personal observations as well as upon a study of the literature, is given in a monograph by Dr. Oskar Klotz, of which we have received a copy. He commences by stating that it is now generally recognized that this disease, instead of being generalized, may be localized to the arteries of one particular organ, that it may involve one particular type of artery only, and that it may be limited to one or other zone of the arterial coat. He maintains that the recent studies of Jores and others have established a satisfactory basis for classification of the intimal changes, but that the lesions of the media are more obscure, so that there is still much confusion both as to their nature and mode of development and as to their relationship to the intimal changes.

In opposition to the views of Jores, who maintains that arterio-sclerosis is essentially an intimal disease, Dr. Klotz includes under this term any change in any of the three coats of the artery which leads to a thickening or hardening of the vessel wall. These changes he classifies into productive and degenerative, and further subdivides according to the nature of the resulting lesions in the vessels. He admits that, employed in this manner, the term arterio-sclerosis becomes generic and not specific, and requires a qualifying adjective to distinguish the individual or special forms.

The term atheoma has been variously used by different authors; for Dr. Klotz it is a degenerative change followed by calcification beginning in, and usually confined to, the intima. It may advance into the media, but seldom, if ever, originates primarily in this coat. He gives an interesting review of the histology of arteries and of the functions of the media, and emphasizes the facts that this coat is the mainstay of an artery, and that upon its integrity depends the resisting power against intra-vascular pressure. Dr. Klotz differentiates medial arterio-sclerotic processes from other conditions leading to thickening of the arteries, and he divides them tentatively into productive and degenerative varieties. Certain forms he regards as meriting special recognition, one being syphilitic mesaortitis, which can be recognized both by its macroscopical and histological characteristics; a second being Moenckeberg's arterio-sclerosis, which is a degenerative condition of the media of the peripheral arteries following upon intermittent arterial overstrain. The principal factors causing disease of the media are infections, poisons, work, and old age. The effect of any of these depends upon the histological structure of the artery affected and upon its function. The same agent may give rise to

several kinds of arterio-sclerosis processes, but it must be remembered that the presence of disease in one system of vessels must not be taken as indicating disease in another arterial system, and that medial sclerosis is often present without intimal sclerosis in the same vessel. Dr. Klotz shows that aneurysms are directly dependent upon the diseases of the media of arteries, and that the nature of the aneurysm is determined by the character of the medial disease-e. g., syphilis is the most important factor in the production of chronic mesarteritis and aneurysm of the aorta, while melial weakenings from causes other than syphilis are more frequently associated with aneurysms of the peripheral arteries. Dr. Klotz's work upon the genesis of arterial disease is well known, and we welcome this review of the subject of diseases of the middle coat as a notable contribution to the scientific study of medicine.

斑

DIET IN INFECTIOUS DISEASE.

F. S. Meara, in the Journal of A. M. A., critically discusses the caloric needs of a patient suffering from infectious disease. He points out that these requirements vary, not only according to the work done, but also according to the size and age of the individual, and calculates the caloric values of the different foodstuffs, showing that protein is not an economic fuel, and that it is necessary to provide enough protein to replace the wear and tear. He criticises the use of milk in infectious diseases and points out that to meet the caloric needs in fever of the ordinary individual, one would have to administer over a gallon of milk which would contain almost twice as much protein as necessary.

There are four problems entering into the feeding in acute infectious diseases. They are (1) gastro-intestinal disorders; (2) pyrexia; (3) toxemia, and (4) starvation. The last of these it is the plea of this paper to prevent. It is admitted that the gastro-intestinau tract is infected in infectious diseases, as shown by the coated tongue, anorexia, etc., but he thinks that the ability of the alimentary tract to perform its normal function has not been duly appreciated. It is more affected, of course, he says, in the early stages than later, and that the state of the mouth and of digestion is due in no small measure to an insufficiency of water and is aggravated by withholding food.

