We call attention to this article because leucocytosis is still one of the very debatable subjects. It is of special interest to the surgeons and by some is greatly depended on as an indication that suppuration has taken place, while others believe that it is a very deceptive sign and place little or no dependence upon it.

The article referred to calls attention to the confusion in the nomenclature of the subject, and notes that there are in the literature at least five different classifications of the leucocytes. There is a lack of uniform standards, and for this reason the discussions of the subject are hampered.

The author brings to our mind a very important point when he says that there are two factors which govern the number of cells belonging to any cell type in either health or disease; (a) the total leucocyte count, and (b) the relative percentage for the cell types, that is, the relation which the various cell types bear to each other.

He gives a minimum and maximum nor. mal percentage for each cell type as follows: Small lymphocytes, 20 to 30; large lymphocytes, 5 to 9; transitionals, 1 to 2; polymorpho-nuclear, 60 to 70; eosinophiles, 1 to 2.

Thus we see that while the number of leucocytes in health has a range from five to ten thousand the various cell types also have a range of their own. For example, the small lymphocytes may vary in health from 1100 to 3000. All of these cells types, excepting the small lymphocytes have the pow. er to pass through the vessel walls. The The small lymphocytes do not seem to have this property, consequently their number is of special importance.

He relates a number of cases which seem to demonstrate that a gradual decrease in the small lymphocytes is distinctly unfavorable, and that when repeated examinations show a

continuously low small lymphocyte count an unfavorable prognosis is indicated.

This paper would seem to indicate an important step in the study of blood conditions. C. E. B.

ONE of the most important addresses delivered before the International Congress of

Psychiatry in its Relation to Other Sciences.

Arts and Sciences in this city, in September last, was that of Charles L. Dana., A. M., M. D., of New York, on Psychiatry in Its Relation to Other Sciences (American Medicine, January 21, 1905). Dana is one of the leaders of advanced thought in clinical psychiatry in America, and his original work, together with his masterly and comprehensive grasp of the importance of psychiatry in its relation to economic, sociologic educational and forensic problems of the day, places this address as an appeal for a wider knowledge of psychiatry among medical men, students of economics and the problems of state and legal medicine. This address should be read by all medical men and medical journalists should see to it that its essentials at least should appear in their columns. There is a crying need for a cam. paign of education in psychiatry-at least to the extent that mental disease be early recognized and early treated. Further, the clinician in internal medicine, the family physician, is the first to come in contact with mental disease, and in order to perfect his knowledge of real disease, the essentials of science of modern psychiatry must be understood by him. Dana, aptly and truly emphasizes this important consideration when he points out the fact, that "during the past twenty years there has been steadily developing a science which deals with mental dis

ease.

"Our knowledge has developed until now we are justified in classifying psychiatry among the medical sciences, surpassing in exactness some, and in importance, interest and difficulty perhaps all of the other branches of medicine. For we are dealing in its study with the ultimate and finest and most elaborately differentiated product of organic life, and our task with it is not only to study and classify, but prevent and save which is most essential to human progress— the human mind."

Psychiatry touches with many branches of human knowledge, and Dana in presenting these various relations in detail says: In so far as psychiatry has a practical side, it stands in close relation with what may be called, in

general, economics; to an extent also, it is in relation with all these sciences which particularly tend to prevent and ward off insanity by improving social conditions through sanitation, education and better heredity.

"

"The relation of psychiatry to economics is one of increasing interest and importance. The loss to the State and the expense in money from disease is a subject that has received increasing attention of late years, until now in many directions public knowledge and State action are almost adequate to the problems involved." This applies more especially to microbic diseases. "Nervous diseases, however, if we include also those due primarily to vascular disease, are probably more numerous than ever. "As to psychoses, there is little doubt that they are also increasing. relatively, more than the population. Statistics in states having carefully kept records and census statistics of this country and Great Britain, sustain this assertion. We may say that in the last twenty-five years the ratio of sane to insane has shown an apparent gradual increase from 1 to 450 to 1 to 300, and this latter seems to be about the ratio in those communities of North America and Europe in which modern conditions of civilization prevail."

Dana says, "It is my opinion, that the increase is a real one, and it is one to be expected, not only from the strenuousness of modern life and increase in city population, but also more feeble children are nursed to maturity and more invalid adolescents are kept alive to propagate weakly constitutions, or to fall victims themselves to alienation; the period of life susceptible to insanity is longer." "Insanity is increasing in part, then, because we are saving too many lives by the careful regulation of our health boards."

