mposed, giving a most offensive and
characteristic odour to the breath. There is pain and difficulty in
swallowing, but unless the disease has affected the larynx no affection
of the breathing. The voice acquires a snuffling character. When the
disease invades the posterior nares an acrid, fetid discharge, and
sometimes also copious bleeding, takes place from the nostrils. Along
with these local phenomena there is evidence of constitutional
disturbance of the most severe character. There may be no great amount
of fever, but there is marked depression and loss of strength. The pulse
becomes small and frequent, the countenance pale, the swelling of the
glands of the neck increases, which, along with the presence of albumen
in the urine, testifies to a condition of blood poisoning. Unless
favourable symptoms emerge death takes place within three or four days
or sooner, either from the rapid extension of the false membrane into
the air-passage, giving rise to asphyxia, or from a condition of general
collapse, which is sometimes remarkably sudden. In cases of recovery the
change for the better is marked by an arrest in the extension of the
false membrane, the detachment and expectoration of that already formed,
and the healing of the ulcerated mucous membrane beneath. Along with
this there is a general improvement in the symptoms, the power of
swallowing returns, and the strength gradually increases, while the
glandular enlargement of the neck diminishes, and the albumen disappears
from the urine. Recovery, however, is generally slow, and it is many
weeks before full convalescence is established. Even, however, where
diphtheria ends thus favourably, the peculiar sequelae already mentioned
are apt to follow, generally within a period of two or three weeks after
all the local evidence of the disease has disappeared. These secondary
affections may occur after mild as well as after severe attacks, and
they are principally in the form of paralysis affecting the soft palate
and pharynx, causing difficulty in swallowing with regurgitation of food
through the nose, and giving a peculiar nasal character to the voice.
There are, however, other forms of paralysis occurring after diphtheria,
especially that affecting the muscles of the eye, which produces a loss
of the power of accommodation and consequent impairment of vision. There
may be, besides, paralysis of both legs, and occasionally also of one
side of the body (hemiplegia). These