appearance of decrepitude after their admission to a home for the aged. We have then a true senile debility in which the manifestations are due mainly to the physical changes occurring in senility and a pseudo or psychic form in which the characteristics of senile debility are due mainly to the mental attitude.

Let us consider the bent posture of the aged. In true senile debility this is due to anatomical changes; there is waste and weakness of the muscles and ligaments of the back and uneven compression and waste of the intervertebral discs. These dises gradually lose their elasticity, the weight of the body compresses them, the compression being greatest where the discs are thinnest, anteriorly in the dorsal and posteriorly in the cervical and lumbar regions. The anterior margins of adjoining dorsal vertebræ are thereby brought more closely together, spreading the posterior margins, thus producing the exaggerated dorsal curvature. The reverse is going on in the cervical and lumbar regions; not so marked, however, as the cervical discs are subject to less pressure and the lumbar dises are much thicker and more even than the dorsal discs.

In addition to the exaggerated spinal curvature the wasted and weakened muscles of the back and neck allow the body to sink and the head to fall forward into the characteristic attitude of senile debility. As these changes proceed very slowly the senile stoop arising therefrom ought not appear until in advanced old age. In the psychic form of senile debility the senile stoop may appear early for this reason: The most natural position of an individual is the one involving the least physical effort, hence one allowing complete relaxation of the muscles. This is seen in the infant, in sleep, under depressing emotion, and in the careless individual. The erect position, head up, shoulders back, chest out, is the result of effort, which, when long continued, becomes a habit. The child is taught to sit up straight and to stand straight because an erect carriage is more pleasing to the eye and is supposed to be more conducive to health. There is, however, always the tendency to relapse into the slouching position, this tendency being overcome, consciously or unconsciously, by a sense of pride in one's appearance.

Another incentive to maintain the erect position is the ambition to gain approval in any field of human activity, such recognition being more readily secured when the individual presents a pleasing appearance. The inherent tendency to avoid physical effort is overcome by ambition, pride in appearance, and habit. The last factor is not in itself strong enough to overcome the

tendency to slouch. The pride in one's appearance, though arising from self-esteem, is fostered by ambition, the desire to gain approval, and to appear pleasing to others.

When ambition is lost this sense of pride goes with it, the person makes no effort to overcome the tendency to slouch, he allows his body to sink, his head to droop, his arms to hang and his legs to drag. This is the usual attitude of the lazy tramp. When the aged individual begins to feel the infirmities that come with advancing years, that he gets out of breath, that he gets palpitation of the heart, that he soon gets tired and that there is a stiffness in his muscles and joints that make his usual labors more difficult he realizes that his life's work will soon be over. From that moment he loses ambition, he loses interest in his work, in his surroundings, in everything except in his life. He loses the pride in his appearance and makes no effort to maintain the erect bearing of former years. There is now the dread of the inevitable end, perhaps the fear that he has not provided sufficiently for his last years, or that with his death there may be dependents unprovided for, all producing a mental depression which overcomes the habit of erect bearing. The loss of sexual virility may produce the same effect.

After ambition and pride in the appearance are lost the individual ages far more rapidly than can be accounted for by the progressive anatomical and physiological changes of senility. That this aging is mainly due to mental influences is evident from the ease with which it may be overcome by mental stimulus. Relieve the old man of worry about means of livelihood in his closing years by placing him in a home for the aged, and he will improve in appearance and in his mental attitude. Flatter an old fellow upon his youthful appearance and activity and you arouse in him a sense of pride in his appearance; he will try to appear youthful by sitting up or standing erect to show that he is not as old in feeling as he is in years.

HEART TONICS.

G. E. Cornwall, in the Medical Record, is of opinion that the preparation of digitalis which is used matters little, provided it is reliable. For general prescription the tincture is probably as reliable and convenient as any. The common prejudice in favor of the infusion does not seem to be justified, at least, considering the manner in which that preparation is often dispensed. The range of dosage of digitalis is rather large and directions regarding the dosage cannot be given in a few words. Extensive practical ex

perience is necessary to give anything like precision in its use. The following suggestions may, however, help: Give it in doses large enough

to produce the desired effect; do not expect to produce the full effect immediately; do not keep it up if the symptoms grow worse under its use; do not keep up its administration too long.

