What Causes the Decrease?

THE Chicago Health Department ever alive to the value of scientific inquiry into statistics has carefully com piled the mortality statistics of diseases of the nervous system for the past ten years. The results are startilng in a measure inasmuch as they controvert the very much talked of increase, nervous diseases and high mortality rate in the great centers of population. In Chicago "The Strenuous Life" is lead at a pace equal to that of any great city on the Western Continent and yet in its endeavor to establish equality of conditions conducive to long life and happiness, it seems to have turned modern prophets to a ready jest by showing that the pace that kills is after all a salutary servitude in that great city. This contrast with New York, which in light of truth shed by Dr. Darlington, health officer of New York, shows that there is something in Chicago civilization which contributes to longevity and good health; then there is individual happiness, the pursuit of which lessens nervous strain. Perhaps the equality of conditions which in the American democracy such as Chicago presents, renders men so much alike that education, fortune and tastes interpose to lessen the strain. The similitude of their connitions, habits and manners with the average Chicago citizen, suburban in birth, lays a foundation for good healh, even in Chicago, and fortify against the lofty stationary barriers which New York presents, and which eventually leads to the strain that kills.

We pre

We hardly know why Chicago is such a retreat as statistics would indicate. sent Heatlh Commissioner Whalen's report; it affords food for thought:

"Nervous strain" is discussed editorially in the current number of the Journal of the American Medical Association, the keynote being struck in this, the opening, paragraph: "It seems to afford a kind of pleasure to this generation to look on itself as the victim of high pressure. We hear much on all sides of the hurry of the time, of the pace that kills, and of the disturbing and demoralizing effects of modern industrialism and commercialism. There is no lack of remedies for the existing order. We are told that we must concentrate, not dissipate, our energies, that we must forsake city life and return to nature in the guise of a $60,000 farm, or at least of a commuter's garden; that we must altogether give up trying to be rich and must rest content with the common lot. It is no wonder that a dazed old lady was heard to remark: A little while ago we had to live the

strenuous life; then it was the simple life; and now it is the equitable life.

After pointing out the fact that "the feeling that life for most involves a large measure of struggle and output of nervous energy is not peculiar to our time," but "each generation looks back with longing on the calmer life of its predecessors," the writer seems to admit it to be true that "nervous strain" and its consequences are really increasing, and closes with an appeal to the individual factor of presonal hygiene:

"The root of the matter is that neither modern life nor urban life is to be blamed indiscriminately for what is popularly denominated nervous strain. If certain factors at present little studied and poorly understood, are tending to increase diseases of a nervous type, they may be found on investigation to be such as lie within the control of the individual more commonly than has been supposed. There is still room for him to consider what the Roman emperor meant who said that even in a palace life may be led well."

But it is not true-as a matter of fact, and not of an egoistic self-coddling imagination -that "diseases of a nervous type" are increasing. Contrariwise, as Tweedledum

says,

Not only here in Chicago, but, in a lesser degree of course, in all the large cities of the country, this type of disease is decreasing more rapidly than any other.

Taking the vital statistics of the last thirty years for this city it is seen that less than half as many persons in proportion to the population died form "nervous diseases" in 1900 than in 1870. The figures for the four years, per 10,000 of the census population are-1870, 37.6; 1880, 33.4; 1890, 28.3; 1900, 15.7-a decrease of 58 per cent. For the last four years the figures are-1901, 15.1; 1902, 14.7; 1903, 14.5; 1904, 12.8-a reduction of 18.4 per cent during the "strenuous" period since the last census year.

If it be objected-as it undoubtedly will be by some of the men with muck-rakes, who so long and so vituperatively objected to the Department's pneumonia figures-that the classification of diseases, especially those of the nervous system has been changed since 1870 so as to vitiate the comparisons, the following table will be sufficient answer. This table includes only deaths from forms of diseases of the nervous system concerning which there is no question of classificationcerebritis, convulsions, dementia, encephalitis, epilepsy, insanity locomotor ataxia, mania, melancholia, meningitis, paralysis, paraplegia, softening of the brain, spinal meningitis, etc. and the period covered embraces

Per Total. 10,000 17.5 15.0 13.0

2,151

13.6

1901.

