when in normal position, on the left of the median line. Consequently in effusion into the right pleura, the, artery becomes easily displaced toward the left, bringing with it the whole. mediastinum; where the left pleura is affected, the aorta can only be pushed a little toward the right, while the other organs sliding over it fall to the right side of the thorax.

The new clinical sign described by Grocco is valuable for diagnosing slight effusion into the pleura. It permits particularly to distinguish spleno-pneumonia from pleurisy, which reveals itself by identic physical symptoms, and cannot be suspected until after several small operations with the exploring needle have remained without result; the absence of the triangle of Grocco will put down to spleno-pneumonia the symptoms attributed at first to the existence of a pleural effusion.

Rectal Constipation in Women.

Grace P. Murry (Med. Record, vol. 66, no. 6) says:

1. It is generally recognized that women for various reasons are most subject to constipation, nevertheless rectal constipation, from which a large number suffer, has received, at the hands of the profession, scant consideration.

2. Rectal constipation may be, but is rarely, due to a nervous condition, i.e. nervous rectum. While it may occur as the result of inflammatory conditions, such as hemorrhoids, fistulæ and fissures, which are common to men and women alike, in very many cases it is occasioned because of the peculiar anatomical construction of the parts, and is mechanical in its origin. Anteversions, retrodisplacements, neoplasms, especially fibroids, and periuterine inflammations obstruct the downward passage of the feces. Conversely, owing to the close juxtaposition of the rectum and the genital organs of the woman, a loaded rectum in its turn may occasion ovarian and uterine displacements and disorders..

3. A form of rectal constipation which heretofore has received but little recognition is that which occasions and is the result of the pulling down of the rectovaginal septum, thereby forming a pouch, constantly increasing in size, changing the direction of the intraabdominal rectal pressure to that of the vagi

nal, which is at right angles to it, and making it difficult for the rectal sphincters to relax so as to void the contents of the bowel. The result is not only to render defecation difficult but incomplete. The retention of fecal matter causes rectal irritation and autointoxication. This condition..occurs not only.in women who have borne children, but in nullipara and the unmarried, although not so frequently in the latter.

4. In regard to treatment: Cathartics may be useful in those cases in which the obstruction is due to inflamed and displaced organs or neoplasms, which prevent the descent of the contents of the bowel and in which the hardened masses of the feces press and inflame the genital organs, but would be useless in those cases in which there has been a displacement of the rectovaginal wall. In such cases, glycerin or gluten suppositories, or injections of small amounts of olive oil, glycerin, or soothing fluids, may be employed. The use of daily enemata, as ordinarily practiced, is to be reprehended from every point of view. The use of bougies or dilators may prove beneficial. For constipation of purely rectal origin, massage, electricity, and measures designed to improve peristaltic action are of no avail.

Interhepatic Cholelithiasis.

SURGERY.

E. Beer (Med. News, vol. 85, no. 6) concludes an interesting and thorough investigation of gall stones with this summing up:

The most radical method of dealing with gall stones, and the one which aims at getting rid of all these dangers, is that advocated by Kehr. If the gall bladder is removed, no stones can form there again. If to ectomy is added choledochotomy and drainage, stones in the ducts which have or have not eaused symptoms will be removed by the operation or by the subsequent drainage of the choledochus and hepaticus. This combination of operative procedures has proven very successful, as far as immediate results are concerned. In 17 per cent. of his 93 cases during the after treatment stones and fragments have been removed by lavage and drainage of the ducts.

A suture of the choledochus at the operation would have run the risk of recurrence in many of these cases.

As yet no method seems to approach this in its ability to deal with the secondary intrahepatic formations, as well as the stones that may have wandered into the intrahepatic ducts from the gall-bladder, and even though it may fail to remove all of these, as was shown by autopsy in one of Kehr's patients, who died some eight days after the operation, still it surely does much more for the prevention of "Recidivs" from this source than any other method. In cases of cholangitis the drainage of the hepaticus must be carried out if these new fragments and stones are to be removed.

A large number of cases of stone in the common duct that have had signs of obstruction have also had cholangitis, and although at the time of operation no sign of cholangitis is present, the intrahepatic stones must be considered and dealt with. From an examination of the bile obtained at operation, unless done under the microscope and by biological methods, one can not be sure that cholangitis is not present. Moreover, as Riedel has recently shown, a most extensive suppurative cholangitis may be present and give no symptoms. He saw three such cases, and one of my own resembles Riedel's series.

