suffer from actual disease, and many live to be very old, dying of old age after having passed a complaining, and, to themselves, a not very happy, if not actually miserable, existence.

In some forms of irritable bladder, and in inflammation, the nerve ramifications are themselves affected by the congested state of the vessels, and their nuclei or bioplasts concerned in nutrition and growth as well as action, increase in size. There is increased activity of the nutrient processes through the whole thickness of the mucous membrane. That this is so is manifest from the growth of pus corpuscles from the youngest epithelial cells and in the follicles of the mucous membrane, as well as the rapid growth and multiplication of the pus corpuscles themselves. In this increased nutrition all the tissues of the bladder participate. Young children often suffer from over sensitiveness of the mucous membrane of the bladder, which causes the greatest trouble to the mother or nurse, and is sometimes associated with an irritable condition of the mucous membrane of the lower part of the small and large bowel, resulting in the discharge of three or four or more watery motions during the day, and sometimes the discharge cannot be restrained. The trouble often begins during an attack of whooping-cough. Improvement in the general health is usually accompanied by the disappearance of the troublesome symptom. Tonics, cod-liver oil, small doses of belladonna, often afford relief. The child must not be punished, for in this way fear is caused, and the patient gets worse instead of better.

Irritable bladder may be a purely nervous affection, in which case it ought to be classed with nervous affections occurring in other parts of the body. Gout and rheumatism affect the nerves and muscles of the bladder occasionally.

Frequent discharge of urine in young children may depend upon almost any peripheral irritation, such as dentition, intestinal worms, enlarged glands, etc., but very often it is connected with a naturally excitable state of the nervous system. When arising from teething, or from worms, the treatment is obvious. Commonly enough, it occurs only during the night, and sometimes the child acquires a habit of thus voiding the urine, unless care is taken by the nurse to take him up regularly after certain

intervals of time (three or four hours), so as to prevent much urine accumulating in the bladder. In many cases the urine is a little too acid, when a few doses of bicarbonate of potash, lime water, or liquor potassæ, and attention to diet, will relieve the affection. This troublesome symptom occurs in young persons of both sexes, and is occasionally very obstinate. Not unfrequently it seems to be due to the habit of sleeping on the back, when a blister applied to the buttocks will generally cure the malady by compelling change of position. I have seen it in youths of scrofulous habit whose strength had suffered from growing too fast. Such cases are almost certainly cured by a generous diet, the tincture of perchloride of iron, quinine, and cod-liver oil, but it is often necessary to keep the patient under this plan of treatment for two or three months.

Nervous old men often suffer a good deal of inconvenience from irritable bladder, not dependent upon organic disease. If they take a little more wine than they ought, or a richer diet than usual, or become a little more irritable in temper, they will be called up several times in the night. The state of urine causing this annoyance is generally dependent upon the stomach being a little out of order, and a few doses of liquor potassæ or bicarbonate of potash, after meals, a mild sedative and a gentle purge, will generally remove the annoyance. Sometimes a small dose of blue pill or calomel cures the troublesome affection at once. If obstinate, it is well to try the effect of an opium or henbane suppository.

In old age, although there may be no morbid change in its structure, the bladder often becomes very irritable, and a patient is unable to retain his water for more than half an hour or an hour at a time. Patients who suffer thus, by concentrating their attention too much upon their ailment, often make matters worse. Any disturbance of the digestive organs will sometimes produce increased distress. In many of these cases it is very important to prevent the patient from thinking continually about the bladder, and it is probable that the advantageous effects sometimes following the application of a blister are due to the attention being diverted to another part.

In some cases irritability of the bladder seems to be due to the organ being congenitally small, and not growing in proportion. as the body grows, or in proportion to the increased quantity of water secreted. As the demand for larger capacity arises, the bladder very soon gets distended, and it empties itself very frequently, to the patient's great inconvenience and distress. This is, fortunately, not a very common case, but it is a very difficult one to treat successfully. The physician must do all he can to reduce the secretion of urine to the most moderate amount consistent with health, and in some cases he will be able to effect a cure in this simple way, and if he explains to the patient the extreme importance of taking as little nitrogenous food and fluid as he can do with, he will sometimes, in addition to "curing" his troublesome affection, greatly improve his general health and strength. The wonder is not that we occasionally find a bladder too small for the organism to which it belongs, but that bladders in general do not rebel at the greatly increased and worse than needless amount of containing power that is expected from them by their owners.

