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termediate sac-formation, after gunshot injury. In this case the author was obliged to perform double ligature of

both vessels, and to resect the vein. Recovery was complete in both cases.

F. R.

CLINICAL PATHOLOGY AND DIAGNOSIS.

UNDER THE CHARGE OF

The Laboratory of Clinical Observation, 616 Madison Avenue.

The Classification of The old classifica-
Bright's Disease.
tions of nephritis
have always been very unsatisfactory from
a clinical standpoint. Even classification
Even classification
from the gross and microscopic pathol-
ogy are not very accurate, as the condi-
tions found at autopsy are phases of the
same affection, and the pathological pro-
cess may not have made similar progress
in all parts of the kidney. At the same
time certain features in the microscopical
picture usually stand out more promi-
nently than others, and the actual condi-
tion can, as a rule, be classified within a
certain subdivision or group.
An at-
tempt, however, to classify the type of
nephritis by the results of the urine
analyses meets with too many cases that
are at variance with the post-mortem
findings to be at all satisfactory from the
clinical standpoint. Clinically, cases of
chronic nephritis are best classed under
two headings. Those with a large amount
of albumin, diminished amount of urine,
with dropsy and without any rise of ar-
terial tension, should be classed as cases
of "chronic nephritis with dropsy"--a
type clinically corresponding to that
which was described as "parenchyma-
tous nephritis," but which has not proved
to be parenchymatous always. The other
group, corresponding to what has been.
known as the interstitial type, is best
styled "chronic uræmic nephritis." This
name is applied by Castaigne because the
typical feature in this group of cases is
a tendency toward træmia, which may
show itself only in minor symptoms or

may develop into the classical ræmic seizures. In this latter group the fea-. tures of the urine are an increased quantity, a low specific gravity, a low amount of solids, little or no albuminuria, with few or no casts; no dropsy, but uræmic symptoms, with raised arterial pressure and hypertrophy of the heart. This is a clinical classification, which is sufficient for the purposes of treatment, and corresponds closely to actual experience. There are, however, mixed types, as, for example, cases in which both uræmia and dropsy may exist in the same case. The name of the clinical type of nephritis is given in such cases according to the primary or predominant feature-dropsy or tendency toward uræmia.

It is probable that this classification will be adopted generally within the next few years, and that the old classification into parenchymatous and interstitial nephritis will be completely abandoned.-La Tribune Medicale.

Leucocytosis in Inflam- The practical value.
matory Conditions.
of the enumeration
of the total number of leucocytes and the
differential count of the white cells, and
especially the comparison of the number
of leucocytes with the relative number of
polynuclear cells, is well demonstrated in
a monograph by Albrecht in the Zeit-
schrift fur Geb. und Gynakologie. The
cases were acute pelvic peritionitis, a
palpable tumor in the adnexa, a large
exudate or abscess in the small pelvis,
puerperal or abortion sepsis and postop-

erative inflammatory processes. A number of case histories under each class are given in detail, the leucocyte count proving surprisingly instructive and reliable, especially the differential, re-enforcing the findings of the qualitative count.

The percentage of polynuclears at the time is an idex of the severity of the affection, but large numbers of polynuclears do not indicate an unfavorable prognosis if only the absolute number of the polynuclears is increased in proportion to their percentage. The disappearance of eosinophiles and mast cells suggest severe infection.. A decline in the absolute number of polynuclears, with a simultaneous reduction in their percentage, shows that the infection its subsiding. Sudden decline in the absolute number of polunuclears while their percentage shows only a small decline or an increase is a sign of unfavorable prognosis, as it demonstrates that the emigration of polynuclears no longer keeps pace with their consumption, owing to exhaustion of the blood-forming organs or for other reasons. A sign of absolutely unfavorable prognosis is a sudden decline in the absolute numbers of lymphocytes. When the number of lymphocytes is considerably below normal the infection may be regarded as especially serious. In all the cases studied the turn toward recovery was manifested in the blood picture by the marked relative increase in the absolute numbers of mononuclears and eosinophiles, sometimes rising above normal figures. Among the examples cited is one of puerperal sepsis, with 14,300 leucocytes, including 84 per cent. polynuclears, 15.4 per cent. lymphocytes and 0.6 per cent. eosinophiles. The prognosis was regarded as favorable in this case, and the patient soon recovered. another case the leucocytes numbered 28,000, including 74.5 per cent. polynu

In

clears, 24 per cent. lymphocytes and 1.5 per cent, eosinophiles. The fifth day there were 79.3 per cent. polynuclears, 19.3 per cent. lymphocytes and 1.4 per cent. eosinophiles. Pyæmia then developed, and the leucocytosis constantly increased to 52,000 on the day of death, with 88.5 per cent. polynuclears, 10 per cent. lymphocytes and o eosinophiles. In another case the eosinophiles were 1.5 per cent., then 0.5 per cent., then o per cent. the thirteenth day, when an abscess was discovered and evacuated, after which the patient rapidly recovered, the eosinophiles numbering 4 per cent. six days later.

Source of Ova.

