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any impossibilities, exaggerations, or delusions, except that he has an exaggerated view of the severity of his case, with the idea that he is going insane, and that he will never recover. Restless- ness is often a marked feature, the patient being unable to remain in one position, or to sit still for more than a minute or tv/o at a time. Irritability cheapest tenormin in some cases is very marked, the patient break- ing out into uncontrollable fits of temper on slight provocation, perhaps swearing and breaking the furniture, the symptoms resembling those of acute mania. Timidity may be a very marked symptom. Constitutional neurasthenia is another form of the disease, according to Charcot and other writers, but the symptoms are the same, the sub- jects being those who are either congenitally, or from some acquired condition, less able to bear the nervous and mental strain of the struggle for existence, and who, therefore, more easily suc- cumb to the strain of life. I do not believe that the pressure of civilization is greater now than in former years ; if more work is accomplished, more responsibilities carried by the individual, than formerly, it must be remembered that the advan- tages of modern methods and appliances render such efforts more easy; and, besides, if the work- ing strain is greater the opportunities for diver- sion and recreation are also greater than formerly. There is, perhaps, one condition in modern life which tends to produce nervous and physical breakdown, and that is that to-day the large majority of business men take but little exercise. Our forefathers either had to walk, to ride horseback, or drive; in the latter case the time consumed on a journey was longer than in these days of express trains, and was to a ereat extent a rest from business cares, combined with a Nov. lo, 1906] MEDICAL RECORD. 731 change of scene and environment, which could not but be beneficial to the overworked man. We, however, see men to-day who have led active business lives for half order tenormin a century or more, hale and hearty at eighty years of age, and again we see men whose responsibilities have been light, and whose anxieties have been few, succumb to nurasthenia. In the so-called constitutional neurasthenia the clinical history reveals but little of the etiology tenormin atenolol of the case ; as an example, a young man of thirty comes to the office with many of the symptoms detailed above; in his history is neither heredi- ty, alcoholism, nor syphilis — those ever-ready ref- uges for. the perplexed diagnostician; he may never have had any severe illness, and possibly the ordinary diseases of childhood have been so mild as to have almost escaped his recollection ; he is possessed tenormin online of a private income which renders him free from the anxieties of workifTg for a liv- ing, and purchase tenormin is, perhaps, working in some office more to employ his lime than for pecuniary gain. There is one point, however, in many of these cases which show the cause of the neurasthenic condition, viz., that puberty was delayed, that the patient ceased to grow at the age of about sixteen or seventeen ; that he was backward men- tally, not perhaps as calculated from the standard of the school, but rather in his psychic develop- ment, associating with boys younger than him- self, and finding amusement in boyish or childish games. At about eighteen or nineteen the aver- age boy becomes a man ; he puts away childish and boyish things; but in this case he has re- mained a boy till perhaps twenty, or even longer. In women, in whom this form of neurasthenia is more common than in men, menstruation may not have commenced till eighteen or nineteen years of age, and always been more or less scanty and irregular. The genitalia of the male are often small and poorly developed, and there has never been much sexual desire. Such cases are not true neurasthenia; they may belong to the class of cases known to the French as "type Loraine," or they may be cases of infantilism, in which the thyroid has failed to develop fully, or has atro- phied early ; or they may be cases of anangio- plasia. The mean blood pressure is high ; the arteries feel hard and small, suggesting arterio- sclerosis; the heart beat is rapid and forcible. These cases do not belong to neurasthenia, prop- erly speaking, their etiology being very diflferent, tenormin 25mg and consequently their treatment also. The prog- nosis, as regards perfect recovery, is, however, not good ; the symptoms may be ameliorated, but the patient will probably spend the rest of his life under the care of a physician, dying at a com- paratively early age from some intercurrent dis- ease, owing to the reduced resistive power of the system. True neurasthenia is found among those men who lead strenuous lives, having great responsi- bilities and anxieties, without taking a sufficient amount of recreation and physical exercise, com- bined with irregular and bolted meals. The im- portance of the digestive apparatus cannot be overestimated; its complications render it liable to get out of order ; consider that the saliva, the pepsin, hydrochloric acid, enterokinase, pancre- atic juice, with its three ferments, the bile, the succus entericus, and other ferments, which