The author shows how nasal insufficiency leads to improper development of the bones of the face and teeth, and causes a feeble vesicular murmer. This feeble vesicular murmer is more noticeable during sleep, when the parts are relaxed and the soft palate falls of its own weight. The current of air passing through the mouth has to raise the soft palate before it can enter the larnyx on its way to the lungs. This diminution of nasal respiration reacts on the general system, by interfering with the oxygenation of the blood, by facilitating infection through the air passages, and in other ways. The effect of improper nasal breathing naturally varies with different periods of life, younger subjects being more succeptible than adults. The author very properly calls attention to the fact that adenoids are not the only cause of the classical symptoms of nasal obstruction. The profession, by being educated to the importance of adenoids as a cause of nasal obstruction, may have overlooked the fact that there are other causes that are just as important, though many times more difficult to recognize. This paper calls attention to these other causes very forcibly, and urges the necessity of a careful examination of the whole tract. The intellectual slowness and mental inaptitude accompanying nasal obstruction, which was named by Guye, "Aprosexie Nasale," is discussed. Attention is drawn to the importance of even moderate degrees of nasal obstruction as a factor in the production of pulmonary consumption, and the work of Lombard is quoted.

The effect of improper breathing as cause of sinus disease and middle ear infection is considered. The author advises surgical treatment in many of these cases, but believes that some of the inflammatory troubles, such as hypertrophic rhinitis, can be successfully managed by nonsurgical methods. In the first period of hypertrophic rhinitis the condition is a simple vasomotor trouble, with congestion of the mucous membrane and dilatation of the vascular sinuses. If this continues the walls of the sinuses lose their contractility, and the mucous membrane passes into the second, or hyperplastic stage, where there is a true histologic modification of the mucous membrane.

The paper deals with the arthritic diathesis as a factor in the production of nasal congestion, and calls attention to the frequency with which the lower bowel is affected, and the susceptibility of these patients to atmospheric changes and the ingestion of cold water. The author prefers to call this condition the "Congestive Diathesis," rather than the vague term, "Arthritic Diathesis." This tendency to congestion is a sign of a permanent arterial hypotention of vasomotor origin, dependant upon the nervous system. Medical and hygienic treatment should be used in these cases, and the patient should practice respiratory gymnastics.

PROCTOLOGY.

LOUIS JACOB HIRSCHMAN, M. D.

CLINICAL PROFESSOR OF PROCTOLOGY IN THE DETROIT COLLEGE OF MEDICINE.

APPENDICOSTOMY.

TUTTLE, in Jama, Volume XLVII, Number VI, states that the name appendicostomy was first suggested by Willy Meyer in 1902 to designate the operation devised by Weir, which consisted in the fixation of the appendix to the surface of the abdomen and utilizing its calibre and opening into the cecum for washing out or medicating the colon in chronic inflammation of this organ.

In describing the technique of the operation Tuttle says that the cecum should be brought up and stitched to the parietal peritoneum, the appendix fastened to the lower angle of the wound and the abdomen. closed by layer sutures. The appendix is cut off at the end of two days at about one-quarter inch from the skin and the opening dilated. A catheter is then introduced two to four inches, and allowed to protrude about four inches. It is held in place by a ligature. On the third or fourth day irrigations are begun.

In amebic dysentery, Tuttle uses normal saline solution at a temperature of 65° to 75° Fahrenheit, although quinin solutions in various strengths are largely used.

In catarrhal conditions, with or without ulcerations, silver nitrate, one to five thousand; ichthyol, one-half to one per cent; peroxid of hydrogen, ten to twenty per cent; aqueous fluid extract of krameria, ten per cent, and argyrol, five to twenty-five per cent have all given satisfaction.

The operation is indicated in all chronic inflammatory diseases of the colon, particularly in amebic dysentery, mucomembranous colitis, and syphilitic ulcerations of the colon.

Tuttle has collected seventy-seven cases done for the following conditions:

Amebic colitis

Mucous colitis

Syphilitic ulceration of colon..

Tubercular ulceration of colon...

Multiple papillomata

Intussusception

Volvulus ...

Chronic constipation

Carcinoma tranverse colon...

Hemorrhagic colitis....

In resection of ileum as precaution against gaseous distension.

RESULTS. In the forty-four cases of dysentery there were six deaths following, but not due to the operation; two from unsuspected tuberculosis, two from extensive ulceration of bowel with chronic

nephritis, one from exhaustion before the appendix was opened and one from cerebral disease, three months after the operation, the dysentery having been apparently cured for two months. The balance of the cases (thirty-eight) are reported cured. Two relapses are reported, one after two years. In the cases of papillomata the operation was only palliative, as was also the fact in carcinoma. The cases of syphilitic ulceration appear to have been greatly benefited, if not permanently cured. In the cases of volvulus and intussusception the operation was effectual. In the cases of mucous colitis the reports are all favorable. In these, however, we must consider how much was due to the removal of the appendix and how much to the effects of the appendicostomy. The relationship between chronic appendicitis with adhesions and chronic mucomembranous colitis is a very close one. By appendicostomy we get rid of the appendix, whether it be the cause or effect of colitis and at the same time give access to the parts for local treatment.

NEUROLOGY.

DAVID INGLIS, M. D.

PROFESSOR of NERVOUS AND MENTAL DISEASES IN THE DETROIT COLLEGE OF MEDICINE

AND

IRWIN HOFFMAN NEFF, M. D.

ASSISTANT PHYSICIAN AT THE EASTERN MICHIGAN ASYLUM.

