Treatment.-Hygiology rules the situation. Generally speaking, kidney stone is diagnosed too often. Frequently there is only gravel or sand; not concretion. Regulation of regimen should be rigidly righted. Not only too much meat and eggs, but too much sugar and starch are to be forbidden. Chapter II will serve as a guide. Indigestion is to be treated, see p. 35. Jellies and gelatinous substances should be avoided both in gout and rheumatism.

The skin is kept secreting by warm woollen clothing cap-àpied and by exercise, or massage for infants. Cold and damp may be avoided by the same means, and by careful attention to the bedroom and play-room or nursery. Attention must be given to the hygiology of the nervous system (see p. 398). Drink is most important. Two pints a day for a child of seven is not too much. Distilled water, aërated, or salutaris are the best. Thin, sweetened and flavoured barley water is also good. The flavouring may be done with any of the cook's essences, but the quantity used should be the least possible-of vanilla, lemon, aniseed, &c. Saccharine well. deserves a trial, for food and drink may be rendered sweet without entailing the use of more than a few drops of it. Animal broths should be avoided. Rhubarb as yielding oxalates should be prohibited. If such measures do not clear the urine of blood and sand, alkalies should be prescribed. Bicarbonate of potash or the citrate may be given in ten-grain doses three times a day for a boy of seven. The urine, to be lithontriptic, should be kept neutral or alkaline. This is the indication for the amount of alkali required. Stimulants should, as a rule, not be ordered. If the child be feeble, however, a little sound claret or high-class wine may do good. A wineglassful to dinner may be given to a boy of seven. The dinner should be at midday.

Nephritic colic requires the use of hot baths, temp. 98° F.; hot fomentations to the loins, and free potations of warm

bland fluids like thin flavoured barley water.

Opium may be given if these measures do not relieve påin. Five drops of laudanum may be given, if there be no evidence of renal disease, to a boy of five, and then drop doses every quarter of an hour till relief is obtained. Of course care is required not to narcotise the child. Massage over the suspected kidney and downwards along the ureter may do good. Belladonna tincture may be given in five-drop doses with or without the opium. If the pain is unbearable and uncontrollable inhalation of chloroform may be legitimately used and tends to relax spasm.

The persistence of symptoms is an indication for renal sounding either by punctures with a fine needle or cutting into the loin by a careful and antiseptic surgeon. Nephrotomy should be performed if a stone be detected. Cleanliness and asepsis should be carried out as rigorously as possible. (Consult surgical works.)

Tonics of iron and nux vomica sometimes remove the habit of passing gravel and sand in debilitated atonic, though not necessarily anæmic boys.

KIDNEY TUMOURS.

Congenital hydronephrosis and sarcoma are the chief kidney tumours. The tumour is the chief indication. Hæmaturia is a sign of sarcoma, but I have seen four cases of renal sarcoma without hæmaturia from beginning to end.

The tumour may be suprarenal or extrarenal when the physical signs are the same. In one suprarenal that I examined after death the external genitals were over-developed and covered with long large hairs in a female aged two years. Dr. Dickinson has recorded a similar case in the

Pathological Transactions." The tumour occupies the loin; the dulness goes right back to the spinal muscles; it does not move with respiration; the colon is in front of it, as palpitation or percussion may reveal. The liver is often dis

located forwards and downwards, and may be flattened. Pressure signs occur later on-large superficial veins, oedema, and dyspnoea are the chief. Secondary deposits nearly always occur in the glands of belly and mediastinum, in liver and lungs.

The sarcoma may fluctuate from softness of the roundcelled growth into which blood is often extravasated. The exploring syringe may draw off blood and cells if the growth be a sarcoma; if hydronephrosis, clear fluid containing urea may be withdrawn. Pyonephrosis may occur, and may be, not always, indicated by pyuria and by chills with fever.

Renal sarcoma is most frequent during the first few years of life. All the six cases I have seen were under four years of age.

Wasting and anæmia are the chief symptoms of sarcoma ; pain is not frequent; hæmaturia may occur. Most cases die before a year has elapsed after the detection of the tumour. Hydronephrosis may last longer. Double hydronephrosis usually causes still-birth. In an interesting case I saw one kidney was cystic, like a small bunch of grapes; the other kidney was hard and fibrous, but functional; there was remarkable lipæmia; the blood looked on the post-mortem table like milk, or as if it had been mixed with carbolic acid. No tumour was felt during life. The infant was ten months old. It is important to remember that renal tumours of congenital origin are frequently accompanied by other congenital abnormalities. In six hundred post-mortem examinations I have found one kidney absent thrice.

The diagnosis of kidney tumour, as distinguished from enlargement of the liver and spleen, or ovarian tumour, psoas abscess, or mesenteric swellings, is usually easy. I have not seen a case of primary malignant disease of the liver in a child.

There is but little to be done in renal sarcoma except to support the strength and relieve the symptoms. It is useless

to remove the tumour. When the kidney swelling is detected, secondary growths are almost inevitable. The shock of the operation is ill-borne. The treatment of hydronephrosis and pyonephrosis should be left to the surgeons. Free drainage and antisepsis would perhaps in both cases be better than aspiration.

CHAPTER XV.

DISEASES OF THE NERVOUS SYSTEM.

HEADACHE.

As in the adult, the number of causes of headache is legion. Megrim, hypermetropia, and other errors of refraction are common causes of headache in children. Any blood condition may induce it. Anæmia, toxæmia from kidney or liver defects, indigestion, constipation, rheumatism, typhoid fever, and other acute specifics are also common causes. Meningitis and cerebral tumours are not likely to be forgotten.

The diagnosis will rest on the associations of the headache. Errors of refraction are readily discovered by the ophthalmoscope; the headache is generally frontal and often supra-orbital. I have observed that headaches are more prone to occur in hypermetropics, myopics, and astigmatics even when there are other causes adequate to account for the headache-typhoid fever, indigestion, anæmia, over-work, or debility of any kind. This fact may be placed side by side with the observation of Dr. Gowers that optic neuritis from head disease (? other causes of neuritis also) is more prone to occur in eyes which are not emmetropic.

Megrim is irregularly or sometimes regularly periodic in its occurrence, like epilepsy and other neuroses. It is frequently hereditary on the maternal side. Other neuropathic conditions may coexist in the family. Fitful or recurrent vomiting is probably often of "megrimous" import or relationship. The first step in the treatment of headache is to find out and remove or avoid the cause. In most cases a combina