Ernest Watson Cushing.

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the vomiting diminished but

these changes he lost flesh raf

jections, so the mother stated, v

ly green and at times contain(

Her observations were probab

frequently, was green or yello)

yellow. The child slept well a

He was brought to the Out-I
Hospital May 6, 1898. He ^
jaundice must have appeared, t
weeks old. He was poorly
fontanelle was level. The tong
was deep jaundice of the skin
negative. The abdomen was ra
of fluid. The superficial veins
slightly enlarged, the surface i
tip of the spleen was just palpa
and a left inguinal hernia, botl
brownish and stained the diapei
smooth, clay-colored, very foul i
The temperature was normal.

Icterus neonatorum was rulec
jaundice, the presence of bile ii
and the digestive disturbanc(
Winckel's Disease and AVcil's
absence of a source of infection
clay-colored stools, the normal
Syphilitic hepatitis was exclud
history and of other evidences
symptoms of portal obstructioi



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REPORTS OF CLINICAL CASES. 329

out because of the small size of the spleen and the "absence of signs
of portal obstruction. This left as the cause of the trouble some
obstruction of the common bile duct. Congenital absence of the
bile ducts was ruled out on the late appearance of the jaundice
and the fact that the jaundice was preceded by marked digestive
symptoms. Stone in the common duct was ruled out by the early
onset of the symptoms of indigestion and by the absence of any
attack of pain. Thus by a process of exclusion a diagnosis of
catarrhal jaundice, or duodenal indigestion, was reached. In
fact, the history and physical examination are characteristic of
this condition. The unusual point is the early age of the patient.

Calomel and small doses of brandy were ordered. He was also
ordered a modified milk, containing the lowest percentage of fat
with a low percentage of sugar and a high percentage of proteids.
The alkalinity was 20 per cent and ten feedings of two ounces
were to be given in twenty-four hours.

The child was not brought back to the hospital. He was locked
lip at his home, however, on May twenty-seventh. The treatment
prescribed had not been followed, but they had at once called in
an outside physician. He had put the child on Horlick^s Malted
Mk, apparently about as unsuitable a food for this condition as
could have been found. Nevertheless, the child had improved
greatly and the jaundice had nearly disappeared.

•^17 Marlboro Street, Boston.



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830 E]



THE DURATION (
THERIA CASI
RUM TREAT]^

Director of i
Translated from the Ge:

EDI

Aural Surgeon to the Ca
Massachusetts Ohari
to the Long Island I
of the Massachusettfi

As regards the durg
have hitherto written 1
importance to detenni:
to estimate its minimiii
cessf 111 cases. For with
percentage of recoveric
with intubation. Moi
general method of est
wearing: tlie tube may
intubated diphtheria c
al?o obtain, of course,
proper time for the pc
account of the possible

As I performed intu
268 recoveries in all, i
1895, T have determin<
ing questions, and as,
tioned, 90 cases with 4f5
tion of serum-therapy,
question, how does the
tubation in cured cases'

♦Delivered at the ai
derftrzte at Llibeck, in Se

fDnrinsr the space c
formed in this hospital ii



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DUUATION OF INTUBATION IX CURED Dli'HTHERlA. SSI

Before venturing upon a discussion of the questions advanced,
on the ground of my observations, I will insert liere some literary
data more worthy of mention, which bear upon this subject.

Dillon Brown,* O'Dwyer's colleague, places the average mo-
ment for final extubation at 5 days and S^ hours, that is, at 123^
hours.

In the following table, Mount Bleyer compiled his experience
with regard to final extubation, for the Berlin International Con-
gress, held in 1890. Final extubation was performed upon his
189 cured cases:
On the



l8t


da>


in


5


cafies -




2Dd




a


29






8id
3 1-2




i*


37
14




" 79 1-3 i>er cent


4th




»'


48






dth




*(


22






6th




<<


10






7th




ii


13






9tb




-


6






lOth
11th




4i


4
3




► 20 2-8 per cent


16th




-


2


i4




20th




»i


1


case





Mount Bleyer, therefore, performed final extubation within
120 hours in 79 1-3 of his cured cases, and the remaining 20 2-3
per cent wore the tube longer than five times 24 hours.

