subcutaneous application, as it dissolves in 4 parts of water, and so administered rarely produces an irritation. Where so employed, as recommended in the Journal de Médecine de Paris for June 15, 1890, a little carbolic acid should be combined with it.

MENTAL OVERWORK IN modern lIFE.

noted writers in the medical profession have been men who have diligently kept good their physical powers while performing an enormous amount of brain-work; we need only instance such professional lights as the late Dr. S. D. Gross, Dr. Austin Flint, Sir Thomas Watson.

At this season of the year, to businessmen, students, and professional men, this advice is opportune, and, however trite, needs

peculiar, in the sense that multitudes are obliged to toil harder with their brains than any previous race. Never before, perhaps, in the history of mankind did arduous strife and competition, involving the higher nervous energies, become so necessary. The present generation is the heir to all the acquisitions of the past, but these have been an ever-accumulating burden, which is almost too great for the strong to bear, while the weak and exhausted must succumb beneath the load, though the latter be no more than just sufficient to equip its possessor for a fair chance in the struggle for existence.

It has been said a hundred times, and cannot too much be reiterated, that many of the conditions of our modern life are unfavorable to the best physical and mental development; that a sedentary life stunts and dwarfs the muscular powers, while constant study, without physical exercise, dwarfs and dulls the intellect; that overwork of every kind exhausts the organs and tissues concerned in such overwork; that the fruits of overschooling and intense competitive examinations are seen everywhere in the neurasthenia and premature decay of the present generation.

It has been proved, however, that hard study can be borne with impunity, provided that sufficient physical exercise be taken. This is a truth which the literary man and the student should ever have in mind. We have a good instance of this in the life of the late Frenchman, Littré, one of the most indefatigable literary workers of this age. His habit was to spend most of the day out of doors in physical recreation and in exercise; and he only began his studies and his writing about seven o'clock in the evening, when he would enter his library and pore over his books, absorbed in study, or bend over his writing-desk, working without cessation, till three or four o'clock in the morning, when, yielding to fatigue, he would seek a few hours' refreshing sleep.

It is well known that many of the most

Don't let the muscles become toneless and atrophied from disuse. Seek frequent occasions for breathing mountain air or sea air; leave the city and go to the country. The flagging mental powers are best rallied and quickened by change, recreation, and physical exercise.

Physicians above all others often feel that they cannot afford to go away from home for even a short vacation; but such economy is short-sighted and deplorable.

In a recent spirited publication,* Marie Manacéine, whom we may call the Mary Somerville of Russia, has traced the causes, effects, and remedies of mental overpressure in modern life. She lays great stress on the want of gymnastic training in schools and the numerous unhealthy conditions of our civilization. The besetting infirmities of the "cerebral anæmia" and "nervous age are exhaustion." The causes are complex, but they all act similarly,-" by producing irregularities in the vascular sphere;" i.e., by impairing the tonus of the cerebral bloodvessels. "When once the tone of the blood-vessels is lost, when their nutrition is disturbed, and the circulation no longer responds to the exigencies of normal life, phenomena of dissolution begin to manifest. themselves."

paper affirmed that they were believers in the administration of alkalies in the large doses recommended by that therapeutist.

vessels. Hence the proper counsel would be moderation or abstinence. The evils resulting from excess are undisputed. In this age of excitements and unrest there is an importunate demand for stimulants of all kinds, but he is the wisest and happiest man who can live calmly and at ease without them.

THE ALKALINE CACHEXIA; TREATMENT
OF PSEUDO-GASTRALGIA DUE TO

EXCESSIVE (HYDROCHLORIC)
ACIDITY BY LARGE doses
OF ALKALIES.

TROU

ROUSSEAU taught that alkalies, when their medicinal use is long continued, or when they are taken even for a brief period in enormous doses, impede the organic combustions, and produce a peculiar kind of cachexia called by him the alkaline cachexia. This doctrine has been confirmed by recent experimenters, as far as excessive doses are concerned, which, undoubtedly, have a "deglobulizing" action on the blood, while diminishing the proportion of urea in the urine and increasing that of uric acid. That, however, moderate doses, no matter how long continued, are pernicious, in the way that Trousseau maintained, has been disputed by Mealtre, Martin Damourette, Harley, and others, who affirm that alkalies are trophic agents, which energize nutrition, increase the figure of blood corpuscles, and augment the proportion of urea excreted. The waste of the organism is increased under their use, but, at the same time, a powerful impulse is given to assimilation; more food is demanded and appropriated; anæmic and cachectic states are really made better. "It is a mistake," says Martin Damourette, "to believe that the alkaline waters are debilitating and contraindicated in anæmia, for they are among the most active agents of reconstruction."

