pipes. An attack may be mild or exceedingly severe. It is usually attended by obstinate constipation and by contraction of the abdo

men.

The severe paroxysmal pain attending the passage of a gallstone from the gall bladdder to the intestine is called biliary colic. In biliary colic the pain is usually most marked in the region above the navel or about the stomach (epigastric region). The paroxysms begin and end suddenly. Severe nausea and vomiting occur. The skin and eyes may become yellow or of a yellowish hue (jaundiced). Gallstones may occasionally be found in the stools, if carefully looked for. Some cases, however, are difficult to distinguish from ordinary intestinal colic.

The severe excruciating pain caused by the passage of a small rough stone or calculus or particles of sandy substance from the kidney through the ureter to the urinary bladdder is called nephritic colic, kidney colic, or an attack of "the gravel." The pain usually begins with a one-sided, boring backache. Suddenly it increases in intensity and shoots down the loin to the hip and thigh, and the patient writhes in agony until the "stone" or particle, sometimes not larger than the head of a medium-sized pin, reaches the bladder, when the pain suddenly ceases. The paroxysm may last from half an hour to a number of hours, or one or two days. It may not recur for months or years; on the other hand, there may be two or more paroxysms at comparatively short intervals.

Colicky pains are present in many different diseases. Appendicitis frequently begins with pain not unlike that of intestinal colic. (See p. 169.)

Treatment. If the colic is due to indigestible food, or too much food of any kind, an emetic should be given, such as mustard and water.

After the stomach is emptied give a teaspoonful of aromatic spirits of ammonia in water. Apply a large mustard plaster or a hot poul tice or cloths wrung out of hot water, or heat of any kind to the abdomen. (Local applications of hot water usually afford some relief in any variety of colic or wherever pain exists.) If the colicky pains persist, 10 or 12 drops of laudanum or one-quarter grain of morphine sulphate should be given by the mouth, and repeated, if necessary, in two hours; or 30 or 40 drops of laudanum in a little. water or starch may be injected into the rectum.

If the bowels were constipated when the attack began, an injection of soap and warm water should be given by the rectum, or small doses of Epsom salt or castor oil may be given by the mouth. The diet for a day or two should be light food in small quantities at a time. The treatment for lead colic is about the same, except that the constipation should be relieved at once by full doses of Epsom

salt or castor oil. Apply heat to the abdomen or place the patient in a warm bath. Pressure applied to the abdomen affords some relief. Remove the cause or remove the patient from the cause of the disease.

In biliary colic the bowels should be freely moved, patient should be placed in a hot bath, and laudanum. 30 drops, given to relieve pain.

In nephritic or kidney colic hot baths and laudanum, 30 drops, are the remedies. For the treatment of infantile colic see p. 193.

In no case should paregoric, laudanum or other opiates be given in baby colic.

APPENDICITIS.

Appendicitis is an inflammation involving the appendix vermiformis. This is a small attachment of the large intestine situated in the right lower portion of the abdomen. It may begin suddenly with violent pains in this region, some fever, colicky pains, nausea, and vomiting. The seat of the pain is usually on a line drawn between the bony prominence (the large bone of the pelvis) just above and on the outer side of the right groin and the navel. As the attack progresses, that region of the abdomen may become hard like a board and exceedingly sensitive to the touch. Often you will find that the patient bends the right leg on the abdomen, and the effort to straighten it out causes him great pain. Sometimes the attack is much milder, with only an uneasy sensation in the affected region, very slight fever, if any, and a sense of tenderness over the part affected. This pain may be in the pit of the stomach or about the navel.

After this pain has been present for a few days a swelling may appear, due to the formation of pus or to a large protective exudation of lymph.

Treatment. The right course to pursue in a case of appendicitis is to immediately call a surgeon. If the services of a surgeon or physician can not be secured, the plan of treatment should be as follows: Absolute rest in bed with an ice bag over the appendix, to be continued during the stage of severe pain. Do not give purgatives. Only a small quantity of liquid diet should be given. If the pain is severc, 20 drops of laudanum or a quarter grain of morphia sulphate in a little water may be given to control it. If the bowels move, a bedpan should be used, and under no circumstances should the patient be allowed to get up.

PILES.

Piles are varicose dilatations of the veins of the rectum. The symptoms may be slight or severe. Inflamed piles are very painful. There is a constant burning sensation at the anus, which is greatly increased during and immediately after each movement of the bowels.

When the veins rupture you have "bleeding piles." Occasionally the inflammation of a nodule results in an abscess.

Treatment.-Piles are frequently due to habitual constipation, and when that condition is remedied the piles often disappear, or at least cease to be troublesome. The bowels should be kept in good condition. One easy movement should take place regularly every day. This desirable habit should be brought about by careful attention to diet and by drinking water in the morning before breakfast rather than by the use of cathartics.

In acute attacks, if the bowels are constipated, give a full dose of Epsom salt; put the patient on light, soft diet. Apply ice to the anus or inject cold water into the rectum. An ointment composed of 5 grains of menthol mixed with 2 tablespoonfuls of vaseline often affords great relief. If the piles protrude, especially if they become strangulated, they should be pushed back with the finger; olive oil or vaseline may be applied. If the piles are large and persistently painful, see a surgeon and have them removed by operation, which is the only sure cure.

KIDNEY DISEASE (NEPHRITIS).

