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weakness of the limbs; a cloud comes before the eyes, all appears gray with black moving spots, objects near and far are confused and seem to be on the same plane. These phenomena resemble accommodative asthenopia, which often coexists with vertigo; examination of the eye reveals little or nothing; the pupils may be dilated, usually equal in size, reacting a little slowly to light, and the retina is normal. These attacks of vertigo are most apt to occur on the patient rising from the buy tadacip uk recumbent, or sitting, to the erect position, or when any emotion is evoked, however slight. A form of agoraphobia may exist, the patient being afraid to walk along the street or to pass through a door, for fear the walls tadacip erectalis 20 mg will fall upon him, or an open space may produce intense sensations of fear. The vertigo shows itself most often in the morning, and, like other symptoms, it is less fre- quent during and immediately after meals, gen- erally disappearing in the evening, and never oc- curring in bed. In some cases there are pains in the spinal col- umn, either in the cervical or at the junction of the lumbar and cialis generika tadacip sacral vertebrse. The pains radi- ate in the former case toward the shoulders and arms, causing a sensation of weight and oppres- sion ; buy tadacip canada in the latter case the same feelings are ex- perienced in the lower limbs. The patient locates the pain in the column exactly, but examination reveals nothing, except perhaps a slight hyper- esthesia ; there may be a sensation of feebleness and numbness suggesting paraplegia, but the sphincters are normal ; the reflexes may be nor- mal and equal on both sides, though exaggera- tion is not infrequent. The headaches and vertigo suggest organic brain trouble, the pains and symptoms from the cord suggest spinal trouble, and mental depression, insanity ; and careful analysis of the clinical symptoms is necessary to form a correct diagnosis. The stomach and intestines are also more or less affected in neurasthenia, suggesting autoin- toxication : there is retarded and difficult diges- tion : on rising the tongue is coated and the mouth sticky; the appetite is poor; during eating and immediately after the painful sensations are milder, or they may disappear altogether, the gen- eral condition improving. A light breakfast is usually well digested, but it is necessary that another light meal be taken in an hour or two, or the patient will suffer. The condition of the stomach is one of continuous secretion of hydro- chloric acid with a want of motility ; it is there- fore necessary that the neurasthenic be fed fre- quently at short intervals, and on no account should he eat a large meal. Although the hydro- chloric acid is being continuously secreted in small quantities, the glands are in a state of fatigue, and are therefore unable to respond to the demand for the excess of hydrochloric acid necessary for a tadacip 5 mg large meal. After a test meal the analysis gives various results; usually the amount of free and loosely-combined hydrochloric acid is normal, or slightly reduced, though at times there is a marked hyperchlorhydria. The test meal is never a very satisfactory method of diagnosis in a nervous patient. In the first place, the Salzer meal is not very appetizing, and is more than the patient cares to eat, consequently the "psychic juice" is not secreted in full amount; the Ewald breakfast is not appetizing, especially with Amer- ican bread; in Germany the "Brodchen" is much more pleasant to the palate, which may have some- thing to do with the larger amount of free hydro- chloric normally found in examinations made in that country. To give a nervous patient a test- meal at 8 A.M., another at noon, and to draw his stomach at i p..m., during which time he is on a mental rack as to the terrible ordeal he is about to go through with the tube, is not calculated to produce normal digestion and give accurate re- sults. Judging from the urinary analyses in these cases, one would consider that there was a marked hyperchlorhydria, and I believe that there are cases in which not only is the secretion continu- ous to a greater or less degree, but, on taking a full meal, there is a hypersecretion of hydro- chloric acid which prevents proper peptic, and also retards pancreatic digestion. In many cases the digestive symptoms are secondary to the nervous trouble, though careful attention to the diet tadacip 20 price india and digestive organs mitigates the sufTering, especially the insomnia. It is evident that no dis- ease can be treated successfully unless the nutri- tion is normal ; the absorption of partially- digested proteids or imperfectly-converted sugars cannot but be detrimental to the general condi- tadacip 5mg online tion. Tympanites and acid eructations follow a heavy meal consequent on the general atony of both the stomach and the intestines, producing a certain amount of autointoxication, but the patho- logical condition of the nervous system is often primary, the digestive symptoms disappearing as the patient improves. The intestinal trouble con- sists usually in obstinate constipation, with occa- sional attacks of diarrhea, in which, on micro- scopic examination, there will be found blocks of mucus, evidence of membranous enteritis, a very common accompaniment of neurasthenia. In women there is often a mucomembranous dys- menorrhea. The general condition of the patient suffers, and flesh is lost rapidly, though in some cases the "embonpoint" is preserved. The urine is clear, limpid, and large in quantity, suggesting hysteria, though at times it may be less abundant and dark in color. The urea nitro- gen is low, the ammonia and uric acid normal, but the residual nitrogen is markedly excessive, and there is usually a marked phosphaturia; the pro- portion of chlorides to nitrogen is below normal, while