After summarizing the facts regarding the economic loss of insanity Dana says, "It seems to me that it would not be far out of the way to say that the care and cost of the diseased and defective brain of the country is over $8,500,000 annually, and is increasing at the rate of 4%. These figures, perhaps, are not so alarming to a nation with an income of $600,000,000. But it is an item to be reckoned with by economists; and the side of which cannot be represented by figures is still more important, viz., the sorrow and suffering and indirect loss of health and happiness.

Dana then discusses psychiatry and psychology, and he here emphasizes the importance of a knowledge of psychology in order to study the clinical aspect of mental disease. "The science of psychology stands nearest to psychiatry of all the non-medical sciences.

It should, in fact, bear the same relation to clinical psychiatry that anatomy does to medicine. "It furnishes us the normal standard of mental activity, and should give name and definite description of what takes place in the healthy mind. Therefore, it is as important that the psychiatrist should have a sound knowledge of the elements of psychology as that the neurologist should know the anatomy of the nervous system. "Psychiatry is a clinical study-only the clinical diagnosis is made as a rule, and this clinical diagnosis is really dependent mainly on the study of the psychology of the patient. Clinical psychiatry is, in fact, only morbid psychology. The older alienists never knew the science of psychology because there was none; the modern are only learning it." Dana next considers psychiatry and psychotherapy and chotherapy and his last paragraph aptly summarizes his statements of this relationship: "So far as internal medicine is concerned, mental influences produce many distressing disorders of function, which may simulate various diseases. The mind is a factor always in modifying the picture of disease, and the physician can never diagnosticate or treat his patient without taking the individual's mental attitude into account. This fact, which psychiatrists learn, can be improved with advantage on the followers of internal medicine."

Psychiatry and neurology and internal medicine form a most interesting and valuable contribution to current literature The family physician, the specialist in internal medicine in diseases of children, the psychiatrist in public institutions, and educators, each and all can profit from a perusal of this section of the address.

Dana says: "In the past the field of work of the psychiatrist has been perforce much narrowed through necessities of psychiatric administration. It was long confined to the study of types of mental disorders, which had reached their height and shown their hopelessness. It was as though pulmonary tuberculosis had been mainly studied in its third stage, or typhoid fever mainly in its second week, or heart disease after dropsy had set in. For when a psychosis is fully developed and has bloomed into mania, or a dementia, the morbid condition has arrived, the God is no longer behind the machine, but on it." "It can now be watched and its natural history studied, but in 75% of cases that is all; it cannot be cured. In only a small percentage will it be possible to learn why it came, and psychiatry can only reach a certain stage of progress when its study is limited to the middle and terminal parts of mental disorders."

"The field of psychiatry needs thus to be broadened by securing the help of those branches of internal medicine in which the earliest phases of mental deterioration and disorder show themselves."

It was long ago noted that neurasthenia might be called abortive paranoia. It is my experience that about a third of the cases of decided melancholia are preceded by attacks of what is called nervous prostration; and the same is in a measure true of the early demential psychoses and paresis. In fine it seems to me that a fruitful practical field just now for clinical study is that of what I term the minor psychoses, which includes a vast number of indeterminate mental conditions, classed as neurasthenias, hysterias, phrenasthenias, obsessions, impulsive manias and mild melancholias and hypochondrial

states.

"These patients fall into the hands of the general practitioner who is wearied and unimpressed by them, and who fails from lack of interest to study them, or into the hands of specialists who treat their reflexes, generally without avail, or into the hands of neurologists who deal with, them generally as having a temporary neurosis instead of a psychosis or the thing out of which one may grow. It is to be hoped and expected that the follower of internal medicine and the neurologist will study the cases more seriously, and from the point of view of the psychiatrist especially. In this way we shall be able to learn the very earliest symptoms that suggest the oncoming of mania and dementia praecox; we will learn better the type of infancy and childhood out of which it grows; we shall learn how to check and to prevent it."

An illustration of such help of neurology and syphilology to psychiatry is already shown in the development of our knowledge of general paresis. This diseases was recognized 100 years ago. Its etiology was not even distinctly suspected till 50 years ago. An established connection of its relation to lues is hardly more than ten years old, this being worked out by the co-operation of the syphilographer, the neurologist and the psychiatrist. New features of its course, particularly the physical symptoms and early symptoms have been derived within a few years largely through the help of psychiatrists, neurologists and syphilographers working together, until now the onset of disease is recognized almost before it is present. By reason of this its course has been checked, and it is my belief that cases have been permanently arrested in their progress, so that we may now say that paresis may sometimes be aborted, if not cured. All this has been

done through the co-operation of alienists, neurologists and syphilographers.

"So it seems to me like co-operation will enable us some day to cope with mania melancholia, chronic melancholia, and the precocious dementias. In this work we must have the help of the practitioner and of the educator, who studies the growing child.

