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these were relieved by aspiration. Nevertheless. the pulse became very poor, cardio-vascular
weakness increased and she died 30 hours after entering the machine.
Diaphragmatic involvement was never marked in this case. The striking feature
was the progressive cardio-vascular failure, which in this stage of the disease we
believe to be of central (bulbar) origin.
Case 8 was one of severe diphtheria in all stages of the disease. Paralysis appeared early,
with involvement of the palate on the 21st day. Complete pharyngeal paralysis developed on
the 29th day and was followed three days later by ocular paralysis.
On the 36th day diaphragmatic movement was impaired for the first time. He was put
in the respirator next day, although some diaphragmatic movement could still be detected.
On the 38th he could not remain out of the machine without respiratory distress appearing,
and by the 39th day diaphragmatic failure was complete. Whilst in the respirator he received
complete relief, but it was necessary to keep him in until the 51st day.
As the result of our accumulated knowledge, this severe case gave rise to no
anxiety. He was put in the respirator early, responded well, and cleared up in
fifteen days, a longer period than had been necessary in any of the other cases.
The experience culled from the series is summarised below:—
(1) Cases must be put in the respirator early, as soon as diaphragmatic paralysis
is suspected, otherwise there is considerable danger of bronchopneumonia developing.
(2) When exudative changes are present in the lungs, the respirator is of little
or no value
(3) The pharyngeal paralysis which so frequently accompanies the diaphragmatic
must be treated thoroughly. Owing to the fact that the respirator employed
was not tiltable, the valuable procedure of postural drainage could not be employed.
Mechanical aspiration and manual removal of mucus are, however, adequate if
carried out thoroughly. Nasal feeding is usually necessary and should be done
without stopping the machine.
(4) The patient should be retained in the respirator continuously. Among
the recoveries, the shortest period necessary was 4 days and the longest 15 days.
This provides valuable, and hitherto unknown, information concerning the natural
duration of diaphragmatic paralysis in diphtheria. When there are signs that
movement of the diaphragm is returning, the patient can be tried without the
apparatus for short periods.
(5) If the respiratory rate of the patient is grossly abnormal, no attempt
should be made to synchronise the respirator with it; rather, the apparatus should
be adjusted to a rhythm of about 20 per minute in the expectation that this will
be imposed upon the patient.
(6) Positive pressures are without advantage and sometimes produce discomfort.
Negative pressures need not be great. A variation of from 0 to -16 or
-18 cm. of water is usually the maximum required. Hyper-ventilation, which has
been practised in America to produce periods of apnoea whilst the patients are receiving
attention, was not attempted in our series.
(7) A patient who is going to improve responds in a definite manner: (a) his
respiratory rate adjusts itself almost immediately to that of the machine; (b) cyanosis
and dyspnoea rapidly disappear ; (c) restlessness, due largely to violent respiratory
efforts and the consequent embarrassment of a heart already labouring under
difficulties, disappears. The rate of the pulse falls, its quality improves, and not
infrequently the patient falls into a restful slumber. This sedative effect can be
most striking. Cases which fail to respond in this way are unlikely to derive benefit
from the respirator. Such cases are usually those in whom bronchopneumonia
has appeared.
(8) The equable and slightly raised temperature which was maintained inside
the respirator by the heating lamp appeared to have a beneficial effect upon the
circulatory collapse which occurs in this stage of the disease.
Of the five cases which recovered, four would certainly have died without the
assistance of the respirator. Of the three deaths, two had evidence of commencing
bronchopneumonia before entering the respirator. In both the respiratory rate of
the patient failed to adjust itself to that of the machine; in consequence, no relief