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being suspicious, a further difficulty arises. Bacilli not forming clumps are often more numerous in some leucocytes than in others. Are these more richlyladen leucocytes to be excluded? If so, at what point and on what grounds are we to draw the line between what ought and what ought not to be included in the count? The same difficulty is, he says, felt still more acutely in dealing with cocci.

A table is given showing the details of an actual count of 100 leucocytes. The majority of these cells contained each either two or three cocci; but one contained 21 and another 29. These two, it may be said, ought obviously to be excluded. But what should be done with several others, each of which contained 5, 6, 7, 8, 9, 10 or II cocci? Here, again, it seems impossible to lay down an objective rule for determining what is and what is not admissible. A further difficulty in the accurate counting of cocci arises from the fact that the cultures used generally contain many organisms which are commencing to divide. These examples are quoted by the author as illustrating the "subjectivity" of the technique involved in opsonic work.

Jürgens also criticises the alleged the alleged therapeutic value of vaccine treatment guided by determinations of the opsonic index. If we take a general review of Wright's clinical material, the treatment, in many instances, unquestionably gives us a favorable impression, and in some cases this favorable result is remarkably striking; but the large majority of his cases tend to cancel this impression. Precisely where, according to the character of the opsonic curve, a successful result should be anticipated, amelioration often fails to take place; and in other cases the course of the disease takes a favorable turn, although vaccine therapy has not

affected the opsonic index precisely as desired. Instances also arise in which, after the onset of an improvement coincident with the commencement of vaccine therapy, unmistakable changes for the worse set in later, showing that the original favorable impression was quite misleading.

According to the opsonin theory, vaccine treatment produces favorable results when it causes a rise in the opsonic curve. Jürgens concedes that when we take a large number of cases many examples can be selected which support this theory, but he does not regard these results as proving a general law. "When, however, we compare, in each individual case, the curve influenced by vaccine therapy with the course of the disease, we see at once that curves are not always produced which correspond to Wright's theory. Many cases conform to it, but many others do not."-The Post-Graduate.

In order to remedy a certain confusion in

The Folin Methods.

the use of the term, Folin's method of ammonia determination in. urine, W. H. Buhlig, Chicago (Journal A. M. A., June 27), points out that the procedure described under this name in Simon's "Clinical Diagnosis," sixth edition, was abandoned by Folin in 1902. That given as "Folin's method" in Hawk's "Practical Physiological Chemistry," 1907, is the only one that should bear the name, as it was used by Folin with confidence as late as 1905, while the third method called "Folin's" in Emerson's "Clinical Diagnosis," though originating in Folin's laboratory, is better designated the vacuum-distillation method of Shaffer. Folin himself credits it to Shaffer in a controversy with two German authors who had published a similar method. Buhlig describes and compares the Folin and Shaffer

methods as above elucidated, and says he does not use the latter in his ammonia determinations, as several, perhaps more, determinations can be made simultaneously in the Folin way, several sets of apparatus being connected with one pump

The Influence of Pregnancy Upon Certain

Diseases.

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.

The New York Medical Journal, May 30, 1908, has the following abstract taken from the London Lancet for May 8, 1908:

of required strength. The saving of time is then not so much an advantage over the Folin method. The vacuum-distillation method needs watching, which is not necessary when one is acquainted with the Folin process.

French, in the second of his Goulstonian lectures, considers the influence of suppurative calculous and tuberculous affections of the kidney on pregnancy. He reports one case in which the sequence of events was renal calculi, hydronephroses, pregnancy, microbial infection of the kidneys, pyonephroses, suppurative pyelonephritis, cystitis, uræmia, and death. Tuberculosis of the kidney and pregnancy are practically never associated. As regards nonsuppurative renal affections, it is clear that pregnancy will have a deleterious effect upon the kidneys of women suffering from nephritis, and that such women should not marry. There are two groups of cases in which the renal disease is direrctly attributable to pregnancy, those in which renal cedema is developed in the middle months and those terminating with eclampsia. In most cases albumin and tube casts disappear from the urine soon after the pregnancy has terminated. The writer ranges himself with those authorities who regard these kidney changes in pregnancy as essentially similar in kind to those which may 'occur in scarlet fever, and holds that there is no intrinsic difference, but only

ers.

cases.