Strophanthus shares with digitalis the primacy among heart stimulants. The power of digitalis within its narrow range is perhaps greater than that of strophanthus, but the wider range of the latter at least equalizes their value. Strophanthus can be used like digitalis to restore lost compensation in chronic valvular disease and in some forms of valvular disease, particularly mitral stenosis and aortic stenosis and incom

petence, it is usually the more effective of the two, and in all forms of valvular disease in children it is the better drug. It is much more useful than digitalis in the myocardial conditions produced by the acute infections, and it is often of great value, if used cautiously, in the chronic degenerations of the myocardium. High arterial blood pressure is not a contraindication to its use. In the comparative infrequency with which it disturbs the stomach, and in its freedom from

cumulative action, it possesses notable superiority over digitalis. In short, it does nearly everything that digitalis does and a great deal more besides, and does them more pleasantly and more safely.

The effective dosage of strophanthus is considerably smaller than that given in the textbooks, most of which advise 3 to 10 minims of the tincture. The dosage which will be found to give the best results in ordinary cases is 12 to 3 minims every 4 hours. It is seldom that we can with advantage exceed 3 minims as the dose unless the drug has been given for a long time, so that the patient has acquired a tolerance. It should be given at intervals of 4 hours, for it is rapidly eliminated. Failure to get good results with strophanthus are probably due in many cases to the fact that the doses given were exclusively large, following the mistaken general notion of its dosage. For the widely diffused myth that the preparations of strophanthus are unreliable, the author has found no adequate foundation in fact. The preparations of it, made by reputable drug houses, which have been dispensed on my prescriptions have answered expectations.

Strychnine is perhaps the most extensively used of important heart stimulants. It is a much less powerful agent for increasing the cardiac systole than digitalis and strophanthus, which act directly on the heart muscle; its effect is

HEREDITY AND INSANITY.

Carlos MacDonald, writing on the subject in the Medical Record, declares that hereditary influence manifests itself in the progeny in one of three ways, namely: (1) by congenital absence of mind (idiocy); (2) arrest of mental development in early life before full mental power has been attained (imbecility); or, (3) the development of a psychopathic temperament or insane diathesis which expresses itself in a defective or unstable nervous and mental organization which in turn predisposes the individual to succumb to circumstances in the nature of so-called exciting causes that would not affect a person of individual having a strong hereditary predispoinnate stable constitution. That is to say, if an sition to insanity and another who inherits no such tendency be subjected to the same or to substantially similar exciting causes, as, for instance, domestic afflictions, loss of fortune, severe mental strain and worry, ill health, childbirth, dissipation, excesses, etc., the former would be likely to suffer a mental breakdown, whereas the latter would not; and while it is true in respect to the transmission of psychopathic tendencies that the ancestral taint may be, and frequently is, transformed in the progeny so as to appear in an entirely different form, or it may remain dormant in the second generation to reappear in the later one, or it may be deflected from the direct line of descent to a collateral branch, it is destined to crop out from time to time in one form or another, until it is finally rendered inert through the attenuating influence of wise intermarriage, or until the family become extinct through the sterilizing effect of degenerative processes going on through generations.

"He who inherits a predisposition to insanity," says Maudsley, "does not necessarily get it from a parent who happens to be insane-no, not even though his father was insane when he was begotten, or though in madness his mother conceived him. He gets it from where his parent got it-from the insane strain in the family stock."

knife the new mucous membrane was regenerated by proliferation of the glandular epithelium at the edge of the lesion, the cells growing over the raw surface, which they cover in a single layer. The glands are subsequently developed from this single layer of cells.