tenormin 50mg are as yet imperfectly understood, cheap tenormin have all to secrete sufficiently, and in proportion, in order to convert the food into the condition in which it is most easily absorbed and assimilated, and that, if any links in the chain are omitted, the nutrition will suffer, not only from decreased assimilation, but also from the absorption of imperfectly digested food products which must act as poisons to the system. The etiology of neurasthenia can be classed under four heads: (i) Mental strain; (2) dis- turbances of digestion, malnutrition, and auto- intoxication; (3) toxemia from infectious dis- eases; (4) traumatism, and shock. It is a matter of general knowledge that emo- tions affect the digestion, anxiety and grief cause loss of appetite, coated tongue, constipation, etc., producing malnutrition and autointoxication, which, in their turn, act upon the already over- tenormin 25 strained nervous system. In many cases of neu- rasthenia the digestive disturbances antedate the nervous symptoms; in others, the nervous symp- toms tenormin iv are the first to appear, the one reacting tenormin 25 mg upon the other in a vicious cycle. Toxemia from grip, buy cheap tenormin scarlet fever, diphtheria, and other buy tenormin diseases sometimes leaves the patients a nervous wreck. Traumatism and shock are a cause of the same condition as seen in those nerv- ous troubles dating from railway accidents, etc. It is apparently the vasomotor nervous system which is principally affected. All emotions act upon this system of nerves. Leonard Hill has shown how buy tenormin online mental work raises the mean blood pressure 30 to 40 mm. Hg. ; if the nervous mech- anism is continually under a severe strain for months or years, it is evident that it will become fatigued, and refuse to act normally to stimuli. I have observed that there is a reversed postural blood pressure in neurasthenics ; under normal conditions, on taking the erect position from the recumbent, the mean blood pressure rises from 10 to 30 mm. Hg., while in neurasthenics, under the same conditions, there is a marked fall, some- times as much as 40 mm. Hg., with a great in- crease in the pulse rate, showing that the vaso- motor system fails to respond to normal stimuli. In neurasthenia the blood pressure is variable and erratic, falling suddenly when it would normally rise, producing vertigo ; at other times rising excessively, causing flushing of the head and neck, while the hands and feet may be cold. The vasomotor system regulates the blood supply to the various organs, and it seems probable that many of the nervous symptoms classified as sep- arate diseases are due to a defect of the vasomotor nerves controlling the blood supply to some par- ticular portion of the nervous system, the varia- tions in the symptoms depending upon the part affected. There is yet another etiological factor which is of great importance from a therapeutic stand- point, viz., a gouty constitution. In these cases the urine is intensely acid, and the carbon nitro- gen factor very low. The most marked symptom is irritability of temper, sometimes so great as to resemble an attack of acute mania. There tenormin tablet is no specific treatment in neurasthenia. Removal of the cause of worry, if possible, in- creased physical exercise, anything to interest the patient in some form of recreation, attention to the digestion, to the removal of the purchase tenormin online toxins from the system, and order tenormin online to the building up of the whole system in every possible way. Drugs, such as the bromides, the coal-tar derivatives, etc., should be used as little as possible on account of their 732 MEDICAL RECORD. [Nov. 10, 1906 effect upon the assimilation, the circulation, and the blood ; the coal-tar preparations are particu- larly contraindicated on account of their de- tenormin syrup structive action on the red corpuscles. Bromides depress the heart and the vasomotor system, and should be used with cautiun. The difficulties of the physician are much increased by the intracta- bility of the patient ; he will refuse to leave his business, or perhaps he is unable to do so ; he will not take his treatment regularly, will absent him- self from the office for a week or two at a time, returning perhaps to scold the physician because he is not better, or perhaps he will seek a new doctor every month; it is no uncommon occur- rence to have a patient produce a pocketful of prescriptions from (different physicians, upon all of which he will dilate with a curious mixture of astuteness and perverted knowledge, which would be amusing if it were not tedious. The first duty generic tenormin of the physician is to gain the patient's confidence, and, by firmness and sympathy, hold him to his treatment, a task often of great diffi- culty, requiring great tact and patience. ELECTRICITY IN THE TREATMENT OF DISEASE.* By JOHN V. SHOEMAKER, M.D.. LL.D., PHILADELPHIA. In opening this discussion upon the therapeutic ap- plications of electricity, it is very evident, at the out- set, that in the short time permitted by the program I cannot make any adequate presentation of the subject, and I know that a systematic review of all the medical uses will not be expected of me. Cur-

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