answer "yes," but by the time this has occurred, which is usually at or about puberty, the deficient facial and chest development, the chronic rhinitis, sore throat and the damaged hearing are practically beyond benefit, and the person so fated is lucky if his infirmities do not increase, for they will certainly grow no less. Again, we are often asked as to their recurrence after removal. A few years ago I should have said no; that their non-recurrence was as sure as death and taxes." During the last two years, however, I have had two recurrences in cases which I know at the time I removed as thoroughly as any others so that I do not speak so positively now.

The third member of this group, the lingual tonsil, at the base of the tongue, differs from the others in one marked respect-it has no tendency to atrophy at puberty, and conversely is seldom affected before the twenty-fifth year. It is composed of two lobes lying on either side. of the base of the tongue, its tissues continuous with the faucial ones. Its hypertrophy is not so infrequent as might be cursorily thought, for Browne quotes 28 per cent. of the cases applying to the Central London Throat, Nose and Ear Hospital for catarrhal diseases as affected by it. Another peculiarity of chronic inflammation of this gland is the tendency of its blood vessels to become varicose, so that lingual varix is a well established term in the literature of throat diseases. There is no pain on opening the mouth when hypertrophied even sufficiently to interfere with the action of the epiglottis, and consisting, as it does, of two lobes, one may be involved alone and earache complained of, when nothing of an inflammatory nature can be found in the middle ear. Hypertrophies in this region are most often found in vocalists, or those using their voices much in dusty or the open air. The so-called clergyman's sore throat is undoubtedly kept up by it. Abdominal and hepatic plethora, as found in alcoholics and in cirrhotic conditions of the liver, conduce to its chronic inflammation, as it does of all mucous membranes of the respiratory tract. Two of the most severe and uncontrollable cases of epistaxis I ever met with in practice were in confirmed alcoholics with symptoms of cirrhosis. Elongated uvula is often associated with it and abscised for the relief of symptoms, with no benefit. It is often associated with dyspepsia, especially when of an acid nature, so-called, with frequent eructations, and it is really a question worthy of investigation whether "globus hystericus" is a fanciful and neurasthenic symptom or a real material one due to enlargement of this tissue, since the sensation can often be induced in these subjects by pressure upwards and backwards over the thyroid.

That infection of this tissue can easily lead to glossitis in varying grades of severity, is apparent when we recall the anatomy of the blood supply of the tongue, and several cases of Ludwig's angina have been traced to this organ as the etiological factor. Brown quotes Gillot as stating that he considers lingual tonsillar hypertrophy and varix as indications of a predisposition to apoplexy. As symptoms, blood spitting and blood oozes found on the pillow in the morning are frequently noted by these patients and are indications of its presence, especially if examination shows no lung involvement. The sensation of a foreign body having been swallowed and lodged at the base of the tongue is frequently complained of, patients refusing to believe after a most thorough and careful examination by laryngeal mirror, that no such body is present. The discomfort is often of a sticking nature, and fish bones and toothbrush bristles are often thought to have lodged there by them. Shortness of breath and the complete disappearance of all sensations of pain or discomfort during the taking of a meal are pointers as to its enlargement. It is rather more frequently found in the overworked and underfed woman than any other individual, and women, generally speaking, are more often affected than men. I have had recently a very intelligent lady patient of whom I have made a good friend by removing some of this tissue at the base of the tongue, which was keeping up a constant desire to clear the throat, with a hemming cough, and who had taken cough mixtures and throat lozenges time and again with slight, if any, relief. Some of us may recall the uneasiness of a part of the public mind, at least, at what was thought at the time to be the serious hemorrhages which occurred in the case of Sarah Bernhardt several years ago, presumed at that time to be pulmonary in origin, but later found to be from a lingual varix, vicarious in character, evidently, from their periodicity and associated with a history of beginning menopause. There seems in some instances to be a very intimate relationship between the two.

As I said in the beginning of this paper, gentlemen, I have not touched on the treatment of these conditions at all; my idea has been to call your attention to the seriousness of tonsillar hypertrophies, and also to point out a few symptoms outside of those generally recognized which shall help us to know when these serious conditions are present and at work, so that familiarizing ourselves with them in this manner and acting on that knowledge, we can undoubtedly banish much of pain, disfigurement, lack of development, mental and physical, as well as do much to preserve the valued sense of hearing. In so doing we

are all the better fulfilling our offices as true physicians in every sense of the word, and making this world of ours the better and happier for our having lived and worked intelligently in it.

ACUTE ANTERIOR POLIOMYELITIS.

BY PHILIP F. BARBOUR, A.M., M.D.

Professor of Diseases of Children, etc., in the Hospital College of Medicine.

Anterior poliomyelitis is the most frequent cause of paralysis occurring in children. The type is clinically so distinct and the location of the lesion so well known that the disease is frequently named infantile spinal paralysis. While easily diagnosed as a rule its etiology is uncertain and its treatment very unsatisfactory.

