View report page

27
Case 2 was one of severe diphtheria. Toxaemic and cardiovascular manifestations were
marked. The paralytic stage commenced on the 27th day with paralysis of the palate.
On the 44th day the rhythm of the heart was tic-tac in character, and the pharynx was
paralysed.
On the 49th day she became pyrexial; respirations became rapid and jerky ; diaphragmatic
excursion was poor. She was put in the respirator but was undoubtedly worse. Her respiratory
rate was 40, and failed to adjust itself to that of the machine. An attempt was therefore made to
adjust the rate of the respirator to hers. This also failed, firstly because the respiratory rate was
irregular, and secondly because it was too rapid. In an attempt to get some degree of synchronisation
between the two rates, that of the respirator was diminished to 20, that is, half the patient's,
in the hope that alternate respirations would be assisted by the apparatus. This also failed.
In consequence, she was struggling against the action of the machine. She became restless and
her colour worse. Moreover, mucus was accumulating in the paralysed pharynx. Attempts to
keep this clear by the use of an electrically operated aspirator were in some measure successful.
Nevertheless, after four hours in the respirator her condition was worse and she was removed and
was never put back.
On the 50th day definite signs of consolidation appeared in the lungs, particularly at the
right base, and on the 52nd day she died. Permission for a post-mortem examination was refused.
From this case valuable experience was gained and can be classified under
three headings:
(1) The first is concerned with the synchronisation of the two rates, that
of the patient and that of the machine. We realised that some patients could
not adjust their rate to that of the respirator and that attempts to make the
machine conform with the patient were unlikely to succeed. In such cases, no
assistance, but rather actual harm, must be expected and a bad prognosis
anticipated.
(2) The second is concerned with the concomitant pharyngeal paralysis
which occurs frequently with the diaphragmatic. The accumulation of mucus
in a paralysed pharynx can be controlled by postural drainage through the nose
(by raising the foot of the bed), by aspiration, and by manual removal. Since
our respirator could not be tilted (see fig. 1), we were deprived of the valuable
procedure of postural drainage, and frequent aspirations were necessary to keep
the pharynx clear. (Respirators which can be tilted are now in use in the Council's
hospitals—see fig. 2.)
(3) The third is concerned with the prognostic significance of exudative
changes in the lungs. It was soon obvious that this case, showing pneumonic
signs and a rapid respiration rate, was going to do badly.
Case 3 was complicated by a super-added streptococcal infection. There was ulceration
as well as membrane on the fauces. Eight days later this had healed.
On the 43rd day after the patient had been allowed up, paralysis of the palate appeared:
he was put back to bed. The pharynx was involved four days later.
On the 50th day he became critically ill with signs of diaphragmatic paralysis and exudative
changes in the lungs. Mucus accumulated in the pharynx; coarse rales appeared at both bases;
the percussion note at the left base was impaired; breathing was chiefly intercostal; the temperature
rose to 101°, and the respiratory rate to 30. That afternoon he became acutely dyspnceic
and death appeared imminent. He was put into the respirator, but his respiratory rate did not
alter, he became restless, and obtained no relief. After half an hour a transient improvement
occurred; his breathing became a little easier and his colour improved. His pulse, however,
gradually failed and he died 5 hours after entering the machine. A post-mortem examination
revealed fairly extensive bronchopneumonia.
In this case, the severity of the paralytic manifestations was greater than was
anticipated. The patient was not put into the respirator until late, by which time
there was definite evidence of lung involvement. Our experience in this case was in
conformity with that of case 2. In addition, the danger of delaying the use of the
respirator was emphasised.
Case 4 was critically ill on admission, and her general condition was extremely poor. During
the cardiovascular stage she had uncontrollable vomiting and subsisted for eight days on intravenous
glucose, without which she would have died. The paralytic stage commenced on the 17th
day with involvement of the palate and pharynx. Ocular and facial manifestations followed.
On the 44th day the diaphragmatic movements were impaired for the first time. She was
put in the respirator, the pharynx was aspirated regularly, and she was fed nasally. Next day
the paralyses of the pharynx and diaphragm were complete. The rate of the respirator was
18 cycles per minute and the pressure 0 to -—16 cm. of water. Her response was immediate
and striking. Before, she was a restless and difficult child, sleeping badly and breathing with