Waxham (Archives of Ped., Mar., 'OS).
If the case is not one of mixed infec tion all sprays and douches and applica tions to the throat can be abandoned. In case of mixed infection if there is much offensive discharge from the nose and throat a simple non-irritating anti septic solution should be gently used in the nasal cavities with the douche or syringe and in the throat by means of the spray; at the same time giving antitoxin and supporting the patient by stimulants and nourishment. How long should the tube be allowed to remain in the larynx? This will depend upon circumstances en tirely. If there is a considerable amount of membrane in the trachea it must necessarily come away; sometimes it softens down and is expelled through the tube in the form of muco-pus without difficulty, but not infrequently large flakes or patches become loosened and endanger the life of the patient by ob structing the tube. If a too tightly fitting tube has not been used it will fre quently be expelled on the second or third day on account of obstructing mem brane below it and commonly it will not be necessary to replace it. It is always to be feared, however, that the tube may not be expelled when it becomes obstructed. Whenever there is evidence of partially detached membrane below the tube, indi cated by a flapping sound, a peculiar hoarseness of the cough, or by sudden and evident closure of tube during an ex pulsive cough we should at once extract the tube whether it has been in one day or three days or four days, or else remain constantly with the patient in order to extract the tube in case total obstruction occurs and the patient is unable to ex pel it.
In eases where antitoxin has been used it is advisable to extubate after thirty six or forty-eight hours. This is the time when, by the action of the anti toxin, the membrane is being thrown off. It may be necessary to reintubate. J. C. Connell (Brit. Med. Jour., June 5, '97).
The principal indications for removing the tube previous to its final removal are severe discomfort or pain from pressure, especially if the pain be radiating in character, severe attacks of coughing, and sudden stenosis due to the lodgment of membrane in the lumen of the tube.
W. K. Simpson (Med. News, Mar. 19, .98).
Obstruction of Tube.—The attendants should be instructed in case of emer gency if obstruction occurs suddenly to hold the child with the head down shak ing him, while another suddenly and sharply strikes the patient a smart blow upon the chest and back.
Syncope caused by intubation of the glottis should be treated by repeated blows upon the back and prmcordial region, the child being held with the head downward. Poulet (Bull. Gen. de Therap., Nov. S, '96).
In case total obstruction occurs the child will die in a few moments unless the tube can be expelled. Happily these emergencies do not frequently occur. If everything goes smoothly and the patient is taking nourishment well and there has occurred no evidences of obstruction it is my custom to remove the tube on the fourth or fifth day. It will very seldom happen that the tube will be necessary for a longer time, providing the opera tion has been skillfully performed and no damage has been done to the larynx. The shorter time the tube is worn the less likely are we to meet with paralysis of the vocal cords and other conditions that often require its long continued use.
In extracting the tube the patient should be placed in the same position as when it is introduced. The gag should be placed as before and the index finger of the left hand introduced until it reaches the head of the tube. The ex tractor, held in the right hand, should quickly follow the finger, the point of which should be guided into the tube. (Fig. 16.) By pressing on the lever above the handle the jaws of the instru ment are separated, thus holding the tube securely while it is removed.
In a case where attempts at extraction caused a small tube to sink farther down into the larynx, pressure made with the thumb on the trachea, just below the cricoid cartilage, where the cod of the tube could be felt, caused cough, which forced the tube out. This method of ex pression never failed in subsequent cases. The pressure may be made with both thumbs inward and directly upward. If a more powerful pressure is exerted the tube may be forced entirely out of the mouth. Trumpp (Munch. med. Woch., Apr. 2S, '96).