As regards pyrexia, he agrees with those who hold that fever is a specific reaction against injurious materials that infect the tissues, that it is essentially a protective reaction. Pyrexia below

104 F. is to be let alone; above that figure it does harm and antipyretics are indicated. Fever is the result, however, of toxins and not of heat production, which may go much above it in the normal individual.

Another effect of fever is to destroy protein, and this can be made up for by sufficient feeding. There is considerable loss of protein, however, apart from fever and starvation which has been variously accounted for. It is certain that it is dissociated with pyrexia as such, but it is often intense when there is no rise in temperature. The effect of infectious diseases on the nitrogen output is discussed in some detail, and he finds that in the acute infectious diseases there is a loss to the intrinsic structure of the body, and while this is compatible with a perfect ureaforming function, there are a certain number of cases in which the liver has become incapable of desamadization and abnormal metabolism occurs. It would seem as if the body was losing considerable nitrogen over the intake, and that it might be made good by increasing the intake. This he finds cannot be brought about without the help of other foodstuffs.

The work of Folin and Chittenden has shown that only a small amount of nitrogen is really necessary, and Shaffer and Coleman have been able to establish nitrogen equilibrium in typhoid fever with from ten to fifteen gm. of nitrogen when sufficient carbohydrate was used. Fat and carbohydrate, especially the latter, are sparers of body proteids, and when enough of these two are taken nitrogen equilibrium has been obtained. While it has been proved that in some cases of severe infectious disease the usual protein loss can be stayed by the administration of a large amount of food, it is still an open question whether this fact can be wisely used as a basis of procedure in all cases.

GONORRHEA SIMULATING APPENDICITIS.

Rene Le Fur, in the British Medical Journal, reports seven cases in which gonorrheal inflammation of the vas deferens simulated appendicitis. Statistics have been published to show that in about 40 per cent of cases of gonorrheal epididymitis the vas deferens, prostate, and vesiculæ seminales are involved. He goes much farther than this, and states that, having systematically examined these parts per rectum in all cases of gonorrhea, acute or chronic, he has always found them involved in cases of epididymitis. cases of inflammation of the vas simulating appendicitis may be divided into two classes, those which are accompanied by epididymitis and those

The

which are not. The former cases may clinically take several forms-acute, subacute, or chronic, just as may appendicitis.

Cases of very acute epididymitis with severe pain in the abdomen and right or left iliac fossa, vomiting, obstinate constipation, tympapitis, and a temperature of 104° or 105° F., due to an intense peritoneal reaction and exactly simulating the symptoms of acute appendicitis, are well known. These symptoms are due to concomitant inflammation of the vas and vesiculæ seminalis which has involved the cellular tissue and even the peritoneum covering the pelvis part of the vas and the vesiculæ seminalis.

The following is an example of inflammation of the vas simulating appendicitis. A man, aged 25 years, had slight epididymitis about the fif teenth day of a first attack of gonorrhoea. In the fourth week on returning from a railway journey he was seized with violent pains in the right side of the abdomen, tympanitis, vomiting, and a temperature of 105° F. There was absolute constipation and flatus was not passed. He showed the pinched peritoneal face. He and his family were very uneasy, and thought he was suffering from appendicitis. The author reassured them, though he was himself uneasy, and prescribed opium and the application of ice to the abdomen, which relieved the pain. But on the following day the vomiting and the fever persisted, there was some delirium, the tongue was dry and furred, the pulse was rapid and weak, and the tympanites had increased. He then diagnosticated appendicitis and called in Professor Berger, who confirmed the diagnosis of appendicitis, but advised against operation, and recommended that the treatment be continued.

