rest. If it fails other sedative drugs may be tried, such as hyoscyamus, the bromides, antipyrin, aspirin, chloral, etc., but they are not likely to succeed when belladonna fails. Instillations of strong silver nitrate (1 per cent.) sometimes prove efficacious by diminishing the sensibility of the neck of the bladder.

Electrical treatment is disappointing.

Albarran and Cathelin have advocated an attempt to diminish the excitability of the nervi erigentes which bring about the act of micturition, using intra-dural injections of various substances in the coccygeal region. They have obtained the best results with 10 c.c. of normal serum given every second night for eight days, but success is not by any means universal. The method is worth a trial.

In obstinate cases suggestion has a powerful influence, but its employment is not unattended with other disadvantages, and should never be undertaken lightly.

Leonard Williams has recently reported considerable success from the exhibition of thyroid extract.

CHAPTER VIII.

BILHARZIA HÆMATOBIA.

THIS disease has assumed a certain importance in England since the occupation of Egypt and South Africa by English troops, as it may be the cause of a painless or painful

hæmaturia.

The symptoms are produced by the passage of the eggs of a parasite through the walls of the bladder. The characteristic symptom is the passage of a few drops of blood at the close of the act of micturition, apart from which there may be no other sign that anything is wrong.

The patient may notice a tickling sensation in the urethra, and that the frequency of micturition is increased.

Secondary infection with bacteria will give rise to a painful cystitis and the formation of stones in the bladder, and to pyelonephritis, but these complications are hardly ever seen in the cases in England.

The diagnosis rests upon three factors:

1. The history of a residence in Egypt, Arabia, or South Africa.

2. The finding of the eggs of the parasite in the urine by microscopic investigation of the last few drops passed.

3. The cystoscopic appearances.

Patches in the bladder-wall are seen with the cystoscope dotted over with brilliant white spots, surrounded by healthy mucous membrane or by velvety hyperæmic areas, the white spots being the tails of the adult worms seen through the mucous membrane.

The eggs are about one tenth of a millimetre long and are ovoid in shape with a spine at one end. They consist of an outer shell surrounding a ciliated embryo or "miracidium." If placed in fresh warm water the miracidium hatches out. The embryo perishes in one or two days, and is killed at once by dryness or cold. There is no intermediate host, but the embryo appears to enter a fresh human being again directly, either making its way through the skin of the legs into the blood, and so to the liver as Looss holds, or directly up the

urethra as Dr. Allen, of Natal, maintains. All are agreed that it does not enter in the drinking-water.

The adult worms develop in the portal veins of the liver, taking three to six months to attain maturity, from which they make their way to the pelvic veins, and having anchored in the bladder-walls they proceed to hatch out brood after brood of eggs. In this state they live on for three or four years when they die of old age, though exceptionally they have been known to live for many years longer. If, then, the victim leaves the infected country he may reasonably expect his parasites to die out in about four years' time, but the symptoms will usually disappear long before that.

The prognosis as regards life is excellent if reinfection can be avoided, though amongst the Egyptians themselves there is a small mortality from calculus and pyelitis.

Treatment.-Europeans in infected districts should avoid bathing in stagnant, muddy pools frequented by native children, and if Dr. Allen's hypothesis be correct circumcision or a careful drying of the meatus and foreskin after bathing is a certain prophylactic.

When the disease is established it has to be left to die out of itself, reinfection being carefully avoided.

Sandwith states that good effect may be obtained by the exhibition of the liquid extract of male fern in fifteen-minim doses three times a day for a fortnight, and any irritation of the bladder can be controlled by giving a methylene blue pill containing three grains twice a week.

If cystitis or calculus is present the treatment for these conditions must be carried out as already described.

SECTION IV.

DISEASES OF THE PROSTATE.

CHAPTER I.

FIBRO-ADENOMA OF THE PROSTATE
("ENLARGED PROSTATE").

Definition.

THE clinical term "enlarged prostate" has been loosely applied in the past to include several different forms of prostatic disease in men over fifty, but has not included several varieties of prostatic enlargement met with in men under fifty. The advance in pathology has rendered the term obsolete, though it will be long before it disappears from the clinical field.

Ætiology.

In one man out of every five who attains the age of fifty years trouble in urination arises sooner or later, caused by disease of the prostate gland. In 90 per cent. of the cases this disease consists in the formation of benign adenomatous tumour masses within the gland; in the remainder it is due to malignant disease, or to the fibrous prostate of chronic prostatitis.

The cause of the formation of benign adenomata in any part of the body is unknown, but it is a distinct step in advance to recognise that the common cause of enlargement of the prostate in men over fifty is benign tumour formation. The disease often appears in many members of the same family through several generations, but there is no proof that it is in any way inherited. Efforts have been made to prove that there are predisposing causes, such as sexual excess and