PARALYSIS, Diphtheritic.
This condition is due to a peripheral neuritis, as in the case of poisoning by alcohol and arsenic. Though the patient is certain to recover the use of the paralysed members, provided he can be kept alive till the poison is eliminated, nevertheless the danger of sudden heart failure from involve ment of the cardiac nerves and muscular fibres adds gravity to this type of paralysis. In the very onset of the paralysis, occurring sometimes within a few days after recovery from diphtheria, or during the course of the disease, the heart muscle may be the first to suffer from weakness, and when the first symptoms of this are overlooked by the physician, sudden death may unexpectedly follow.
As soon as the pulse and temperature of the chilled extremities show any evidence of weakness of cardiac muscle the patient must be treated with promptness. He should be put to bed and warmth with friction applied to the limbs, whilst a small sinapism is applied over the heart, and whiskey or brandy given in warm milk, both by the mouth and by the rectum. A full hypodermic dose of Strychnine gr.) should be given without delay, and Ammonia, in the form of strong liquor, may he applied to the nostrils, and Sal Volatile in full doses, well diluted, may be administered every 13 or 3o minutes, whilst Faradisation of the precordial region may he resorted to in severe cases. Where paralysis of respiration threatens, artificial respiration and Duchenne's plan of reflex stimulation of the respiratory centre by Faradism of the back and chest may be resorted to.
When the paralysis, as is usually the case, begins in the lower extremities or in some of the peripheral muscles, as in the eye or palate, the paralysis comes on at a later period during convalescence; though the danger of sudden cardiac failure is much less, these cases are apt to be very tedious, and before recovery almost every muscle in the body may become para lysed. Feeding should be rigorously attended to, and as soon as swallow ing becomes difficult or impossible rectal alimentation or feeding with the nasal tube must be instituted, and the hypodermic administration of horse serum may be resorted to in desperate cases where vomiting persists. In every way that is possible the nutrition of the body is to be improved, and when the appetite is weak, tonics, such as the well-known combination of Quinine and Diluted Nitrohydrochloric Acid, are to be resorted to. In the
later stages of the neuritis moderate exercise may be indulged in, but absolute rest in the early stage is essential. Where walking is difficult, the patient should be carried out to sit or recline in the sunshine, or be pushed in a bath-chair. Where these are impossible, as in the middle of winter, indoor exercise and general massage may be tried, and the appetite coaxed in other ways, as by unusual variety of choice and carefully cooked foods administered often and in small amounts at a time.
Where the gastric function gives up, all food must be peptonised or a small quantity of Pepsin with I lydrochloric Acid should be given after each meal. Rectal enemata should be peptonised before administration, or Pepsin, Trypsin or Papain may he added to each dose immediately before its injection into the bowel. The patient should always be wakened during the night for nourishment at least once, and in the case of children two or three times. When fluids regurgitate through the nose or cause choking sensations by trickling into the larynx, pultaceous food as 'blanc mange may be easily swallowed.
By the above measures (feeding by the nasal tube, rectum and hypo dermic use of horse serum) life can be saved when nearly every muscle in the body has become paralysed and when artificial respiration and Oxygen inhalations may be necessary at times to keep the blood aerated.
Drugs are of secondary importance to feeding. As already stated, in all urgent cases threatening life by cardiac paralysis Strychnine should be given hypodermically without delay. In ordinary peripheral diphtheritic paralysis it is not considered advisable to give strychnine in the early or acute stage, and though this may be a wise precaution, nevertheless the drug should be promptly administered upon the first suspicion of cardiac failure. It is at least doubtful if strychnine possesses any reliable cardiac tonic action when given in ordinary safe doses by the mouth; for the treatment of an emergency, like the one under consideration, the drug must be given hypodermically. In very chronic cases the advisability of inject ing strychnine into the paralysed muscles has been seriously questioned, since it is argued that the alkaloid had no action upon the muscular fibre unless through the spinal nerve cells. The subject need not be discussed, since in any case the injected drug will ultimately reach the anterior cornua of the cord.