This view seemed to be sanctioned at the late meeting of the Société de Thérapeutique, and most of the participants in the discussion which followed the reading of Huchard's

The title of Huchard's paper was “PseudoGastralgia from Hydrochloric Excess treated by Alkalies in Large Doses." It is known that there is a painful affection of the stomach, often assuming an intermittent gastral

tion of hydrochloric acid; this affection is generally accompanied by dilatation of the stomach. "It is," says Huchard, "dyspepsia by continuous secretion of hydrochloric acid" (pseudo-gastralgie hyperchlorhydrique).

The pain is very apt to come on when the stomach is empty, and is relieved by albuminous food, by milk, and by alkalies. Among the symptoms are pyrosis, acid eructations, and attacks of neuralgiform pain, which are generally nocturnal.

Among the remedial measures proposed is the restricting of the patient to an azotized diet and to milk. Debove suggests the drydiet treatment. The patient should eat five light meals a day and drink little. The hyperacidity is combated by alkalies,-from half an ounce to an ounce of bicarbonate of sodium daily, in divided doses. Charcot gives from one to two ounces, but Huchard considers this dosing as excessive. ities prefer a combination of sodium bicarbonate with prepared chalk, giving doses of 15 grains every hour after meals.

Some author

To combat the intestinal atony and constipation so common to this disease, laxatives, as aloes, podophyllin, cascara sagrada, etc., are useful; all aliments of slow digestion and all fermented or distilled liquids are to be avoided, as being calculated to increase the gastric atony and dilatation.

At this meeting M. Labbé stated that the large doses of sodic bicarbonate were as applicable to cases where there was deficiency as to those where there was excess of hydrochloric acid.

Dumas and Blondlot long since proved that the effect of the ingestion of bicarbonate of sodium was to promote the secretion of gastric juice, and, in particular, of hydrochloric acid. Trousseau, and later Gubler, made their patients take a glass of Vichy water a quarter of an hour before meals to excite the appetite and provoke an acid secretion.

Evidently, however, there is a great difference between giving alkalies in small doses to stimulate secretion, and in massive doses to neutralize acidity, and to this Huchard referred in his summing up.

This whole subject of hypersecretion of the natural acid of the stomach needs elucidating. The fact of the benefit conferred by the alkaline medication is none the less acknowledged.

PILOCARPINE IN CHRONIC ARTICULAR RHEUMATISM.

HE therapeutics of rheumatics is bounded

THE

by narrow lines; for while in acute rheumatism in salicylate of sodium, antipyrin, salol, and phenacetin we have remedies any one of which is in many cases worthy of commendation, and enables us to treat the disease quite as satisfactorily as is the case in malaria or syphilis, in the chronic form but little may be expected from them.

Massage, from which, upon its first introduction, so much was expected, has likewise not yielded the promised results, since in the treatment of chronic rheumatism we have to deal not with the removal of a serous exudation, but with the treatment of connectivetissue contraction and hypertrophy, while more severe mechanical measures are contraindicated by the fact that irritation of the joints may result in inflammation and renewed suffering. Besides, it should be remembered that the muscles, which are the seat of contracture in this affection, rather tend to tear than to stretch on forcible extension, and attempts in this direction may, therefore, result in an entirely useless joint. The indications thus are, as a rule, incapable of fulfilment, though a paper by Dr. Hochhalt, in the Internationale Klinische Rundschau for June 8, 1890, calls attention to a measure which he claims to be of the utmost value in the treatment of such cases.

About ten years ago, Dr. Colman Korda called attention to the use of pilocarpine in cases of chronic articular rheumatism, but his statements appear to have attracted no attention, and we have met with no publication on the subject until Dr. Hochhalt published the results of his experience. Pilocarpine, as is well known, produces great increase in the secretion of the salivary and sweat glands, and leads to such increase in tissue-change that organized exudation products of inflammation are dissolved, and results of retrograde tissue metamorphosis are eliminated. As an illustration of the truth of these statements, it is only necessary to recall the value of pilocarpine in ophthalmological practice, as in cases of opacity of the

vitreous humor, or in iritis or irido-choroiditis, where it is especially serviceable in removing the products of inflammation. In diseases of the internal ear and in severe types of syphilis, and in dropsy of renal origin, it has recently been recommended by Von Ziemssen and Senator.