The early presence of primary germ cells in the superficial germinal epithelium of the ovary has long been known and satisfactorily demonstrated, but Professor Waldeyer went a step further and regarded the demonstrated fact of their presence in the germinal epithelium as evidence or proof that these germ cells were derived from it. Waldeyer's view was accepted by many zoologists, and is still taught in most of the medical textbooks and in Professor Haeckel's books, notwithstanding the fact that Professor Waldeyer has abandoned his old view. Dr. Beard has demonstrated that a fertilized ovum gives rise by segmentation to a larval (asexual) structure and a definite number of germ cells, one of which germ cells develops into an embryo, into which embryo the other germ cells migrate by passing from the yolk sac along the yolk stalk into the embryo, and ultimately reaching the germinal epithelium. At this stage of development the germ cells are seen "embedded" in the superficial germinal epithelium, though not "derived" from it. Bennet M. Allen of the University of Wisconsin has lately reinvestigated this matter, and he writes:

"The sex cells lie among the peritoneal cells, but are not derived from them." Thus it has been demonstrated that the germ cells are formed prior to the embryo, that there is a continuity of germ cells from generation to generation, and that the body (or soma) serves merely as their host.

Professor Waldeyer accepts this new view, and writing about it in 1903, said that the consequences of this doctrine of the continuity of germ cells are almost unbounded for every branch of biology. British Medical Journal.

Purin-Free Diet.

C. Watsons declares that there is no special therapeutic value in a purin-free diet in the class of cases in which such a diet is often prescribed, but that the undoubted benefit which follows in certain cases is to be explained along other lines. Purins, says the author, are constructed on the base CN, e.g. uric acid, xanthin, hypoxanthin, adenin and guanin. These are present in certain articles of diet. Meat and meat extracts contain a large amount of purins; similarly certain glandular organs, such as the pancreas and liver, are rich in purins. They are also present, though in smaller amount, in many vegetable foods-for example, beans, lentile and oatmeal-and they are relatively abundant in some accessory articles of diet, notably tea and coffee.

Purins which are taken in the diet are spoken of as exogenous purins. Purins in the tissues exist chiefly in combined form in the nuclei of cells and in the muscular tissues. Xanthin and hypoxanthin occur in muscle extracts, adenin is yielded chiefly by decomposition of nucleic acid present in thymus, and guanin is derived mainly from the pancreas. The purins in the tissues are spoken of as endogenous purins in contrast to the exogenous purins of the dietary. Purins exist in the urine chiefly in the form of uric acid, xanthin, hypoxanthin and adenin. Roughly speaking, about one-half of the purins in the urine are derived from the ingested food (exogenous purins), the remaining half being derived from tissue metabolism (endogenous purins). The author does not believe that there is at the present time any evidence that the purins bases per se are in any way more intimately concerned in the actual causation of gout and gouty disorders than is their ally, uric acid, which has now by common consent been discarded. Gout is probably due to intermediate purin metabolism arising from a defect in one or more organs, as revealed by the inability to produce the ferment or ferments required, as a result of which proper oxidation of uric acid does not occur, and the latter consequently accumulates in the tissues in the manner observed in gout.British Medical Journal.

OBSTETRICS AND GYNECOLOGY.

UNDER THE CHARGE OF

WALTER B. JENNINGS, Ph. B., M.D.,

Formerly Assistant in Gynecology, New York Post-Graduate Medical School; Attending Physician (O. P. D.) St. Mary's Free Hospital for Children.

Bimanual Rotation in Dr. Wm. D. Porter Occipito-Posterior Po- of Cincinnati, in a sitions. paper read before American Medical Association (Journal American Medical Association, November 23, 1907), says that practically all

methods which have been recommended for manual rotation in posterior positions involve grasping the head with a hand. in vagina.

He places the left hand in the vagina, and the fingers of the right hand are

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Danger of Pregnancy Dr. William S. Following Operations Cheesman of Aufor Cancer of the Breast burn, N. Y., says (Buffalo Medical Journal, January, 1908) that whatever theory one adopts as to the nature and etiology of cancer in general,

it must be conceded that when located in the female breast its development is influenced by some unexplained sympathetic correlation with the pelvic organs. The clinical fact has long been recognized, and is sometimes mentioned in text books, that under the physiological stimulus of pregnancy mammary cancer takes on a specially malignant character. On the other hand, Beatson by ablating the ovaries in some cases of late inoperable cancer of the breast, was able to effect the disappearance of the disease.

The highest functional act of these organs is gestation. This may associate itself with mammary cancer in one of two ways:

Either cancer attacks the heart during the course of pregnancy, or pregnancy occurs as a complication of already existing cancer. In which ever way the association arranges itself the result is the same, viz: A stimulation of the disease to unexampled malignancy and rapidity of growth. The doctor reports two cases bringing out the point in question, and concludes that the danger has not been clearly appreciated. Patients after being operated upon for malignant tumors of the breast are warned against pregnancy.

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tigations in the following statements: I. Pregnancy.-(a) In 85 per cent. of the examined cases typical changes could be demonstrated in the interior of the nose, affecting definite areas and consisting in hyperæmia and hypertrophy. These changes do not present any periodicity in the sense of Fliess (meaning that their appearance is not limited to the time. of the presumptive menstrual period), and they do not give rise to increased. secretion.

(b) The hyperæmia of the nasal mucosa, in about 22 per cent. of the pregnant women, leads to epistaxis in contradistinction to emesis gravidarum (19 per cent.)

II. Parturition. In almost one-third. of the cases there is during each laborpain, but not prior to it, an acute but not well-marked increase of the congestive symptoms under an augmented secretion.

III. Puerperal stage and following period. (a) The hyperæmia almost invariably begins to diminish early in the puerperal period, whereas the hypertrophy persists approximately unchanged.

(b) The hypertrophy also undergoes complete retrogression within a few months, so that actual intranasal changes due to pregnancy do not exist.

IV. Subsequent pregnancies.-The intranasal changes which were present during the first pregnancy having undergone temporary retrogression, reappear in practically the same manner as before.

F. H.

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