For two days the condition of the patient was serious. There were a frequent and imperious desire to micturate, and a feeling of weight in the lower abdomen. On the fifth day the urethral discharge, which had disappeared completely, reappeared in an abundant form. Rectal examination showed that the right vesiculæ seminalis was much enlarged and painful; the vas deferens could be followed along the pelvic wall as an elongated, painful swelling. On pressure on these organs and on the protate pus exuded from the urethra. Further, there was in the pouch of Douglas a median swelling of the size of a Tangerine orange, which was painful and soft.

The urethral injections were resumed, suppositories of thigenol were inserted, and the bladder was washed out with a 1 in 4,000 solution of permanganate of potassium. Rapid development

SEXUAL ELEMENT IN NEURASTHENIA. McNaughton Jones, in the London Practitioner, describes the 67 symptoms of neurasthenia thus: (1) Psychoses; shown in such symptoms as irritability and capriciousness, restlessness; disinclination for exertion (physical or mental) in work or amusement; loss of power of concentration; forgetfulness, sensation of unreality, feeling as if an arm or limb "were not there"; unusual apathy; moroseness; fanciful ideas of ill-health generally of some special organ-commonly the heart or stomach.

Minor degrees of agoraphobia and claustrophobia; insomnia, development of erratic tendencies, dyspareunia, and repulsion towards marital relations. (2) Physical symptoms, subjective: Pain -exaggerated, causeless, diversified, transitional and shifting, aroused by suggestion and often relieved by it; headache, hemicrania; pain in the left lower costal region; at the lumbosacral junction; over the ovaries, in the neck of the bladder, during or after micturition; in the anus and coceyx; in the throat, when swallowing or speaking; dental neuralgias; throbbings and noises in the head and ears; hyperæthesia acustica; globus hystericus. (3) Physical symptoms, objective: Various pharyngeal and laryngeal neuroses in which dysphagia or troublesome attacks of spasmodic cough occur; changes in the character of the voice and possibly complete aphonia; periodical turgescence (often unilateral) of the turbinals, susceptibility to "hayasthma"; various types of migraine (more commonly ocular); intolerance of light, ocular fatigue and slight amblyopia (refraction and ophthalmoscopic signs being normal); cardiac rhythmic disturbance and palpitation; rapid respiration, "catching of the breath" and proneness to syncope; epigastric pain and sickness with flatulent distension, morbid cravings and so-called "stomach cough"; mammary sensitiveness and turgescence; vasomotor disturbances in the skin, especially of the face, such as flushings, morbid blushing, periodical pigmentary changes, hyperæmias and perspirations; other vasomotor disorders, as burning in the hands and feet, and icycoldness of the extremities.

CLOTHING AND BODY TEMPERATURE.

Wolf, in the New York Medical Journal, points out that the demands on modern man have increased enormously with the advance of civilization. If is to meet them adequately all controliable external conditions must be made most favorable to him. Exposure to all kinds of weather without adequate protection by clothing, would require the useless expenditure of so much energy that little or none would be left to him for higher pursuits. Only the strongest race would, under such unfavorable conditions, ultimately survive. The well known backwardness of the races of the torrid zone, where the climate makes clothing practically unnecessary, and where food is obtainable with great ease, shows that lack of incentive for obtaining food and clothing leads to degeneration of a race. On the other hand, in the frigid zone, where the struggle for existence is notably severe, the higher stages of civilization have rarely been attained. Struggle for existence, up to a certain point, is necessary for the highest development of the gifts of man. Of the many external stimuli to which we are exposed in daily life, we are most sensitive to changes in temperature. By the use of clothing. we surround our bodies with a layer of quiet air of uniform temperature. It can properly be said that we live in a uniform tropical climate. Cloth

CALCAREOUS WATER IN HEALTH AND DISEASE.