According to G. Baer,t final extubation, in 30 cases cured in
the Ziirieh Children's Hospital, took place at the following inter-
vals:

The tube was finally removed :



Once


on


the l6t


day





3.2 per


cent.




5 times


a




2nd




^rr:


16.2 "






6 -
3 -


it

ti




3rd
4th




^


19.3 **
9.6 *^




" 64.5 per cent.


6 -


a




5th




^


16.2 ^'






Once


n




6th




=-


3.2 *'


i.




3 times


**




8th




^ir


9.6 ^'


*' 1




2 **


a




9th




=


6.5 **






2 **
Once


a
it




10th
33id







6.5 **
8.2 *'




^ 35.5 per cent.


ti


i*




34th




-=


3.2 **






a


ti




52nd




_^


3.2 '*







*The Medical Record, June and July, 1887.

"KSustav Baer, Tracheotomie und Intubation in Kinderspital Ziirieh,
Inau^iral Essay. Leipzig, 1892.



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*■ 72.6 per cent.



382 EDWARD M. PLUMMER.

In the Ziirich Children's Hospital, therefore, 64 5-10 per cent
of the cured cases were finally extubated within 120 hours, and 35
5-10 per cent, after 120 hours.

Professor v. Ranke,* before the serum-treatment, compiled his
observations as follows: Final extubation was performed:

Within 24 hours in 8 per cent, of cured cases

it 4g i* u 26 ** *' ** •* **

a 72 ** t* 13.5 a . ** *. »* **

ii 96 «i a 20 ** *" ** **
Over 96 ** ** 27.5t** ** ** *» -

In von Eanke's material, therefore, 72. 5 per cent of the cured
cases were permanently extubated within 96 hours.

In conclusion, I would mention that Heubner,:]: according to
his Leipzig experience (25 cured cases), settles the average dura-
tion of intubation before the serum-period, at 100 hours.

The time since the introduction of the serum-treatment has
placed scarcely any literary data relating to this subject, at our
disposal. In 10 intubation cases by Heubner,§ the average pe-
riod in connection with serum-treatment amounted to 37 hours,
in von Ranke's material,^ in the serum-treatment, the tube was
finally removed:

Within 24 hours in 18.5 per cent, of cured casos.

« 48 *< ** 48.1 <* **

it 72 <* << 11.1 ** ** **

« 96 ti <* 10.0 <* ** ^•

Over 96 *• *< 8.7 ** *' *•

Of my 673 intubation cases, performed in the period before
serum-therapy, 223 recovered, that is to say, 33 1-3 per cent. The
duration of intubation in these cured cases amounted to the fol-
lowing:

I hour, ^ hour, 1 hour (2 cases), 1^, 2, 6, 6^, 9, 10 (3 cases),
11, 15 (2 cases), 17^, 18 (2 cases), 27, 28^, 29, 30 (2 cases), 31, 33
(2 cases), 35, 36 (6 cases), 37 (2 cases), 38^, 39 (2 cases), 40, 41
(4 cases), 42 (3 cases), 43 (3 cases), 44 (3 cases), 45 (3 cases), 46
(2 cases), 47 (6 cases), 47|, 48 (6 cases), 49 (2 cases), 50 (2 cases),
51 (3 cases), 52 (3 cases), 53, 53^ (2 cases), 55 (2 cases), 56 (2

♦H. V. Banke, Mflnchener med. Wochenschrift, 1895, No. 8.
tFalsely piven in the article as 36 per cent.

to. Heubner, Kliniache Stndien Clber die Behandhing der T)lph-
therie. Leipzigr, 1895.

§1. c.