The

8.5

1904....... 1,638

With the exception that, during the last seven years, 1898-1904 inclusive, deaths in the County institutions at Dunning-outside the city limits-are included, the figures in the above table are absolutely comparable. The inclusion of the Dunning death works, to some extent, to make the per cent of reduction less.

But even so, the decrease of deaths from diseases of the nervous system in the last twenty years is seen to be fully 60 per cent.

"Nervous strain," it may be remarked in passing, tends vastly less "to increase diseases of a nervous type" than does the malign influence of such a disease as influenza-as shown in the 1891 nervous-diseases death rate in the table. The average rate of the five years preceding the influenza pandemic of 1890 was 22.7 per 10,000 of population; this was swelled to 26.6 in 1901-an increase of more than 17 per cent.

Further confirmation of the general decrease of nervous diseases is found in "A

Discussion of the Vital Statistics of the Twelfth Census," by Dr. John Shaw Billings (1904). The following figures for the six cities having populations of more than half a million each in 1900 are compiled from table 3 in the "Discussion" and from Part II of Vital Statistics of the Eleventh Census:

Management

of Uterine Fibroids.

IN a recent paper upon this subject. Dr. B. B. Davis, of Omaha, said: Though the profession is practically in accord in the management of these tumors, a few moot points are worthy of discussion. So many modes of treatment have been lauded, then dropped, that skepticism has been developed. The Apostoli has been given up. Mackenrodt and Martin report 16 of 36 cases made distinctly worse by it. The Tait operation of removal of the ovaries to secure artificial menopause has also fallen into disrepute. The atrocity

of removing healthy ovaries, with all the nervous and mental symptoms it entails, is enough to condemn. Elimination of these two procedures narrows the discussion to medical treatment or direct surgical attack. If medical measures could accomplish any. thing, they should be tried. Many drugs It have been used, with ergot at the head. was thought that it checked the growth of the tumor by contracting the vessels which fed it and that extrusion followed. No one believes this now. The risk of death from hemorrhage during its use was great. Sloughing and sepsis have cost many lies. The logical treatment of any tumor is its complete removal, but the surgical removal of fibroids gave a frightful mortality. Spencer Wells published in 1878 the results of his first twenty-four cases of hysterectomy; his morIn 1887, Keith put the tality was 62.5%. mortality at 25%. The extraperitoneal method of treating the stump has given way to the subperitoneal. Now, the technic is to save one or both ovaries, remove the body of the uterus and retain the cervix, covering it with peritoneal flaps. The retention of the cervix furnishes a much more normal relationship between the rectum, bladder and vaigna, and avoids the shortening of the vagina and vaginal prolapse. The total removal of the uterus is also a much more formidable

operation, and also involves more danger of wounding the bladder, cutting the ureters and the induction of sepsis from below. Occasionally, the tumors may be enucleated from their beds, the cavities filled by layer sutures and the uterus retained. In these cases of enucleation, the dangers of postoperative hemorrhage are greater than after hysterectomy. Great care should be taken that normal fibroids should be overlooked. A submucous tumor can be removed from be

low, without removal of the uterus, if it is certain that neither an intramural or subperitoneal is present. Vaginal hysterectomy is not rceommended bcause: (1) It necessitates the removal of the cervix, and its retention is of great advantage; (2) it is impossible to perform the enucleation operation in connection with vaginal hysterectomy; (3) the conversion of one or both ovaries can be best carried out through an abdominal incision; (4) the removal of a large tumor by the vaginal route is impracticable. The following are the positive indications for immediate operation: (1) Rapid growth of the tumor; (2) very profuse menstruation, or irregular hemorrhages; (3) sufficient size of the mass to make this retention a burden; (4) pain enough to interfere with sleep, or to necessitate analgesics; impaction of a tumor in the pelvis; (6) urinary symptoms from pressure, or obstruction of the ureter, causing hydronephrosis; (7) sufficient pressure to the rectum to interfere seriously with defecation; (8) infection of the tumor, or pyosalpinx; (9) purulent discharge from the uterus; (10) disturbance of the patient's mind sufficient to render her life a burden. If a patient with a fibroid is married and childless, what prospect is there of her bearing a child? Can full term be reached and safe delivery follow? Will Cesarean section be necessary? If the tumor is low down on the cervix, or in the broad ligament, or is adherent in Douglas' cul-de-sac, the prospect for normal delivery will be remote. Exceptional conditions might demand permission for pregnancy to go on and be terminated by Cesarean section.

