(a) Pos(diphtheritic Paralysis Characteristic paralytic symptoms occur after diphtheria both in children and in adults. Whether adults are more disposed to post diphtheritic palsy than children, as has been supposed on the strength of certain not quite uniform statistics, must remain undecided for the present. At all events postcliphtheritic palsy is very frequent in children. Heubner observed paralysis in five per cent., and Goodall in about eleven per cent. of their cases of diphtheria, and these figures are prob ably too low; for in the public clinics of large cities children do not consult the same physician for nervous symptoms as for diphtheria. The question can be cleared up only by statistics carefully compiled from private practice. It has recently been asserted in many quarters that the number and severity of the cases of paralysis have increased since the introduction of antitoxin. Although it cannot be said that the statement has been definitely- proved, it is nevertheless quite plaus ible when it is remembered that the antitoxin treatment often effects a cure at a stage of the disease when the intoxication of the tissues is so severe that death would have resulted without it.
11le distinguish an early and a late form of diphtheritic palsy. In the early form the paralysis—the palate is always affected first—comes on immediately after the angina, so that it is often at first difficult to decide whether the dysphagia is due to the acute pharyngeal disease of whether it is already, the effect of paralysis of the palate. 'More fre quently the paralysis is delayed until the second or third week, when the diphtheria itself has run its course and the children are already consid ered well. I have also observed both f orms of palsy separated by a short interval of freedom.
The most important symptoms are: (1) paralysis of the palate, which manifests itself in nasal speech, insufficient closure of the larynx during deglutition, and the regurgitation of fluid through the nose. In severe cases the speech is quite unintelligible, and the ingestion of food considerably impeded. The velum is absolutely immovable and does not respond to electric irritation; the pharyngeal reflex is abolished. Sometimes the palsy is unilateral (corresponding to the side where the exudate was heaviest ?); the uvula is drawn toward the sound side. In mild cases interference with speech is the only distinctly recognizable symptom. (2) When paralysis of the palate is severe, there is often associated partial paralysis of the deep pharyngeal, and of the laryngeal muscles; swallowing is greatly interfered with; there is tendency for the "food to get into the Sunday throat" (failure of the epiglottis to close); and contact of the food with the larynx incites a hoarse, spas modic cough. The voice is weak or there may even be absolute aphonia.
Paralysis of the laryngeal muscles (posticus paralysis) can be seen with the laryngoscope. (3) Paralysis of accommodation is not infrequent, although the phenomenon is not so noticeable in children. It shows itself in inability to do fine work or read, and the patient usually first consults the oculist. Subjective phenomena such ftS MUSCTE volitantes are rare. In older children inability to fix an object that is held near the eyes is readily recognized. have also observed ocular palsies (abducens, oculoinotor). (I) The patellar and tendo Achillis reflexes are almost regularly abolished early in the disease; in exceptional cases they may be preserved and even quite active (personal observa tion). In severe cases paresis of the legs, ataxia and inability to walk are observed. The legs are very much emaciated and the reactions of degeneration are present, but there is no pain either spontaneous or elicited by pressure on the nerve trunks. Other groups or muscles may become partially paralyzed, especially the muscles of the neck, as a result of which the head drops forward on the chest or is inclined to one side. Tremor, ataxia and paralysis may be present in the arms, and the abdominal and thoracic muscles are sometimes attacked in severe cases. Whether the cardiac weakness and sudden death from heart failure which occur in cases of severe diphtheritic palsy are due to the same causes as the nerve palsies is difficult to decide, for we must always reckon with the possibility of a direct infectious myocarditis. General depression, pronounced pallor and albuminuria are frequent concomi tants of a severe palsy.
Postdiphtheritic neuritis presents many degrees of severity, from a simple peripheral paralysis with no more serious disturbance than nasal speech to severe general paralysis, and may be arrested at any of these stages. The way in which the paralytic phenomena make their appear ance is usually as follows: paralysis of the palate, diminution of re flexes in the legs, then paralysis of accommodation, then paralysis of the neck and legs, of the larynx, and filially of the entire body-. When the primary diphtheritic lesion is elsewhere in the throat, the paralysis begins in the muscles nearest the diseased focus instead of in the palate (abdominal paralysis after diphtheria of the umbilicus).