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f






DDBATION OF INTUBATION IN CUBED DIPHTHERIA. 333

^ases), 57 (2 eases), 58 (3 cases), 58^, 59, 60 (3 cases), 60^, 62

Hy 68 (4 cases), 64 (3 cases), 64^, 65 (5 cases), 66 ,67, 67|, 68,

H(2 eases), 69, 69^(2 cases), 73^, 74 (2 cases), 75^, [76], 77,78

^^ f^ases), 79, 80, 85, 86, 87i, 88, 90, 91 (2 cases), 92, 92^, 93,

^Oe ^«se8), 95, 96 (3 cases), 96^, 97, 98 (2 cases), 100, 101, 104,

JSq ' C^O^I, 108, 110, 112, 114, 120, 121^, 124, 129 (3 cases);

l^' ^^1 (3 cases), 133 (2 cases), 134, 135, 136, 140, 142, 143,

2i^^* I4r^, 145, 151, 153, 154, 157, 161^ [181], 184, 213, 217,

353' f 2S7], [240], 243, 247, 273 (2 cases), [276], [300], 349,

^>3eo,[400].



tra,



^h,



tla.



ise 223 cases, only 8 required the further operation of



obtaj *-**^^:3niy (the figures in brackets);* if we deduct these, we



i'^^*



'•^'^



't*



\\



€ number of cases which were cured by intubation alone,
^- Al. In these 215 cured cases, intubation lasted:



. 216



to 24 hours in 27 cases ^= 12.65 per cent.



** 48
** 72
'* 96
*' 120
a 144
" 168
** 192
** 216
*' 240



** 56
** 52
<* 29
<* 13
^« 21



:^ 26.04 **

r= 24.18 '*

= 13.50 "

= 6.06 **



. 82.83 per cent.



ov



reV 10 days



u 5 *<

** 1 case

** 2 cases

•' 1 case

•• 7 cases .

Total, 215 cHseK.



y 17.67 per cent.



The minimum duration, therefore, in my cured cases amounted
to I, ^y 1, li, 2, 6, 6^, and 9 hours, the maximum period, 217,
218, 243, 247, 273, 349, 353, and 360 hours.

My more interesting accounts of cases relating to the question
under discussion are as follows.

Case T. — Alexander S., ten years old, admitted Oetolier 9. HI

since October 1, with mild symptoms of faucial diphtheria. On

account of severe attacks of suffocation, he was intubated October

9, at his home in Kerepes, not far from Budapest. At this time

an insular coating of slight extent was visible, on the left tonsil

only. Immediately after intubation, the patient expectorated a

copious purulent substance, which contained a small piece of

croup-membrane. The breathing became perfectly free. A few

♦Of my 673 cases prior to the serum-treatment, T performed aec-
ondary tracheotomy on 25 patients.



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3;i4 EDWARD

minutes later he expectorated
ued sufficiently clear, no reir
was removed to the hospital i
10, the patient breathed per
October 14, the fauces were
On October 15, he left the ho
at home by the parents.) Tl
a quarter of an hour.

Case II. — Kosa K., six ye
Faucial diphtheria since the 1
ing for three days. A small
stenosis. On the 29th, marl
The proper tube immediately
Half an hour later this tube
stenosis moderate, so that nt
the 30th, cough loose, stenos
breathing is unobstructed, the
ber 9, cured. Intubation pei

Case III.— Stefan II., 2^
111 since the 22nd, hoarse, lab
admitted, but very severe ste
to be performed immediately,
ous purulent secretion the bre
ter the expiration of an hour
bation is not necessary. M
Discharged "May 14, cured,
hour.

Cask IV. — Kolonian K., ii

26, 1891. On October 19, tj
breathed with difficulty for
mitted, stenosis severe. At '
is performed. The dyspnoea
At 7 o'clock in the evening,

27, the patient passed the ni
The stenosis moderate. Oc
breathes qnietly. The voice
still slightly impaired, in oth
intubation amounted to one a

Cask V. -Charlotte K., '
1S92. Allesred sore throat f



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DURATION OF INTUBATION IN CURED DIPHTHERIA. 385

theria, moderate stenosis. The stenosis increased considerably
in the afternoon, so that at 6.30 p. m., intubation had to be done.
She expectorated a copious viscid, purulent mucus, and soon after
coughed up the tube also. Reintubation was immediately per-
formed, and the breathing became perfectly clear. Two hours
after she again coughs out the tube. The breathing, however,
remains unimpeded, on that account reintubation is not at-
tempted. On July 3rd, the throat was clean, the breathing free.
On July 10, complete recover^'. Period of intubation, two hours.