one of degree and acuteness, between the renal changes in eclampsia cases and those in cases where renal œdema is a prominent symptom less late in the pregnancy. Albuminuric retinitis is more common in pregnancy kidney cases than in any other forms of nephritis. The deleterious effect of twin pregnancy upon the kidneys is more marked in the eclampsia cases than in those of general edema without eclampsia. All statistics show a high mortality amongst the children of nephritic mothThe treatment of an eclamptic case lies mainly with the obstetrician. The nephritis of the earlier months, however, calls for obstetric measures in but few Rest in bed, with suitable medication and diet, ameliorates the renal symptoms in many cases. Pregnancy seems to be one of the causes of tetany, differing in no essential way from adult tetany due to other causes. The affection develops during the later months of preg nancy, as a rule, but the spasms are rarely met with during labor. They may occur for the first time during lactation. Pregnancy does not predispose to a primary attack of appendicitis, but may light up another attack in a person who has previously suffered from the disease. This last it probably does by stretching or breaking down old inflammatory adhesions as the uterus enlarges and rises out of the pelvis. It is not at present pos

sible to state whether the coexistence of pregnancy makes an attack of appendicitis more severe than the average. Yet pregnancy does increase the risks and dangers; even after drainage of the abscess a septic salpingitis or endometritis may be set up. The fœtus is born dead in 90 per cent. of the cases. On the whole, operative measures should be accelerated rather than postponed in cases of appendicitis complicated by pregnancy. It is in the last degree undesirable that obstetric measures for terminating the pregnancy artificially should be resorted to for fear of breaking down adhesions that are helping to localize the inflammation. Early operation is the best chance of saving both the mother and the child.

Relation of Weight of Dr. W. P. Manton Placenta to That of of Detroit has an inNewborn Child. teresting article on this subject in May number of Buffalo Medical Journal. He says, in part:

Coming now to the influence of multiparity on the weight of the placenta and child, we find that the weight of the average offspring, regardless of sex, of primiparous mothers is seven pounds and one ounce, and that of the placenta is eighteen ounces and one-half, a slight diminution in the normal average weight of both.

In the instance of the multiparous mother the converse obtains; the weight of the child is augmented 7 pounds and 43-8 ounces, while the placenta remains at the average weight.

Sex appears to exert some influence as regards the weight of the child, but has little effect upon that of the placenta. Thus the average weight of the male child is 7 pounds 4 ounces, that of the female 7 pounds 1 ounce. The respective placentas weigh 182-31 ounces and 18 2-3+-ounces.

It is interesting to note that among the

400 cases the largest child, a male, weighed 10 pounds and 8 ounces (placental weight 28 ounces; multiparous mother); the smallest child, a female, 3 pounds (placental weight 16 ounces; mother not stated). The largest placenta weighed 40 ounces (male child, 8 pounds II ounces; primiparous mother); the smallest placenta weighed 6 ounces (female child, 6 pounds 12 ounces; primiparous mother).

Conclusions: The figures above presented are interesting on many accounts. They at least indicate that, as a rule, the development of the placenta goes forward with that of the child, and its size may be taken ordinarily as an index to the weight development of the latter. It is further shown that while there may be individual variations in any given number of cases, these will not be sufficiently numerous to greatly influence the normal weight ratio. between child and placenta, that is, 6+1.

ages.

Present Status of Con- Dr. John E. Cannaservatism in Surgical day, surgeon-inTreatment of Append- charge ShelteringArms Hospital, Hansford, W. Va., considers this subject (Buffalo Medical Journal, May, 1908). He summarizes as follows: The majority of the gynecologists interrogated favor a restricted conservatism; that the number of pregnancies occurring after tubal operations is very small; that the results after plastic work on the ovaries is better; that age, the presence of pus, tuberculosis and malignant disease indilapsed ovaries, generally speaking, should be elevated in the pelvis by suspension operations on the uterus, by shortening the ovarian ligament or by placing the ovary in front and on top of the broad ligament; that the functions of the tube and ovary should be preserved whenever consistent. with health; that the artificial induction

of the menopause brings a very serious disturbance into the life of the patient, and that ovarian transplantation experi

mentally and clinically has, in a limited field, been productive of satisfactory results.

PÆDIATRICS.

UNDER THE CHARGE OF

VANDER POEL ADRIANCE, M.D.,

Consulting Physician to the New York Orphan Asylum and Pathologist to the Nursery and Child's Hospital.

Treatment of Rachitis.

