irritability, oedema of one ankle, loss of vision in one eye, stiffened arteries, slow pulse, slight vertigo with partial loss of consciousness, increased arterial tension. With such an array of symptoms there could be but one diagnosis, arterio-sclerosis, or chronic endarteritis. An unfavorable prognosis was given, and subsequent treatment at home and at health resorts has only succeeded in bringing somewhat of comfort to one who is rapidly reaching the end of this life.

The study of this subject of arterio-sclerosis is a wonderfully interesting one, and I very much doubt whether we have advanced far in comprehending it. It is surely a general degenerative process with many differing phases according to the organ or tissues in which its ravages are made manifest. Whether in its pathology, it is inflammatory, traumatic, or septic, is not for us to argue at this time; but it is for us as students of the nervous system to bear in mind that it may be a factor in the production of many focal diseases,' and that it asserts its right to be reckoned with as an individual entity by establishing a "nervous" symptomatology of its own.

How the condition of the arterial coats can have such a powerful and direct influence on the nervous system can be readily understood when we remember how the blood supply is furnished to the nerves themselves; and this is told well by a well known author: "As an artery approaches the nerve sheath it divides into pairs, one branch going upward and one downward, sometimes on the outside and sometimes on the inner side of the sheath or epineurium. These branches divide and subdivide again and again. They pierce the perineurium at an oblique angle, and when they reach the interior of the nerve bundles they break up into fine capillary networks. The arrangement of vessels in the nerves, as in the brain and in the cord, is such as to prevent bad effects from sudden changes in the circulation. The functions of nerve tissue being in a high degree specialized and requiring abundant blood and yet a supply that often changes abruptly, its vessels are adapted to do their work with the greatest facility and with the least danger of rupture. Both in the brain and in the spinal cord are two vascular systems, one cortical or circumferential, and the other central. From the cerebral and cerebellar arteries certain branches dip into the central region of the brain; other distinct branches pass to the brain cortex. The terminations of the central and of the cortical vessels are near to each other, but they do not communicate." This magnificent and benevolent arrangement serves all the varying needs of the nervous mechanism admirably so long as there is a reasonable integrity of the structural elements. If it be necessary that the walls of these blood canals be compressible, elastic and rather straight, in order to main

tain ordinary health and function, we can all readily see that the conditions comprised under the term arterio-sclerosis, where the vessels are thickened, firm, incompressible, tortuous, cylindrical and hard, will make even more strongly for serious chronic degenerative maladies. Where the vessels have become so brittle that they cannot withstand the impact of a rapidly changing circulation, we have cerebral or spinal hemorrhage. There is some danger that we consider this the only result of sclerosis of the brain blood vessels. This is not so, for accurate examination and diagnosis will give an "array of distinctive symptoms." Yet the pathological condition of the vessels is so wide-spread, that in the earlier stages it may be carelessly passed by or confounded with other nervous dieseases that affect the same centers for other reasons and with different clinical histories; for instance, brain tumors, chronic meningitis, hysteria, Meniere's disease, neurasthenia, atheroma.

One of the worst distinctive and distressing symptoms of this disease is vertigo. In the earlier stages this may be a simple faintness as for want of fresh air, or it may be a giddiness or whirling feeling, and at times a partial loss of consciousness and fear of impending death. As time goes on the attacks are more frequent, the symptoms are more severe, the face is flushed and bloated, the vision is blurred and increasingly impaired; the speech is blurred also in so much that pronunciation is inaccurate and the vocal sounds are all muffled and imperfect, reminding one very much of the talk of the paralytic or the one with a hot potato in his mouth. Loss of memory is a prominent symptom, but the hearing is very rarely seriously impaired. Shuffling gait, owing both to muscular weakness and dulled mentality follows soon.

The tissues of the body are scantily supplied with proper nourishment and the process of elimination is very incomplete-so we may have epistaxis, oedema of the lower exteremities, bronchitis, albumen and casts in the urine (very much as in a case of original chronic interstitial nephritis), valvular heart lesions making it possible to have a slow arhythmic pulse one minute, and the next minute after even a slight change of position, a strong changing thumping of the heart. Add to these peculiarities mental irritability, and change of disposition to the petulant, suspicious, crafty, scolding, sullen moods, and we have the completed picture of one of the most interesting and perplexing maladies on record-interesting because of its clinical history, and perplexing because up to date it presents unsolved problems as to its management. We are not familiar with any well authenticated cases that have ever been cured. Still much is demanded of us to further understand the disease, if not for purpose

other than to benefit the patient in the way of added comfort and length of days. This disease, again, is particularly interesting to members of our own profession, because mental overstrain and protracted emotions are undoubted factors in causing many cases. Mosso's plethysmograph proves that "emotions induce a spasmodic contraction of the arterioles."

Huchard says that "strong and repeated emotions can produce cardiac affections by their incessant action upon the peripheral circulation. This is one of the reasons why, according to my observations, arterio-sclerosis is so frequent in members of our profession. It is the disease of medical practitioners, because their profession is associated with mental and nervous overstrain." It is really surprising to note how frequently those nerve specialists who have to do with the institutional care of "nerve invalids" and the insane, succumb to its ravages.

Chronic headache, vomiting vertigo, disturbances of organs of special sense, errors of locomotion, are many times associated with brain tumors; but these symptoms are also among the nerve disturbances in arterio-sclerosis-hence the necessity for accurate diagnosis.