Case VI. — Irene T., five years old, admitted on the morning of
January 24, 1892. Ill for two days. Moderate faucial diph-
theria and stenosis of the middle grade. Stenosis gradually in-
creasing until intubation was performed at 5.30 p. m. At 7 o'clock
in the evening she expectorated the tube. Until the 26th she
breathed quite easily without the tube. On the afternoon of the
26th, the stenosis again appeared in a severer degree. In the
evening at 11 o'clock, reintubation necessary. On the morning
of the 27th the patient expectorated the tube. The breathing,
however, was free. Discharged on February 27, cured. The
tube was retained in the trachea 6^ hours.

Care VTT. — Ferdinand A., seven years old, admitted February
2, 1894. Sick for a week. Stridulous breathing for two days.
Moderate diphtheritic process in fauces. Intubation February 2,
forenoon, at 10 o'clock. The breathing becomes perfectly free.
The patient expectorates the tube in the evening at 7 o'clock.
Reintubation no longer necessary. On February 20, paralysis of
the palate appeared. Discharged on the 25th, cured. The tube
was worn nine hours.

Cask YTTI. —Felix St., four years old, admitted February' 27,
1892. TToarseness for nine days. The throat is clean. Moder-
ate stenosis, which increased by evening to such an extent that in-
tubation had to be performed at 9.30 p. m. On February 27, at
9.30 in the forenoon, he expectorated the tube. Keintnbation no
longer necessary. During the course of the disease, scarlet fever
appeared, followed by acute nephritis. Discharged on March 27,
cured. The tube lav in the trachea ten hours.

0a8k TX. — Bertha K., aged H years, admitted August 24,
1890. Dl for three days. Throat clean, breathing decidedly
stenotic. Intubation performed in the afternoon at two o^clock.
After intubation a large mass of tenacious purulent mucus was



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336 EDWARl

ejected. Albuminuria in a
she coughed out the tube.
27th, the patient can alread
of intubation amounted to te

Case X. — Michael T., tw
111 for two days. Middle ^
stenosis. On July 2, the di
such an extent that intubatio
the morning. In the foren
tube by means of the thread
in the evening. On accoui
tion was done at 11 p. m. A
the tube was expectorated,
twelve o'clock in the afternc
he again drew out the tube.
On the 18th, discharged cun
all.

Case XI. — ^Irene Oe., fc
1892. Hoarse for three da
preceding day. Recovered
stenosis is so severe that in
After intubation, a copious
and with it a small piece of <
came perfectly clear. Abui
course of the disease, extu
eighth extubation was the fi
convalescence a retrophar
ruptured spontaneously,
mained in the trachea 349 h

Case XII.— Ludmilla D.
20, 1891. HI for one da]
tonsils, very severe laryngo-
the afternoon. After inl
Dvring the progress of the
tube seven times, extubatic
fore she was intubated sixt(
tembor 5. On September "
in the trachea, with trifling
3f>0 hours.

According to those data, t



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L>URAT10K OF INTUBATION IN CURED DIPHTHERIA. 'iSl

eases CT66), that is, 62.77 per cent, were extubated within 72

hoars; between 72 and 120 hours, 19.56 per cent were extubated;

^ter X iiO hours, 17.67 per cent of my cured cases were still wear-
^g tiiG tube, and final extubation was not performed upon seven
vntil after 240 hours.

If I sum up as a whole, the intubation period of my cured cases
(17, OS Of hours), and divide by the number of cases (215), I ob-
tain trla^ average duration of intubation ; in my material before the
seriEm -treatment, this average amounted to 79 hours. I must
lay s pj^cial stress on the fact, that in the hospital under my direc-
tion tte first attempt at extubation is not made until the expira-
tion of 48 hours (extubation by means of the thread) ; the circum-
8tattc?e^^ that in 12.65 per cent of fny cases the total period of in-
tubatrion did not exceed 24 hours, is explained thus: in these cases,
the x^«.t:ient either expectorated the tube or extubated himself by
meaxi s of the thread, which is always left attached to the tube, and
a nc^-v^i- operative procedure became unnecessary on account of re-
mission xi or cessation of the stenosis.

