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(1) The toxcemic stage : ls£ week.—Evidence of toxic effects on all organs and
on metabolism.
(2) The cardiovascular stage: 2nd, and, to less extent 3rd weeks.—A period of
circulatory disturbance with clinical and/or electro cardiography evidence of
damage to the heart. The commonest lesion is myocarditis. This is associated
in many cases with evidence of conductive lesions : intra-ventricular block, bundlebranch
block and complete heart block. These changes often disappear before the
next stage is reached. Sometimes they persist into the next stage, and may erroneously
be thought to arise then. Occasionally they may persist for months or years.
(3) The paralytic stage: 3rd to 6th weeks.—The manifestations suggest lesions
of the nervous system. Although opinion is still divided, our view is that these
lesions are central in origin, not peripheral. Cardiovascular manifestations such
as premature beats, gross irregularity of the heart and hypopiesis may occur at this
stage, but must be clearly distinguished from lesions of the previous stage, because
we attribute all the disturbances of this stage to a central (bulbar) effect. This
point is of importance because Wilson (1932) in discussing the types of respiratory
failure in poliomyelitis, expressed the view that those of bulbar origin were the least
amenable to treatment in tne respirator.
Death may occur in any one of these stages. A patient who has had severe
manifestations in the earlier stages and has survived will, in all probability, have
trouble in the later ones as well.
In the paralytic stage structures tend to be affected in a more or less regular
sequence—the palate, the eyes, the heart, the pharynx and the diaphragm being
a common order. The last two often occur together. Thus, diaphragmatic
paralysis is a late complication of severe diphtheria and tends to be associated with
involvement of the pharynx. Death in this stage may be due to concomitant
circulatory failure, but is commonly the result of respiratory failure or bronchopneumonia.
Involvement of the lung is of some importance in this paper. It
depends either directly upon the paralysis of the respiratory muscles, or is secondary
to accumulation of mucus in a paralysed pharynx. Therefore at this stage of the
disease, the problem with which we are confronted is a failure of respiration which
depends upon a paralysis of the musculature. The Drinker respirator replaces or
augments the failing musculature.
In table I the cases are summarised. The severity of each is indicated by the
distribution of the membrane, the amount of antitoxin administered and its route,
and the manifestations in the three stages of the disease. Below, clinical details are
given of the paralytic stage in each case at the time the respirator was employed;
and a comment is added in which the experience culled is recorded.
Case 1 was of severe diphtheria with dangerous manifestations in each stage of the disease.
On the 46th day diaphragmatic paresis, mainly right sided, appeared. Although the patient
was not in acute distress, he was put in the respirator. The rate of the machine was 18 cycles
per minute and the pressure 0 to-—18 cm. of water.
On the 47th day he was tried outside the respirator, but as his breathing was now distressed
and purely intercostal, he was put back again.
On the 48th day breathing was still intercostal and he could not remain out of the respirator
for more than half an hour without becoming uncomfortable.
On the 50th and 51st days he managed most of the day outside the apparatus and was
returned only at night.
On the 52nd day respiration was normal and he was removed from the machine.
Further progress was uneventful.
This, the first case, was put into the respirator at the earliest sign of diaphragmatic
paralysis. His respiratory rate adjusted itself readily to that of the apparatus
and he was quite comfortable throughout. It is impossible to say how he would have
fared had he not had the assistance of the respirator, but the severity of his previous
manifestations and the distress which appeared when he was left out for short periods
suggest that the result might not have been so fortunate. We were not convinced,
however, that this case would necessarily have died.