Meniere's disease has many symptoms in common with arteriosclerosis, especially the vertigo and tinnitus; the degree of accompanying deafness will probably decide which is which. In atheromatous inflammations of the encephalic blood vessels the trouble is in the smaller vessels (more especially the circle of Willis) and begins in spots. These spots are milky elevations which either ulcerate or calcify, in the one case predisposing to aneurism, and in the other to embolism. Many symptoms in this trouble are the same as in arteriosclerosis, and mistaken diagnoses are necessarily many.

Neurasthenia has on its list many symptoms that would strongly suggest arterio-sclerosis, inasmuch as brain fag can and does show cortical, sensory, motor and special sense variations that while truly functional, yet are puzzling to the diagnostician because they counterfeit the superficial and earlier manifestations of the graver organic disease. Hysteria, frequently strangely simulates organic nervous disease, and as frequently requires keen perception and close analysis to properly diagnose. Grave hysteria has been diagnosed as monoplegia, neuritis, amblyopia, brain tumor, hemianaesthesia. arteriosclerosis, epilepsy.

So in relation to the nervous system, arterio-sclerosis or chronic endarteritis may be a cause or a result of disease. In either case the condition is one of intense interest to every up-to-date practitioner and student of medicine. In its beginnings, in its individual history

and peculiarities, in its similarities to other diseases, in its endings, arterio-sclerosis demands close attention, constant study, accurate diagnosis, careful consideration and management. I have purposely avoided the question of treatment, which, however, is really out of the province of this paper. But I am sure you are all in a position to contribute much to the discussion of this phase of the subject, as well as to those other points that are a part of this important study.

SURGICAL ENGLAND.

NEWMAN T. B. NOBLES, M. D., CLEVELAND, O., PROFESSOR OF SURGERY, CLEVELAND HOMEOPATHIC MEDICAL COLLEGE.

There seems to be a general impression in America that the surgical work of our English cousins is not strictly up-to-date; that it is necessary in order to see good technic to go over the continent. I had this idea; but my experience in England showed it to be erroneous. If a medical man is up on his French and German he will be much interested in the work of the German and French surgeon. If he has no linguistic accomplishments he will learn more in England. As a rule the English surgeons are ultra conservative, yet they are very sound and one does not often see them doing operations based upon indefinite symptoms. American surgeons can afford to spend much time in having this point impressed upon them. It is probable that the ordinary medical tourists spends less time in London and the smaller cities than he does in his investigations of medical centres like Berlin and Vienna. London is such an enormous place that it takes months to find just where to put in one's time to the best advantage. I was there four months and heard of new places to go nearly every day.

All of the hospitals are supported by voluntary contributiins. Very few of them have any endowment, and those that do have, find the same wholly inadequate. This being the case, practically all of the work done in the hospitals is for charity, and each hospital must make a big showing in order to stimulate contributions. There is a marked tendency in this condition to the great injustice to the physicians who practice in the neighborhood. By the misappropriation of funds committed to the trust care of the worthy poor, charity is in many instances diverted from its proper channels to the giving of free service to people who can afford to pay-a condition of hospital abuse with which we are quite familiar at home.

The size of the British hospitals varies from about 200 to 850 beds. They are fairly clean, and the food is good. The nursing seems satisfactory. Each hospital has a three-year course of training for the nurses. Generally speaking, however, I do not think that the English hospital service is quite up to the best American standards, but as nearly all of our hospitals take pay patients it is hardly fair to make direct comparison, unless it be with some of the American hospitals that are entirely devoted to charity work.

Throughout Great Britain choloform is used almost exclusively as an anesthetic. Ether is very seldom given, except by the few men of whose work I shall speak of more in detail later.

Silk is rather generally used as a ligature and suture material, only a small number of the more advanced surgeons using catgut, while the old-fashioned sea-sponge is still the favorite. For hand cleaning lysol solution is used extensively. Iodoform is used more freely in wounds than it is in America. It is kept in a solution of bichloride, 1-1000, and is scooped out of this and used with enough of the solution to make a paste.

Many of the operating rooms are quite sloppy and wet, so much so that the surgeons wear short rubber boots on acount of the excessive use of irrigation, etc. Practically all of the more advanced surgeons whom I saw, however, operate in most modern fashion and conduct their operating theaters in every respect as they are conducted here.

London has so many fine hospitals and such wealth of surgical material that it is difficult to know where to begin to describe it. I shall therefore mention only a small amount of the work that appeared to me as being particularly good. I would place Mr. Robson first. While he has no hospital appointment he does a large amount of private work in nursing homes. A profound scholar and an experienced operator, it is a pleasure to see him work. He very seldom drains gall bladder or common duct cases through the abdominal incision, but rather through a stab-wound near the tip of the floating ribs, tube drainage being used nearly exclusively. If any gauze is used, it is a very small strand inside the tube to drain the space outside of the gall-bladder. He does cholecystenterostomy by suture without button or bobbin, and in all of his common duct cases he does not rest satisfied until he has passed a large probe through the common duct into the duodenum.

At the Temperance Hospital I saw Mr. Paterson do some very clever operations upon the stomach and upon the large intestines. Mr. Paterson is a fine pathologist and his work is based upon sound