showed 6 per cent. of neutrophilic myelocytes, but the number of leucocytes was not increased. The patient became markedly anemic under observation and steadily declined in health, dying 17 months after anemia was first noted. His only complaints were of progressive weakness and shortness of breath on exertion.

Only after several months' observation did the spleen become enlarged. It gradually increased in size until it reached the umbilicus at the end. There was little glandular swelling until toward the end. He developed gangrenous stomatitis in June, 1902, and died on the 22nd, comatose. No autopsy.

From January, 1901, until the death of the patient frequent blood exami nations were made. At first there was no increase in the leucocytes. These gradually increased and toward the end the ratio of erythrocytes to leucocytes had fallen to 1 to 16.6. Neutrophilic myelocytes were present from the first and steadily increased. Toward the end they diminished but did not fall below 25 per cent. The polymorphonuclear neutrophiles steadily diminished as did also the small mononuclears. The large mononuclears increased and were finally as high as 54.8 per cent. Mast cells were absent at first but later appeared and increased toward the end. Only two eosinophiles were seen in all the examinations made. Nucleated reds were present throughout the disease but more numerous at first.

The special points of interest in this case, which do not correspond to the characteristic picture of myelogenous leukemia as laid down by Ehrlich are: (1) The absence of leucocytosis until late in the disease; (2) Absence of eosinophiles; (3) Low percentage of mast cells at first; (4) Late development of enlarged glands and spleen: (5) Predominence of large mononuclear non-granular cells late in the disease. (W. H. W.)

The Diagnosis of Diseases and Functional Activity of the Kidneys.— PROF. H. SENATOR (Berliner klin. Wochenschr., No. 21 and 22, 1903) details modern methods of diagnosis of diseases of the kidneys and the means of determining the functional activity of these organs. The diagnostic measures at our disposal are divided into two groups—the first composing all methods of directly examining the kidneys and their secretion, and the second all other organs or systems affected by disturbed kidney function. Every systematic examination of the kidneys should begin with inspection of the region, followed by careful palpation. Percussion is considered of doubtful value in the diagnosis of disease of these organs. In examination of the urine he dwells upon the importance of systematic procedure. The temporary presence of albumin in the urine after forced marches, cold baths and meals rich in albuminous foods is considered physiologic. Albumoses and especially deuteroalbumoses are found in the urine in infectious diseases, also in connection with albumin, preceding or following the same.

Of greater importance he considers the presence of Bence-Jones bodies in the urine as indicative of myelomatous or sarcomatous disease of the bones.

Nephritis may exist without the presence of casts in the urine. Casts are the product of disturbed or altered function of the epithelium of the uriniferous tubules and not, as was formerly believed, coagulated albumin from the glomeruli. For this reason casts may be entirely absent in the

chronic interstitial forms of nephritis. Considerable importance is attached from a diagnostic standpoint to the presence of mononuclear leucocytes in the various affections known as "morbus Brightii," while in pyelitis, cystitis, urethritis, etc., the multinuclear forms predominate.

Cylindroids are most often found in desquamative forms of nephritis. In renal hemorrhage the red cells appear fragmented and more or less devoid of color, while in hemorrhage from the rest of the tract they are well preserved in outline and color.

The determination of the molecular concentration of the urine is of diagnostic value only when its valenz value according to H. Strauss is established. This is done by multiplying the total quantity of urine passed in twenty-four hours by the freezing point of the urine. If the total quantity is 1500 and the freezing point is 1 degree the valenz is 1500. This, however, is subject to considerable variation under normal conditions. It has been established that whenever the valenz value of urine falls below 800 the functional activity of the kidneys is below normal.

The functional activity of each kidney can be determined by obtaining the urine separately by means of the ureteral catheter and applying the following tests:

1. The patient is made to drink a large quantity of carbonated water within fifteen to twenty minutes. It will be seen that the normal kidney will secrete urine in larger quantities than does the diseased organ. 2. The determination of the molecular concentration of urine of each kidney, the percentage of sodium chloride and nitrogen. 3. The phloridzin test. After subcutaneous injection of one-half centigram of phloridzin, sugar will appear in the urine from the healthy kidney in from one-half to three-quarters of an hour.

An increase of the molecular concentration of the blood serum or transudation beyond normal limits is considered of value in the diagnosis of renal insufficiency. The depression in the freezing point of normal blood runs from 0.54 to 0.59. The normal concentration of the blood is maintained chiefly through the activity of the kidneys, and if their activity is diminished the molecular concentration increases and the freezing point is lowered to 0.60 or even less. (L. F. J.)