"A great deal of work has already been done in measuring children, studying their growth, their mental activity and reactions, but not much has yet been formulated which is helpful to us as psychiatrists, to foresee a coming psychosis.

"This field needs further study from the anthropologist and the doctor of infancy and childhood. We do not want to know alone that a child is nervous, excitable, easily febrile, a bad sleeper and a noisy dreamer. But what are the special symptoms which may lead us to foresee a dementia praecox at 18, or a hysteria, or a mania melancholia before adolescence, or a paranoia at maturity."

PSYCHIATRY, PATHOLOGY AND PHYSIOLOGIC

CHEMISTRY.

"There is an increasing conviction among psychiatrists that some inherited defect, often most subtle and difficult to recognize, is present in all those who develop mental disorders. Without some original weak spot in the psyche or soma, the man who is infected will not get paresis or tabes; the man who has fevers, toxemias, shocks and emotional crises, will not get a delirium or insanity.

But the weak point in a degenerate constitution may not be especially in the nervous system. It may be in a glandular defect or insufficiency. One can imagine a person having congenitally defective adrenal glands; as a result, the blood vessels are not kept at their proper tonicity, and widespread defects in function follow. In the same way, there may be defective or overactive thyroids, and the tonus of the nervous system is disturbed. There is no doubt that the large colon has important functions in selective absorption, and to an extent in secretion. It is an organ that seems especially attuned to cerebral states. It goes wrong at times with every one, but if it is congenitally wrong, if it is born wrong, it is then one of the stigmata of degeneracy. Thus a person may have a psychosis, because he has congenital defect in the colon or other organs than his nervous system; the brain may be a very good one, but these adrenal organs-the thyroids, the blood-making organs, the enteric membrane, the liver-may be fundamentally defective or the circulatory organs may be badly developed."

"Now it will be the part of the clinical pathologist and chemist as well as of the anatomist to search out these factors, and in this way help the psychiatrist to steer his way in. the future."

"I do not believe that the results of this work can be very fruitful as regards the severe dementing forms of mental disease; here there is always fundamentally a fault with the brain in structure or function. But in the functional and non-dementing psychoses, such as mania and melancholia, and in the minor psychoses, such as hysteria, many types of neurasthenic insanity, we may expect much help.

"Insanity, on the whole, is not a very curable affection. It is probable that less than a fourth get permanently well, and its rate of cure is therefore less even than that of pulmonary tuberculosis, pneumonia or the infective fevers. Nor is it likely that the percentage of cures will ever be a very high one.

"We may look to the sciences of pathology and chemistry, however, for some help in this direction. It has been already shown that in degenerative disease of the nervous tissue there is the perverted metabolism, which leads to the breaking up of the lecithin, the important fat constituent of the nervous substance into poisonous by-products, neurin and cholin. These circulate in the lymphatics and bold vessels and irritate and further poison the nerve centers. So that when the brain actively degenerates it produces a poison. This poison reacts on the nervous centers, causing new symptoms, and thus a vicious cycle is set up. Some of the crises of paresis and the dementias may have this origin."

"The function of the lower bowel seems to have some close relation with the functioning of the nervous centers, and an autotoxemia is perhaps an important element in both depressive and maniacal states."

"Indeed the appearance of mania especially suggests an autointoxication. One can

not observe the apparently causeless recurrence of mania and melancholia without the conviction that behind it all is a disorder of metabolism leading to a toxic state.

"We may expect therefore much from the further studies of the physiologic chemist. Such studies will include the activity of the ductless glands, the adrenals and thyroid, and particular of kidney."

"We cannot, it is true, expect to find any objective explanation of the tendency which the alienated possesses to pass repeatedly into states of mania. But we may find the nature of the nutritional change that excited it, and by proper methods we may be able to keep off recurrence of insanity.

"Pathologic anatomy is a subject of more

EPIDEMICS OF INFLUENZA.- Peoria, Illinois, is having a severe epidemic of la grippe -over 2,000 cases have been reported and the disease still spreading.

A LAND of mystery and magic, the Everglades of Florida are almost as little known

today as when the early navigators first charted the contour of the Cape of the End of April. Announcements of the February Century include an account of "The Everglades of Florida" by Edwin Asa Dix and John Nory MacGonigle, which the editors of The Century believe will give a wider range of information on the theme than has ever before been presented in a single publication. The authors, some of them redrawn by Harry Fenn from material secured by the New York Botanical Garden and from other sources, should be of unusual interest.

HARE'S PRACTICE OF MEDICINE.-Messrs. Lea Brothers & Co. announce for early publication a completely new work which will be welcomed by every practitioner, teacher and student. Hare's Practice of Medicine, a textbook of the practice of medicine for students and practitioners. As the student of today is the physician of the future, and as the physician must always be a student, a single volume can be conceived as answering the requirements both of a text-book and work of reference. To produce such a volume the author has brought to bear his experiences of twenty years of active hospital and private practice, during which period he has been constantly engaged in teaching the subjects of clinical medicine and therapeutics.

