From the columns of totals we find that for the first quinquennium, the deaths for both diseases together were 516, and for the period of five to twenty, the legal school period, they were 352, and in the five to nine period separately, 244.

It will be observed that the ratio of deaths in the first five years of life is about three times that in the second five-year period for scarlatina, and twice that for the same period in the case of diphtheria. We see in this an apparent disagreement from the foregoing statistics regarding the cases as reported in the different illustrated statistics given.

There is, however, a natural explanation for this in the fact that the percentage mortality of scarlatina in England in 14,000 cases between 1888 and 1893 under five years was 16.8 per cent., while that for the five to nine year period was 5.6 per cent.

In the same way diphtheria which, between 1895 and 1899, had 25.6 per cent. of deaths in cases of children under five years, had 14.6 per cent. of deaths for the five to nine period. Or there were 1,536, as compared with 695. What is very pleasing to notice, however, in this study of English statistics, is the relatively great decrease in recent years, not only of the total cases and total mortality, but also of the lessening percentage in school children, due doubtless to the closer inspection of school children, and the very general removal of first cases to the isolation hospitals.

To conclude this reference to the relative prevalence in the two periods through illustrative statistics, I shall take the returns of our two largest cities, Toronto and Ottawa, for 1903. Except for the first three months of the year, the following are the number of cases, as well as deaths, for the year 1903. We find that for the ten months from March to December, Toronto had 418 cases of scarlet fever and 62 deaths, and 806 cases of diphtheria, with 100 deaths. The deaths for the whole year by ages are seen in the following table:

Not

Ages.

0-1 1 2 3 4 5-9 10-14 15-19 20-24 25-29 40-44 60-69 given. Total

Scarlet Fever..

Diphtheria..

Diphtheria and

Scarlet Fever

Comparing cases with deaths as given, we find that the percentage death rate was 14.7 for scarlatina, and that for diphtheria was 11.7. I have not the figures enabling us to determine the death-rate at different periods, but we may assume that the relative rates would be much the same as in other years and places.

We find for scarlet fever that in the nought to five period the deaths were 44, while those for the school period, five to nineteen, were exactly the same. Applying the rate in the London Report, this means that there were three times as many cases among children of school age as in those from nought to five years.

For diphtheria it would appear that the record for children of school age is more favorable. Assuming that the London rates prevailed of two to one for the two periods, we find the prevalence in the schools to have a ratio only 50 per cent. greater than that for the nought to five year period.

The following table illustrates the relative prevalence in the city of Ottawa:

From the figures here given for scarlet fever, we similarly conclude that the prevalence of cases among the school children was three times as great in the five to nine period as in the nought to five year period; but we find that in the matter of diphtheria there is by no means the same relation, there being twenty-two deaths in the nought to five period, and but five in the five to nine period.

These figures are of extreme interest since they represent the results of a year's work, where for nine months all cases of diphtheria were removed to the isolation hospital so soon as diagnosed, and the school children of the rooms, where cases had been, were inspected till the period of incubation was over. The very consid erable number of cases which occurred during the year (320 of scarlatina and 351 of diphtheria) removes the element of incorrect deductions which may result from a small number of cases.

The history of these Ottawa figures as a statistical study is most interesting. For years the city had an unenviable reputation in the matter of contagious diseases. In 1902, there were in all 689 cases of scarlet fever and 234 of diphtheria. In February, 1903, a new well-equipped isolation hospital was opened, and after March all cases of the diseases occurring in the city were sent to the hospital. Of the 320 of scarlet fever, 198 were treated in the new hospital during the eleven months; the balance, 102, were treated else

where, or after the complete removal to hospital of all cases began, there were for the nine latter months of the year but 159 cases compared with 161 in the first three months.

Of the diphtheria cases (251 cases), 69 occurred in the first three months of the year, and 182 in the latter nine months, during which all cases were treated in the hospital. While not directly bearing on this subject, it is pleasing to remark that the total deaths for the nine months from scarlet fever were but three, while those from diphtheria were nine, or 1.52 per cent., and 4.9 per cent. of the cases. Such a low record of deaths for so large a number of cases has, so far as I know, never hitherto been obtained. But the other important point is the effect of the removal to hospitals of first cases in lessening the prevalence of the disease. In 1902 there were 689 cases of scarlet fever in Ottawa with thirty-nine deaths, and 487 cases of diphtheria. As a matter of fact, there has resulted from the more effective methods adopted in 1903, a reduction of over 50 per cent. in the cases of scarlatina and 85 per cent. of deaths, and 41 per cent. in the cases of diphtheria, and 54 per cent, of deaths.