Various theories have been propounded to explain the origin of this disease. One may select a number of different pathological findings and believe that any one of them explains the disease, but the pathology as so far developed explains results rather than demonstrates causes. The most widely accepted theory is that anterior poliomyelitis results from an inflammation attacking the anterior horns of the gray matter of the spinal cord. Without attempting to recall to your mind these various theories, I would lay stress upon the most recent theory, which seems better to explain the phenomena of the disease than any of the previous hypotheses. All authorities seem to agree that the lesion lies primarily in the blood vessels of the cord, and that the involvement of the gray matter is secondary to the pathological condition of the blood vessels. They hold that the trouble in the blood vessel is inflammatory in nature, but because the disease is so rarely fatal, and when fatal so much time has elapsed since the acute stage of the disease, the character of the acute lesion can not be demonstrated, and its inflammatory nature is only inferred from the results. It has been suggested that the true lesion is a thrombosis of the arteria fissuræ anterioris, which passes inward through the anterior fissure, and when it reaches the gray matter breaks up into fine capillaries which are distributed to the anterior horns of gray matter. These arterial vessels are terminal, which explains the severity and the irrevocableness of the result. The inflammation involves principally the nerve cells in the anterior horn, and the symptoms result from the atrophy and destruction of these cells. The causes of this thrombosis are various. The contagious diseases, such as scarlet

* Read before the Louisville Neurological and Psychological Society, December 8, 1904.

fever, measles, typhoid fever and influenza have very frequently been followed by anterior poliomyelitis, and therefore it would seem that a number of organisms stand in an etiological relationship to this trouble. It is believed, however, that it is not the direct action of the germs, but the toxins elaborated by them which produce the local condition in the arteries which results in thrombosis.

Other causes which have been assigned are exposure, traumatism, teething and psychical phenomena, such as fright. But these are most probably only predisposing causes, for they do not explain the fact that the disease is frequently distinctly epidemic, and much more prevalent in the warm months. It is a disease of early childhood, for So per cent. of cases occur in the first three years of life.

The onset of the disease is usually acute, commencing with a temperature of 101 to 104° F., with headache and occasionally convulsions. There are vomiting and diarrhea and general hyperesthesia, with numbness and tingling. Usually there are pains in the back and traveling down the nerves of the extremities. There may be prodromata, such as weakness, malaise, etc., but again the child may awake after a sound sleep, paralyzed. Usually the paralytic symptoms come on in from three to six days, showing at first extensive involvement of the upper and lower extremities. The lower extremities are involved in the great majority of cases, the right more frequently than the left. The cranial nerves usually escape, and the sphincters almost never are affected.

Within a few days of the onset of the disease the paralysis begins. to clear up and there is a continual improvement for several months, nature reaching its limit usually in about three months. It is thought that the zone of inflammatory reaction in the anterior horn of gray matter is more extensive at the onset, and after the inflammatory products are absorbed the surrounding cells regain their former activity, but the cells which were actually diseased are atrophied and undergo granular degeneration and finally disappear. Consequently, the onset may be characterized by loss of power in an entire limb, but when the inflammation clears up only a few cells or a group of cells may have been destroyed, so that nearly all the muscles of the extremity regain their tone, and the permanent paralysis is seen to involve only a few muscles and usually those which are co-ordinated in their functions. The primary lesion may have been so slight that no permanent damage has been done, and the paralysis eventually completely disappears. As the lesion is confined to the anterior horns

there are no sensory disturbances after the immediate attack, but the death of the giant cells will eventually result in great atrophy of the muscles with which they are connected.

The electrical reactions are quite diagnostic, and consist in a very rapid loss of faradic irritability, which soon disappears completely. Galvanic irritability remains increased for several months and then diminishes, disappearing entirely in from one to two years if the paralysis is permanent. Reaction of degeneration is always observed, and serves to differentiate from other similar conditions. When the paralysis is not complete and permanent, the faradic irritability will return in from six to twelve months, though the muscles may still remain weak. Sometimes a child is able to walk again, but when grown it is unable to walk because the weakened muscles are not able to carry the heavier load of the increased stature and size.

Atrophy involves the muscles and produces marked wasting early. Trophic changes eventually will be seen in the bones also, for frequently they fail to grow as rapidly as the symmetric bones, and shortening of the limb results. Then the loss of muscular power, coupled with the poor growth of bone and the overaction of the muscles which were not paralyzed result in subluxation of the joints and the so-called flail joints and extremities. Various deformities,

club feet of every description will be met with.

The muscles which are usually involved are the anterior tibial group and the extensors in general. The deltoids of the upper extremity are most often paralyzed. The explanation of this is that the cells governing the forearm and hand lie laterally to the other cells of the anterior horn and receive their nutrition in part from the blood vessels which surround the cord. So that a thrombosis of the arteria fissural anterioris only partially affects their blood supply.

Trophic changes in the blood vessels of the extremities occasion the blue and cold hands and feet. The circulation becomes poor, but strangely enough, bed sores do not occur.

The diagnosis usually is easy, for the symptom complex is quite distinctive. However, the following diseases should be kept in mind in arriving at a diagnosis:

Cerebral palsy is differentiated by the absence of reaction of degeneration and of atrophy, except from disease, by the character of the palsy, which is spastic, and by the presence of knee jerk and characteristic contractions, and of cerebral symptoms present or of which a history is obtainable.