Dr. Hochhalt describes a case of chronic articular rheumatism, which seems to show that the use of pilocarpine is capable, to a certain extent, of relieving the less intense form of connective-tissue contraction, and to a certain extent of restoring the use of an affected joint. Of course, where the joints are bound down by old contractured muscles, or where the bone itself has become affected, but little may be expected, though the very fact that in certain cases relief may follow the use of pilocarpine is to be regarded as an important addition to our therapeutic

measures.

THE PREVENTION OF THE TOXIC EFFECTS OF COCAINE.

THE

HE great disadvantage attending the use of cocaine is that it sometimes, when least expected, produces serious or annoying toxic effects. It is a striking fact, however, that the local use of cocaine in the eye seems to be most free from these results, while its application to the ear, nose, and throat is often followed by alarming results. In the New York Medical Record for June 21, 1890, Dr. Isidor Gluck writes that the combination of cocaine with phenol does away with these risks without interfering with the anesthetic properties of the cocaine. Dr. Gluck dissolves two drops of phenol in one drachm of distilled water, shaking until solution is perfect, and then adds ten grains of cocaine hydrochlorate.

The author states that he has been using this formula for over a year, and has since then, as yet, met with no instance where cocaine produced any toxic effect. He has been able to use it in any quantity, and in any part of the nose or throat, without the least fear of harmful consequences. Phenol, in the same manner as cocaine, by suspending the functions of the sensory nerves, is itself a local anesthetic of no mean power, while the combined action intensifies the anesthesia. Phenol also coagulates albumen, and combines with fats, forming a very superficial eschar, which prevents the rapid absorption of cocaine, and hence its toxic effect. Phenol is also destructive of bacteria, fungi,

In conclusion, as results of this combination, Gluck claims the following advantages:

Toxic effects are prevented; the anæsthetic action is increased; it prevents congestive reaction and decomposition of the solution, and renders the solution aseptic.

The same principle has been also employed by Hummer, in Geneva, who has likewise recognized the fact that one of the chief dangers in the administration of cocaine is its extremely rapid absorption. He has recommended as a preliminary measure when local anesthesia is to be produced for an operation by injection of cocaine, to first apply Esmarch's bandage, the anæmia so produced greatly retarding the rapidity of absorption, and hence the risk of toxic symptoms. Occasionally it will be found that symptoms of poisoning, after the administration of cocaine for this purpose, do not appear until some time after the operation. Hummer likewise explains this fact as attributable to the bloodless character of the operation, for, if bleeding is entirely prevented, there is no escape of the solution from the tissues; so that, therefore, after the operation has been completed, bleeding should be encouraged.

remedies failed, the importance of exploring the interior of the uterus was insisted upon. Removal of the ovaries in very intractable cases might be requisite. The reliable remedies for checking uterine hemorrhage were mentioned, ergot being one of the most potent. Hydrastis in cases of myoma was often of great service. Iron in suitable cases was of much value, but needed discrimination. The ordinary astringents, such as gallic or sulphuric acid, had really very little influence in restraining hemorrhage. Quinine and strychnine would often succeed in restraining hemorrhage where the system was much depressed from repeated or prolonged losses. Bromide of potassium in cases of ovarian irritation was very useful. Cases illustrating the difficulties of diagnosis and the methods of treatment were given.

DR. FANCOURT BARNES said that in the large majority of the cases of metrorrhagia,ie., cases where bleeding was going on continuously, the hemorrhage was due to retained products of conception. He recently had two cases in one ward at the Chelsea Hospital for Women. One was that of a woman, aged 40, who had been losing for nine or ten months continuously. She was very anæmic, and was altogether in a very unsatisfactory condition. The cervix was dilated by laminaria tents, and he curetted

DIAGNOSIS AND TREATMENT OF MET

KORRHAGIA.

At the meeting of the British Gynecological Society, held May 28, 1890, DR. EDIS read a paper on the "Diagnosis and Treatment of Metrorrhagia" as an introduction to a discussion upon the subject (Medical Press and Circular, June 4, 1890). Alluding to the fact that the uterus was the only organ in the body from which blood flows as a physiological process, he showed how this function was influenced by many and various conditions, both general and local. A correct diagnosis as to the cause of any undue loss was the first and most important element of successful treatment. This could often be arrived at on the principle of diagnosis by exclusion, not forgetting the influence of diseases of the heart, liver, or kidneys. Some of the most difficult cases to deal with were the terminal floodings about the climateric period. The most frequent local causes were enumerated, and cases illus

which he always preferred when possible. He removed a large mass of placental tissue, and the hemorrhage ceased, the patient making an uninterrupted recovery. There was another patient in the same ward with practically the same history: she had been losing blood for eighteen months; her age was 30. He dilated the cervix in the usual way and curetted as above. For two weeks she was much better, but then the hemorrhage recurred so that he was obliged to curette a second time, on that occasion using the blunt curette as well. She was again relieved, and he thought he had removed all the placental tissue remaining in the uterus. He was, however, deceived, for the hemorrhage recurred after a few weeks, and she was so bad that in his absence Dr. Edis had kindly seen the case, and had removed what he considered to be the remainder of the placenta. He, too, however, was deceived. She had no more hemorrhage to speak of for some time, but she developed symptoms of septicemia, to which she succumbed.