In his experiments on motor insufficiency the author found that the delay in healing occurred in the early stages before the single layer of cells had developed, but that when once the base of the ulcer was covered with epithelium the regeneration of the mucous membrane was chiefly a question of time, but was also to some extent dependent upon the density of the fibrous base of the ulcer. From the clinical point of view, therefore, the important point in promoting the healing of ulcer is to exercise special care in the early stages of the healing, so that the single layer of cells covers the base of the ulcer as rapidly as possible, and when once that is accomplished, the chief difficulty is over.

TREATMENT OF GASTRIC ULCER. Chas. Bolton, in the British Medical Journal, presents the following conclusions from long and careful experimentation:

1. The theory with regard to the part played by the gastric juice in the production of gastric ulcer receives further confirmation, because ulceration is the more rapidly produced in proportion as the gastric juice is allowed a longer period of contact with the wall of the stomach.

2. The epithelium grows over the base of an ulcer more rapidly when the animal is given a milk diet than when it is given a meat diet. In the case of a milk diet the base of a moderately sized ulcer is usually completely covered by the twentieth day, whilst in the case of a meat diet the same sized ulcer would in most cases be uncovered in the center at that time.

3. Frequently, in the case of meat-fed animals, the ulcer is completly uncovered on the twentieth day, the granulation tissue of the base of the ulcer having become necrotic. Such an ulcer may be only one-fifth of the size of the original ulcer owing to the contraction of the fibrous tissue in the base, although healing has only commenced at the edge.

4. In the treatment of a case of ulcer of the stomach the following principles should be observed:

(a) During the early stages of the healing of acute ulcer the patient should be given a food which does not stay long in the stomach, and which does not excite a copious flow of gastric juice.

(b) The period of treatment in bed should be at least three weeks.

(c) The starvation diet of the older physicians is not necessary, because the general nutrition suffers too much, and because ulcers heal well on some diet such as the above.

(d) In the case of acute ulcers which are extending, or chronic ulcers, healing cannot be expected to occur in three weeks, because the ulcer must first be got into a suitable condition for healing, and then, owing to its size and thickness, the healing must take some weeks longer to be completed, so that the treatment in bed is to be conducted like that of simple acute ulcer, but extended over a period at least twice as long.

e) Since in many cases of gastric ulcer there is hyperacidity of the gastric juice, and when the gastric juice is acting destructively hyperacidity increases this destructive, tendency, this high degree of acidity should be controlled by the administration of alkali. This is not so necessary in acute ulcer as in the more chronie forms, because the few estimations that have been made of the gastric secretion in acute ulcer show that it is not hyperacid, and the author has found experimentally that the effect of acute ulcer is to diminish the secretion in the early stages, and that the latter becomes normal as the ulcer heals.

FRUIT CURES.

At the Congress of Physiotherapeutics, Linossier advocated the use of various fruits as a valuable form of treatment, recommending their employment even at the patient's own home, and not necessarily, as at present, at the different foreign resorts. There is no evidence that the grape loses its efficacy by transmission, or that any change takes place in its therapeutic activity until it comes to be cooked; so that any doctor, in any country, may prescribe this simple and agreeable remedy. agreeable remedy. Not only the grape but all the sweet fruits may be used-strawberry, lemon, orange, apple, pear, raspberry, etc.-so that no season need be without its appropriate remedy.

As to the way in which they act, the mechanism is complex. In the first place fruits, even when acid in themselves, render the blood alkaline, because the tartrate, citrate, or malate of potassium constituting their acidity decomposes in the body and forms an alkaline carbonate of potash. differs from alkalinization caused by the ingestion of sodium carbonate, first, because the mechanism of its action is different. Carbonate of soda excites the secretion of hydrochloric acid.

It

in the stomach, by means of the decomposition of chloride of sodium in the blood, so that the resulting alkalinization is that of subtraction.