I have known patients suffering from very frequent calls to make water, and from what they concluded to be irritability of the bladder, for some years; but as soon as the case was investigated the bladder was found to be full and distended to overflowing. In one case the patient had suffered for five years, when five pints were removed from the bladder by a catheter. After this the instrument was used three times a day for a week or two, and then less frequently. The patient, although upward of seventy, completely recovered, and regained full control over his bladder, and lived to an advanced age. The urine was clear and perfectly healthy. It is curious how people become gradually accustomed to this state of distention, and consider the uneasiness they experience due to some change consequent upon old age, and it never occurs to them that the bladder may be full to overflowing. Sometimes, although they have a suspicion as to the nature of their malady, they forbear to obtain advice, from the ridiculous dread they feel of instrumental relief. It is a pity people should make themselves uneasy about interference,

which will afford them certain relief in a few minutes, while there is not the slightest risk and seldom more than very slight pain accompanying the careful introduction of a flexible catheter. Nay, it is an operation which, with a very little instruction, the patient can perform for himself.

When the bladder is very irritable, and especially in cases in which the desire to empty the organ at very short intervals is accompanied with uneasiness or actual pain in the bladder itself, or in the course of the urethra, from twenty drops to half a drachm of tincture of henbane, or ten drops of laudanum, may be added to each dose of tincture of perchloride of iron; or extract of henbane or opium may be used as a suppository the last thing at night. In cases in which the pus becomes decomposed in the bladder and the urine is ammoniacal, it may be necessary to have recourse to injecting the bladder and other modes of treatment.

Some time since I was consulted about a gentleman who was sixty years of age and had been suffering for a year from great irritability of the bladder, the water not being retained for more than twenty minutes at a time, day or night. The urine was alkaline, and contained one-thirtieth of its volume of pus and numerous crystals of triple phosphate. The patient had been losing weight for some time, and was very weak. Pareira brava, buchu, uva ursi, belladonna, tincture of perchloride of iron, nitric acid, opium, copaiba, leeches to the region of the bladder, blisters, and many other plans had been carried out, but with no relief. I recommended that the patient should be put on a nourishing diet, with pepsine, if necessary, and ordered him to take twenty drops of tincture of perchloride of iron in infusion of quassia, twice a day. This plan was adhered to steadily for a month, with marked benefit, and the patient was persuaded to go on with the treatment. In three months the patient had much improved, and could retain the urine for an hour at a time. His general health was much better, and he had increased fourteen pounds in weight. The urine contained no sediment of pus. The patient was persuaded to persist in the same plan, and at the end of a year from commencing this

system he considered himself pretty well, could retain the urine for three or four hours, and had gained more than twenty pounds in weight. Another case with similar symptoms, in which the state of the bladder clearly depended upon a chronic gouty state of system, greatly improved in six months upon tincture of perchloride of iron, henbane, and quassia, and I might bring forward many others, differing as regards the severity of the symptoms, which illustrate the same point.

OF CASTS OF THE URINIFEROUS TUBES.

No one has contributed so much valuable work toward the elucidation of the many very important questions bearing upon the clinical significance of casts as my colleague, Dr. George Johnson, whose memoirs in the "Medico-Chirurgical Transactions," and works on Kidney Diseases, have been before the profession for more than thirty years. Casts are never found in healthy urine, though it is possible that some of the so-called "mucus" present may be composed of the same material as that which under certain circumstances takes part in the formation of a "tube-cast." Casts occasionally present in the urine are, however, sometimes found in some of the smaller glands which open into the urethra, as well as in some of the ducts of the prostate, in the seminal tubules, and in the convoluted and straight part of the uriniferous tubes of the kidney.

Some of the most important forms of casts are represented in Plates III, IV, and VIII of "100 Urinary Deposits."

The diagnosis of many forms of renal disease is much assisted by taking note of the character of the cast, and in the case of fatty kidney may sometimes be made from an examination of the casts only; for there is no other condition in which numerous casts containing collections of oil globules are passed during a period extending over several weeks, except that form of renal disease which is due to the fatty degeneration, and which occurs in children and young people belonging to a scrofulous or tubercular family. Blood and pus corpuscles, epithelium in various states, urates, phosphates, crystals of uric acid, and dumb-bell crystals or minute calculi of oxalate of lime, are often seen in