It must be borne in mind that the presence of fibroids in pregnancy conduces to abortions and subsequent infection, and adds materially to the danger. When infecction occurs, the tumor often suppurates and sloughs. The proneness of myomata to malignant transformation is much greater than the perusal of text-books would indicate. Repeated instances have been seen of long standing, quiescent fibroids which have suddenly increased, become painful, and have shown severe hemorrhages demanding operation, at which an operable sarcoma has been found. One assumes a grave responsibility therefore in advising a waiting policy. The only definite indications for non-interference are that the tumor is causing no untoward symptoms, is distinctly atrophying, and is found in a woman who is nearing, or past, the men

opause.

Phytolaccin given to cause faint nausea most powerfully dissipates congestions of the mother's breast.

DR. S. KONN contributes a very thoroughgoing disquisition on asthma (Med. Record,

Asthma.

The

August 26), in which all aspects of the disease are discussed. The affection has no distinctive pathology, and the lesions that actually cause it have not as yet been discov. ered, but the essential cause of the disease, that which constitutes an individual an asthmatic, is probably some organic lesion of the nerve centers of the medulla, though this has not yet been demonstrated. mooted point of the nasal origin of asthma is considered at length, and in this connection the author says that although the views of causation, especially as regards the nose, are very divergent; the fact which stands out distinctly, in all that has been written, is that peripheral or central irritations, be they in the nose, throat, bronchi, skin, viscera, or in the circulatory media, or in the brain itself, in certain individuals of a neurotic temperament produce a characteristic, distressing, periodic dyspnea which is sui generis; it is unlike the dyspnea of destructive lung disease; it is entirely different from cardiac or uremic dyspnea; it is well defined and unmistakable in the suddenness of onset of the paroxysm, the seeming gravity of respiratory insufficiency that makes those about the patient fear that death is imminent, and in the more or less rapid return to a normal condition. It is the consensus of opinion that this uniformity entitles asthma to be considered as a disease and not as a symptom. The writer has been able to find the record of only three autopsies on asthmatics, and in none of these was anything characteristic discovered. Thus far no change in the nerve centers has been discovered to which the disease can be positively attributed; we are consequently driven to the hypothesis that there must be a molecular change in the nervous centers or a periodic disturbance in their vascular supply, and that, as stated, the asthmatic attack, like that of urticaria migraine, or epilepsy, is the culmination of a series of irritations transmitted to the nerve centers, which finally result in the explosion which, in this case, is the asthmatic paroxysm. The matter of treatment is also discussed at length, and the author says that of the list of drugs recommended he has had most success with potassium iodide. doubts the universal utiilty of operative work in the nose, and says that there must be internal treatment directed to the underlying cause in the brain, respiratory and vasomotor centers. Every asthmatic should have his nose examined and treated, of necessary, but it must be borne in mind that

He

the asthmatic is such not because of some abnormality in his nose, bronchi, or in some other organ, but because, at bottom, there is a derangement of his entire nervous system and an irritable condition of his nerve centers with explosions in the domain of the vagus nerve. In conclusion he speaks highly of the value of institutional treatment for asthma and urges the establishment of sanatoria for this purpose.

