View report page

31
was provided. One was in for four hours only, the other for five hours. In the
third case the respiratory distress was relieved, but death appeared to be due to
circulatory failure of bulbar origin.
We have been unable to find any reference in the literature to the use of the
Drinker respirator in empyema. The three cases here described suggest a new and
valuable field for the use of the apparatus.
Empyema.
Case 1.— The first case was that of a child of 1¾ years, admitted for measles and bronchopneumonia.
A localised pneumococcal empyema in the right middle and outer pulmonary zone
was treated by aspiration and later by rib resection. Progress was extremely slow, and 54 days
after the operation the wound was still discharging. Repeated X-ray examinations showed
that the only abnormality present was a collapsed lung, which, owing to its failure to expand,
prevented the cavity from closing. As the child was too young to be taught to inflate its lungs
by respiration against resistance, it occurred to one of us (M. M.) that the respirator might be
usefully employed to expand the lung by negative external pressure. The healthy side of the
chest was strapped and the patient put in the respirator for one hour daily at pressures of 0 to
-18 cm. of water. Four such treatments sufficed to expand the lung and the wound healed six
days later. A later X-ray showed only a narrow band of opacity to indicate the site of the former
cavity.
The success which attended this experiment was so immediate and so striking
that it was decided to try another case which was proving troublesome. This was
not a simple case such as the one just described. Nothing definite was hoped for and,
as it happened, a successful issue was not obtained, but definite improvement
occurred.
Case 2 was a female of 4 years who had previously suffered from asthma and several attacks
of pneumonia. She was admitted for whooping-cough and pneumonia. Six weeks after admission
she developed a pneumococcal, interlobar empyema which ruptured into a bronchus and infected
the general pleural cavity. Despite a rib resection, progress was negligible ; the wound continued
to discharge and she remained desperately ill for weeks. Several X-rays revealed an empty
cavity in the mid-pulmonary field with collapse of the base of the lung. As all efforts at inflation
failed to expand the lung, she was treated in the respirator on the same lines as case 1. The
discharge diminished at once and her general condition improved. An X-ray showed that the
basal collapse had largely disappeared and treatment was discontinued. The discharge immediately
increased in amount, but diminished when treatment in the respirator was restarted.
After seven days' treatment, the discharge only amounted to an occasional bead of pus, and an
X-ray showed evidence of permanent fibrotic changes in the lung. At the request of her parents
she was allowed to attend an out-patient department.
We are of the opinion that this case derived definite benefit from the respirator.
The beneficial effect was due to the fairly rapid disappearance of the pulmonary
collapse. All the other abnormalities were unaffected by the apparatus.
Case 3 was a male of 6. years admitted for scarlet fever. Six days before admission he was
operated upon for a right-sided pneumococcal empyema. Ten days after admission he was still
pyrexical and the wound was discharging profusely. An X-ray examination revealed collapse
of the right base, and an injection of lipiodol demonstrated an air-containing empyema cavity.
24 days after the operation there was no diminution in the discharge. He was put in the respirator
daily as in the two previous cases. After three such treatments there was marked improvement
in his general condition and the discharge had diminished in amount. At the time of
writing he has been in the respirator 10 times and is making marked progress. The discharge
has almost ceased and there is radiological evidence of expansion of the lung and closure of the
cavity.
B. H., aged 5 years, was a case of partial, acute pulmonary collapse who did not respond
to treatment in the respirator. Six days before admission he had an anaesthetic (gas) for the
extraction of a tooth. The day before admission he developed a sore throat and a harsh cough,
and on 6.5.35 was sent to the North-Eastern hospital as a case of laryngeal diphtheria. On
direct laryngoscopy no membrane was seen, but the larynx was injected. Swabs showed a few
colonies of hœmolytic streptococci, but no diphtheria bacilli. The diagnosis of diphtheria was,
therefore, not confirmed. He made satisfactory progress for 10 days, except for the persistence
of the cough. He had been pyrexial on the day of admission only. On the 11th day there
was a recurrence of pyrexia and the cough increased in frequency. Fourteen days after admission
(20.5.35) an X-ray examination was performed and a small triangular area of collapse found at
the right base obscuring the cardiophrenic angle. He was put in the respirator for half-an-hour
and re-X-rayed immediately afterwards, when the appearances suggested a slight improvement.
Next day he was again put in. Three hours later his temperature rose to 104° and the cough
became more troublesome. On clinical examination the right base was found to be impaired
and air entry diminished. The temperature settled next day and he was X-rayed again. He
now had a much more extensive collapse of the right base. It was decided to discontinue the
use of the respirator. In the next five days he was mildly pyrexial. After this the temperature
Idiopathic
pulmonary
collapse.