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by the radiograms obtained. We have since triedthe method with very satisfactory results.The patient sits on a chair and leans towards the

side to be injected, the head supported by his hand.A 20 c.cm. syringe is filled with well-warmed lipiodol.To the syringe is attached a smooth-ended cannula,length 10 cm., bore 3 mm. The tongue is protrudedas far as possible. This is held as in laryngoscopy.The end of the cannula is placed over the base ofthe tongue between the uvula and the side of the

pharynx. No part of the mouth must be touched.The oil is now injected slowly while the patient is

encouraged to breathe deeply. No local anaestheticis used, the only preparation needed is the usualtest for iodine idiosyncrasy, and of course to empty,by posture, as far as possible the cavities in casesof bronchiectasis. Should the patient be foundintolerant it is an easy matter to revert to thecricothyroid method. In one recent case, for example,the first drops of oil induced a violent paroxysm ofcoughing and the expectoration of large quantities ofpus. Therefore the oral method was abandoned andthe cricothyroid membrane method, with the usualinjection of cocaine, used and no dimculty wasexperienced. The essentials of the oral method appearto be the full protrusion of the tongue producing closureof the oesophagus and deep inspirations throughoutthe whole proceeding.The method is not suitable for young children or

where a picture of the apex is desired.We are, Sir, yours faithfully,

August 9th, 1927.

F. G. CHANDLER,Physician ;

W. BURTON WOOD,Assistant Physician, City of London Chest

Hospital, Victoria Park, E.

RED CELLS AND HÆMOGLOBIN NORMALS.

To the Editor of THE LANCET.SIR,-I have read with interest the annotation

on this subject in your issue of August 13th. Thequestions raised therein have to do with what maybe called the physics of the blood. In this depart-ment of investigation the blood is to be regardedas a mixture of two constituents only, serum andhoemoglobin, in varying proportions, and no con-

clusions can pretend to accuracy which do not takeinto consideration in every equation the specificgravities of the blood, of the serum, and of thehaemoglobin. Given these data, which can be easilyand accurately determined, and an adequate alge-braical technique, a number of indisputable con-

clusions can be established and incorporated in asmall table. A definition of " standard aqueoushaemoglobin " would be required, and a conventionshould be arrived at as to the number of the redcells that should be contained in one cubic millimetreof healthy blood. The number 5,000,000 is a veryconvenient one for purposes of calculation and forthat reason, if for no other, should claim precedence.With the aid of this table any of the questions yourarticle suggests can be easily answered as well asothers of perhaps greater interest and importance.

I am. Sir. vours faithfullv,Bolton, Lancs, August 14th, 1927. B. DERHAM.

PALPATION IN EXAMINATION OF THEAPPENDIX.

To the Editor of THE LANCET.1 0 Me Eaitor OJ ’1’HE LANCET..

SIR,—Mr. J. W. Dowden, while discussing chronicappendicitis at the Section of Surgery of the B.-’4.A.annual meeting (THE LANCET, August 13th. p. 333),referred to the necessity for judicious palpation inorder to ascertain the site of the main tenderness.In many cases it is of the greatest use to employ twohands, one of the two being the patient’s right hand.The right hand of the examiner having been usedlightly to touch over and around the suspected areais placed upon it, and the patient is instructed to

press on the examiner’s fingers with the right hand ;instruction is given that if tenderness results thepatient is causing it. Invariably a free and fullpalpation of the appendix results whether tender-ness be elicited or not ; the appendix may begrievously affected without the slightest tenderness,and in this contingency it is all the more completelypalpated, especially if affected. Adjuvant to thismethod, and in order to make assurance doubly sure,deep palpation while the patient elevates the wholeof the extended right lower limb, with the rightknee rigid, can be readily practised. I have frequentlyfound the successive use of the two methods to clearthe issue and to enable a correct diagnosis to bemade in cases deemed doubtful or difficult to diagnose.

I am, Sir, yours faithfully,R. CUNNINGHAM AFFLECK.

I Royal Medical Society, Edinburgh, August 12th, 1927.

ASTHMA AND ARTHRITIS IN ALTERNATION.To the Editor of THE LANCET.

SIR,-Dr. Wigoder’s report in your issue ofAugust 13th of a case of alternating asthma andrheumatoid arthritis, leads me to give a brief accountof a similar case under my care at present.

Miss X., aged 70 years, first developed asthma in1918. The following year the asthma having beencontrolled by vaccine treatment, she developed acuteinfective e arthritis, the metacarpo-phalangeal andknee-joints being those chiefly affected. Duringthe onset of the arthritis the asthma completely clearedup. The arthritis was treated with rheumatismphylacogen (P. D. and Co.) and after a prolongedcourse involving large doses the pyrexia disappearedand all active trouble in the joints subsided. Ashort while after this, in 1921, the asthma againreturned, and the two conditions have relapsed,although mildly, alternately ever since. I am nowon the track of an intestinal organism, a non-lactose-fermenting bacillus, which I hope is the cause insome way of both conditions, and that a furthercourse of autogenous vaccine from this source willarrest both conditions.As your correspondent mentions the rarity of this

condition I thought an account of this case would beof interest.-I am, Sir, yours faithfully,

HAROLD O. LONG.Stormont-road, Highgate, N., August 13th, 1927.

OTITIS MEDIA FOLLOWING NASALSYRINGING.

To the Editor of THE LANCET.SIR,—I have recently met with two cases of acute

otitis media which resulted from the using of a

syringe for douching the nose.A. B., a girl of 18 years. After an operation on the nose

for right-sided ethmoiditis she was recommended to usea syringe for cleaning out her nose. Two weeks later sheattended with a subacute otitis media on the right side.This subsided, fortunately without an operation, on alteringthe nasal treatment and discontinuing the use of the syringefor the nose.

C. D., a man of 20 years. He had been suffering for somemonths with ethmoiditis on both sides and this had becomemuch worse lately. Under treatment his condition wasimproving until, unfortunately, he was told to use a

syringe for his nose. When he was next seen about a weeklater he had acute suppurative otitis media in both ears,with the usual severe symptoms. His tympanic membraneswere incised and the ear-condition went no further. Hewas advised to use the syringe no more, and to sniff the lotionup his nose instead. He had no further ear trouble.

Cases such as these are of frequent occurrence.

With an ordinary simple catarrhal condition of thenose, methods other than sniffing the lotion up thenose often lead to middle-ear infection, either acuteor chronic. Sniffing up a nasal douche creates a

negative pressure in the nose and postnasal space,so that any infected material tends to be aspiratedfrom the region of the Eustachian tubes. In