In the case of the fruits their salts penetrate to the blood, and, being there changed into carbonate, cause alkalinization by addition, the alkali being possibly more active by reason of its nascent condition. Another difference is that the salt is one of potassium instead of sodium, and as potassium is found specially in the cells of the body and sodium in the fluids, it is probable that fruits act upon the cells and mineral waters upon the secretions.

The alkaline action of fruits is greater than is often supposed, 1 kilogram (2 lb.) of strawberries producing as much alkalinity as 9 grams (138 grains) of sodium carbonate. Besides this fruits are diuretic, probably because of their sugars and their potash salts, laxative by means of their alkaline salts and cellulose, and are also efficient agents for the remineralization of the organism, their ash containing the same constituents as that of the body, with the sole exception of sodium carbonate. Iron and manganese are especially abundant, and potassium is, according to Traube, an excellent cardiac tonic. These all being in a colloid state, act differently from ordinary mineral substances.

The treatment can be varied so as to influence nutrition in different ways. If nothing else is taken, there is a reduction of alimentation generally, and especially of nitrogenous substances, suitable for the various forms of arthritis; whilst added to the usual diet, fruit causes an increase of hydrocarbon with a reserve of nitrogen, which is probably the action of the grape cure in commencing tuberculosis.

TREATMENT OF ARTERIO-SCLEROSIS. E. D. Rudolph, in the British Medical Journal, makes a threefold classification of the disease: First Stage (1) Toxaemia.

Second Stage-(1) Toxaemia; (2) organic change in walls of vessels and left heart, and probably in kidney.

Third Stage (1) Toxaemia; (2) organic change in walls of vessels and left heart, and probably in kidney; (3) breaking down of the diseased circulatory apparatus.

Take a man of, say, 45 in whom we find a systolic pressure of some 160 mm. Hg. He seems well, but probably has a slight increase in the amount of urine, which will be too watery and may show a trace of albumen occasionally and probably now and then a few hyaline casts.

If this patient show a family tendency to arterial disease so much the worse. If in such

an individual we cut down his animal proteids, putting him chiefly on a lacto-vegetarian diet, cut out excessive smoking and the use of alcohol, and give him some saline every morning, with an occasional mercurial purge, he will probably improve very much and his pressure will come down to normal or nearly so, and, as long as he keeps to such simple rules, may remain so. If such a regime be not sufficient regular small doses of potassium iodide may help very much. Pharmacologically Stockman showed years ago that this drug had no effect in lowering blood pressure except in enormous doses, but clinically nothing seems to be more evident than its effect in hyperpiesis due to toxæmia. Probably it helps in elimination. Every clinician has seen its good effect in relieving the pain in aneurysm. Diuretics may be useful, especially theobromine.

The treatment so far mentioned is applicable to all cases of arterio-sclerosis where the pressure is high, whether the case be early or more advanced. But if, in spite of it all, the pressure remain too high, and perhaps symptoms of cerebral trouble-such as transient affection of speech or even paralysis-are showing, then severe purgatives or even bleeding may be required. But the question always arises here whether we should interfere actively with a high pressure merely because it be high-whether this pressure may not be compensatory, and the best thing under the circumstances for the crippled patient. May not his symptoms be due to an anæmia of a vital part of the brain, owing to a sclerosed and narrowed vessel of supply? Here the high pressure may be keeping him alive. Again, thrombosis may be occurring in such a vessel, and the most likely thing to increase such clotting will be to reduce the flow of blood through the artery, and to increase the coagulability of the blood, as may be done in both instances by the operation of bleeding.

It is probable that no one rule can be laid down about the care of high blood pressure in cases of advanced arterio-sclerosis beyond those of diet and other simple means applicable to the presclerotic stage.

Moreover, it is wonderful how well many people are with blood pressures that may at first surprise us, and not only well, but may remain so for years. Especially in stout individuals, we may find pressures reading even over 200 mm. Hg, in whom there may be practically no symp

toms.

Occasionally, however, the pressure is producing some trouble that makes it urgent that we reduce it, and here blood-letting or the use of vaso-dilators may be of much value.