the carbon-nitrogen factor is normal or low. Indol and ethereal sulphates may be high or nor- mal, depending on the condition of the bowels, but the neutral sulphur is invariably high. The heart suffers with the other organs; the maximum pressure is low in proportion to the mean, and extremely variable. Under normal con- ditions the taking of food raises the mean pres- sure, but in neurasthenia so marked tadacip 20 mg uk is the arteri- olar contraction of the abdominal vessels, that an intense flushing of the face takes place, with a 730 MEDICAL RECORD. [Nov. lo, 1906 feeling of congestion of the brain, and a beating of the cephalic arteries. At other times, owing to the relaxation of the abdominal vessels, there is an accumulation of blood in the abdomen, causing a general sensation of cold ; the hands and feet, especially, being cold. To a certain extent the vertigo is due to the same. cause. On taking the erect position from the recumbent there is under normal conditions a rise of arterial mean pressure of about 10 mm. Hg., and a slight increase of the pulse rate ; in the neurasthenic, on the contrary, there is a fall of mean blood pressure, on taking the erect position, of from 20 generika-apotheke tadacip to 30 mm. Hg., and a very marked compensatory increase of the heart rate. This is, however, insufficient to overcome the want of arteriolar contraction, and an anemia of the brain is the consequence, producing a ver- tigo for a few minutes tadalafil tadacip 20 mg until the arteriolar con- traction takes place, when the vertigo passes off; in other words, the compensatory vasoconstrictor mechanism tadacip price in india necessary for the erect position is de- ficient, reacting slowly to the stimulation of standing up. The physiology of the blood pressure has been but recently investigated, since Leonard Hill and Bernard introduced their sphygmometer, it being the only one which will record both the maximum and mean pressures; the Riva-Rocci instrument usually used in this cialis generico tadacip country is of little use clini- cally, as it records only the maximum pressure, and, owing to its depending upon the sense of touch of the operator, the results are usually too low. Oliver and Hill have shown that any men- tal work or emotion raises the mean blood pres- sure, and it follows that continuous mental strain upon the vasomotor nerves will result in their enfeeblement; tadacip online kaufen and, further,Sir William Broadbent has shown that continued mental strain produces a dilatation of the heart, the result of the continu- ous increased back pressure upon the ventricle. The effect of mental strain in the causation of neurasthenia will be referred to later, but enough has been said to show that primarily the neuras- thenic condition is the result of a decreased sensi- bility or accommodative power of the vasomotor system. Angina of a special type is common in neuras- thenia ; there is a little precordial anxiety, but no painful radiations to the left arm ; the thorax seems as though it were held in a vice, the pulse, instead of being, as in true angina, small, tadacip 20mg generic cialis thready and intermittent, is full and regular; the heart beats are strong, even violent ; the sounds dis- tinct. Sometimes there is hyperesthesia in the precordial region resembling somewhat the con- dition found in hysteria; though the attacks of this angina are severe, there is no danger of tadacip (generic cialis) col- lapse. There is also a shortness of breath, oxygen hunger, the patient sighing frequently. The functions of the genital organs are de- pressed, loss of power and desire are frequent causes of complaint. Coitus may be possible, but is followed by a feeling of intense lassitude, with increase of pain in the lumbosacral region. More rarely, the patient tadacip erectalis 20 mg tabletten is troubled with buy cheap tadacip noctiirnal erect'ions which coitus does not relieve, sometimes accompanied by emissions, increasing the weak- ness and mental depression. At other times coitus is incomplete, ejaculation following almost imme- diately an erection. These symptoms suggest disease of the cord. In other cases, each defeca- tion is followed by an emission of a thin fluid con- taining spermatozoa; in this condition the pros- tate and vesicles should be examined for abscess and the discharge stained for gonococci. tadacip by cipla The writer treated a case which appeared to be a typi- cal one of neurasthenia without headache, in which the patient recovered completely on the treatment of the prostate for a gonorrheal ab- scess ; the spermatorrhea is due to atony of the seminal vesicles, and can be cured by cold douches in the rectum. Cases with the above symptoms have been classed as sexual neurasthe- nia, melancholia being a marked psychic symp- tom. Another symptom, which, however, is rarely present, is a certain amount of tremor, usually slight, vibratory, affecting at the same time both the upper and lower extremities; the tongue is very rarely affected, but there may be a tremor of the lips, causing difficulties of speech which suggest paresis. The mental condition presents a general de- pression of the faculties without perversion ; usually the mental activity is increased, some- times decreased ; intellectual work becomes diffi- cult, and, above all, the inability of the patient to make a decision on any matter, however trivial ; the memory, though slow, is intact, and the judgment tadacip pille 20mg cialis generika is normal. With an effort the pa- tient is usually able to recover his mental aptitude completely, dift'ering in this form from the true melancholic, in whom there are mental perver- sions, and from the paretic, who has more or less lost control of his ideas. The neurasthenic will describe his mental condition exactly, and the psychic depression from which he suft'ers without

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