Healing of Granulating Wounds. The remainder of the chapters are devoted to Operations and their Post-Operative Treatment.

A COMPEND OF THE PRACTICE OF MEDICINE. By Daniel E Hughes, M. D., late Chief Resident Physician Philadelphia Hospital; late Physician-in-Chief Insane Department, Philadelphia Hospital; formerly Demonstrator of Clinical Medicine in the Jefferson Medical College of Philadelphia, etc. Seventh revised edition, edited, revised and in parts rewritten by Samuel Horton Brown, M. D. P. Blakiston's Son & Co., 1012 Walnut St., Philadelphia, Pa.

In the preparation of the 7th edition of this work, the previous edition has been subjected to most careful revision. The arrangement of the diseases has been changed considerably to conform with the more modern divisions of pathology. Introductory notes have been placed at the beginning of each section. Many new prescriptions and modern modes of therapy have been incorporated in the text.

The new material worthy of especial mention includes the articles on the classification and general characteristics of fevers, the blood and its examination, examination of the sputum, examination of the stomach contents, urinalysis, physical diagnosis and the introductory notes on symptomatology placed at the beginning of each section. This volume includes a section on Mental Diseases and a very complete section on Skin Diseases.

RECIPROCITY BILL PASSED.

As we go to press we learn that the Reciprocity Bill, referred to editorially in this issue, has passed both branches of the General Assembly. For the passage of this important measure the profession is greatly indebted to the indefatigable and well directed efforts of Dr. T. H. Martin of Cleveland, President of the State Medical Association; Dr. J. W.. Clemmer, Chairman of the Committee on Medical Legislation of the same body; the physicians in the Legislature, various County Medical Societies and many physicians through

out the state.

In trying to find the origin of many cases of chronic pharyngitis, my suspicions were attracted to mouth breathing as one of the common causes of this complaint. With scarcely an exception, patients suffering from chronic pharyngitis and laryngitis have more or less difficulty in inhaling sufficient air through the nose. This is particularly noticeable when exercising briskly out of doors during the cold and damp season of the year. If anyone should take the trouble to observe the people on a cold winter morning as they walk to their places of business, he would be surprised at the number who are inhaling the cold, raw air through the open mouth directly into their lungs. The thin and delicate membrane of the pharynx and larynx is utterly incapable of giving moisture to and heating the air to its proper condition before entering the lungs. The cold air overstimulates the vaso-motor nerve endings controlling the small capillaries of the throat. There is first a contraction and blanching of the membrane from the cold, followed by a relaxation of the capillary walls, and a pouring out of secretion from the mucous glands in this region. The work that this membrane is called upon to do is entirely beyond its capabilities, it becomes thinner, the patient complains of dryness in the throat, and in course of time the result is a chronic pharyngitis.

*Read before the Columbus Academy of Medicine, March 4, 1906.

The question as to the original cause of mouth breathing would seem a little difficult to answer. Very young children, I think, as a rule, have little difficulty in breathing through the nose. It is only in later childhood, subsequent to the hypertrophy of the adenoid tissue in the vault of the pharynx, and hypertrophy of the tonsils, that the children begin to breathe through the mouth.

It seems proper to suggest that our habits of living are such as to bring about these very conditions. In the first place the children are often housed in overheated and ill-ventilated rooms, and coddled in heavier wraps than is necessary for their health. This hot-house preparation illy prepares them for the vigorous and sudden changes that they undergo in passing from these warm rooms into the winter air. These sudden changes are probably a strong factor in bringing about the congestion of the mucous membrane and underlying tissue of the turbinals in the nose, and increasing the hypertrophy of the glandular tissue in the pharynx.

"Does not the continual tropic house warmth actually reduce the tone of the tissues and make them more susceptible to bacterial invasion? The thought is naturally suggesed that perhaps cold air has hygienic as well as therapeutic uses. We. rather look upon hot weather as relaxing and destructive of vitality, and expect health with return of cold weather. Brook trout perish if the water they breathe is raised only a few degrees in temperature. There is enough in this matter to cause us to think about it a little. If so many cured tuberculous patients are now sleeping in cold air every night and living in it in the daytime, too, as much as possible, perhaps the rest of us are only injuring ourselves by the opposite course. Only a few years ago the cold-air fiend, who slept with windows wide open in the coldest winter, was considered a crank. Perhaps he will prove to have been the only sensible one among us, and was merely imitating the ways of his ancestors, who had practically no way of warming their houses."