TRI-STATE (ALABAMA, GEORGIA AND TENNESSEE) MEETING.-The seventeenth annual meeting of the Tri-State Medical Society of Alabama, Georgia and Tennessee will be held in Chattanooga, Tuesday, Wednesday and Thursday, September 26, 27 and 28, 1905. A rate of one fare for the round trip has been secured on acount of the fall meeting of the Chattanooga Fair Association. This organization will have a horse show and other attractions, September 26th and 30th. Membership to this association is open to all members of the profession in good standing, and a most cordial invitation is extended to all such medical men. A program of unusual merit is already assured, and those who have not yet sent the subject of their papers should do so at once to the secretary, Dr. Raymond Wallace, Chattanooga, Tennessee.

THE SPECIALIST AND THE GENERAL PRACTITIONER.-R. C. Myles, New York (J.A.M. A.), in his chairman's address before the section on Laryngology and Otology at the recent session of the American Medical Association, considered the subject of the relations of the specialist and the general practitioner. In large cities, he said, the division of labor between the specialist and the general practitioner is a perfectly natural one, but in rural districts and small towns the case is different, and the importance of having a well-posted, all-around practitioner is more evident. Hence, he insists on the need of having all the essentials of the specialties included in the training of the up-to-date student, not to make of him what has been facetiously called a "general specialist." or to overcrowd his studies, but to make him capable of meeting the inevitable emergencies which occur from time to time. Dr. Myles also refers to the advisability of military surgeons qualifying themselves to treat special conditions, ordinarily referred to specialists in general practice, and the possible practicability of having military medical specialists who can be called in when specially expert treatment is demanded. On the other hand, the specialist should keep himself fully in touch with medicine in general and in full

accord with his professional brethren outside his particular department. A more cordial feeling of fraternity should exist between country physician and city specialist.

FREEDOM FROM URIC ACID AND HOW TO OBTAIN IT. Alexander Haig attributes a great deal of importance to the maintenance of the alkalinity of the blood as a means of preventing the accumulation of uric acid in the body. Although high nutrition is one of the causes of diminished alkalinity of the blood he does not believe that much is to be gained by great reduction of the amount of food ingested, as is recommended by some authorities. His rule of determining the amount of food for an adult is that the body weight in pounds is to be multiplied by nine to get the number of grains of albumin that should be consumed daily. People who underfeed themselves usually have a subnormal temperature, defective circulation, and deficient blood color, and are very susceptible to bacterial infections. The author also emphasizes necessity, if uric acid retention is to be avoided, of warm clothing, avoidance of needless exposure to cold, of an equal division between mental and physical labor, and of abstention from fruit from October to April. He sums up his views by saying that the greatest freedom from uric acid is obtained by introducing none, and by passing out each day regularly and punctually all that is formed in the body, and that this reg ularity of excretion may be attained by clothing warmly, by avoiding exposure to cold in every form, by eating freely of potatoes (especially in cold weather), by avoiding fruits that are out of season, and, indeed, by never taking fruits to any large extent, except in very warm weather. It is also advisable to secure the proper distribution of time between bodily and mental exertion, and to dispense with dependence on tonics, stimulants, and bracing climates. The result will be a better balance of mind and body, and a more healthy, natural and useful existence than has been generally experienced either by ourselves or by our ancestors in the previous century.-Medical Record.

Aconitine quickly and certainly dissipates milk fever if the bowels are kept clear and aseptic by proper means.

Quinine has been used for milk fever but it checks the secretion of milk; aconitine is better and does not affect milk.

Laryngismus Stridulus:-Cut short the paroxysm by emetine, lobelin, copper sul. phate, or any other emetic-apomorphine.

THE REVIEWER'S TABLE

Books, Reprints, and Instruments for this department, should be sent to the Editors, St. Louis.

PHYSICAL DIAGNOSIS. By Richard C. Cabot. M.D., Instructor in Medicine in Harvard University. Third edition, revised and enlarged. With 5 plates and 210 figures in the text. New York: William Wood & Co. 1905. (Cloth $3.00 net.)

