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considerable difficulty. In the respirator her respiratory rate responded to the instrument, she
became quiet and peaceful and slept readily. Without the respirator she was incapable of breathing
for even short periods. On one occasion when the apparatus was stopped for the purpose of
giving a nasal feed, she rapidly became acutely dyspnoeic and cyanotic, but was immediately
relieved when the motor was restarted. For the next four days no diaphragmatic movement
could be detected. On the 50th day there were signs of a commencing return and on the 51st
day she was removed from the instrument.
This was the most severe case in this series. There can be no doubt that the
patient would not have survived without the assistance of the respirator. She was
put in at the first sign of paralysis and her respiratory rate responded immediately—
a good prognostic sign. Moreover, the sedative effect of relieving her of the effort
of breathing was most marked. Before this case we had considered it advisable to
stop the motor when giving a nasal feed. From this case we learnt that, not only
was it unnecessary, but it might be positively dangerous to do so.
Case 5 had severe diphtheria with multiple paralyses in the third stage.
On the 42nd day the intercostal muscles began to overact. She was given one nasal feed
a day.
. On the 44th day the diaphragmatic paralysis became more marked and she was put in the
respirator, with pressure of 0 to —16 cm. of water at a rate of 18 per minute. She accommodated
herself immediately to the rate of the respirator and received immediate relief from her respiratory
distress. By the 46th day she was able to stay out of the respirator for short periods and next
day, diaphragmatic movement having largely returned, she was removed. Thereafter progress
was uneventful.
We were, by now, conversant with the type of case suitable for the respirator,
with the accessory lines of treatment necessary, and with the probable prognosis.
This case, although severe, gave rise to little anxiety, yet she could not have survived
without the respirator.
Case 6 was one of moderate severity, but was complicated by the presence of old pulmonary
trouble. Coarse rales were scattered over the chest and persisted throughout the illness. He had
a history of two previous attacks of pneumonia. Clinical and radiological evidence suggested
early bronchiectasis. The diphtheria responded to treatment, but on the 35th day the cough
became more frequent and the moist sounds on the chest increased. No evidence of consolidation
was detected.
On the 40th day he vomited ; his colour became poor, and the heart rhythm was rapid
and tic-tac in character. The ala; nasi were working.
On the 47th day he developed a pharyngeal paralysis with a typical cough. Diaphragmatic
movement was poor and the intercostals were overacting. He had an attack of dyspnoea with
accumulation of mucus in the pharynx and was put in the respirator. The respiratory rate,
which was 40, settled at once to that of the machine, which was 22. Pressures employed were
0 to —12 cm. of water. Nasal feeding and aspiration of the pharynx were instituted. He experienced
immediate respiratory relief and the tall in respiration rate was accompanied by a fall
in pulse rate.
On the 48th day no diaphragmatic movement could be detected and he became dyspnoeic and
restless without the respirator.
On the 49th day, owing to a mechanical defect, the respirator broke down, and we had an
unwelcome opportunity of seeing what he was like without the machine. He rapidly became
dyspnoeic and cyanosed and during one severe attack of dyspnoea he looked like dying. Fortunately,
after about half an hour the defect was remedied, the machine was restarted and he
rapidly improved again. The return of diaphragmatic movement was slow. By the 51st day he
was able to do without the respirator for short periods, and on the 53rd day he was removed.
He ultimately recovered completely.
In this case we did not consider the prognosis good because of the moist sound
in the lungs. These, however, were due to previous chest trouble and were not the
result of the disease. He was put into the respirator early, and it seems a reasonable
inference that he was saved from an attack of bronchopneumonia with a probable
fatal result. The rapid response of his respiratory rate was a good prognostic sign.
The accompanying fall in pulse rate was in itself valuable, as it entailed less work
for the heart. That he could not have lived without the respirator was convincingly
demonstrated during the short time the apparatus failed.
Case 7 was one of moderate severity and made good progress until the 38th day, when
palatal paralysis appeared.
On the 44th day the pharynx was paralysed, the heart rhythm was tic-tac, and she commenced
vomiting. That night respirations became jerky and diaphragmatic paresis appeared. Although
not acutely distressed, she was put in the respirator and remained comfortable for the next twelve
hours. She had bouts of dyspnoea associated with accumulations of mucus in the pharynx, but
c