milk was stopped and she was put on cereals, beef juice and broth. Improvement was almost immediate, the appetite returned, the movements dropped to one a day and were normal in character, the irritability ceased and the temperature dropped to normal. After a week two ounces of milk were added to each feeding of barley water. Within 12 hours the temperature was up again and all the symptoms had returned. The mother could not believe that the trouble was the milk and kept on with it for a week, although the fever and other symptoms persisted. The milk was again stopped, with, as before, an immediate cessation of the fever and other symptoms. It was several months before she was able to take milk.

A boy that had been well except for moderate indigestion in the early months had been decidedly overfed during his tenth month, the milk being very rich in fat. Loss of weight, vomiting and undigested movements were the results. Directions as to feeding were not followed during the next few months, except spasmodically, so that when he was 14 months old his condition was a serious one. He had lost much strength, weight and color, was very irritable, had four or five undigested, foul movements with mucus daily, and ran a temperature between 99.5° F. and 100° F. Physical examination was negative except for distension of the abdomen and slight signs of rickets. During the next three months he was under the care of a trained nurse and all directions were carefully followed. Milk in some form, whey, skim milk and whole milk, but never cream, always formed a part of his diet. He gained considerably in strength and color and a little in weight, but was very peevish and constantly ran a temperature between 99.5° F. and 101° F., and continued to have several very large, loose, undigested, but extremely foul movements daily. Milk in every form was then cut out. Improvement was almost immediate. The foul odor of the movements ceased after a few days, and the temperature dropped to normal in about a week and remained there. Three months later he was able to take a little milk without being upset, but even after six months, when two years old, he could not take more than eight ounces a day without a return of the fever and the foul odor of the movements.

Finally, there is a class of cases of continued fever in infancy and early childhood in which the most careful examination fails to find any cause for the fever, in which no modification of the diet is of any avail and in which the general condition is unaffected, the child being apparently well and gaining normally in weight. The temperature may remain elevated for many weeks or even months in such cases and finally cease without any cause for it having been discovered. The most reasonable explanation of the fever in these cases is, it seems to me, some obscure disturbance of metabolism. The following case is an example:

A girl of two years had a slight cold lasting about a week. The temperature, which was first taken during the cold, did not drop when the child recovered, but continued elevated. To make a long story short, it ranged between 100° F. and 101° F. in the morning and 102° F. and 104° F. in the afternoon for 11 months, finally coming slowly down to normal and remaining there. During this time she appeared perfectly well in every way and gained steadily in weight and height. Repeated physical examinations failed to show anything abnormal. The urine was always normal and the blood never showed any parasites or abnormalities in the number of red or white corpuscles. She is now, four years later, an exceptionally large, strong and healthy girl.

Such cases justify the conclusion that if a careful study and thorough examination of the child does not reveal the cause of the fever, there is, in the vast majority of cases, nothing serious the matter and no cause for anxiety.

Hypertrophied Faucial Tonsils and Adenoids an Etiologic Factor in Backward Children.

By H. B. ORMSBY, M. D.

Every physician will readily concede the fact that there is no other single condition, with perhaps the exception of heredity, that plays so great a part in retarding the normal growth and development, both mentally and physically, of the infant and young child, as does hypertrophy of the faucial tonsils and adenoids. This fact is so universally recognized that I feel an apology is due my hearers for asking your attention to a paper of this character. Yet the subject is of such vital importance that much good may come from a free discussion of it at this time, and possibly, by this means, we may be able to influence some of our fellow practitioners to be on the lookout for adenoids in infants, even when the tonsils are not enlarged.

That adenoids very often exist without enlarged tonsils is not universally recognized. Snuffles are too often attributed to colds or lues, but if we should examine the fauces of the child that has a cold in its head, in the great majority of cases we will find that the child has adenoids. When we do find them we ought not to temporize with sprays and washes, but should advise their removal with the curette. A general anesthetic is not usually necessary. A few strokes of the hand will quickly clear

Read before the Clinical and Pathological Section of the Cleveland Academy of Medicine, June 5, 1908

the posterior nares. The hemorrhage is not profuse and the next day the snuffles and cold in the head are gone.

F. B. Sprague, of Providence, R. I., in a paper read at a meeting of the New England Otological and Laryngological Society, January 19, 1906, said: "The relation of this subject to the family doctor is of great importance. There is yet a remnant of the generation of doctors who, ignorant of the irreparable damage done to the mouth, throat and delicate structures of the ear during the years of the growing child, discourage operation, advising that the child will outgrow the trouble. It is within the special domain of the family physician to advise and direct the care of children in such a manner that they will grow up vigorous and healthy offspring, with prospects of having a healthy state physically, mentally and morally, and become useful members of society."

We must teach the parents that if there is any difficulty in breathing during the first few weeks or months of infant life they must consult the family physician. We must also teach them that the normal child nurses well, sleeps well, increases steadily in weight, and is not fretful either in its waking or sleeping hours, and we must impress upon the mind of the parents that when the child has these abnormal conditions it is more susceptible to contagious diseases and that its vitality will become markedly impaired, thereby making it more liable to contract the infectious diseases, such as tuberculosis, typhoid fever and intestinal disturbances.

When we explain to the parents that a general anesthetic is not necessary (this being the greatest dread to them), that it takes only a moment, that the child will not be confined to bed, that it will surely sleep better, eat better, and develop faster in every way from the moment it is operated upon, then not one parent in fifty will still oppose the operation.

In 1905, the Health Department of New York began a systematic examination of all school children. These examinations were especially for defective hearing, vision and diseases of the respiratory organs. Nearly 70% of these children possessed abnormalities which could be easily corrected, but which, if neglected, would make them fit subjects for institutions for defectives and delinquents. In one school alone about 90 were operated upon for enlarged tonsils and adenoids. It is a noteworthy fact that this was a special school for backward children, and a report from 80 of them, two years later, showed that they

had done better school work in the subsequent six months than they had been able to do in two years previous to the operation. It goes without saying that had not this inspection been carried on, and had nothing been done for those children, they would have been unfitted for study or any important position in after life, whereas now they will become valuable members of their respective communities. Many of these children had defective noses and throats from early infancy and little attention was paid. to them then. When these children became old enough to enter school they did not learn as normal children, but seemed lazy, dull, stupid, obstinate and rebellious, necessitating their removal to a special school for backward children. Here the true condition was discovered and corrected with the miraculous result stated.

In such a systematic examination of school children, diseased noses and throats would not be the only abnormal conditions found. It would be discovered that a great percentage of the children had defective eyesight, impaired hearing, deformed chests, poor digestion, wrecked nervous systems, rheumatism, rickets, and were slow to learn, etc.

Some parents argue that they themselves had enlarged tonsils and outgrew them, while, as a matter of fact, they did not outgrow them but the relief derived as years advanced was due to the growth of the pharynx rather than the atrophy of the gland. In many cases of enlarged tonsils and of adenoids a true. fibrosis exists, and when a true fibrosis does supervene atrophy seldom if ever takes place, and the condition consequently persists until corrected by operation.

Burkett, of Montreal, reports that out of 10,000 patients complaining of nose, throat or ear symptoms, 1,605 were suffering from enlarged tonsils or adenoids. Chappell reports that out of 2,000 New York school children, 30% possessed adenoids. A routine inspection of school children in Cleveland, where the atmospheric conditions are favorable for catarrhal troubles, would, I am sure, show a much larger percentage of children possessing adenoids and enlarged tonsils.

Before considering in detail the general symptomatology of enlarged tonsils and adenoids it may be well to refer to the anatomy of the throat in infancy and childhood. The nasopharynx, a long narrow passage running obliquely backward and downward from the posterior nares, is nearly as large anteroposteriorly as in adult life, but the soft palate is somewhat lower.

The nasal cavity is large and shallow at birth, so that respiration is not, in a normal condition, as free as in adult life. The posterior openings are usually about as large as a medium sized male catheter. These openings double in size the first six months, then remain nearly stationary the next two years. Opening into the anterior and lower portion of the lateral wall of the nasopharynx opposite the posterior termination of the lower turbinated. bones, on either side are the Eustachian tubes. In the upper central portion of the pharyngeal vault there is a crowding together of a large number of glands into a distinct mass. This mass is known as the pharyngeal or third tonsil, first described by Luschka, and sometimes called Luschka's tonsil. This structure is always present in this region, but, of course, in different degrees of development. When diseased it covers the roof and posterior wall of the nasopharynx, covering the whole extent of the occipital bone and constituting a serious obstruction to the free passage of air, with a resultant menace to good health. The nasopharynx derives its arterial supply from the ascending palatine branch of the facial, the ascending pharyngeal branch of the external carotid and palatine and sphenopalatine branches of the internal maxillary. The internal jugular receives the venous supply. The nerve supply is derived from the second division of the fifth, and from branches of the glossopharyngeal and vagus. The mucous membrane is covered with columnar ciliated epithelium, which, together with the extensive glandular structures of this region secreting an abundant supply of mucus, facilitates the free passage of food to the esophagus.

Etiology: Enlarged tonsils and adenoids are diseases of childhood and young adult life. In many instances the condition will subside as the child reaches maturity, but in waiting for that time to come irreparable damage may be done, and many of the most important years of the child's life lost, for it is during these years that the foundation of the child's future health is begun. This general predisposition to enlarged tonsils and adenoids in childhood is probably due to the high activity of the epithelial and lymphatic structures, that is, a child seems to possess a lymphatic temperament so that, when kept in too close quarters, or when there is not sufficient fresh air in the sleeping room, it gets a marked congestion of the mucous membrane of the air passages as soon as it is taken out of doors. This being often repeated produces a swelling of the mucous membrane and lymphatics, with a resultant obstruction to the free passage of air, and still