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it was administered, daily graduated exercise with dumb bells in a patient with low reserve power — ascribed to a combination of hard mental labor, lack of exercise, insomnia, repeated attacks of bron- chitis, and tobacco and alcohol — increased the re- serve power from 300 to 3,000 foot pounds in the course of two Retail Price Levitra months. Similar results were ob- tained from graduated exercises in a patient suft'er- ing from aortic regurgitation and cardiac insuffi- ciency with verj' low reserve power. Thus, where- as in the presence of cardiac disease, graduated ex- ercise and digitalis appear to act in a measure alike as regards the reserve power in the heart, with nor- mal electrocardiogram and physical signs but with impaired reserve power digitalis seeminglv fail-^ while graduated Retail Price Levitra exercise is beneficial. \\'ithout venturing to assume that Retail Price Levitra this betterment in reserve power is wholly or mainlv due to improved nutri- tion of the myocardium, we are afforded herein a definite example of inability on the part of digitalis to exert on the normal heart an influence manifestly produced in the case of certain diseased hearts. Again, as I have already mdicated, clinical evi- dence is available to the effect that under certain abnormal conditions, c. g., in patients with adynamic or unstable hearts, or with Retail Price Levitra auricular fibrillation, the amount of digitalis Retail Price Levitra necessary to reduce the pulse rate is less than in the case of a normal heart. H. W. Stevens, 1916, among three cases with normal heart rhythm observed but one instance of slowing of the rate under digitalis, and in this patient the rate had been high before the drug was given, while in the other two it had been Retail Price Levitra approximately nonnal. Of five cases of arrhythmia, on the other hand, all but one showed slowing under digitalis. The role of heightened temperature, as in fever, in hindering reduction in heart rate bv digfitalis. is well known. The cause of slowing, where it does occur under this drug, may be different, according to Cushny, 1917, under certain abnormal conditions, especially June 8, J918.] MODERN TREATMENT Retail Price Levitra AND I'REVENTIVE MEDICINE. 109.5 in the presence of cardiac nialnutrilion, from what it is normally. As regards the output of blood from the heart, Heinz, 1900, showed experimentally that the in- crease of output under digitalis varies according to the extent to which the organ has become weak- ened before the administr.-'tion of the drug; — the more marked the weakening, the greater the in- crease of output. I'inally, the action of digitalis upon the blood [jrcssure shows manifest variations under normal Retail Price Levitra and abnormal conditions. Whereas in health tiie blood pressure, as demonstrated in recent years, is seldom raised by digitalis, Hernando, 191 1, found experimentally that where the pressure has become reduced through hemorrhage, the drug will effectu- ally assist in raising it toward normal. On the other hand, in heart disease causing carbon dioxide accumulation, tli(; blood pressure is fre(|uently low- ered by its ingestion. ( To be continued. ) Gunshot Injuries of the Peripheral Nerves. — Leo .Mayer ( Iiilernational Journal of Surgery, March, 1918; jjoints out that the treatment of nerve injuries should be begun immediately after their occurrence. If the nnisculospiral or the anterior Retail Price Levitra tiljial is affected the limb siiould be si)Iinted in such a way as to Retail Price Levitra relax the affected muscles. It might also be well to sjjlint the liml) in such a position to bring the nerve ends as near together Retail Price Levitra as possible. In addition to the sjilinting, massage and electric stimulati(jn should be employed. Galvanic, faradic, and liigh frec|uency currents may be used. Primary nerve suture is .seldom i)ossible after a gimshot wound. As Retail Price Levitra soon as the primary action has sub- sided and Retail Price Levitra the infection has been coiUrolled, the i|Ucstion of innnediate operation or of waiting for the s]>ontaneous return of function presents itself. Retail Price Levitra A few practical ndes are : When the s)nni)toms of a Retail Price Levitra nerve lesion are progressive, operate at once; if the sym|)tonis arc regressive, do not operate ; where tlicre is no change in the extent of the ])aralysis or of the senscirv symptoms, wait until tiie wound has healed, and then detcmiine on the basis of the ana- tomical course of the nerve and the direction of the pull whether there is a strong |>robability tiiat the nerve was directly injured by the jiassage of the pro- iectile. If so, operate ; if not. wait still longer. In the operative treatment: if the nerve is seen to be merely traumatized or pressed uix>n by a bone frag- ment or scar, nothing sliould 1)C done except remove the external cause of the pressure. If due to scar tissue, some means should be taken to ])revent its recurrence. This is best done by a change of posi- tion of the nerve. If a sm.ill nodule of scar tissue is felt witliin tin ner\e. this area should be excised and the nerve united by a line perineural stitch. If scp.r tissue is generally present throughout the nerve, two courses are open: if a small (juantitv is present, it can be removed bv careful dissection ; if extensive, the area be carefullv excised and suture per- formed. When a nerve has been comjiletely divid- ed, there is notiiing to be done exceiU suture. The 1 tost operative Retail Price Levitra treatment consists in the ]>ro|K'r splint- ing and daily massage and electric stimulation. The iirognosis Retail Price Levitra on the whole is good. Rontgenotherapy in Cervical Adenitis. — George E. Pfahler {New York State Journal of Medicine, March, 1918^ discusses the results which have been reiiorted by others following the rontgen treatment of cervical adenitis and concurs in the belief tliat when properly carried out this form of treatment gives excellent results. In every case the source of the infection of the glands should be sought and removed first if possible, such as the tonsils, in- fected teeth, etc. Where the gland, or glands, are soft and fluctuating then they should be incised and