PEDIATRICS.

T. H. Hay, M.D., R. C. Brown, M.D.

Clinical Results with Antistreptococcus Serum in Scarlet Fever.LOUIS FISCHER, of New York (Medical Record, March 7, 1903), cites the conclusion of Baginsky and Sommerfeld that the streptococcus is a distinct etiological factor in scarlet fever. Aronson's serum was made from the cultivation of germs taken from a child with scarlatinal angina; he also utilized germs taken from the bone marrow of a child that died of scarlet fever. The serum was first successfully tried on animals. He cites Arenson's conclusion that as long as streptococci are found in the blood of the animals there was therapeutic indication for the use of the streptococcus serum. Aronson maintains that the serum has no direct specific action on the streptococcus, but there is something else in the animal body in addition to the serum which

stimulates cell activity and produces both immunizing and healing action. He gives the summary of the results in Baginsky's cases in which there were three deaths in fifty-eight cases. Fischer reports two cases of his own, which made good recoveries, in which he used the serum. He says that it is too early to formulate definite conclusions, but that the clinical results are striking. The effect on the temperature showed that the serum did inhibit bacterial products and the necrotic membranes in the throat seemed to melt away. The temperature descended by lysis. He feels warranted in indorsing the view expressed by Baginsky advocating this new serum in the treatment of scarlet fever. (R. C. B.)

The Occurrence and Mortality of Typhoid Fever in Infants and Children. HENRY KOPLIK (Archives .of Pediatrics, May, 1903). It is now generally acknowledged that typhoid fever can be conveyed from the mother to the fetus through the placenta, and in a large number of cases causing miscarriage. When carried to full term the child is born infected with the disease, and dies soon after with symptoms closely resembling a sepsis of the newly born. The disease runs an atypical course the classical symptoms being absent, the infection of a hematogenous character, and the mortality very high.

Typhoid occurs later in infancy, up to two years, without a doubt. Henoch reports nine cases of typhoid in infants and children under two years in a series of 381 cases. Some of the cases in older literature are to be doubted owing to the lack of laboratory methods to confirm the diagnosis, but the exact methods we now possess establish the contention of the earlier writers that it does occur below two years, though not with the frequency of a later period of childhood. A sufficient number of cases have not been diagnosed by our present methods to establish the relative frequency of the disease below two years as compared to later periods. Koch, in studying lists of absentees from school in one village, found 72 cases of typhoid, only eight of which had been diagnosed as typhoid, the rest being diagnosed and treated for other maladies.

The mortality below two years, the author says, cannot as yet be definitely stated, but is, he thinks, larger than is generally appreciated. Griffith collected a number of cases below two years and shows a mortality of 50 per cent. Above the second year the mortality diminishes. Curschman shows a mortality of only 4 per cent. between two and five years. Marfan encountered a mortality of 50 per cent. in early childhood. Stowell, in four cases under two years, did not lose a case. Ashby and Wright, in 592 cases, had a mortality of 8 per cent.; Comby, in 250 cases, 7 per cent.; Curschman, in a larger number of cases in 1986, only 7.3 per cent.; in 1887 6.8 per cent. American authors make the mortality low. Holt collected 2,603 cases and found a mortality of 5.4 per cent. The author's own experience does not support the theory that typhoid fever is always a mild disease in children from the ages of two to ten years. In 1900 and 1902 his mortality was 3 per cent.; in former years in the same service it mounted as high as 10 per cent. The author's general conclusion is that the mortality varies in different epidemics and shows very slight variation from the percentages shown by adult cases. In mild epidemies the mortality varies from 6.6 per cent. to 13 per cent. from

the ages of two to ten years, whereas in the adult the percentage is not much higher. Children in severe epidemics are subject to a mortality of 30 to 40 per cent. if toxemia is great. (T. H. H.)

Malnutrition.-THEODOKE J. ELTERICH (Phila. Med. Journal, May 23, 1903) says that while all patients present the same clinical symptoms of extreme wasting, yet they can be separated into three distinct groups. Certain cases are due to want of food of sufficient quantity or quality, others to an impairment of the function of assimilation. The third class is that in which the malnutrition is the result of constitutional or local organic disease. Dr. Elterich cites cases illustrating these three classes. In the treatment of these cases he gets the best results in modifying the milk so that it contains a low percentage of fat and proteids. He believes that these infants are able to digest but very little fat and that the, giving of cod liver oil is harmful in malnutrition. (R. C. B.)