This

REPORTS ON PROGRESS

Comprising the Regular Contributions of the Fortnightly Department Staff.

INTERNAL MEDICINE.

O. E. LADEMANN, M. D.

A Contribution to the Study of Ulcerative Endocarditis.-M. H. Sicard (American Jour. for the Medical Sciences Nov. 1904) gives a thorough analysis of over thirty cases of this infection, concluding that malignant endocarditis is a disease of bacterial origin differing from an acute simple endocarditis in the extent of endocardial inflammation and tissue necrosis; in fact the right heart is more often attacked; in the more frequent embolic processes which are septic in character. During life the micro-organisms are demonstrable in the blood and on the affected valves of the heart and in the emboli after death. Nothing in the clinic appearance of the disease is distinctive of any peculiar variety of germ causing it. Primary cases, although they do exist, are rare; most cases, however, accompany other affections, as rheumatism, sepsis, acute infectious diseases, or are engrafted on an old pre-exstent endocarditis. The termination in almost all the cases is a fatal one; those do to a severe infection in a few days; the septic ones in a few weeks. The first variety have a leucocytosis of 15,000 or over, the latter usually below that number, some being very slight. Emboli and hemorrhages are of frequent occurrence, and may be fatal in their results. The urine usually shows evidence of a nephritis it may contain blood and pus from hemorrhage or infarct. The treatment is usually unavailing, excepting the serum therapy, which is of uncertain value. Infants and young children seem to be almost exempt from the disease.

Primary Congenital Cardiac Hypertrophy. -E. Hedinger (Virchow's Archiv, Bd. 178, Heft 2, 1904) reports an instance of this kind in a fourteen-month's old child. At the autopsy, the heart weighed 190 gm. with a maximal ventricular diameter of 8 cm. No cause to account for the hypertrophied heart was ascertainable, as the valves, arterial system and kidneys were found normal. The author attempts no explanation as to its production.

A Contribution to the Diagnosis of Renal fuberculosis.-R. Milchner (Berliner klin. Wochenschrift, No. 49, 1904) records an instructive case in a girl 11 years old; a diag. nosis of renal tuberculosis being based on an abundance of blood and pus in the urine, the sediment of which containing numerous acid

fast bacilli. The left kidney was considerably enlarged and painful on pressure. Emaciation was a marked feature. The extirpated organ showed no signs of a tuberculosis, but a hydronephrosis. The fact that the aid fast bacilli proved to be smegmas bacilli prompts the author to suggest animal inoculation in such instances.

A Study of the Effect of Potassium Iodide in Arteriosclerosis.-Müller and Inada (Deutsche med. Wochenschrift, No. 48, 1904) noted that the internal administration of this medicament in healthy individuals caused a diminution in the viscidity of the blood. They attribute the alleviation of symptoms in a beginning arteriosclerosis to this fact, contending that the reduced glutinous consisting of the blood lowers the resistance between the circulating fluid and wall of the vessel, particularly in the capillaries, result ing in a more rapid propulsion of the blood and a better arterial supply. The authors emphasize that beer, sour foods and drinks should be avoided when iodides are administered.

A Clinical Study of the Diazo-Reaction.W. T. Cummins (University of Pennsylvania Med. Bulletin, Sept., 1904) summarizes the results of his investigations regarding Ehrlich's diazo-reaction as follows: 1. The reaction is of importance in differentiating a relapse (in which it is positive) from a complication in typhoid fever. 2. It may be of signal assistance in separating measles (in which it is positive) from German measles. 3. It has great prognostic significance in pulmonary tuberculosis. It does not appear until late and is usually noted in a rapid case. When it once appears it persists until death. The average duration of life after the appearance of the reaction is about six months. An unfavorable prognosis should be given in every patient presenting it. The diazo-reaction at a dilution of 1:40 is of some value in the diagnosis of typhoid fever, but upon employing a dilution of 1:50 other conditions are eliminated (except a small percentage of tuberculous cases), and the test, therefore, is considerably enhanced in value.

4.

The Diagnostic and Therapeutic Value of Lumbar Puncture.-D. Gerhardt Mitteil (aus den Grenzgeb. der Med. u Chir. d. XIII Heft 4 and 5, 1904). From an exhaustive review of the literature, together with many personal observations, Gerhardt deducts the following inferences as to the merits of lumbar puncture. (a) Diagnostic: It is of inestimable value in tuberculous and purulent meningitis, in acute febrile diseases, a serous