of this sign is compromised by the existence of similar figures in the case of excessive meat diet, fever, and various diseases that lead to acidosis.

The determination of the amino-acids furnishes an important diagnostic criterion. These acids are regularly increased (above 0.5 gram N.) in the cirrhoses. The significance of this sign is all the greater in view of the fact that Frey observed this abnormality only in one case of amyloid liver, and in one case of marked congestion of the liver, among a large nnumber of cases he had investigated. Among diseases of other organs, hyperacidaminuria was noted in pneumonia, typhoid fever, and pancreatic diabetes. The diseased liver is capable of disposing of ingested animo-acids as well as the healthy organ.

It is hoped that the development of these, as well as of other methods of diagnosis, will render possible the early recognition and differentiation of heptatic disease with a faccility equal to that of the urinary diagnosis of diseases of the kidney.

A NEW PHYSICAL SIGN.

Textbooks on physical diagnosis says the New York Medical Journal usually state that the upper limit of the absolute liver dullness begins posteriorly at midline and only anteriorly crosses the middle of the abdomen. Any dullness posterior to the left of the midspinal line is not accounted for, as a rule, by any increase or transposition of the liver limits. Yet Grocco, who has already pointed out a neglected physical sign, the so-called Grocco's paravertebral triangle, in cases of pleurisy with effusion, again takes issue with the textbook descriptions. Careful physical examinations of patients, combined with the observation of anatomical and pathological material, have shown to him that even the normal limits of absolute liver dullness pass beyond the midspinal line and extend for from 3 1-2 to 5 cm.

to the left. In cases of enlargement of the liver the posterior boundary is, of course, moved still further to the left, sometimes reaching as far as 12 cm. to the left of the midline. Grocco has examined over three hundred normal and abnormal persons in reference to this point and gives in the Wiener klinische Wochenschrift for May 11, 1911, detailed directions for demonstrating his new physical sign. Of course, the determination of the left boundary of the liver posteriorly should prove of interest in cases where enlargement of the left lobe is suspected. Whether such determination will prove of much clinical value. remains to be seen. Grocco himself thinks that in the future this new physical sign will be elicited as an important. part of the routine physical examination of the thorax and abdomen.

In

HOT AIR DOUCHES IN NEURITIS. Leopold Stieghtz, in the Medical Record, says the main principles of the actual cure of the disease can be summed up in two words: Rest and heat. the severer cases little or no headway will be made until the patient is put to bed and kept there till he is well on the way toward recovery, and then the return to active life should be gradual and cautious; a premature use of the affected limb is punished almost invariably by a setback. The beneficial effect of rest is indirect, inasmuch as it protects the inflamed nerve trunk from the innumerable small traumatisms active use of the limb would entail, traumatisms which aggravate the condition as indicated by the pain they create. Although rest is a sine qua non in the severe cases. rest alone will not cure this form of neuritis, owing, as stated above, to the very slight tendency toward spontaneous recovery of an inflamed nerve trunk. This failure to heal of its own accord is accounted for by the poor blood supply provided for the nutrition of the peripheral nerve trunks, and in general it may be said that the more poorly tissues

are fed the more slowly do they throw off inflammatory or other diseased conditions. This is the point at which the second curative factor mentioned, heat comes into play. For many years I had heat applied in the shape of hot salt or sand bags placed along the course of the affected nerve, and the results obtained were not bad. Nowadays wherever we have the electric current at hand it is well to wrap electrically heated pads (so called thermopads) about the affected arm or leg and to keep these pads in place for a good part of the twenty-four hours. Hot poultices and other hot applications can be used for the same purpose. Far more effective than any of these methods of applying heat is the use of superheated air. Under the influence of Dr. Willy Meyer's teachings of Bier's methods of treatment of inflammatory conditions, I began using superheated air in the treatment of neuritis two years ago, and the results obtained have been so satisfactory that I thought it worth while to call your attention to this most efficient method of treating this trying class of cases. neuritis the superheated air is applied best as a hot-air douche along the course of the affected nerve trunk. This method gives decidedly better results than the use of the hot-air boxes, so useful in joint cases. The application is made two or three times a day, or even oftener, according to the severity of the case. Each application should last from half to three-quarters of an hour. Briefly, it may be said that the douche should be applied as hot as the patient can bear it, care being taken, of course, not to burn the skin. After a few treatments, the tolerance increases greatly. The amount of heat can be controlled both by regulating the source of the heat and by holding the conducting tube more or less closely to, and moving it more or less rapidly or slowly, over the skin; the closer it is held and the longer the current of hot air strikes a given point of

In

the skin the greater is the sensation of heat. At first I used an apparatus built along the lines of the one described in Dr. Meyer's "Bier's Hyperemic Treatment." The source of heat was either a special Bunsen burner for gas, or, where gas was not obtainable, a special alcohol lamp, both supplied by Kny Scherer. At present I use an electric hot-air douche, which is exceedingly handy and simple, and which at the same time gives off a much higher degree of heat than any other apparatus I have tried. The construction of this electric hot-air douche (made originally to dry hair quickly) is simplicity itself. It consists of a small electric motor, which drives a small fan; the latter forces a current of air over a coarse wire coil heated by the electric current. Within less than five minutes the air as it leaves the conducting tube shows a temperature of 200° F., this is hotter than any patient will stand applied closely to the skin..