But little more, I think, need be said on the subject, as the methods for dealing with infectious diseases in schools will be dealt with in another paper. To me, and I think to every one, it must be apparent that practically there is no limit to the economic and lifesaving results which public health work, moving along the lines of experimental science, is capable of. What it is apparent is necessary is:

I. A conviction arrived at by such statistics as have been cited that disease is disseminated in such ways as I have indicated.

2. That we be convinced by the results of such methods as have been especially illustrated by the Ottawa statistics, that an enormous saving of cases of disease and deaths is possible.

3. That we possess scientific methods so certain when persistently and systematically carried out, that they will suppress outbreaks of epidemic disease almost with the same certainty as the demonstrated amount of work which a properly constructed machine will perform with the combustion of a definite weighed quantity of fuel. All that is further required is to educate the public that such work is life-saving and patriotic, and that, like all other philanthropic work, the results are not only good to the receiver, but also to the giver. As Sir Launfal, in his search for the Holy Grail, came to realize:

"The Holy Supper is kept, indeed,

In whatso we share with another's need;
Not what we give, but what we share;
For the gift without the giver is bare;

Who gives himself with his alms feeds three:
Himself, his hungering neighbor and me."

-"Canadian Journal of Medicine and Surgery," March, 1904.

THE WEAR AND TEAR OF LIFE-NEURASTHENIA.

By GUTHRIE RANKIN, M.D., M.R.C.P., of London, Physician to the Dreadnought Hospital, Greenwich; Senior Assistant Physician to the Royal Hospital for Children and Women, Waterloo Road.

The term "neurasthenia" was first given in 1879 by Beard, of New York, to a group of symptoms which, though sometimes illdefined and always capable of infinite variation, yet retain a general relationship which serves for the groundwork of a disease entity, little understood and never described before Beard's time, but through his investigations and those of many successors nowadays universally recognized as a formidable enemy of mankind. Speaking generally, neurasthenia may be regarded as a derangement of function resulting from exhaustion of nervous energy. The causes upon which it depends are varied and often obscure, but, despite the testimony of contrary opinion, it can scarcely be denied that the increasing wear and tear of life at the present day probably plays the most important part in its etiology. It is not suggested that the greater pace at which the world moves is the sole explanation. The disease has probably existed from the remote ages, but it seems unlikely that it can have been prevalent in the earlier period of the world's history, else it could not have escaped description at the hands of the many eminent clinical observers of ancient days. And even coming down to recent times, it will be admitted by most physicians that in their individual experience the number of cases which they are compelled to classify as neurasthenics is infinitely greater than a few years ago; that it is one of the disorders which in its prevalence has become fashionable enough to be designated "the disease of the century"; and, most noteworthy of all, that its victims are to

be found in far greater abundance among the restless inhabitants of busy communities and large centers of industry than in country districts where life is passed under conditions of uneventful monotony, and of prosaic, unexciting occupation and duty.

Cases occur in rural as well as in urban districts, but the former bear but a small proportion to the latter, and are usually found to have been determined by a definite cause, such as an accident, adversity, or mental shock. The dweller in town, on the other hand, frequently develops all the classical features of the disorder without any unusual occurrence in his life or circumstances to account for it. He has been living his ordinary, every-day existence; but this is one of continuous high pressure, and ultimately his staying power becomes overtaxed, and terminates, without the development of organic disease, in a functional wreckage which is the expression of Nature's revenge for the lack of due attention to her imperative demand that rest as well as work is necessary for the maintenance of the mens sana in corpore sano. But the fault does not always or wholly lie at the door of a badly regulated life. The original capital of nervous force with which humanity is endowed is not the same for every individual. One man is descended from ancestors who have been proverbially healthy, and have most of them attained long lives; another is the inheritor of a nerve instability which has manifested itself either in his immediate or remote progenitors in various forms of mental trouble or nerve disorder. Obviously, the latter individual has a serious handicap to begin with, and is more likely than the former to break down under the stress of work and worry.

To all who are exposed to excessive and prolonged attacks upon the citadel of their vitality, capitulation of their resistive power may follow at any moment, and unless such early warnings of waning energies as sleeplessness, incapacity for mental concentration, physical languor and disturbed digestion are given heed to and counteracted by proper means, the sufferer will inevitably find himself ere long in the midst of neurasthenic tribulations, from which it will be tedious and difficult for him to emerge. A short period of rest and leisure may, if adopted in time, restore a life which would otherwise become miserable to its possessor and wholly unequal to its daily task of usefulness and healthy activity.

The disease is widely distributed, and, though specially prevalent in America, is met with in all the civilized countries of both hemispheres. "It is," says Proust, "equally spread among all civilized peoples in whom the struggle for existence keeps up an