water, as hot as can be comfortably borne, will usually assist the passage of urine.

GALLSTONE COLIC.-This disorder is more frequent in women over forty years of age. The gall bladder is situated immediately under and below the lowest rib, about one and a half inches above and one and a half inches to the right of the navel. The pain usually accompanies the escape of gallstones from the gall bladder into the passage which conveys the bile from the gall bladder to the bowels. The pain begins suddenly, and is often agonizing and of an aching, tearing character, and sometimes is not continuous, but occurs in violent attacks with comparative ease between them.

It is felt in the region of the stomach, but more in the right lower chest and right shoulder blade. Pressure below the ribs on the right side may at first give relief, but tenderness in this region soon appears and is the most distinguishing feature of this form of colic. Pressure should be made over the seat of the gall bladder-an inch and a half above and to the right of the navel-and compared with similar pressure upon a corresponding point of the other side of the belly. The patient commonly suffers so intensely that he rolls about in agony, and is pale, covered with cold sweat, and vomits frequently, while the pulse is feeble. There is often chilliness at the onset of the attack, followed by fever with a temperature of 102° to 103° F. The pain may last a few hours or, with

intermissions, for days or weeks. It is occasionally continuous and dragging instead of occurring in sharp attacks. Jaundice coming on either with or after an attack of pain, such as described, is another distinctive point, and taken with violent pain and tenderness over the gall bladder, will enable one to be reasonably sure of the existence of gallstones. Jaundice is shown by yellowness of the eyes, tongue, skin, and urine, with whiteness of the bowel discharges, but jaundice is not always present.

Treatment. It is impossible to dissolve or remove stones in the gall bladder by any medicines. It is also true that they exist in a large number of persons without causing any trouble; and their existence would be unknown if it were not that they are so frequently found at examinations after death. During the attack of pain the treatment recommended above for colic in general should be followed. After an attack has passed, the patient-if in fairly good healthshould take plenty of outdoor exercise, as horseback riding ("the outside of a horse being often the best thing for the inside of a man"), gardening, sawing wood, hunting, golf, or whatever is most congenial, unless the attacks are frequent and there is much tenderness in the region of the gall bladder. It is well to move the bowels freely each morning by sipping slowly a glass of hot water containing a teaspoonful or more of sodium sulphate and sodium phosphate, about half an hour before breakfast; that is,

a teaspoonful of each of these salts or enough of them to give a good daily movement of the bowels. Itching, which is frequent if there is jaundice, may be relieved by baths containing baking soda, and by dusting the skin with cornstarch. If the attacks are frequent, or severe, surgical treatment is demanded, as complications may arise which will not only ultimately cause death, but will at a late stage make surgery a precarious resort. The gall bladder, like the appendix, is not essential, and its removal, if necessary, is not attended with any future damage to the patient. The necessity for immediate operation at the time of attack is not imperative, as in the case of appendicitis, but operation on the gall bladder or the passages connected with it, if done before much jaundice or inflammation have occurred, is attended with little more danger than an operation for appendicitis when undertaken by surgeons experienced in such work. It is now recognized by physicians that the surgical treatment of gallstone disease is as successful as that for appendicitis. The sooner, therefore, that a case of gallstones can come under the care of a skillful physician, the better, as very careful study is required for the understanding of the exact diseased condition existing in each case in order to determine the proper treatment. Many cases will not require operation; in others only an operation will avert death.

RENAL COLIC-Renal colic is usually caused either by the presence of a stone in the kidney or in the

narrow tube (ureter) which connects this organ with the bladder; or occurs during the passage of the stone from the kidney into the urinary bladder. It is more common in men, and in late or early life. The attack begins suddenly with agonizing pain in one side, more particularly just below the ribs in the narrow part of the back, but also in front in the corresponding situation, that is, in the belly just below the ribs on the same side. The pain is also sometimes felt all over the belly and even in the chest; but what serves to distinguish it from the other colics is that the pain shoots down into the groin, inner part of the thigh, and testicle in front. There is, in addition, tenderness on pressing firmly on the small of the back, just below the ribs on the painful side. The pain is accompanied usually by vomiting, cold sweats, and feeble pulse. The passage of urine is frequent, painful, and often bloody-a very important point-although it may look perfectly natural. Occasionally the urine is scanty or entirely lacking. There may be a chill at the onset of the attack and the temperature may be raised to 102° to 103° F. The pain may last an hour, or even a day or more, with intermissions. If the urine be carefully examined, the stone may be found within a week or so after the attack of colic. Soreness and tenderness remain for a time in the affected side, and if the stone lodges in the bladder, there may be frequent urination and some pain in the lower part of the belly. Occasionally the stone remains in the

bladder and gives rise to inflammation of this organ, with frequent and painful urination and the appearance of pus or thick, white sediment in the urine. More often after the stone has escaped from the ureter into the bladder, it is expelled in the urine without the knowledge of the patient. Very rarely does it become lodged in the passage (urethra) leading from the bladder outside of the body. The location of the pain is one side serves to separate renal colic from intestinal colic; while the extension of the pain into the thigh and testicle, with drawing up and tenderness of the testicle, distinguishes it from all the other colics. In gallstone colic the pain is in the right side, and the pain extends up rather than down, as in renal colic. The presence of blood in the urine, with intense pain in the side shooting down into the thigh, makes the existence of stone in the kidney or ureter practically

certain.

Treatment.-Relief from pain may be secured by following the treatment recommended for colic generally (p. 519). There may never be a recurrence of an attack of renal colic, or attacks may be frequent. This follows because after one stone escapes, more may remain in the kidney or ureter. A stone in the kidney may cause no trouble at all during the course of many years, or during the patient's life, or may give rise to inflammation with more or less frequent attacks of pain and escape of blood and pus in the urine. If the attacks of pain are severe and frequent, or if the