breathing to a rhinologist before beginning the correction of the narrow arch which is invariably present. From the standpoint of the orthodontist any tendency toward mouth breathing should be recognized and receive immediate attention, for it means in the majority, if not in every case, a deformity of the dental arch which finally makes the normal closing of the mouth impossible, and a deformity of the face results.

The essayist spoke of the mechanical cause of the high arched palate. We have ascribed the arched appearance to the pulling of the buccinator muscles when the mouth is constantly held open. This tension on the muscles pushes in the alveolar process, carrying with it the teeth, and so narrows the arch. As I came away from the office I slipped into my pocket a model which I will pass around, showing the characteristic form of arch in a mouth breather. Notice the contraction opposite the attachment of the muscles. It is the opinion of many that the hard palate is not pushed up in these cases, but the alveolar process is drawn down by the pulling of these muscles, which are abnormally stretched by the constantly open mouth.

A very gratifying result that often follows the treatment by widening the arch and restoring its normal form and the proper occlusion of the teeth is the restoration of normal breathing, even when removal of obstructions by the rhinologist failed to do so. It seems to indicate that the maxillary bones are carried spart with the teeth and the nasal passages opened. Many orthodontists have noted this effect even when a comparatively small amount of expansion was done. This fact led me to notice the condition of the posterior nares of the two skulls which have been referred to by the essayist. There is much in this subject of mutual interest to the rhinologist and orthodontist, and I am very much pleased to hear the paper and to receive the privilege of discussing it. I thank you for your attention.

Dr. J. E. Brown.-The subject which Dr. Linhart has brought to the notice of the Academy is one that should be of as much interest to the general practician as to the specialist,

and I am glad that the doctor has so well brought the subject before the Academy tonight.

The very important bearing of mouth breathing upon the growth and development of a child has been known since Meyer of Copenhagen brought the subject of postnasal adenoids to the attention of the profession. The subject never received the attention which it should in this country until the paper of Gleitsmann in 1897. Since that time nose and throat specialists have labored to bring the subject to its proper position at the hands of the profession and the people. It is gratifying to note that this work has, in the last few years, been ably reinforced by the members of the dental profession. I find, from conversation with Dr. Hawley, that dentists accept as explanation of the V shaped alveolar processes and high arched palate that offered by Gleitsmann.

If you will refer to the cuts in the reprint of Dr. Hawley's paper you will see how, in normal cases, the bicuspid and molar teeth of the upper jaw are supported by those of the lower jaw held in firm contact with the upper. Now note the place on the skull where the cheek muscles and those of mastication are attached. Remove, now, the support of the lower jaw from the upper, and you will see at once how traction of its tissues will tend to turn the alveolar processes of the upper maxillary bones toward one another. As a result of this not only is the alveolar border made V-shaped, but the nasal passages themselves are actually narrowed, the lateral bony measurements of these passages being considerably diminished.

Taking postnasal adenoids as the great cause of mouth breathing in childhood, it becomes a matter of great interest to know why we have so much disease in this lymphoid tissue. In this connection I wish to suggest that it would be much better if we would cease to speak of adenoids and hypertrophied tonsils, because the average person is apt to think that by the term "adenoid" some peculiar and unusual form of growth is meant. These are cases of disease of the lymphoid tissue of the upper respiratory tract, and if it is diseased in the postnasal space the chances are more than three to one

that that portion of it in the fauces is also diseased. The reverse of this proposition also holds true.

Why do we have so much hyperplasia of these tissues? To my mind the following is the explanation: When the child is ushered into this world bacterial invasion is chiefly threatened by air entering the upper respiratory tract and by food and drink entering through the mouth. At the gateway of the former in the postnasal space we have a mass of lymphoid tissue on which is deposited, largely, the pathogenic organisms entering by air. That taken in with food and drink must pass over the fauces. Under the conditions in which our children are brought up, whether from lack of care or from too much care, the phagocytic function of these tissues is overtaxed, and instead of longer defending the organism from invasion they themselves become infected, inflamed, and, in turn, hypertrophied. When this is the case the health of the child is far better protected by the removal of the diseased lymphoid tissue than by allowing it to remain as a nidus for further and future infections.