^f the 90 patients intubated in the serum-period, 45 were
cur^<l ^ that is, 50 per cent. In these cases, the duration of intu-
batio:rx was as follows :

^ >fcOTir, 7 hours, 12 hours, 13, 17, 19, 22, 24, 25 (2 cases), 29,
32, 3 S, 42 (2 cases), 43, 44, 45. 46, 47, 48 (6 cases), 50 (2 cases),
57. «S, 68, 69, 70, 71, 78, 81, 88 (2 cases), 104, 108, 133, 150,
154-^ X60, [183].

'^Ti:^on^ these 45 cured cases secondary tracheotomy was sub-
pe^i'^^^^Titly performed upon one flSS hoursl ;* this single case
(le<*^^<*t-ed, 44 remain treated with intubation alone, in addition to

v^io poriod of intubation in these 44 cured ca^^oi^ amounted to:



1


to


24


hours


in


8


cases —


18.18


per


cent


24




48


a




18


it _


40.90


n




48




72


n




8


a -—


18.18


ii




72




96


'i




4


n ~~


9.09


n




96




120


'i




2


(i _-


4..'?4


•<




120




144


ii




1


case zr-


2.27


a




144




168


n


''


3


cases ^


6.84


a










Total.


44


cases.









•Amon^ my 90 cases occiirrinp in the sernm-period, T performed
-^^ondarv* tracheotomy in fonr cases only.



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388



EDWARD M. PLUMMER.



In this group of my patients, therefore, the minimum of the
duration of intubation amounted to 1 and 7 hours; in the maxi-
mum, to 150, 154 and 160 hours.

The relatively more interesting cases which I treated are the
following:

Case I. — O. S., 14 years old, admil
for five days. Well developed girl,
stenotic breathing. Axilla tempers
Eoux's serum. In the evening incr
At 7 o'clock in the evening, intubatioi
tube is expectorated, simultaneously
pieces of croup-membrane. Breathii
ary 15, the throat affection is better, tl
In the morning at ten o'clock, the dy
to necessitate intubation. At half-pi
tube was expectorated. Severe albu
Roux's serum. On January 16, the t
slio'htly difficult. Amount of albu
January 18, 5 c.c.ni. of senim is adr
continues stridulous. On January \
pcared from the urine, the breathing
eruption of the skin, resembling that oi
fever sym]>toms, but disappeared on 1
slight paralysis of the palate. On ^
of intubation, one hour. 25 c.c.m. E

r^ASE IT. — Three-year-old girl, adni
for three days. Extensive faucial di]
sils. Severe laryngo-stenosis. On a
mediate intubation and injection of "
rum. Several extubations on accour
branes. On the morning of October
child drew^ out the tube. Breathing
therefore no re-intubation. On Octo
Laryngo-stenosis disapy^earing. Xo
14, the breathing clear, throat almost (
of tbe throat still to be felt. On Octo
sw^ollen, fauces clean. The period
seven hours. 2,100 units of Behrin^

Of my cured cases, therefore, 77.5
finallv extubated within 72 houi^s; 1



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M'RATION OF INTUBATION IN CURED DIPHTHERIA. -339

^'^'(i3 per cent of cases were extubated; after 120 hours, 9.11 per
^^t of ixiy cured cases were still intubated.
'^^e data obtained in the period before the serum-treatment
th ^'^^ during the serum-therapy are placed beside each other in
^ ^"^ll owing table:

Before Serum-period. Serum period.
1 >uration of Intuba- Percentage of Percentage of

tion. cured cases. cured cases.

1-4 to 24 hours 12.55 18.18

24 *• 48 - 26.04 40.90

48 ** 72 - 24.18 18.18

72 '' 96 •' 13.50 9.09

96 ** 120 ** 6.06 4.54



V



120 •* 144

144 ** 168

168 ** 192

192 '* 216

216 '* 240



2.27
6.04



17.67



Vv^^



^* table shows plainly that the number of patients extu-
in the serum-period during the first and second 24 hours, in-
^^sed to a marked degree.

The average duration of intubation in this group of my cases
(•2,683 hours, 44 cases) amounted to 61 hours, in contrast to the
79 hours of the period before serum-therapy. Therefore, serum-
treatment reduced the average duration of intubation in my cured
cases about 1 8 hours.

After the enumeration of all these data, let us see by compari-
son when the canule can be finally removed if tracheotomy has
been performed.