Opinions of surgeons are still at variance as to the advisability of drainage of the hepaticus. Some oppose it except in the severest cholangitic cases, while Kehr considers it the ideal operation in non-acute cases, even if cholangitis is not present. From the cases brought together in this paper, from the study of the causation of intrahepatic stones and their possible relation to recurrences, as well as to future changes in the liver, it would seem that drainage of the hepaticus was the only method of operation for even mild cholangitic cases as well as for cases that have had symptoms of choledochus obstruction and cholangitis at some previous time, though the immediate cause of the present operation may be in the gallbladder itself.

Another practical conclusion can be drawn from this study. Courvoiser said that a choledochus obstruction should be relieved at an early date to avoid the formation of intrahepatic stones. Here we are between two fires. As is well known,

early choledochotomies are liable to lead the operator into trouble. The duct may be empty, the stones having passed, or the duct may be filled with countless stones. When a stone and cholangitis are certain an operation before the second month naturally would avoid the danger of intrahepatic stones forming and future trouble. This problem, purely therapeutic in character, scarcely enters the scope of this study, though the decision as to when to operate is of great interest and importance. It must, however, be emphasized that the earlier the operation the less danger there is of intrahepatic cholelithiasis.

Prostatic Enlargement and Prostatectomy.

A. Schachner (Ky. Med. Jour., vol. 2, no. 3) says of prostatectomy:

The opinion of the majority of operators is, that a total removal is neither necessary nor desirable. Before removal from the operating table, it is the practice of some surgeons to inject about a liter or more of saline into the mammary region. The bladder should be thoroughly irrigated with a large full stream of hot saline and a good-sized drainage tube inserted, packing the cavity and surrounding space with iodoform gauze. A few temporary silk worm sutures will render excellent service in preventing the displacement of the packing and overcoming any tendency to oozing. The drainage tube is allowed to remain from three days to a week. The bladder being irrigated twice daily with a warm Thiersch solution. This antiseptic irrigation is supplemented by the use of urotropin three or four times a day.

In view of the age of these patients and the great importance of perfect drainage, it is desirable to get them into a sitting posture or out of bed, the earliest possible time; usually they can be placed in a semi-recumbent posture in bed at the end of twenty-four hours and at the end of forty-eight hours can, as a rule, be lifted out of bed, into a proper chair and left in a sitting posture.

So far the tendency to the occurrence of stricture has not manifested itself in those cases where partial removal was practiced.

Vol. 24-35

The keynote of success in prostatic surgery is to avoid, if possible, making prostatectomy the operation of last resort, of waiting until serious kidney lesions have developed and until the patient's vitality is at its lowest ebb. In addition to this, when we do operate, we should do a rapid operation, we should establish perfect drainage and practice the removal of the patient from the bed, changing him from recumbent to a sitting posture as early as possible. The observance of these rules has changed the mortality of prostatectomy from that of a high one to a mortality of practically nil, notwithstanding the undesirable conditions which these patients usually present.

Castration for Tuberculosis of the Testicle.

C. G. Greene (Amer. Jour. Med. Sc., vol. 127, no. 6) says that radical treatment should not be allowed to become obsolete, that castration has an exceedingly low mortality, considered as an operation, and that if performed at an early period of the disease there is a good chance of preventing further infection from the bacillus of tuberculosis from taking place. Castration certainly complies with one of the most urgent demands of modern therapeutics, namely, the eradication of the soil breeding the disease, when, of course, the affection has not been present for too long a period and has not extended to other parts of the body. Conservative surgery applied to the testicle is practically useless when the organ is affected by tuberculosis, and it allows the dangerous consequences to arise which the radical treatment directly

tends to avoid.

Does Gonorrhea Cause Prostatic Hypertrophy ?

E. L. Keyes, jr., (Jour. A. M. A., vol. 43, no. 3) endeavors to reduce theory in this connection to a basis of scientific fact, and presents the results of exhaustive study and analysis in these conclusions:

1. Among 433 cases suffering from prostatic hypertrophy, only 18 show clinical evidence of previous prostatitis.

2. These 18 present no marked difference in point of size of the prostate, or of beginning of the disease to differentiate them from the remaining 415.