Dr. Linhart.—I am very much pleased with the discussion. In a short article like this, it seemed to me best to allude to many of the common evils resulting from mouth breathing, rather than to speak of a few in particular. I am glad that I did this, for many of the explanations brought out this evening are much better than I could have made in a formal paper.

I quite agree with Dr. Heckler in regard to the recommendation that parents should take more care to provide their children with handkerchiefs, and think this is particularly applicable to young boys, who are noticeably lax in their use.

The point that Dr. Davis makes in regard to swallowing when the nostrils are completely blocked would also illustrate the injurious effect on the tympanic membrane of the middle ear.

It is quite true, as Dr. Brown states, that the term adenoid is not expressive enough, and that the thickening of the glandular tissue should be called lymphoid hypertrophy, and that the walls of the pharynx generally are implicated. Fur

thermore, the adenoid vegetations in the nasopharynx are not the only manifestations of hyperplasia in the system. The lymph glands in the neck and under the jaw are more or less swollen in these cases, and the swelling almost invariably subsides after the removal of the adenoid vegetation.

There is no doubt, as Dr. Hatton says, that rheumatism. and the exanthematous diseases are causative factors in inflammatory conditions of the throat, but this does not lessen the argument that mouth breathing would materially promote the trouble.

In the light of the many favorable reports in the current medical journals showing the rapid improvements in patients convalescing from typhoid fever, pneumonia and tuberculosis who have been given the open-air treatment, it seems hardly necessary to argue that fresh air is one of the requirements for good health.

PARK'S PATHOGENIC MICRO-ORGANISMS. A Manual of Pathogenic Micro-Organisms, including Bacteria and Protozoa. For Students and Practitioners of Medicine and Surgery and Health Officers. By William Hallock Park, M. D., Professor of Bacteriology and Hygiene in the University and Bellevue Hospital Medical College, and Director of the Research Laboratory of the Department of Health, New York. New (2d) edition, enlarged and thoroughly revised. In one octavo volume of 556 pages, with 165 engravings and 4 full page plates in black and colors. Cloth, $3.75, net. Lea Brothers & Co., Publishers, Philadelphia and New York.

This is the second edition of Park's Bacteriology. The title has been changed to "Park's Pathogenic Micro-Organisms." Throughout this new edition, as in the previous one, the practical side of the subject is kept uppermost and the needs of the student, the practicing physician and surgeon as well as the Health Officers are kept constantly in mind. This book, owing to the convenient and logical arrangement of subjects, with the details of laboratory technic and well selected illustrations, will be found a most helpful text for practical workers in this line.

THE MEDICAL COLLEGE CURRICULUM

LAST TWO YEARS.*

WILLIAM A. DICKEY, A. M., M. D.,

THE

Dean and Professor of the Practice of Medicine of Toledo Medical College, Toledo, Ohio.

In his very excellent paper Dr. Oliver has gone over the subject so thoroughly that little more can be said. I am in thorough accord with the idea that the last two years of student life should, as far as possible, be clinical; particularly is this true of the last year. He should be taken into the wards of the hospital and allowed to see and examine cases; to familiarize himself with the best and most approved methods of making a diagnosis. The cases should be watched from day to day and week to week and note any changes that may come in the patient's condition. He can see the results of the treatment employed. A few cases, well and carefully studied in this way, are of more lasting and permanent benefit to the student than many cases viewed at long range. In this respect a small class has a great advantage over a large one. The out patient department offers a rich field for observation and study, for here the student comes in contact, for the most part, with a different class of cases, cases of a more chronic character, those in which his powers of analysis and exclusion will be tested to their fullest extent. Clinical teaching, no matter how desirable it may be, will never wholly take the place of didactic lectures; in the very nature of things it can't. There are many tropical diseases, such as yellow fever and plague, that never occur in this latitude, and yet it is vitally necessary that the student should have a good working knowledge, a mental picture of them, if you please.

The doctor has said that each student should serve an interneship. As an abstract proposition I agree with him, but this would be extremely difficult, nay, impossible to carry out. There are not a sufficient number of hospital appoint

*Discussion of Dr. Oliver's paper (published in March issue) before the Ohio Association of Medical Teachers, Columbus, December 26, 1905.