Three editions of a book within a period of five years readily proclaims the value of its contents. The present volume, thoroughly revised and considerably enhanced, differs from its predecessors in the respect that it also contains a comprehensive inclusion of the diagnostic methods of the abdominal organs. The author makes no attempt to describe technical processes with which he has no personal familiarity. His long experi

ence as a teacher and clinician enables him to present a book which will not only be a favorite with the medical student, but of service to the general practitioner as well. Each chapter, of which there are twenty-five, is abundantly illustrated, well and clearly written and an expression of good judgment. Although the present edition is almost twice the size of the previous ones (577 pages), the price, however, has increased only fifty cents. O.E. L.

THE DOCTOR'S RECREATION SERIES. A series of 12 volumes devoted to matters of and at the expense of the doctor and his patient, purposing the permanent record of various matters of both amusing and serious character which are features of the Doctor's life. Already published; Vol. I.-The Doctor's Leisure Hour: Facts and Fancies of Interest to the Doctor and his Patient Arranged by Porter Davies, M D. Vol. II.-The Doctor's Red Lamp: A Book of Short Stories concerning the Doctor's

as much a master of the art of weaving fiction and fact into a highly readable story which commands the interest of the reader from its early pages to its very end. The next volume in the series, which is now in press, is "Book About Doctors," by John Cordy Jefferson, who made such a success with his "Book About Lawyers," "The Real Lord Byron,'' etc.

Laryngismus Stridulus :-No remedy cuts short the paroxysm so quickly and well as glonoin, hot solution dropped on tongue.

A POSTHUMOUS STORY.-A posthumous story by Elizabeth Cherry Waltz, "A Lady of Balance," one of the September Century's features. A pathetic interest attaches to all of Mrs. Waltz's work since her death just at the time that her first-and as in proved her only-book, "Pa Gladden." was in press. Mrs. Waltz was literary editor of the Louisville Courier-Journal for several years, spending herself on her work and her writing with unusual zeal. Indeed, her devotion to her work is believed to have induced the illness that caused her death.

SURGERY, GYNECOLOGY AND OBSTETRICS. In July a very exceptional journal under the above title made its initial appearance. The journal appears under the editorial management of Drs. Franklin H. Martin and A. B. Kanavel, with a staff of eleven of Chicago's strongest men. The collaborating staff is

A

In the Year 1800: Being a Relation of Sundry Events Occurring in the Life of a Practitioner in the Year 180. novel, by Samuel Walter Kelley, M. D. The Remaining volumes to appear serially. Artistically printed and bound. 400 pages each volume. Akron, Ohio; The Saalfield Publishing Co. Price, Silk cloth, Gilt top, Deckle edge, per vol. $2.50; Half-Morocco, Gilt top, Deckle edge, per vol. $4.00.

We have previously reviewed the two earlier volumes of this series and expressed our thorough enjoyment of every page, the third volume is very different in character, but no less interesting. Dr. Kelly bas contributed a very excellent historical novel which must please a medical audience and many others. In the matter of plot and detail the novel is the work of a master and shows that the medical man is a versatile being, and may prove a success in almost any field. Aside from the literary worth of this novel it has exceptional worth in that it brings out the homely details and intimate happenings of the life of the profession in the early days of our country. The profession is very generally acquainted with Dr. Kelly's work as an author, but more intimately with his scientific contributions to literature, it will be a pleasure to find that he has proven himself quite

the Chicago Medical Society, Dr. L. L. McArthur, president Chicago Surgical Society, and Dr. J. C. Webster, president Chicago Gynecological Society, followed by 36 names of Chicago men of like eminence, and further by names of leaders in these three special lines in New York, Boston, Philadelphia, Baltimore, San Francisco, Denver, Washington, St. Louis, Rochester (Minn.), Kansas City and Louisville, St. Louis being represented by Drs. N. B. Carson and W. B. Dorsett which means that our interests are in the best of hands. The journal is established and will be conducted on a high scientific plan. The two numbers already issued indicate that it is to be a little superior to any other of its kind. Though covering a wider, range it is in the class with Annals of Surgery and one or two other special journals to which the American profession points with pride. We congratulate Dr. Martin on the excellence of the journal and the auspicious start it has made on what must be a long and useful existence.