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1. Leaves cancer tissue behind, and the disease returns.

2. So injures the bladder wall that a vesico-vaginal fistula may form, which if recognized and repaired at the time, is apt to fail to unite, because the fistula is situated in a portion of the bladder wall whose outer coats have been torn and whose blood supply has been injured by the operation.

3. If he does not produce a fistula the injured portion of the bladder may be unable to resist infection and a severe cystitis may result.

III. On account of the above, if the cervix is adherent to the bladder the portion of the bladder wall adherent should be excised, in order:

1. That a wider excision of the primary growth may be. obtained.

2. That the injured bladder wall may be repaired, for one may then unite healthy bladder tissue together and so feel assured of a successful repair of the injury.

3. That the bladder may be better able to resist infection, for the portion of the bladder weakened by the operation has been removed.

IV. Post-operative vesico-vaginal fistula may occur:

1. From undiscovered accidental injuries to the bladder or the failure of the repair of injuries recognized at the time of the operation.

2. From the intentional formation of such fistula at the time of the operation in order to relieve intra-vesical tension and give the bladder a rest, and also the formation of fistulæ after the operation in order to minimize the dangers of postoperative cystitis.

V. Frequently post-operative vesico-vaginal fistulæ close spontaneously. This may take place in a short time, as a few days or weeks, or may require as long a time as six months or a year; on the other hand, some will never close.

VI. Apparently the early operative closure of such fistulæ, unless in healthy bladder tissue, is difficult, and operative measures should not be undertaken until the tissue has had a

chance to regain its natural blood supply. One should probably wait at least two months before undertaking such steps.

VII. The radical operations for cancer of the uterus diminish the sensibility of the vagina and bladder to pain, so that post-operative vesico-vaginal fistulæ may be closed without the use of a general or local anesthetic.

VIII. The following principles should be employed in the closure of these and all vesico-vaginal fistulæ.

1. Approximation without tension.

2. A broad area of denudation exposing healthy bladder tissue.

3. Accurate approximation with inversion of the bladder


4. Tying the ligatures so as not to strangulate the tissue.

IX. Very fine silver wire fastened by means of perforated shot form a very satisfactory suture material, and if a small piece of rubber tubing is placed between the shot and the vaginal mucosa a most efficient "splinting" suture is formed, which, through the elasticity of the rubber tubing, maintains accurate approximation without strangulation.

The Heart and Circulation in Pregnancy and the Puerperium.

A. Stengel and W. B. Stanton (Univ. of Pa. Med. Bul., vol. 17, no. 7), from a series of investigations state that there is not, during pregnancy, any hypertrophy of the left ventricle, nor any special increase in its work. The increase of dulness toward the left is due to the upward displacement of the diaphragm and the consequent displacement of the heart in an upward and outward direction.

The comparative outlines before and after labor show a rapid return to the normal position.

They were struck by the frequency of an increase in the extension of dulness toward the left in the second and third interspaces and by the frequency of distinct pulsation in the same area. In the absence of any evidence of retraction of the lung, and in view of the fact that the pulsation discovered

in this region was distinctly marked, it is evident that this condition of things is ascribable to distention of the conus arteriosus and root of the pulmonary artery. The frequent presence of a systolic murmur most clearly audible in the same area further substantiates this opinion. Moreover, the position of the right border of the heart seemed on the average somewhat too far toward the right, which, with the conditions present at the root of the pulmonary artery, convinced them that there is probably during the latter months of pregnancy some continuous dilation of the right ventricle, though this is apparently of very moderate degree. Such a state of affairs can scarcely be regarded as surprising when we reflect that the upward displacement of the diaphragm and pressure upon the lungs must necessarily increase the difficulties of the pulmonary circulation. Their belief in the existence of a dilation of the right ventricle is, however, based upon observed facts rather than upon theoretical deductions.

The condition of the abdominal recti is important from the point of view of the circulation. In multiparæ separation of the recti materially lessens the tendency to displacement of the diaphragm, and diminishes in a corresponding degree the displacement of the heart during pregnancy. After delivery this diastasis of the recti, however, may occasion a downward displacement of the apex of the heart, and the contrast before and after labor may be quite as pronounced as in primipara, though the first position occupied may not have been far from the normal. Later, if the separation of the muscles is not considerable, and the normal tone of the abdominal walls is regained, a restitution to the normal of the heart and its apex occurs.

The investigations of the blood pressure made by them show conclusively that there is no material increase of this pressure before or after labor. During labor they sometimes found notable increase in the blood pressure, such as has also been observed by others.

Memphis Medical Monthly

Memphis Medical Monthly, established as the Mississippi Valley Medical Monthly, 1880 Memphis Lancet, established 1898.


Subscription Per Annum, One Dollar in Advance.

Official Organ of the Tri-State Medical Association of Mississippi, Arkansas and Tennessee, Memphis Medical Society, and Yazoo Delta Medical Association. RICHMOND MCKINNEY, M.D., EDITOR




Ir is always a pleasure to us to chronicle the date of the meeting of the Tri-State Medical Association, for we know that this is an occasion to which the practitioners of this section look forward with a growing interest every year. This association is the child of the physicians of the territory contiguous to Memphis, and the keen interest manifested in its meetings by the large number of physicians who attend is evidenced in the full program and large attendance at every meeting. At these meetings papers of practical value to the practitioners of this section are presented, and the discussions are such as to bring out every point of interest and worth to those who participate as speakers and auditors.

The meeting this year will be held at the Hotel Gayoso, Memphis, on November 15th, 16th and 17th, and already a large list of titles for the preliminary program is in the hands of the secretary. Every physician who has a paper in mind," or who has unique cases in practice which he desires to report is urged to forward his title to the secretary at once in order to receive a place upon the preliminary program. The indications are that the meeting this year will be the largest ever held by the association, and no physician in the Memphis territory who is eligible to membership should fail to attend this meeting. Every one who comes will return feeling that he has been fully repaid for any time that he has given for this purpose, for no one who attends a meeting of this association does not go away expressing his intention not to miss

any meeting in the future. All railroads entering Memphis will make the customary reduced rate of one and one-third fare, on the certificate plan, for the round trip.


WHEN a practitioner of medicine reaches that state of erudition where he does not feel the need of medical literature as purveyed for him by the numerous excellent medical periodicals in this country, he should be caged, labeled as a curiosity and put away in camphor balls where the moths can't reach him and whence he cannot escape to inflict his learned presence upon the community wherein he is wont to practice. That such an individual exists we are led to believe from a communication recently received by the MONTHLY, and we take it as a compliment that the writer did not single out our journal as the one he did not want, for he did not want "any other medical journal." Our contemporaries will thus feel the stigma likewise placed upon them, and can join with us in wondering why a practitioner of medicine in active practice should fail to find a need for a medical journal. Does he believe that by reading text-books he can keep up with medical progress? Does he not realize that text-books are from six months to a year late in publishing the results of scientific investigations? Should not common sense teach him that everything new in medicine first is heralded through the pages of medical journal literature? If he will pass in review all of the best discoveries in medicine and the entire sum of surgical achievements he will find that these were given to the profession through the medical journals months in advance of their incorporation in text-books. It stands to reason that no practitioner who desires to keep en rapport with this rapidly developing science of medicine (and every practitioner owes it to his patrons. to endeavor to keep in touch with every advance that may be of benefit to them) can do so without being supplied with current medical literature as furnished by the weekly and monthly periodicals. No practitioner is fair to himself or just to his patrons unless he subscribes to and reads one or

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