Diphtheritic paralysis is not limited to cases in which the throat affec tion has been severe. The slighter forms of the distemper are as liable as the more serious forms to be followed by the nerve-lesion. Nor is its oc currence determined by the seat of the diphtheritic manifestation or the presence or absence of albuminuria. It may follow in cases where the false membrane has been limited to the skin, and in cases where albuminuria has not been observed. The period at which the paralysis appears is also subject to variety. From an analysis of sixteen cases Dr. Abercrombie found that the paralytic complication might appear from two to five weeks from the beginning of the illness. Sanne has noticed it as early as the second or third day of the disease, but states that it generally comes on from one to two weeks after the disappearance of the false membrane. According to this observer, when the paralytic symptoms appear early they usually develop gradually and spread slowly from one part to another.
When the onset is retarded, the development of the paralytic phenomena, is much more rapid and regular.
The motor lesion may be preceded by increase of languor and irritabil ity of temper. Dr. Hermann Weber has noticed in many cases a marked diminution in the rapidity of the pulse. The paralysis is symmetrical as a rule. Usually it begins either by loss of power in the soft palate and phar ynx or, by what is equally common, paralysis of accommodation of the eye. It is noticed that when the child attempts to swallow he coughs vio lently and fluids return through the nose. His voice has a nasal quality and he snores in his sleep. If the patient is old enough we can ascertain by inspection that he has no power of elevating the uvula, and perhaps, also, that there is more or less anaesthesia of the fauces. If the ocular muscles are affected the child complains that he sees double. Reading is difficult or impossible, and sometimes there is an evident squint. In rare cases there is temporary blindness.
When the pharynx is first affected the paralysis may remain limited to this part. If it be complete, the power of swallowing is lost and food can no longer be propelled down the gullet. The food taken is found to col lect in a pouch formed by yielding of the walls of the oesophagus. In such cases nourishment has to be conveyed to the stomach by mechanical means. The use of the stomach-tube is of the greatest service in these cases, both as a method of maintaining nutrition and also as a means of preventing the entrance of food into the glottis. From the pharynx the paralysis may spread to other parts. The tongue and lips may become affected so that the child dribbles and speech is greatly interfered with. Loss of power may also be noticed in the limbs, the neck, and the back. Of the limbs, the legs are affected more commonly than the arms. The paralysis almost invariably takes the form of paraplegia, for even if the weakness is more marked on one side, it will be usually found on examination that the side which appears to be sound has not entirely escaped. The motor paralysis may be accompanied by some disturbance of sensation. In rare cases con trol over the sphincters is lost. Paralysis of the respiratory muscles some times occurs. There is then dyspncea : mucus collects in the lungs, for there is no power to cough it up ; and the child usually dies suffocated. If the diaphragm is paralysed the child has attacks of elyspncea, coming on at the slightest excitement or when an attempt is made to cough. Death
may ensue in such an attack. The most moderate catarrh in such a con dition adds an additional element of danger to the case.
Besides these forms of motor lesion, sudden death, attributed to paraly sis of the heart, has been already referred to (see page 99).
Diphtheritic paralysis is fatal only in exceptional cases. When death occurs, it is usually the consequence of cardiac thrombosis or syncope ; less commonly it is due to impaired nutrition through difficulty of swal lowing, or to nervous exhaustion. Recovery is the rule, and the rapidity with which this takes place is very variable. The course is much shorter in cases where the paralysis is limited to the palate. This usually passes off in a fortnight or three weeks. When the loss of power becomes gen eral, a cure is effected with much greater difficulty ; but even in these cases it seldom lasts longer than three, or at the most four months. Sometimes the limbs recover their power very rapidly while the pharynx remains ob stinately paralyzed for a considerable longer period.
Diagnosis.—When diphtheria gives rise to well-Marked symptoms, its detection is easy. The tough-looking gray or fawn-coloured membrane in the throat, the redness and swelling of the fauces, and the enlarged cer vital glands are sufficiently characteristic. In tonsillitis the uvula is not swollen, and the whitish exudation occupying the mouths of the crypts, and sometimes spotting the surface of the tonsils, is very different in ap pearance from the consistent false membrane of diphtheria. It never forms a coherent layer, and never invades the naves or the larynx. Moreover, in quinsy, although the swollen tonsils can be felt externally, the cervical glands are seldom appreciably enlarged. If, in diphtheria, the exudation is soft and pultaceous, instead of being coherent and tough, there is still enlargement of the superficial cervical glands, and the general symptoms indicate profound depression. Any huskiness or weakness of the voice implies extension of the inflammation to the larynx, and points unmistak ably to diphtheria. The difficult cases to detect are those in which the throat affection is imperfectly developed, or is slow to appear. At first, nothing may be noticed but redness and swelling of the fauces, with some discomfort in swallowing. In such cases until the false membrane ap pears, we cannot say that we have not to deal with an ordinary inflamma tory sore throat ; for although the weakness and pallor of the patient are usually out of proportion to the apparent mildness of the local affection, no positive inference can be drawn from this discrepancy, as some chil dren are more depressed than others by a trifling ailment. If such a con dition be met with at a time when diphtheria is known to be prevalent, we should regard the symptoms with much apprehension. Indeed, in any case of sore throat, if enlargement of the glands of the neck can be dis covered, we should withhold a positive assurance that the complaint is one of little consequence. Sometimes the appearance of albumen in the urine comes opportunely to clear up a doubtful case. Sometimes after the ter mination of an ill-defined angina, the oecuiTence of paralysis throws a new light upon the past indisposition.