E. Kohl, who describes in detail the difficulties in removing the
canula after tracheotomy, in consecutive numbers of the Archivs*
fiir Minische Chirnrgie, for the year 1887, compiled, approxi-
mately, 800 cured cases, tracheotomized for diphtheria. He
forms the opinion from the study of these cases that one has no
ri^ht to speak of difficulty in removing the canula, unless it can-
not bp finally removed at the expiration of three weeks. Tn this
compiled material, the canula was finally removed on the third
day. in 24 cases; on the fourth day, in 71 cases; on the fifth day,
in 94 cases; between the sixth and tenth days, in the majority of
cases, that is to say, in more than 800 cases ^37^ per cent), and be-
tween the tenth and thirtieth days, in 200 cases (25 per cent).



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340



EDWARD M. PLUMMEB.



Fifty patients, approximately, wore tiie canula from one to twelve
months, and in conclusion, Kolil mentions several cases in litera-
ture, in which it was impossible to remove the canula for good, in
patients cured of laryngeal diphtheria.

My own experience relative to the final removal of the canula
are in brief as follows:*

In the majority of my cases (84 per cent), I succeeded in re
moving the canula within ten days, most frequently on the sixth
or seventh day. In 23 J per cent of my cases, the canula could be
finally removed within five times 24 hours. f If we* compare
these figures with those acquired in the same direction in intuba-
tion, we cannot fail to observe the immense difference in results.

As there are always physicians who prefer tracheotomy to in-
tubation in the practical treatment of diphtheritic stenosis, it is,
perhaps, not entirely in vain to point out these differences more
definitely.

My data, previously given in detail, show, as we have seen, that
the average duration of intubation in my material amounted to
79 and 61 hours respectively, and that the majority of my cases
(83.8 per cent) were extubated within five times 24 hours. A
comparatively large number would have been intubated longer
than five times 24 hours, save that the too prolonged wearing of
the tube might have become dangerous to the patients. For as
no severe decubitus developed in either larynx or trachea in all
these cases, we may safely conclude that the final extubation
proved a success, and that we avoided secondary tracheotomy.

If we tabulate the successful cases of Mount Bleyer, G. Baer,
and my own, and compare them from this point of view, we obtain
the following data:





Narae of the
observer.


The number

of cases
cured by in-
tubation.


In how many

cases was
final extuba-
tion per-
formed with-
in 120 hours?


What per
cent, of col-
lective cures?


In how many

cases was
final extubar

tioh per-
formed after
120 hours?


Whatoer
cent of col-
lective
cores?


M. Bleyer
G. Baer
J. Bokay


189

31

269

479


150

20

217

387


79.8
64.5
83.8

80.8


39
11
42

92


20.7
35.0
16.2




19.2



♦This experience was up to Aiig^ist. 1890. From this time on. t
performed primary tracheotomy only in a few cases.

. fl am sorry to say that T do not know the statistics compiled by
Professor Bose (Giessen), which he acquired from the performance of
tracheotomy dnrinjr the sernm period.



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DURATION OF INTUBATION IN CURED DIPHTHERIA. 341

According to the table, out of 479 cured cases, three authors
successfully treated 92 (that is 19.2 per cent of the cases) later
than five times 24 hours.

The maximum length of time of wearing the tube, in my cases,
was, as before stated, 360 hours: seven of my patients were in-
tubated over 240 hours. That diphtheria patients can sometimes
wear the tube without danger even beyond this moment is proved
by the intubation material of the Ziirich Kinderspital,* in which
we find three cured cases, the patients having been intubated 33,
34 and 62 days respectively, or 792, 816 and 1,248 hours. Final
extubation was then performed, f

The question is, then, whether the fact that severe decubitus
may appear in the course of the intubation, sufiiciently confirms
the opinion that secondary tracheotomy should be performed in
order to avoid this complication, if the tube cannot be finally re-
moved in from four to five times 24 hours. It was known that
Escherich:]: first made public this view in 1891, and V. Ranke
and Heubner are of the same opinion, as the reports of last yearns
Wiener 'Wanderversammlung show.§

Tn a discussion 'of Escherich's view at Halle in the year 1891.
I called particular attention to the fact that a sufficiently large



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