The Etiology of Endocarditis in Childhood.-SANFORD BLUM (Archives of Pediatrics, May, 1903), considers the subject under congenital and acquired defects, which, when once established are certainly a condition predisposing to attacks of endocarditis in childhood. Acute endocarditis originating in early infancy, under three years, is rare, 3,000 autopsies by Holt, Northrup and O'Dwyer furnishing only one case of acute inflammatory lesion. Acquired endocarditis, after the fifth year of age, is not uncommon and in later childhood is of frequent occurrence. Among the causes he gives first rank to rheumatism, which furnishes more cases than all the other causes combined. The severity of articular symptoms is no index to liability of cardiac complication. Endocarditis may be the first and only manifestation of the disease, the result of a micro-organism having a predilection for the serous surfaces attacking the endocardium just as it does the synovial membranes of the joints. Under this head, as closely related to rheumatism, he refers to chorea and tonsillitis. Scarlet fever, measles, diphtheria, pneumonia, all of the acute infectious diseases, may be starting points for endocarditis. Malignant endocarditis is exceptional in infancy. Under this head the author reports a case, two and a half months old, due to the bacillus pyocyaneus. The bacilli were found in the blood ante-mortem, and cultures made after death produced pyocyaneus endocarditis in rabbits. Malignant endocarditis differs only from the majority of simple cases in the gravity of the constitutional symptoms; rheumatism and chorea may be etiologic factors in the causation of, both varieties. Experimentally positive results have been obtained by himself and others with the streptococcus, staphylococcus, pneumococcus, tubercle, typhoid, and pyocyaneus bacilli.

(T. H. H.)

THERAPEUTICS.

Chas. H. Stoddard, M.D., B. L. Schuster, M.D.

(Klin.

A New Treatment of Unresolved Pneumonia.—SCHUELLER Therap. Wochenschrift, Jan., 1903) reports a case of what was diagnosed as abscess of the lung apparently cured by a novel mode of treatment. The history of the case was as follows: Following an attack of influenza the patient developed a right-sided pneumonia which did not resolve. Aspiration drew off a large quantity of fetid pus. Two days later the seventh rib was resected; the lung was found firmly hepatized but no sign of an abscess cavity was seen after two months. Schüller injected 120 c.c. of a sterile salt solution into different parts of the lung. In a few days the expectoration became more profuse, the dullness less intense, and vesicular murmur audible. After some time the patient made a complete recovery. The explanation given by Schüller is that the salt solution rendered the exudate more fluid, allowing some of the alveoli to empty themselves so that air could again enter the consolidated area. The movement of the air cells caused a re-establishment of the circulation which led to a removal of the remaining exudate. (C. H. S.)

Chronic Ulcer of Leg.-HANS BAATZ in an interesting monograph (Sammlung Klinischer Vorttraege, No. 267) explains his method of treating chronic leg ulcers. It consists in first cleansing leg and foot thoroughly with green soap and warm water. The ulcer and surrounding skin are disinfected with a 0.5-1 per 1000 bichloride solution. With sterile cotton the disinfected area is dried. Iodoform is dusted over the ulcer which is then covered with oil silk extending slightly beyond the margin of the ulcer. Over the eczematous and callous skin about the ulcer Pasta Lassar is applied, (Zinci Oxidati, Amyli, aa p.l, Vaselini, p 2). Over the whole area several layers of sterile gauze and cotton are placed. The author then paints over the leg as well as over successive layer of bandage covering the leg, Unna Zinkleim paste (Zinci Oxidati, Gelatine aa 20.0, Glycerine, Aquæ dest. aa 80.0). The patient is thus enabled to walk about and to attend to his work. This application must be repeated as often as size of ulcer and secretion demand. When the ulcer shows marked granulations salves are applied. He uses ung. hydrargyrum oxydat. rubrum. In later stages this is replaced with boracic acid salve. Exuberant granulations should be checked by the application of the silver nitrate pencil. If on first visit the ulcer shows a marked erithistic character und the surrounding skin erysipelatous or phlegmonous inflammation, the author prescribes rest and moist applications of Liq. Alumin Acetici to which a little ice has been added. The disappearance of this condition usually follows within 3-4 days, and then he treats the ulcer as described. (B. L. S.)

Treatment of Migraine.-Karplus (Klin. Therapeutische Wochenschrift, p. 142, 1903) makes a sharp diagnosis between true migraine and migraine-like attacks of headache which occur in other diseases. To an incorrect diagnosis of "migraine" must be attributed those cases cured by a