significance of colic and to its danger symptoms as a guide to its control and the saving of human life.

Colic may signify—

(1) Indigestion, either as a result of simple acid fermentation or of ptomaine poisoning. Under this head it may be but a minor disorder of digestion, with no ill results or after-effects, or it may be rapidly fatal-resistant to all forms of treatment.

(2) Constitutional-As in lead poisoning, locomotor ataxia and hysteria.

(3) Local-As for disease of the appendix and gallbladder, kidneys, bladder, uterus, fallopian tubes, intestines and intestinal obstructions, hernial or otherwise, these conditions may exist singly or combined.

Attacks of colic which fail of prompt relief under opium, or which relieved and then relapse, always indicate danger.

When with colic you have a pulse low in tension, small in volume and rapid, you have a symptom of the utmost gravity. It is the pulse of perforation with peritonitis, and calls for immediate action if the patient's life is to be saved. Colic with temperature is always to be regarded as an important symptom, and should never be neglected. Always in colic note the temperature and pulse.

Always in colic, when the origin is not clear, make your examination carefully and thoroughly so that you may differentiate intelligently.

The area over the appendix is the location naturally to first attract your attention, then follows the area over the gall-bladder and region of right kidney; where the right mammary line prolonged intersects the free margin of the ribs is the usual location of the gall-bladder. Remember that in affections of the gall-badder the colic

tends to radiate over the epigastrium, while in appendicitis it tends to radiate around the umbilicus.

From the region of the gall-bladder next pass to that about the left kidney, and from here to left iliac region, when you can palpate the sigmoid flexure of the colon. After examining these various areas, next go carefully over the hernial openings. If the patient is a woman make your examination of the femoral opening most carefully, as here a small hernia often escapes attention, and as a rule they are never large.

If the patient is a woman, always remember to examine the uterus and fallopian tubes before completing your examination.

Colic may be the result of several abdominal conditions combined, and in these cases even the most expert may be at fault as to the primal cause. However, the more careful and thorough you are in your examination, the less the liability to error.

When to colic is added persistent constipation, nausea and vomiting, with or without distention of the abdomen, the cause is probably intestinal obstruction, especially so if the patient is a child.

It is not my desire to write a long article or to dwell on a fine, drawn-out diagnosis, but rather to impress upon you the true importance of colic as a symptom of possible danger, and having done this to dwell upon the importance of carefully examining each case coming under your observation that you may first exclude serious abdominal disease before you accept the symptom as of no importance. The advanced surgery of to-day, excluding malignant disease and constitutional conditions, can and does sucessfully cope with abdominal diseases in which colic is a symptom; provided, only, that the

condition be recognized before peritonitis has advanced to such a state as to make recovery impossible. We can all doubtlessly recall some case in which the symptom of colic neglected ended in death.

Thus warned, and with a full knowledge of what colic carefully considered reveals, we should never have to reproach ourselves for the patient's death the result of this symptom neglected.

11 mt

A REPORT ON ONE HUNDRED AND TWENTY

KNEE-JOINT OPERATIONS.

BY MICHAEL HOKE, M.D., AND C. R. ANDREWS, M.D., ATLANTA.

You will be pleased to know that I have no intention of wearying you with a prolonged, detailed report of the knee-joint operations mentioned in the title of this paper. It is not often that the general practitioner has the opportunity to see the inside of the joints when affected with the various conditions which have necessitated the operations. As the general practitioner is usually the first one to come in contact with these cases, it seems to me that if I select certain ones from the number, describe the conditions found in the joints and state the results obtained, it may be of value to you. Ninety-seven of these cases were the results of toxic arthritis. I wish to take a few of these and show in connection with the clinical history the various degrees of inflammation of the joints in this process, from the slightly inflamed to those in which the process had made further advancement, in which extensive changes had taken place in the joint tissues with consequential deformity.

Case 1.-Miss H. This young lady had had indigestion for a number of years before she was seen by me. When I first saw her both knees were swollen, the left slightly, the right considerably so. There was fluid in the right joint. A diffuse thickening of the joint capsule was palpable, and in the upper, inner quadrant a small

mass could be felt. She had been "rheumatic" for some time. The fingers were inflamed, and she also had pains in the other joints. The right knee was slightly bent. Palliative measures helped her somewhat, but the right knee remained enlarged. Her family took her to Hot Springs. She returned with the knee still swollen. She was then content to have the operation.

The joint was opened and a small amount of fluid evacuated. The synovial surfaces were injected, showing minute ecchymosis, and the small villi were enlarged so that the synovial surfaces showed minute elevations. The margins of the cartilage of the head of the femur were injected. Some of the blood vessels here were as large as a pin. The surfaces of the hyaline cartilage, instead of being white and glistening, presented a very fine tracing of capillaries. The mass in the upper, inner quadrant was a localized thickening of the joint capsule in that area. This tissue was removed and the joint washed out and closed. The subsequent history of this case was tedious, the main factor being the gastro-intestinal disturbance manifested by nausea, vomiting, now and then much gaseous distention, and obstinate constipation. The knee-joint itself continued to be painful for a number of months, though the swelling entirely disappeared subsequent to the operation. It was necessary for this patient to wear a brace for a number of months in order to maintain the anatomical position of the leg.

This was one of the toxic joints in the earliest stages of inflammation. A microscopic section of the tissues excised showed an inflammation which was characterized mainly by infiltration around the blood vessels. This was one of the first joints operated upon. At that time the writer felt that the cause of the inflammation was some poison circulated in the blood. This patient has