The Importance of the T. S. Southworth Early Recognition and (Jour. A. M. A., Jan. II, 1908). Confronted with a case of rachitis presenting but few of the classical symptoms, viz., large square head, narrow chest, marked rosary, pot belly, bowed legs, enlarged epiphyses, delayed dentition, head sweating, open fontanel and lumbar kyphosis, or with one which instead of having reached its full development is still incipient, the practitioner whose knowledge of rickets is derived from books only or from the advanced cases presented in clinics may either hesitate to pronounce the case as one of rachitis or be led by the prominence of some associated symptoms, such as obstinate constipation, chronic intestinal indigestion, convulsions or bronchitis, to overlook the underlying cause and so miss the opportunity of striking at the root of the real ætiologic factor. It is a too common error to assume that because some of the usual symptoms are lacking the affection cannot be rachitis. The disease may manifest itself under many guises. The epiphyses at the wrist may be enlarged while the bones of the head are apparently normal. Again, the head may show varying degrees of enlargement and squareness, due to overgrowth of the frontal and parietal bones, with no recognizable involvement of the epiphyses. Enlargement of the costochondral junctions, commonly known as beading of the ribs or the rachitic rosary, is probably the most constant symptom of

all, and even when not recognizable externally by palpation may be present on the inner surface of the thorax. The real menace of rickets, both during infancy and more remotely in the later life of the individual, lies in its more subtle effects on the organism. In addition to convulsions and pneumonia, there are dangers from laryngismus stridulus and chronic intestinal indigestion, while the greater liability of the contracted chest to tuberculous disease in later life, and the danger to the parturient mother and her infant from rachitic deformities of the pelvis. are matters of general observation.— Archives of Diagnosis.

in Children.

Gonococcus Infection Holt (Jahrbuch f Kinderheilkunde, Vol. 64, 1907-8). The author's observations refer to children less than three years of age. Gonococcus-vaginitis is extremely common in this group of cases, and in view of the highly contagious character of the disease the isolation of all affected children admitted to a hospital is indispensable. The same necessity for strict isolation exists in case of gonococcus-ophthalmia and acute gonococcus-arthritis, although in these forms. the danger of infection is not as great as in vaginitis. If the strict isolation of the infected children is not feasible, they should be refused admission to the hospital, since the disease cannot otherwise be prevented from spreading. In order to prevent vaginitis cases from reaching

the general wards, a bacteriological examination should be made of the vaginal secretion from all female children who apply for admission. If a purulent secretion is present and no microscopical examination has been made, the child must be treated as a case known to be infected. In order to be efficient the quarantine must be extended to the nurses and attendants of the infected children. The underwear, bedding and clothing of infected children should be cleaned separately from the laundry of the other children in the institution. Those cases in which gonococci are found with no discharge, or a very slight discharge only, likewise require quarantine measures, although the danger of spreading is considerably diminished under the circumstances. The risk of infection for the nurses is very marked, especially in regard to the eyes, and the attendants of these children should be instructed accordingly. F. R.

The Effect of Hydriatic Hecht (Jahrb. f. KinProcedures Upon Chil- derheilkd. Suppledren Having Measles. ment, 1907). Very young children, up to the age of four years, are more thoroughly cooled off by cold baths (20 degrees Celsius, lasting 12 minutes) than are children above this age. From the fourth year on the age makes no further difference, but poorlydeveloped and undernourished children. always present a greater drop of temperature than the well-developed and nourished patients. The antipyretic action of the bath is independent of the height of the fever and the daily temperature curve. The temperature after the bath diminishes in about the same manner as during the bath, reaching its lowest point about a quarter of an hour afterwards. Untoward accidents were observed in shape of an enormous drop of temperature in

two cases, and diarrhoea in four cases concerning little children with rubella. F. R.

Radioscopy in the Pneu- Weill - Thivenet monias of Children. (Arch. de Méd. des Enfants, No. 7, 1907). The authors point out the value of X-ray transillumination for the diagnosis of pneumonia. Three forms may be distinguished: (1) Lobar fibrinous inflammation, which yields equally reliable findings with the assistance of auscultation and percussion as with radioscopy. (2) Disseminated broncho-pneumonic foci, which are readily demonstrated by means of auscultation and percussion, but yield no shadow on the X-ray screen. (3) The so-called central prfeumonias. According to the author, the latter are not as common as hitherto assumed, and they yield a distinct shadow on transillumination, whereas they are not easily identified with the remaining methods of physical examination.

Radioscopical examinations are of especial value in the course of pneumonia in children, because the diagnosis at this time of life is subject to certain difficulties. There is no expectoration, the physical signs are absent or delayed, the temperature curves are atypical, and finally, the pneumonias of children are frequently associated with abdominal pains, combined with vomiting. These symptoms often serve to mislead the diagnosis. The radioscopical examination affords information in doubtful cases, the author's studies showing that true pneumonia with a fibrinous exudate invariably presents a dark, distinctly circumscribed zone upon the radioscopal screen. Those pulmonary affections which fail to yield a similar shadow cannot be interpreted as pneumonias. The condition is either a

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