In most cases the disease lasts from 4 to 10 weeks and gradually ends in recovery. A duration of several months is possible. The dangers of the disease are heart weakness, inspiration pneumonia, paraly-sis of the diaphragm and general inanition. Hence the pulse, respiration and the urine (albuminuria is an unfavorable symptom) must be w-atched with the greatest care. Sudden death from heart failure may occur without warning.
According to the view which is generally accepted at the present time the pathologic basis of postdiphtheritic paralysis is an inflammation of various peripheral nerves. Positive changes in the spinal cord are particularly frequent in this form of polyneuritis and their significance has already been discussed in connection with that disease. They are degenerations of the anterior roots, changes in the cells of the anterior horns (Dejerinel, increase in the neurogliar tissue, luemorrhage into the substance of the spinal cord and into the spinal ganglia, and menin gitic process (Oertel). In every instance we find disease of the peripheral nerves, either alone or in connection with the above-mentioned spinal changes (Preisz). The nerves exhibit degeneration of the parenchyma, inflanimation and proliferation of the connective tissue, with new for mation of cells and accumulation of leucocytes or fusiform swellings of the trunk of the nerve (P. Meyer). The cranial nerves also are fre quently degenerated (Mendel, Oppenheim, Siemerling, Anaheim, etc.). The muscles also exhibit parenchymatous degeneration 11 ith increase of connective tissue (Flochhaus). In spite of the great variety of the changes observed, practically all the authorities are agreed that the essential pathologic change at the foundation of the clinical picture is inflammatory disease of the peripheral nervous system. According to Remak the beginning of the paralysis is found in the palate on account of the nerves of that organ being, so to speak, "immersed in the poisonous focus." Experiments to produce diphtheritic palsy in animals artificially have not led to any definite results. According to Babonneix's attempt in this direction it appears probable that the diphtheritic poison is veyed toward the brain along the nerves and not by the blood vessels.
The diagnosis in the presence of unmistakable evidences of an attack of diphtheria and beginning paralysis of the palate pre sents no difficulties. A doubt could arise only in cases of evident
diphtheritic palsy without antecedent diphtheria. Experience leads us to believe that nondiphtheritie angina is also capable of producing paralysis of the palate. But cases of this kind are not altogether above criticism, and admit of two possible explanations: either that there may have been a diphtheria after all, or that the apparent angina was merely a symptom of some other grave disease which was the cause of a general polyneuritis. Hence, notwithstanding exceptional cases of this kind, it is a well-established fact, confirmed by an overwhelming number of cases, that a polyncuritis beginning with paralysis of the palate is practically always clue to an antecedent diphtheria, and that the occurrence of the palsy may be the earliest evidence of the true nature of an apparently benign angina.
In most cases of postdiphtheritic palsy expectant and tonic treat ment is all that is required; but whenever the disease has gone beyond the stage of simple paralysis of the palate, rest in bed with avoidance of all strain on the heart and regulation of the bowels is urgently indicated. If the paralysis interferes seriously with the taking of nourishment, artificial feeding with the stomach tube or nasal feeding may be necessary for a time. In any ease the patient requires the most careful feeding. Sometimes it is found that fluids are regurgitated through tile nose although the child is able to swallow semi-fluid and solid food. On the other hand, some children are able to swallow fluid or semi-fluid substances more easily than solid food. Artificial albumi nous preparations, such as sornatose, puro, sanatogen, etc., which are gen erally speaking superfluous articles, may be occasionally employed for the purpose of insuring a digestible and nutritious diet. Albuminuria may be disregarded in selecting a diet. When the patient is unable to take enough fluid, it is sometimes necessary- to give small pieces of ice, to be diss.olved slowly in the mouth, in order to relieve the thirst. If the nutrition is very much impaired, nutritive enemata may have to be employed.