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THE DRINKER RESPIRATOR IN DIPHTHERIA, EMPYEMA AND
PULMONARY COLLAPSE.
By Norman D. Begg, M.D., D.P.H.,
and
Maurice Mitman M.D., M.R.C.P., D.P.H., D.M.R.E., Senior Assistant Medical
Officers, North-Eastern Hospital.
The Drinker respirator is a mechanical device for administering artificial
respiration over long periods. The principle involved is to induce inspiration by
applying regularly and intermittently a negative pressure to the outside of the
chest and abdomen. In normal respiration the active stage is inspiration. The
muscles of respiration increase the capacity of the thorax and the consequent negative
intrathoracic pressure causes air to enter through the mouth and nose. The Drinker
respirator seeks to reproduce this in patients whose respiratory muscles are, for one
reason or other, out of action. It may be contrasted with other, less physiological,
methods of artificial respiration, where expiration is induced by positive pressure
exerted from outside.
The apparatus consists essentially of a bed on which the patient lies, with the
whole of his body except the head enclosed in an air-tight metal chamber. Artificial
inspiration is induced by rhythmically changing the pressure inside from atmospheric
to negative by means of bellows worked by an electric motor. The magnitude
of the negative pressure and, therefore, the depth of inspiration can be varied by
means of valves ; and the rate of the artificial respiration is controlled by a mechanical
device.
In America the apparatus has been employed since 1929 for paralysis of respiration
in poliomyelitis, alcoholic coma, drug poisoning, drowning, and asphyxia
neonatorum. Gordon, Young & Top (1933) reported two cases of post-diphtheritic
respiratory paralysis treated in the respirator. They were impressed by the possibilities
of the use of the apparatus for this condition.
Since February, 1934, the first respirator purchased by the London County
Council for its infectious hospitals has been stationed at the North-Eastern hospital.
This paper is a report on the use to which the apparatus has been put at that hospital.
A preliminary note has already been published. In the present series eight cases of
diphtheria, three of empyema thoracis and one of pulmonary collapse were treated.
Diphtheria*
To assign diaphragmatic paralysis to its proper place in diphtheria, a simple
classification of the manifestations of the disease may be helpful. According to
the anatomical distribution of the membrane the disease may be classified as :
(i) nasal and naso-pharyngeal; (ii) oro-pharyngeal; (iii) laryngeal and laryngotracheal.
The severity of the disease and the probability of complications varies directly
with the original extent of the membrane, although pharyngeal membrane is more
dangerous than a similar amount situated elsewhere, if obstructive manifestations
are excluded. In the milder types of oro-pharyngeal diphtheria—the so-called
"faucial"—membrane is limited to one or more of the structures bounding the
opening of the oro-pharynx, usually to the tonsils. In the most severe types all
the structures at the opening are involved: the tonsils, the pillars of the fauces,
the margins of the palate and the uvula ; in addition, there is a variable extension,
forwards on to the palate and backwards on to the pharyngeal wall. It is this type
of diphtheria, alone or combined with others, which is responsible for a large percentage
of the calamities which occur in this disease. Three definite danger periods
exist. These we have named according to their principal manifestations. In our
view there is a pathological basis for this division, but we do not propose to go into
the evidence here. The time given for these stages is somewhat arbitrary and varies
from case to case.
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