ for operations about the 
bladder and urethra—would answer for the introduction of 
the interrupted sutures around the opening in the trachea. 
The first suture should be introduced about the middle of 
the wound on each side, and the others in turn toward each 
end, using about five to the inch. After they have all been 4 
TRACHEOTOMY WITHOUT THE CANNULA. 
secured, there would, necessarily remain at each end a fold 
or pucker, since the opening in the skin would he much 
greater than the one in the trachea. This line should also 
be closed by fine interrupted sutures, but it would, be neces- 
sary to include more of the deeper tissues than would, he 
advisable where union of the skin and mucous membrane 
was desired. A fine silver wire should be used, and this 
may be introduced, by means of a short silk loop attached 
to the needle. A metallic suture for a case of this kind 
would be preferable to silk, as it would not excite a local 
inflammation by being retained an indefinite time. It could 
also be utilized, by being bent, to act as a splint in giving- 
form to the flap, and the discharges would not follow its 
course, by capillary attraction, to enter the trachea. 
After twisting the wire sutures just sufficiently to bring 
the parts together, each should be cut off about an inch in 
length. If properly laid down, they will radiate, as it were, 
from a common center and lie flat, without producing any 
irritation. 
The success of the operation will necessarily depend on 
the dexterity of the operator in being able to catch up the 
skin and subcutaneous tissue so that it will slide over the 
raw surface, and thus turn in the edge of the skin in close 
approximation to the edge of the tracheal mucous mem- 
brane. After operating on the children I was surprised at 
the time when noticing the rapid healing of the edges in 
comparison with other cases. Only a single stitch was used 
on each side, but even this was sufficient to cover in a great 
portion of the surface which would otherwise have been left 
to heal by granulation. 
If the details attending the introduction of these sutures 
are properly carried out, with the necessary care which should 
be employed in closing any wound, union should promptly 
take place, and in the shortest possible time. A portion of TRACHEOTOMY WITHOUT THE CANNULA. 
5 
the line in direct contact with the edge of the skin and 
trachea may possibly, have to heal by cicatrization, but it 
would be very limited, and the surgeon could readily keep 
the granulations in check. The procedure as proposed 
would certainly reduce the cicatrizing surface to the mini- 
mum. 
If only the skin, and not the deeper tissues, is brought 
together, the smallest diameter of the passage would be at 
the entrance to the trachea, and this diameter could not be 
encroached upon from without. If the union by cicatrization 
should be as limited in extent as is maintained, the trachea 
will be left far more movable than under ordinary circum- 
stances where the parts have been healed by granulation. 
The small portion of the tracheal tissue which it seems ad- 
visable to remove from the edge will offer no obstacle to the 
final closure, but the opening would remain a mere slit, which 
could be securely covered by denuding an elliptical surface 
on the skin, which would be brought together in a fold 
over it.