Acute nephritis.-This condition follows exposure to cold and dampness, extensive burns, alcoholic intemperance, poisoning from turpentine, potassium chlorate, carbolic acid, cantharides, mercury, and lead. It may also be a sequel of scarlet fever, diphtheria, typhoid fever, smallpox, pneumonia, and a complication of tuberculosis. It occurs in pregnancy, being probably due to renal congestion caused by the mechanical pressure of the womb, or to the altered blood condition.

Symptoms.-The quantity of urine is diminished from 40 to 50 ounces a day to from 5 to 20 ounces a day. The color is a dark red or brown and it will be found to contain albumen if a teaspoonful is boiled with a few drops of vinegar. The presence of albumen is shown by the formation of a cloud in the urine and a deposit will settle upon the bottom upon cooling. Normal urine does not contain albumen. Other symptoms present may be headache, nausea, vomiting, shortness of breath, diarrhea, dropsy, convulsions, or unconsciousness.

Chronic nephritis.-Chronic nephritis may follow an acute attack. It more often, however, comes on slowly without acute manifestation. Drinkers of beer and other alcoholic liquors and those who eat large quantities of meat seem to be liable to the disease. Syphilis and malaria also cause nephritis. It is one of the results of old age, nearly all old persons having at least some symptoms of the disease. Symptoms. The symptoms of chronic nephritis are similar to those of the acute disease, but they may manifest themselves in a mild

form, so mild that a diagnosis can not be made until the urine is examined. In one form of the disease the urine is of a pale yellowish color and may be greatly increased in quantity, sometimes from 2 to 4 quarts being passed in a day. There may be only a trace of albumen or it may be absent altogether at times.

Treatment. The treatment of the acute form and the chronic form when acute symptoms intervene is profuse sweating and free catharsis. The sweating may be produced by wrapping the patient in a sheet wrung out of hot water and then rolling him up in blankets. Children may be given a hot bath and then wrapped up in blankets. Sometimes a frame to which a number of electric lights are attached is placed over the patient when lying in bed and the whole covered with blankets. When the lights are turned on the heat of the lamps causes the patient to sweat. The patient should be watched and at any evidence of exhaustion the sweating should be discontinued. Catharsis is best produced by salts, either Epsom or Rochelle. The patient should be placed upon a milk diet and be given plenty of water to drink.

Persons suffering from the chronic form of the disease should be careful not to expose themselves to cold and wet, should eat sparingly of red meats, and avoid alcoholic drinks. If dropsy is present a saltfree diet is indicated. If possible, the patient should live in a warm, dry climate.

DELIRIUM TREMENS.

Delirium tremens occurs as an incident in the life of persons addicted to the excessive use of intoxicating liquors.

Loss of appetite, sleeplessness, or a marked mental depression are the chief symptoms of the first stage of the affection which is known among drunkards as "the horrors."

As the disease advances the patient talks incoherently; has a wild expression; his mind wanders from one thing to another. He answers questions in a rambling manner. He fancies he is being pursued by wild animals or that he sees rats, snakes, and other animals crawling on the walls or around his bed, or he may imagine himself to be engaged in his regular duties or as master of a ship, giving directions to the men.

The delirium is always worse at night, but the patient requires careful watching all the time. He may try to jump out of a window or commit suicide.

Delirium tremens may be confounded with acute inflammation of the brain or with acute mania (insanity) or with certain forms of pneumonia, and any one of these diseases may also be present. Pneumonia is a frequent complication of delirium tremens, and in fatal cases may be the direct cause of death.

In favorable cases the symptoms begin to improve in three or four days from the onset. The patient sleeps and gradually recovers.

Treatment. The patient requires constant attendance. Physical restraint should be avoided if possible. To support the patient and to procure sleep are the great objects of treatment. Careful feeding is very important. Milk or concentrated broths should be given at regular intervals of two hours. A cold bath is of value in some cases, especially if agreeable to the patient. In other cases a warm bath or a hot foot bath may have a better effect.

The serious symptoms are largely, if not entirely, due to the sleeplessness, and if several hours of sound sleep can be procured improvement is almost sure to follow. To this end bromide of potash, in 30-grain doses, may be given in water every three hours. Morphine or opium are not to be recommended in this disease, except under the immediate direction of a physician. All stimulants should be withheld, except in rare cases when the pulse is weak. The giving of whisky, gin, etc., in small doses to gradually "sober him up," is a bad practice, as it delays the patient's recovery. No amount of begging for stimulants on the part of the patient should persuade his attendants to break this rule.

SUNSTROKE.

The term "sunstroke" denotes a sudden attack of illness from exposure or prolonged exposure to the rays of the sun; but the same condition may be produced in hot weather by exposure to high temperature not in the direct rays of the sun, particularly if the person is engaged at hard work in close quarters. Stokers on steamships are sometimes affected by the heat of the furnace. Men debilitated from or addicted to the excessive use of stimulants are more apt to suffer than those of temperate habits.

Sunstroke occurs in two forms: Heat stroke (heat fever), in which the temperature of the body is very high, and heat prostration or heat exhaustion, in which the surface of the body is cool, sometimes considerably below normal. The difference is very important because of the different treatment required.

In severe cases of heat stroke the patient may be stricken down in a state of unconsciousness and die instantly or within an hour or two. In other cases there may be intense headache, dizziness, marked restlessness, nausea and vomiting, and hot "burning" skin. The thermometer may register 105° F. Pulse is full and may be slow or fast. Breathing is labored, may be sighing or rattling. Patient soon becomes unconscious, the stupor deepens, and death may occur within 24 hours; or the temperature may drop, consciousness may return, and the patient get well.