The

These hot-air applications accomplish two equally important objects: they alleviate the pains, which are the principal symptom of the disease, and at the same time they cure the disease itself. cure is effected most likely by the production of an active hyperemia, not only in the skin to which the heat is applied, but also in the underlying tissues, including the affected nerve trunks. After an application the skin is very much reddened, and at the end of a week the area is browned as from sunburn.

bohls cushion. An incision is made in the loin and the superior lumbar triangle is pulled open and the kidney exposed and freed on all sides from its fatty capsule. The stone is then felt and the kidney gently loosened as far as possible on all sides and brought toward the wound. Then an assistant forces fluid (1 to 1,200 silver nitrate) into the renal pelvis, until it puffs out tense.

As a rule, with a careful preliminary study, the exact capacity of the renal pelvis is already known. Then when the pelvis and kidney are swollen up tense, the surgeon first incises the capsule and then plunges a blunt pointed and blunt edged knife through the cortex on the posterior surface, easily entering the renal pelvis at once and enlarging the incision, in a transverse direction if the stones are small. There is a gush of fluid which stops as he introduces his finger and feels for and finds the stone, which he at once grasps with a small stone forceps and removes. The calices and the mouth of the ureter are now examined for more stones and the kidney is palpated on all sides with both hands, one finger being inside the renal pelvis. After all stones are removed, the wound is plugged or held closed, while the pelvis and the calices are again distended, with the silver solution, when the finger is suddenly withdrawn, letting the fluid escape with a rush, bringing any small calculous debris with it. This may be repeated several times. The points of advantage of the technique are: 1. It involves a minimal amount of damage to the kidney. 2. It is done through the part of the organ most easily accessible. 3. The distention is invaluable in offering a bag of fluid, overlaid with a zone soft tissue, which is easily punctured. 4. An exploration is easily conducted through the opening revealing the presence or absence of other calculi. 5. If it is desirable to keep it open a while for drainage the transverse incision is a good one for this purpose, as it can be

of

left open and will close rapidly when the irrigations are omitted. 6. In the last case in which operation was done, no sutures were put into the kidney, and yet there was no escape of urine after twenty-four hours and practically no bleeding through the incision.

RECTAL HEMORRHAGES.

a

Martin L. Bodkin, in the Medical Times, admonishes that bleeding from the rectum is often the only symptom which prompts the patient to consult physician. The diagnosis of hemorrhoids, as given by the patient, is accepted too generally as sufficient. Bleeding from the rectum is so commonly associated with hemorrhoids that one is apt to be careless and fail to make either an ocular or digital examination.

Why the average practitioner will permit his learning and judgment to be laid aside for the opinion of the layman in such instances is hard to understand. The gynæcologist never fails to be suspicious of malignancy during middle life, if irregular bleeding from the uterus is called to his attention. Blood may be found in the stool, when associated with severe catarrhal diseases of the colon or rectum, internal hemorrhoids, fissure in ano, polypi, ulcer of the rectum; with dysentery, prolapse, malignant and nonmalignant growths, and erosions of the mucous membrane, due to stricture or impact feces.

Besides these, constitutional diseases such as typhoid fever, yellow fever and malaria may be associated with loss of blood from the rectum. Some cases of anæmia, purpura, scorbutus, kidney and heart diseases, where changes in the blood occur, will also present this symp

tom.

The origin and diagnosis of blood from the stomach or small intestine will not be included in this consideration of rectal bleeding, as it is beyond the scope of this paper further than to say that co

agulated blood from the upper portion of the alimentary canal would be incorporated with the digestive residue, while blood from the lower portion is often evacuated independent of the fecal mass in the form of a slight or severe hemorrhage.

Internal hemorrhoids when eroded are probably the most frequent source of bleeding and are responsible for most of the mistakes in diagnosis. Fissure in ano and ulcer are the next frequent and are quite common, but permit me to emphasize the fact that their presence does not conclusively exclude the possibility of the co-existence of rectal cancer.

Adenomata of the sigmoid and rectum are more frequent than is suspected, and in the early stages give the ordinary symptoms of rectal bleeding, but later present a picture of sepsis (septecemia) simulating that of cancer long before a malignant degeneration has occurred. These growths, when extensive, irritate the intestinal canal so greatly that a constant discharge of blood, fecal matter and broken down tissue takes place. These non-malignant growths are too often allowed to progress to malignancy.