Percy G. Lewis led a discussion, at the Royal Society of Medicine, on this topic, and said that drinking water was an element of climate, and that at Folkestone it was hard owing to chalk in solution. Public opinion held that hard water was harmful, causing gout, rheumatism, calculus, constipation, biliousness, dyspepsia, eczema, goitre, and arterio-sclerosis. In favor of the baneful influence of hard water, the condition known as seaside biliousness was said to be due to it. At a previous discussion of the section in 1907 it had been decided that climate had more effect in producing this condition than water. Gouty people at the seaside mostly acquired their gout before residing at the sea. Weber had said that calcareous water seemed to lessen the output of uric acid, but might be of use in diseases due to deficient coagulability of the blood. Rumph inclined to the view that chalky water might increase the calcification of arteries in the aged, but Sir Clifford Allbutt maintained that calcification was protective.

The Commission on the Water-Supply of London had reported that in the form of carbonates lime salts did no harm, but that the sulphates of lime and magnesia were apt to derange digestion. Materia medica books stated that very little lime was absorbed from medicinal doses, therefore only a negligible amount could be got from water. Hard water from the main would be of no use in conditions in which calcium salts were urgently wanted, as in capillary hæmorrhages, urticaria, pruritus, etc. Hard water had no effect on functional uterine disorders, menorrhagia and amenorrhoea being equally common at the seaside. Goitre had nothing to do with hard water, but was generally supposed to be caused by drinking "melted snow" water. On the skin hard water was desiccative and astringent. Parkes said that it was bad for horses in that it spoilt their coats.

Calcium salts had been accused of acting indirectly, and the experiments in vitro of Dr. W. G. Little seemed to support this view. He had found that the addition of small percentages of sodium chloride and of calcium salts reduced the solubility of sodium biurate to almost zero. Thus he explained the composition of tophi. But as lime and common salt were always present in the food of everyone, this in vitro experiment could have no application to the human organism. Against the view of its baneful influence Parkes in his Hygiene stated that chalky drinking water did no harm to man. As four-fifths

of the earth's surface were provided with hard water, it could not have an appreciable bad effect.

The mortality of towns supplied with hard water was rather less than those with soft. Most of the mineral waters used for the conditions which hard water was said to cause contained large quantites of calcareous matter. So if there were anything in the view of its noxiousness, all mineral water treatment would have to be given up. He pointed out that the upper and middle classes, who suffered from these alleged diseases as much as the lower, drank mostly bottled soft

water.

With reference to calculus, the late Sir B. W. Richardson had declared that hard water had no effect in this disease, and this view was supported by Weber. Recently Dr. Benjamin Moore had advocated calcium starvation for oxaluries, but Dr. Johnston Lavis had shown this to be unscientific and ineffective. The late Sir J. Simon had maintained that the prevalence of stone in Norfolk was not due to the water but to the attraction of an eminent lithotomist. The fact that so large a number of people drank chalky water would ere now, if harm had resulted, have placed the matter beyond discussion. On the contrary, calcium salts had a good effect. The withholding of them had been stated to predispose to typhoid fever.

Hard drinking water was very good for children. Birds were notorious calcium-eaters, and hens only suffered when Dr. Chalmers Watson interfere with their diet. In explanation of the alleged baneful effects, he suggested that the origin of the fallacy in connection with chalky water was to be traced, first, to the public idea that tophi were composed of chalk, and secondly to the occurrence of dyspeptic disorders in people when first visiting the sea. The hypothesis in the first case was, of course, absurd, and the phenomenon observed in the second case was due to change of habits and stimulation of the appetite. Both caused the balance of intake and excretion to be upset and led to the blood being overcharged with auto-intoxicative material. This occurred as much in those who drank the hard water as in those who did not.

ARTERIO-SCLEROSIS AND THE ARTERIES.

