DIPHTHERITIC PARALYSES Paresis and paralysis occupy the first place among the nervous complications and sequels of diphtheria. They may appear early, or late in the form of the so-called postdiphtheritic paralyses. The paral ysis appearing early is only localized in the pharynx, occurring in the very severe cases, from the third to the fifth day. The postdiphtheritic paralysis appears first in convalescence from one to three weeks after the disappearance of the membrane.
It is difficult to determine the frequency of postdiplitheritie paral ysis for it is subject to great fluctuations according to the type of the epidemic. The average according to Sanne is 11 per cent., according to Cadet de Gassicourt 13 per cent., while Seitz fixes it at only 5 per cent.; if only cases that recover are considered it is probably from 20 per cent. to 23 per cent. With serum therapy, it appears to be a little less fre quent; at least, when used promptly, there are fewer severe and multiple paralyses. It most frequently appears after descending diphtheria and likewise in the course of malignant diphtheria; mild cases are rarely followed by it and then only with a localization in the pharynx.
It is a flaccid, usually incomplete paralysis with partial reactions of degeneration.
There may also be other nervous disturbances, as parxsthesia, amcsthesia, rarely hypertusthesia, neuralgias, various forms of cramps.
The affection almost always begins with a paralysis of the soft pal ate and pharynx, even in those cases in which the pharynx was not af fected. An exception is seen sometimes, but only in malignant diph theria. Paralysis of the eyes may follow that of the pharynx, then the lower extremities are affected followed by involvement of the upper limbs, the trunk and the neck.
The paralyzed palate hangs in a flaccid condition and is not moved in speaking or swallowing. As a result of the failure to close the nasopharyngeal space there arc nasal voice, dysphagia with regurgita tion of fluids through the nostrils, sometimes aspiration of food with attacks of coughing whenever the attempt is made to swallow. In addi tion, there is lessened expectoration, which adds danger to any affec tion of the bronchi or lungs.
The isolated palatopharyngeal paralysis subsides in ten to twenty days, occasionally earlier, or it may last a month. It may be followed in about eight days by other paralyses (in about 15 per cent. of the cases).
Strabismus comes as a result of the paralysis of the external ocu lar muscles, while the affection of the ciliary muscle leads to disturbances of accomodation with fatigue on reading and blurring of near objects. The pupil of the affected side reacts only to light. In rare cases the retina is involved and amblyopia occurs or even amaurosis.
Through paresis of the legs the gait becomes uncertain and ataxic. The weakness may be so great that walking is impossible. The patellar tendon reflexes are lessened. The arms are not often affected but in rare cases there are weakness and trembling of the hands with incapability of performing delicate movements.
In the severest eases there occurs a flaccid paralysis with diminution of electrical irritability and absence of the tendon reflexes.
It may be impossible to hold up the head because of weakness of the muscles of the neck and back and the patients sit in a bent-over posi tion or are even unable to sit up. Paralysis of the facial muscles is very rare. Much danger arises if the paralysis spreads to the respiratory muscles, while involvement of the diaphragm is surely fatal. In paral ysis of the larynx, which follows only after laryngeal diphtheria, aphonia and dysphagia are present with an irritating cough. Paralysis of the abductors of the vocal cords causes stenosis, paralysis of the adductors causes spontaneous extubation if intubation has been done.
Generalized paralysis almost never occurs, multiple paresis is also very rare, but their mortality mounts to 40 per cent. to 50 per cent., while the ordinary forms show S per cent. to 10 per cent. (Filatow).
A fatal termination results from paralysis of the respiratory mus cles, inspiration-pneumonia, or from exhaustion in inanition. The order of the disappearance of the paralyses, when multiple, is the same as that of their development. The convalescents frequently remain weak, anaemic and apathetic for a long time.