"CYTODIAGNOSIS OF ORGANIC PSYCHOSES."

THIS is the title of an article in the Journal of the Michigan State Medical Society for July, by Clarence E. Simpson. The author presents a short review of cytodiagnosis for diagnostic purposes, and gives details of twenty-five cases of simple and complicated psychoses subjected to lumbar puncture. The author mentions the wide divergence of technique in estimating the lymphocytes in the spinal fluid, and describes a technique of his own which has proved practicable. Presumably from a consideration of his twenty-five cases which were thoroughly studied the writer formulates the following conclusions:

(1) An increased lymphocyte count denotes meningeal irritation. (2) No lymphocytosis is present in cases of dementia precox, epilepsy, manicdepressive insanity, or arteriosclerosis.

(3) An increase of the lymphocytes seems to occur only with paresis or tabes, and its presence in a case in which tabes can be excluded is evidence of paresis.

(4) As a rule the degree of cellular increase is proportionate to the amount and rapidity of pathologic change.

(5) A normal lymphocyte count is not proof of the absence of paresis. It may mean only an arrest in the progress of the disease.

I. H. N.

EDITORIAL COMMENT.

THE TORONTO MEETING OF THE BRITISH MEDICAL ASSOCIATION.

THE meeting of the British Medical Association, held in Toronto, August 21-25, was an event of more than ordinary importance. Through the hospitality of the association, many American physicians. were formally invited, and the generosity of the Canadian members enabled a great many Americans to get on the program. The meeting of the American Orthopedic Association took many men to Toronto about the same time and many others concluded that Toronto would be a good place for part of a summer vacation. Except for the intense heat, this was true. The meeting was a large one. From the British Isles and from all parts of the Empire, members came. The Canadian Medical Association had a small meeting just before, and its members doubtless stayed over in considerable proportion. The Tuberculosis Exhibition and a meeting of the Dominion Alliance-a temperance organization, perhaps added to the crowd, so that in all a registration of some twenty-two hundred was secured. Since among the English members were some of the most conspicuous members of the profession-well-known authorities in all departments, the general effect was that of an international congress, including even diversity of speech. One was often reminded of the sign in Paris stores (or shops, to be more English): "English Spoken; Both Kinds." The American who has heard his speech reviled could gather comfort from the Yorkshire, Scottish, or other brogues, that differ from the kind heard in Mayfair as much as the speech of Fifth avenue from that of Hester

Toronto is a good convention city. Well situated, built on a modern plan, with good hotels and a convenient trolley system, it has room and facilities. The general effect of the buildings is good, though there are still too many tumble-down houses on prominent streets. The civic spirit is illustrated by the fact that funds are being raised for a twomillion-dollar teaching hospital. The bay and islands and the beautiful parks furnish easy refuge from city dust and noises. On one of the islands the Royal Canadian Yacht Club dispensed a royal hospitality, and sent out sailing parties as often as a wish was expressed. The quarters of the meeting were as nearly perfect as could be desired. The main building of the University, a noble pile with its dignity added to by the broad expanse of lawn over which it is usually approached, served admirably for the places of registration. The latter were not so extensive, but apparently as efficient as those of the American Medical Association. In the same building were the telephone and telegraph offices, postoffice, boot-black room, newspaper booth and several section meeting

rooms.

The commercial exhibit in the building was almost as limited as that of the Boston meeting of the American Medical Association. Most of the picturesque piles of samples so dear to many were absent, and the best one could do was to eat patent food ice-cream-very refreshing— and carry away samples of Canadian whiskey. The splendid collection of Paul Kane's Indian pictures, loaned by Mr. E. B. Osler, formed a great attraction to the rooms of the exhibit.

The pathological exhibit was of great interest, containing not only many specimens familiar to all, but a number of hearts from cases of Stokes-Adams disease, shown by Doctor G. A. Gibson. The exhibit of skiagrams was of great interest and very well arranged. Several sections met in the medical, chemical and other buildings not far from the main building. In most space was adequate, aside from the heat the ventilation was good, and above all one missed with pleasure the work of carpenters, riveters and other noisy trades that seem to hold the sections of the American Medical Association in thrall.

The general meeting differed from those to which we are accustomed chiefly in the use of academic costume by many of the chief participants. The effect would have been better in a building more adapted to such purposes than the unfinished and unsatisfactory convocation hall. Of all the general meetings, the one that excited most interest was the Oration in Surgery by Sir Victor Horsley on the "Technic of Operations on the Central Nervous System." In first-hand knowledge of the subject, and in scope and mode of presentation this was a masterly address, and should be read by every physician. It was no less interesting on account of the quiet ease of its delivery, every word being distinctly audible in a building of the most imperfect acoustic qualities. Sir James Barr's address in medicine, on the "Circulation Viewed from the Peripheral Standpoint," was very suggestive, but more adapted to reading than hearing.

error.

The work of the sections differed from that usual in the United States. The number of papers was small; the hours limited to the mornings of four days. The absence of stenographers seemed a serious. It is difficult, if not impossible, to find stenographers who can take verbatim notes of all medical speakers, and when so taken they still need correcting. But it is still more difficult for a speaker to sit down and in the midst of a discussion, or during reading of another paper, write out his remarks. As my attention was confined to the Medical Section I shall not attempt to describe the work of others, but only remark that many of them had important topics under discussion, and the impression I gathered was that these were generally interesting and instructive.

This was eminently true of the Medical Section. The first day had for consideration "Arterio-Sclerosis." As might have been anticipated