Cancer is found more frequently in the rectum than in any other portion of the small or large intestine, and when we consider the advantages of early operation, it seems that more care should be exercised to recognize this one malady before involvement of the surrounding tissue and organs has taken place. Early operation is most promising in either an attempt at radical cure or the prolongation of the patient's life.

The symptoms of this disease are at first vague. The patient complains of fullness in the pelvis or bowel, due to pressure, according to the location of the growth. The pain in the early stages from carcinoma is very little excepting at the margin of the anus. When the growth is situated higher up the fullness of the rectum is complained of more than any other symptom and there is a constant

desire to dislodge the mass. Stricture, hemorrhoids, fissures, or pruritis ani may. be present at the same time. Blood as the result of the ulceration and inflammation is quite early in its manifestation.

TREATMENT OF FURUNCLES. A writer in the International Journal of Surgery states that for many years he has been quite successful in the management of small furuncles with what might be termed the collodion treatment. This consists in covering the boil with thin layers of absorbent cotton, held in place with collodion (not flexible) and extending some distance beyond the inflamed area. The main objects of this procedure were to protect the furuncle from irritation by the clothing and to prevent the dissemination of bacteria into the deeper parts by friction. Under this method it was found that the infiltration would often be absorbed without the furuncle coming to a head, or that the pus formation would be small and localized.

Recently Dr. Fuchs in Muench. med. Wochenschrift has reported upon a method of treating furuncles, the aim of which is to limit the inflammation by encircling the inflamed area with a layer of collodion, without encroaching, however, upon the central zone. This application is renewed in the course of the day and extended somewhat beyond the margins of the inflammation. It is stated that the constant but gentle pressure causes the boil to point in one to three days and rapidly localizes the infective

process.

Either of these methods is so simple and easily applied that they are well worthy of a trial in cases of ordinary furuncle.

GYNECOLOGICAL HINTS.

Ralph Waldo, in the International Journal of Surgery, gives the following: The best time to draw the urine before an operation is after the woman

has been placed under the anesthetic. The bladder is more apt to be thoroughly emptied and there is less liability of infection.

Before suggesting any form of treatment, especially operative, a thorough general examination should be made, for the gynecologist's advice will be much influenced by the condition of the heart, lungs, and kidneys.

The introuterine use of instruments, as sounds, curettes, dilators, etc., is a surgical procedure and should seldom, if ever, be indulged in outside of the operating room, and under no circumstances without thorough antisepsis. Formerly the uterine sound was a fertile source of infection of the uterine cavity, the Fallopian tubes and occasionally the peritoneum, not to mention the large number of abortions that were accidentally produced.

A fractured coccyx may produce many symptoms that may lead one to think that a woman is suffering from uterine disease. I had a case in which a fractured coccyx was overlooked by three competent gynecologists. It can be easily detected by placing the index finger of one hand in the vagina against the coccyx and the other index finger over the coccyx externally. In this manner a false point of motion can be easily determined, and if pressure at this point produces pain, the condition requires treatment. Usually removal of the fractured end of the bone and callus is the only measure that will afford relief.

The only way to obtain primary union. after removal of the coccyx is to have the patient lie on her face during defecation or urination; otherwise the dressing is bound to become soiled and the wound infected. After the first movement of the bowels the patient will find no difficulty. It is well to give a cathartic, instructing the nurse what to do, and let her have it out with the patient.

DANGERS OF "606."

Schamberg, in the Journal A. M. A., discusses the causes of inflammation of cranial nerves after the use of salvarsan. The only disturbing results, Schamberg says, that have been reported after the use of salvarsan are occasional inflammations of cranial nerves, particularly of the optic and auditory nerves. Relative to the number of cases treated, however, such complications have been very small, though it is quite possible, as he states, that more of these may have occurred than have actually been recorded. Ehrlich denies any etiological relationship between the use of the drug and the development of the neuritis, regarding all such cases as fresh syphilitic neuritis; but others, Finger, for example, believed that though these complications are syphilitic, yet that they are related in some way or other to the administration of the salvarsan, perhaps because the drug seems to have a traumatic effect on the nerves. Schamberg believes that these inflammations have occurred exclusively after intramuscular and subcutaneous injections and not after the intravenous administration. Some cases have, however, occurred even after the intravenous route, though definite figures of the proportion of these are not yet to hand. The only way that accurate information will be able to be obtained on this very important subject is for all physicians immediately to report any cases or series of cases that have shown such inflammations, especially so in all such that have never had syphilis, but in whom the drug has been tried as a curative agent-for some other disease (malaria, trypanosomiasis, leukemia, etc.). Negative observations in this latter group should help very considerably in proving or disproving the truth of Ehrlich's contention.

Schamberg, after his careful and critical paper on the subject-which should be consulted in the original by those interested in the matter-concludes: