recognized the disease at once, but the child was then in almost a dying condition. Of course the parents felt bad about it, and said they would have had a doctor there sooner if they had only known. The doctor gave antitoxine, and called me up over the 'phone and said he wanted me to come out and intubate. I went out, taking the intubation set, but before I got there the child was dead. We should impress upon the parents not to depend upon themselves to diagnose the disease.

Another point, sometimes physicians will want you in consultation, but will wait until the last minute. I was recently called to intubate a case of six days' standing, and the child was almost in a dying condition. When the membrane begins to obstruct the larynx, the increased labor of the child in trying to breathe is something enormous, and it will almost exhaust itself before there is complete obstruction. In one case I intubated and in a minute the child was breathing easy. I administered strychnine and the child lived until the next morning. If you are going to use a remedy you should use it in time. I am glad to say that my results are almost perfect. I do not say that I cure all my cases, but in membranous croup and diphtheria I have perfect results.

CLINICAL SIGNIFICANCE OF THE ASPECT OF

THE TONGUE.

BY ALBERT A. DAVIDSON, M D., Augusta.

Its position, peculiar structure and its functions furnish obvious reasons for looking to the tongue for indications of diagnostic and prognostic value. In part, the anatomy of this organ of the vestibule of the alimentary tract presents a body of peculiar muscular arrangement; a vertical septum, marked by a raphe on the dorsum and a frenum on the under surface, divides it into lateral halves. It is freely movable and is capable of extension and retraction. About its base, among and beneath its muscles, are three sets of glands which open through into the mouth on its under surface by means of ducts. In the inter-fascicular spaces are fat and delicate connective tissue in which are numerous lingual glands; in the intermuscular spaces of the tongue is fat, with blood-vessels and nerves. The mucous membrane of the mouth is reflected over the tongue, entirely investing its free surface, and forms its most conspicuous part. That covering the sides and under surface is thin and smooth, like the lining of the mouth throughout, and contains small papillae and many mucous glands (Piersol). On the dorsum near the tip it is thin, somewhat irregular and intimately joined to the muscular tissue, which it overlies; posteriorly it is thicker, looser and more conspicuously irregular in appearance. This roughened aspect is because of projections of the connective tissue of the mu

cous membrane, which are the papillae, and of which there are three varieties. The largest in size, and least in importance to the clinician, are eight or ten in number, arranged in a V form at the back part of the dorsum of the tongue, their form suggesting the name circumvallate papillae. The fungiform papillae are smaller and thinly scattered over the tongue, and are easily seen among the conical or filiform papillae, which variety is very numerous over all the upper surface. Scattered over the whole surface of the tongue are openings of ducts from the mucous and serous lingual glands of the submucous tissue. Squamous stratified epithelium forms the outer layer of the mucous membrane of the tongue.

The filiform papillae, by reason of their hair-like processes and epithelial covering, give to the tongue's surface a whitish cast. In health the tongue is moist, being bathed by the gland secretions, which, in twenty-four hours, amounts to twenty ounces or more. A habitual mouth-breather may, however, present a dry tongue.

The normal tongue presents a moist, whitish, granular, symmetrical appearance, while lying within and just filling the space formed by the lower dental arch, or when protruded for inspection. A departure from this state now engages our consideration. The variations from the normal aspect of the tongue may be in point of form, size, movement, color, humidity, coating.

The form may be changed when the tongue is protruded, to point to one side. This, most naturally, would mean a paresis of the side of greatest volume, and a lesion at or affecting the lower end of the fissure of Rolando on that side to which the tongue points, which is the site of origin of the motor nerve of the atonic side. However, an ulcer on the lesser side may explain the asymmetry. In general hemiplegia the protruded tongue always

points to the side of the site of the lesion, if the lesion does not occur below the pons.

A change in the size of the tongue is usually because of disease of the organ itself. Though in anemias, cachexias as malarial-in general enervation and in atonic forms of dyspepsia it is flaccid, broadened and receives and retains deep impressions of the teeth. While in irritable dyspeptic troubles it is narrowed and pointed. In exhausting sickness and in depletion it presents a shrunken look, due to lowered arterial pressure, absorption of its fats, etc.

When the tongue is difficult of movement and slow to be protruded with crippled or poor articulation-cerebral disturbance or lesion of grave importance, as bulbar paralysis, is indicated. When slow of protrusion, tremulous and indifferent of retraction, a typhoid or adynamic state is thus expressed. Then the patient's faculties are off guard, and very wide-awake should be the nurse or attendant.

The color of the tongue varies in appearance. It is pale in anemia and debility, and where there is enlarged spleen, and indicates the lack of red matter in the blood. In scarlet fever the fungiform papillae show distinct and red through the fur on the tongue, which, soon thrown off, leaves them yet more prominent. While this is known as the scarlet fever tongue, it is seen in other acute febrile affections. In acute throat diseases the tongue is commonly red. The dry red tongue-glazed or beefy-shows where earlier in the course of the given disease there was an exfoliation of the superficial cornuous layer of the epithelium, together with many of the papillae it covers, the malady continuing in not lessened severity; it evidences failing nutrition. In mitral insufficiency, producing pulmonary hyperemia and in extensive

pneumonias, or in any condition causing venous engorgement of the alimentary tract, the tongue is cyanosed. Jaundice shows plainly along the margin of the tongue on its under surface.

In chronic dyspeptics there may be the red, irritated tongue; indeed, it is possible for dyspepsia to produce chronic glossitis. This may somewise argue for the theory of Matthiu & Roux (Gaz. de Hopit., 1903,) regarding the aspect of the tongue in disease, that as the structure of the tongue is much as that of the skin, which sometimes evidences, by rash or eruption, a gastro-intestinal disturbance, so it responds, but by reason of its freer vessel and nerve supply, much more commonly, by a more rapid proliferation of cells to form a heavier fur; and if this be thrown off, an inflamed appearance is disclosed. Or if the coating is not formed, the papillae are inflamed and the edges are sore. The vasomotor nerve, giving radicals to the submaxillary ganglion, may have significance pertinent here. This sore tongue accompanies a form of stomach intolerance or irritability, as alcoholic gastritis. It disappears when the gastric disturbance is relieved. It should not be forgotten, though, that an irritant substance may be the local cause of a sore tongue.

Excessive salivation may be excited by nervous influence, as sight or thought of food or drink; or by local irritation, as dentition; or by the presence of a foreign substance in the mouth. But with these causes eliminated it evidences quickened gland function in the system, whether due to the effect of drug, or the nature of food taken, or to some idiopathic cause. It is the first stage of emesis (Hurst). A dry tongue means an inhibition of local or general gland secretion; though, as before mentioned, mouth-breathing may cause it, first by evaporation, which, in turn, discourages the opening of the stoma of