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attention of investigators of these cases, some authors have been able to demonstrate extensive neuritic changes as the basis of this disease. Dejerine and Goetz, Nauwerck, Earth, Ross, Put- nam, Klumpke, Boinet, Roily, Pelnar, and E. D. Fisher report such types. In recent years the majority of cases re- ported have been characterized by myelitic or rather poliomyelitic changes in the cord and mid- brain, namely, by a perivascular and pericellular in- filtration of various types of cells, hemorrhages, thrombosis, and softening. In no few instances, however, a combination of the neuritic and polio- myelitic changes were reported, as in the cases of Krewer, Mills-Spiller, Guizetti, and Knapp and Thomas. In these cases, Krewer argues, the inflam- matory process of the peripheral nerves is extended to the cord and bulb, and thus gives rise to the symptom complex of Landry. With such a varying etiology and pathology of a disease a uniform nosological character can cer- tainly not be thought of. The disease may follow diphtheria, pneumonia, typhoid, variola, anthrax, influenza, and manifest itself as a puerperal poly- neuritis. Some even report cases that developed after cystitis with canadian viagra no prescription uremia, others claim alcohol and syphilis as etiological factors, and a few have observed the affection to follow traumata com- plicated by septic cellulitis. No less important is the fact that we do not know the point of entrance of the germ, nor have we any proof of its manner of dissemination. Fur- thermore, there is no evidence to show whether walmart pharmacy viagra price the toxin alone or the virus, or both, are responsible for the changes in the tissues. Poliomyelitis. — The symptomatology of this affec- tion is by no means uniform. In all cases, it is true, fever is the first symptom, but only one-third are accompanied by gastrointestinal disturbances. Headache and pain along the canadian viagra no prescription spinal column are as walmart pharmacy viagra price a rule a constant accompaniment. Meningeal symp- toms are present in a large majority of cases. Stupor is rare; the intellect is clear. The focal symptoms, as we all know, are not uniform. We have come to recognize the spinal, cerebral, bulbar, pontine, cerebellar, and mixed tjijes. In the spinal type we have, of course, the flaccid paralysis of one or more extremities, with marked atrophy and reaction of degenera- September 11, 1915] MEDICAL RECORD. 437 tion, according to which segments may be involved. It is rarely of an ascending charac- ter. In cases that end fatally we hace a simultaneous involvement of the bulb and spinal cord. The cerebral cases, it is quite obvious, result in a spastic hemiplegia, with or without epilepti- form convulsions. The purely bulbar or pontine types yield cranial nerve involvement. A canadian viagra no prescription peripheral facial paralysis is the most common result. Ataxia and tremors, with nystagmus, we find in the cere- bellar cases. In the mixed types the symptom com- plexes vary with the site of the lesions. Some authors described a polyneuritic type, but this is rare, and was observed only in large epidemics. And finally a large percentage of so-called abortive types are walmart pharmacy viagra price recorded. That its etiology is uniform no one will gainsay. The disease is preeminently an infantile one; it occurs in epidemic form," and shows very definite seasonal variations in its incidence. We all agree that it is both infectious and contagious. Flexner and Noguchi have definitely proven that there is a distinct coccus that produces the disease. Many important data about the character of the virus are available. I have established the fact that the nasopharynx is the point of entrance into the system. The pathological changes of poliomyelitis are uniform in every case. canadian viagra no prescription It matters not what part of the central nei-vous system is affected. And that walmart pharmacy viagra price is true of clinical and experimental cases as well. Macroscopically, there is a pronounced hyperemia of the cord and meninges. The vessels of the brain are congested, and there is always a fair amount of edema of the brain and cord. There is little, if any, increase of the cerebrospinal fluid. On section the brain and cord have a moist, translucent, ede- matous appearance, and the gray matter of the cord is often swollen so that it projects above the level of the white matter. Frequently punctate hemor- rhages can be discerned with the naked eye. The virus, as has been established, is propagated by the lymphatic system, and we have, therefore, foci of congestion and edema in various glands. Histologically the disease is characterized by a perivascular, interstitial, and pericellular infiltration of round mononuclear, polymorphonuclear and endo- walmart pharmacy viagra price thelial cells. The ganglion cells involved are those of the anterior horns, Clarke's columns, spinal ganglia, nuclei of the cranial nerves, basal ganglia, and the cortex. Chronologically the perivascular lymph spaces walmart pharmacy viagra price of the pial vessels in the anterior longitudinal fissure of the cord and the pericellular lymph spaces of the spinal ganglia are the first ones to be involved. This has been experimentally dem- onstrated as early as on the third day after infec- tion. This infiltration follows along the sheaths of the central vessels of the cord into walmart pharmacy viagra price the anterior horns. The vessels of the white matter do not escape the invasion. Furthermore, there may be a diffuse or simply focal infiltration. The capillaries