As it is the function of the turbinals to supply sufficient moisture to the air, and properly regulate its temperature as it passes into the lungs, it naturally follows that the air must

be made to pass through the nose, over the turbinals, in order that they may be in proper condition to do their work.

One of the probable evils of mouth breathing in early life is the raising of the palatine arch by undue pressure from the inhalation of air through the mouth. This excessive arching of the hard palate, which is also the floor of the nose, encroaches upon the space in the nose. During development the septum would naturally grow so as to fill the space allotted to it in the nose. Now that space, as has been shown, is consequently narrowed in its perpendicular diameter, and it naturally follows that the septum will bend to one side or the other. Where a person has a high arched palate we expect to find either a deflected septum in the shape of a large curve, or a sharp kink or spur. The latter is nearly always seen along the line where the vomer joins the perpendicular plate of the

ethmoid.

A popular impression prevails that deflections and spurs of the septum are caused by a blow on the nose some time during development. While it is easy by suggestive questioning to get a history of an injury to the nose, in almost every instance of deflected septum, I usually find that when the patient volunteers the information of a blow on the nose, that the injury has been sufficient to cause a considerable thickening of the whole septal wall, from the consequent inflammation, which is not found in ordinary septal deformities.

There is no doubt that mouth breathing, with its consequent high arching of the palate, is responsible for the peculiar shaping of the face, seen in many children suffering from adenoids. It is also a factor in causing the protruding and misshapen teeth of the upper jaw. Dr. C. A. Hawley tells me that in looking over twenty-nine plaster casts of corrected deformities of the teeth from narrowing of the upper jaw, he found nineteen with histories of operations for removal of adenoids. These cases were taken at random, and he further states that he had no doubt that some of the others had nasal or post-nasal obstruction. Dr. Hawley called my attention to another interesting point; that a high arched palate and narrow posterior nares might have the relation to each other of cause and effect.

The secretion of the nose is more or less bactericidal. The dust in the air on entering the nose is filtered through the moistened vibrissae, and also becomes deposited on the viscid membranes of the turbinals, consequently the mouth breather, lacking this natural protection, is more susceptible to bacterial invasion, and on account of the discomfort and annoyance of breathing through the mouth will not inhale as deeply as he ought; therefore there is not sufficient oxygenation of the blood and consequent lack of body tone.

There is no doubt that considerable disturbance to digestion is caused by allowing the mucopurulent material from the nasopharynx to get into the stomach, in fact, it is next to impossible to prevent young children from swallowing it. I had a patient who had been troubled with indigestion for several years tell me that it entirely disappeared after being relieved of this annoyance from a chronic nasal catarrh. I venture to say that the fermentative changes which take place in the mouth of a mouth breather have an injurious effect on the salivary secretions sufficient to interfere materially with the digestion of starchy foods, and this in turn would lessen the stimulative effect on the peptic glands of the stomach.

Breathing through the nose develops the muscles that dilate the nostrils, consequently we find narrow nostrils in mouth breathers. Furthermore, where the obstruction in the nose is confined to one side it naturally follows that the narrow nostril will be on that side.

I have had a number of cases of pharyngeal irritation that I could trace to no other cause than a partially occluded nostril, and it seemed to me that the air volume being so much heavier on one side gave it a cork-screw motion as it passed down the pharynx. This whirling and uneven pressure of the air might cause an irritation of the throat by producing an unusual dryness in one part and too little in another. This would account for the little inspissated lumps of mucus found in this class of cases in the vault of the pharynx. Of course one must take into account the fact that so large a volume of air passing in one nostril would not get the heat and moisture that it would from both sides nearer equal in caliber. Whatever the cause, there is always a marked improvement where