Post mortem. They found another mass of placental tissue still remaining in the uterus. These two cases were extremely interesting, as showing that, like all operations, such a case might be easy or difficult. In reply to the President, he added that it was his invariable practice to wash out the uterus with a solution of iodine at the end of the operation, and to apply iodine to the interior of the cavity for a fortnight or so afterwards.

DR. MANSELL MOULLIN observed that though there was nothing very novel in the paper, the subject was one of such extreme importance that it was well for it to come under their consideration from time to time. He mentioned that he had met with several cases of hemorrhage in elderly women from 50 to 55, in whom the menopause ought to have taken place some years previously, and in whom periodical hemorrhage had been so profuse as to reduce them to an extreme state of anæmia and debility. In these cases the resemblance to malignant disease was very great. The uterus was usually in a condition of subinvolution, retroverted, and partially prolapsed. This probably kept up the congestion of the organ, preventing the atrophy which ought naturally to take place. The mucous membrane in these cases was probably in a large measure replaced by unhealthy granulation tissues. Another class of disease was where the symptoms were associated with the first appearance of the catamenia, which was sometimes attended by hemorrhage so profuse as even to cause death, though he had never seen such a case. If the symptoms were persistent and of an alarming nature they would have to be guided by the same rules as in other cases,—that is, anææsthesia, examination of the uterus, followed by suitable applications to the interior.

DR. HUGH FENTON said the paper was a very fitting rider to that contributed by Dr. Lycett, and read at a previous meeting. This question of the diagnosis and treatment of metrorrhagia was a branch of gynecology which was continually cropping up. He feared that it was often made a matter of treatment and not diagnosis in these cases of metrorrhagia, where everything depended on a full and complete examination not only per vaginam, but of all organs of the body. Some of the cases related by Dr. Edis showed how frequently perfectly preventable hemorrhage was allowed to go on for want of a proper examination in the first instance. He called attention to the cases of villous endometritis, where there was nothing to show for

the hemorrhage. He asked Dr. Parsons. whether he had treated any of these cases by electricity, and, if so, with what result? He mentioned two cases in which he had removed the ovaries for hemorrhage, which had resisted all other treatment, with complete and permanent success.

DR. HEYWOOD SMITH said that, apart from the cases of malignant disease and fibroids, there were no cases of hemorrhage of which one saw more than those due to retained products of conception. He observed that all cases did not require to be widely dilated by tents in order to effect a cure, and he had found the application of the solid nitrate of silver to the entire surface of the uterus very beneficial. He said that the oviduct was often long and convoluted in these cases.

DR. FANCOURT BARNES said it was sometimes very difficult to differentiate between a piece of placenta which had become almost a part of the uterine wall and the uterine wall proper.

He

DR. ROBERT BARNES recalled a fact which not seldom occurred in women of that age,— viz., profuse epistaxis. That pointed to a constitutional cause, heart-disease, or some disturbance of the circulation, symptoms which were relieved by the hemorrhage, uterine or otherwise. The term vicarious menstruation, which was applied to these cases, was not altogether appropriate, but it showed clearly that they must look beyond the pelvic organs in order to unravel the mystery of some of these cases. If they took the other extreme of life,-the commencement of ovarian life, they sometimes met with the most tremendous hemorrhages. had seen one or two cases that had terminated fatally. He remembered a case at Brighton some years ago in which the patient had a very narrow escape. Of course when one meets with these cases in young women, one's first thought was to suspect pregnancy, but in this case he was enabled to say that it was not so. He had succeeded in arresting the hemorrhage by local measures. The great thing was to get a diversion of the blood from the uterus, whence it escaped. In one case only transfusion had saved the patient. The cases which were independent of local uterine or ovarian disease were also of extreme importance. They knew that taking away the ovaries in cases of hemorrhage due to fibroids would sometimes stop not only the hemorrhage but the growth of the tumor. He had seen cases of that kind, and it must be looked upon as a last resource in these