Management by mechanical respirator of postdiphtheritic respiratory paralysis

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T HE clinical similarity of respiratory failure in late diphtheria and in certain forms of poliomyelitis is apparent to physicians familiar with the two diseases. Wilson 1 has emphasized that poliomyelitis can prevent efficient respiration through direct paralysis of the primary respiratory muscles, through interference with respiration in patients with pharyngeal paralysis in whom inspiration is continually interrupted by unswallowed secretions collecting around the glottis, and finally through a disturbance of the nerve centers in the medulla controlling respiration. Respiratory difficulty in any patient ill with poliomyelitis may be due to a single one of these factors or to a combination of two or more. The striking difference between respiratory difficulty in poliomyelitis and in late diphtheria is that in infantile paralysis the cause is commonly of central origin, while in diphtheria the difficulty is chiefly concerned with paralysis of the diaphragm and of the intercostal muscles. In both conditions the factor of accumulated secretions following paralysis of the muscles of the pharynx is often important. The careful observations of Wilson have demonstrated that in poliomyelitis the response to management with the Drinker 2 respirator is much more favorable when the lesion is related to the cervical and dorsal cord, with resultant paralysis of the intercostal muscles and of the diaphragm, than when the involvement is primarily bulbar. Our own experience has been the same, and logically led to consideration of this method in the management of late respiratory paralysis in diphtheria. Since 1927, 5057 cases of diphtheria have been admitted to the wards of the Herman Kiefer Hospital, Detroit. The number of deaths was 632,'of which an appreciable number, eighty-seven, were due to the toxic effects of the infection and occurred within the first few days. Circulatory failure was by far the cormnonest cause of death, being responsible for no less than 415 fatalities. Among patients with the laryngeal form of diphtheria the commonest contributing cause of death was pneumonia, ninety-six cases, with suffocation from obstruction essentially uncommon. Septicemia, generalized suppurative peritonitis, nephritis, empyema thoracis and activated pulmonary tuberculosis were rare causes. Fatality in thirteen instances was due to respiratory insufficiency after paralysis,