erethism of the nervous centres which leads to this spasmodic discharge. This state of the nervous centres is sometimes constitutional and closely associated with rheumatism. In this case it goes with, or is allied to, such nervous disorders as nightmare, somnambulism, possibly even epilepsy. In other cases this nervous erethism is dependent upon sensations which have their origin in the developing sexual centre, and unquestionably there is a form of nocturnal incontinence which replaces the seminal emissions of the mature organism. Allow this, and how complex the question becomes. Sometimes there is the low tone and in-bred sensation; sometimes the sensations may be called into being by external circumstances, such as a too hot or too comfortable bed; sometimes, may be, there is some local peripheral excitement, a long prepuce, or an over acid urine, for example. In some children, again, it seems that sleep is too sound, and secretion too rapid; and the reflex centre, uncontrolled, acts in accordance with its natural habit, and the urine is passed into the bed.

Thus, in enuresis, very much the same questions come over again that have already been discussed in connection with the gastro-intestinal derangements of infants. A little physiological reflection, if it does not make the whole subject clear, at any rate leaves one with the comfortable opinion that he knows something about it, and with definite aims in the treatment of a somewhat mixed class of

cases.

Of thirty-eight cases, twenty were girls and eighteen boys. The favorite age is about seven; but twenty-seven of the thirty-eight occurred from six to eleven years; seven others at three and four years of age. Eight occurred in rheumatic families.

The treatment of these cases justifies all that I have said. There are some which are cured off-hand by bromide

of potassium and hydrate of chloral, just as infantile convulsions and night terrors are almost certainly controlled; there are others as certainly controlled by belladonna, which not only heightens arterial tension and thus tends to restore the nervous tone, but also has some paralyzing effect on the afferent nerves, while it is well known to control what is, as I have maintained, the allied condition of seminal emissions. There are other cases best treated by good nervine tonics, such as strychnia and dilute phosphoric acid. Others, those of heavy sleepers, must be less luxuriously housed. Others, again, of rheumatic tendency, may be passing a highly acid urine, which irritates the bladder and provokes expulsion; this may be remedied by cutting off all meat from the diet for a week or ten days, and adding some bicarbonate of potassium to the food. In all cases a better habit should be favored, by restricting the quantity of drink towards the end of the day, and by arranging that the child is taken up to pass water late at night, early in the morning, and, if necessary, once during the night. In all cases the general health must be looked to, and tepid and cold bathing be practiced when possible.

Occasionally, the incontinence is not only nocturnal but occurs during the day also. The affection is sometimes in such cases a part of an imbecile condition, and in rare cases the fæces are evacuated involuntarily also. When daily as well as nightly, they are likely to be very intractable, and are cases for a very careful examination of the pelvic organs under chloroform. It may be that, by long persistence of the habit, the bladder has become so contracted as to be incapable of holding any quantity of urine, and in such cases I have once or twice found it necessary to distend the bladder by injecting water, under chloroform.

In any case, long persistence in the habit will necessarily make the case obstinate. For our comfort we may remem

ber the usual doctrine, that such cases generally ameliorate at puberty; but it may also be said that, in proportion as an early and intelligent appreciation of the problem is brought to bear upon an individual case, so is it likely to prove tractable. Intractability is the recompense of an indolent and undiscriminating administration of belladonna or whatever comes to hand.

Calculus Vesica only needs mention as a complaint of which the diagnosis frequently falls upon the physician. I am under the impression that during the years that I saw out patients at the Evelina Hospital, the majority of cases of calculus were sent into the hospital by me, at any rate five such cases occurred. The symptoms are pain in micturition, frequent micturition, stoppage in the flow of urine, uneasy sensations after emptying the bladder-worse when moving about, the occasional presence of a little blood in the urine, of pus or mucus in excess more frequently, and incontinence of urine.

Diagnosis. Many things simulate stone-e. g., rectal worry by worms or polypus; penile worry-e.g. a long or adherent prepuce; disease of the kidney or bladder, and, in the female, vaginal discharge, etc.

Vaginal and Labial Discharges are due to some eczema of the external parts, or to some catarrhal state depending on the presence of worms or to ill-health in scrofulous or tubercular children.

Treatment.-At first this may be confined to plenty of bathing and to tonics, such as the lacto-phosphate of iron and cod-liver oil. If worms are present, they must be attacked by enemata or aperients. Later on, the vagina may be syringed with a lotion of lead or salicylic acid.

Noma* is so rarely seen that it may go undescribed.

*Noma pudendorum.-ED.

CHAPTER XXXII.

DISEASES OF THE NERVOUS SYSTEM.

Inflammation of the Dura Arachnoid is dependent, as in adults, upon injury or disease of the bones of the skull. It is comparatively rare, and causes no special symptoms other than will be considered as those of meningitis. Meningitis is, indeed, usually associated with it; and one hardly meets with those more chronic forms of disease, or pachymeningitis, that are met with in adults. As a rare instance, however, of something of the kind, the first of the cases which follow may be given. The second case, while it illustrates the occurrence of local collections of pus in the arachnoid, also illustrates the liability which exists for a general meningitis to be set up under those circumstances.

A boy, aged four and a half, was admitted under Mr. Birkett in 1874, for a swelling in each upper eyelid. Twelve months before his admission his left eye began to swell; a month later the other eye did the same, and for three weeks before admission he had been very drowsy. He was admitted for the tumor over the left orbit, and it was then noticed that there was a hard cartilaginous body, freely movable under the skin, beneath the margin of the left orbit. His sight was unaffected, and the movements of the eye-ball were perfect. His temperature ran up to 104° and 105° within a day or two of admission, and he died of pyæmia.

At the autopsy, the history of the case appeared to be this: There had been caries of the first lower molar and abscess; then suppuration in the inferior dental canal, acute ostitis of the left side of the lower jaw, extension of the dis

ease in the pterygo-maxillary fossa, and thence to the base of the skull. Having entered the skull by the foramina at its base, and having thickened and dissected up the dura mater from the base of the skull in the middle fossa and about the body of the sphenoid bone, it had entered each orbit, treated the periosteum of those cavities in like manner, and the tumor in the left orbit was in reality only a tough yellow mass, of inflammatory origin.

A female child of six months was brought for wasting of three weeks' duration. She was emaciated and pale, the veins of the head were distended, and the fontanelle, 11⁄2 × 11⁄2 inches, was bulging and pulsating. There is no note of any paralysis, but there were soft, elastic, tender thickenings over the lower halves of the right radius and ulna and left humerus, a state of things which, at this distance of time (nine years), sounds very like syphilitic disease of the bones, though it does not appear to have occurred to any of those who saw the case, myself amongst the number, to call it so. The child died with convulsions.

At the autopsy, a large collection of pus was found between the dura mater and the right side of the brain. It extended from vertex to base, and from the anterior part of the middle fossa back to the horizontal branch of the lateral sinus. It did not enter the cerebellar fossa. Its wall was ochre-yellow, like a typhoid stool, but the pus itself was "laudable." Pus occupied the ventricles. The lateral sinus was plugged on both sides, the left by clot of older date than the right. There was no disease of the internal ear. The bones were slightly rickety.

A condition such as this is probably more often produced by disease of the bones of the internal ear, and careful search for such should be made at the post-mortem examination; but it may occur from pyæmic conditions, from the extension inwards of erysipelas, or from unhealthy inflammation