The Lancet editorially reminds us that the group of diseases of the arterial walls comprised under the general terms of atheroma and arteriosclerosis is still somewhat ill-defined, in spite of the large amount of pathological and experimental work which has been devoted to its study. An interesting review of this subject, based upon

personal observations as well as upon a study of the literature, is given in a monograph by Dr. Oskar Klotz, of which we have received a copy. He commences by stating that it is now generally recognized that this disease, instead of being generalized, may be localized to the arteries of one particular organ, that it may involve one particular type of artery only, and that it may be limited to one or other zone of the arterial coat. He maintains that the recent studies of Jores and others have established a satisfactory basis for classification of the intimal changes, but that the lesions of the media are more obscure, so that there is still much confusion both as to their nature and mode of development and as to their relationship to the intimal changes.

In opposition to the views of Jores, who maintains that arterio-sclerosis is essentially an intimal disease, Dr. Klotz includes under this term any change in any of the three coats of the artery which leads to a thickening or hardening of the vessel wall. These changes he classifies into productive and degenerative, and further subdivides according to the nature of the resulting lesions in the vessels. He admits that, employed in this manner, the term arterio-sclerosis becomes generic and not specific, and requires a qualifying adjective to distinguish the individual or special forms.

The term atheoma has been variously used by different authors; for Dr. Klotz it is a degenerative change followed by calcification beginning in, and usually confined to, the intima. It may advance into the media, but seldom, if ever, originates primarily in this coat. He gives an interesting review of the histology of arteries and of the functions of the media, and emphasizes the facts that this coat is the mainstay of an artery, and that upon its integrity depends the resisting power against intra-vascular pressure. Dr. Klotz differentiates medial arterio-sclerotic processes from other conditions leading to thickening of the arteries, and he divides them tentatively into productive and degenerative varieties. Certain forms he regards as meriting special recognition, one being syphilitic mesaortitis, which can be recognized both by its macroscopical and histological characteristics; a second being Moenckeberg's arterio-sclerosis, which is a degenerative condition of the media of the peripheral arteries following upon intermittent arterial overstrain. The principal factors causing disease of the media are infections, poisons, work, and old age. The effect of any of these depends upon the histological structure of the artery affected and upon its function. The same agent may give rise to

several kinds of arterio-sclerosis processes, but it must be remembered that the presence of disease in one system of vessels must not be taken as indicating disease in another arterial system, and that medial sclerosis is often present without intimal sclerosis in the same vessel. Dr. Klotz shows that aneurysms are directly dependent upon the diseases of the media of arteries, and that the nature of the aneurysm is determined by the character of the medial disease-e. g., syphilis is the most important factor in the production of chronic mesarteritis and aneurysm of the aorta, while melial weakenings from causes other than syphilis are more frequently associated with aneurysms of the peripheral arteries. Dr. Klotz's work upon the genesis of arterial disease is well known, and we welcome this review of the subject of diseases of the middle coat as a notable contribution to the scientific study of medicine.

DIET IN INFECTIOUS DISEASE. F. S. Meara, in the Journal of A. M. A., critically discusses the caloric needs of a patient suffering from infectious disease. He points out that these requirements vary, not only according to the work done, but also according to the size and age of the individual, and calculates the caloric values of the different foodstuffs, showing that protein is not an economic fuel, and that it is necessary to provide enough protein to replace the wear and tear. He criticises the use of milk in infectious diseases and points out that to meet the caloric needs in fever of the ordinary individual, one would have to administer over a gallon of milk which would contain almost twice as much protein as necessary.

There are four problems entering into the feeding in acute infectious diseases. They are (1) gastro-intestinal disorders; (2) pyrexia; (3) toxemia, and (4) starvation. The last of these it is the plea of this paper to prevent. It is admitted that the gastro-intestinau tract is infected in infectious diseases, as shown by the coated tongue, anorexia, etc., but he thinks that the ability of the alimentary tract to perform its normal function has not been duly appreciated. It is more affected, of course, he says, in the early stages than later, and that the state of the mouth and of digestion is due in no small measure to an insufficiency of water and is aggravated by withholding food.

As regards pyrexia, he agrees with those who hold that fever is a specific reaction against injurious materials that infect the tissues, that it is essentially a protective reaction. Pyrexia below