he who acts upon any other rule is as foolish as the old mother who, when asked by her daughter if she might go in swimming, replied "Yes, my darling daughter; Hang your clothes on a hickory limb, But don't go near the water." Derision and mockery may come and will come, but if the surgical conscience is in harmony, a howling mob like that which surged beneath the window of the great McDowell as he was making his section of the abdomen, will fall as harmless as a summer breeze. Derision and mockery may come and will come, but what were sneers to Marion Sims, engaged in the greatest problem of the age-the means and methods. of rescuing fair womanhood from that epic of misery, an uncured vesico-vaginal fistula. In conclusion, gentlemen, I would be pleased to give you the histories of two interesting cases recently occurring in my practice. Case I. M., female, aged 31, consulted me about eighteen months ago. Found a very large fibroid. She deferred operation until bed-ridden on Feb. 28, this year. By this time the tumor had very much enlarged and the cervix protruded at least an inch and a half outside of the vulva. Dr. B. N. Ward and myself made an abdominal section on the above date. Adhesions were found from start to finish, requiring an incision from umbilicus to symphysis pubis; in fact everything in the locality of the uterus was adhered, including omentum, ureters, intestines and bladder, together with the entire pelvic region. The tumor weighed five pounds. Shock was severe. Patient lived five days, having never rallied from the shock entirely. Case II. A., female, aged 28; was operated on March 22. Abdominal section by Drs. B. N. Ward, G. E. Penn and myself. We found a four-pound fibroid, but it was not adhered to anything but the bladder. An abdominal hysterectomy was done in this case. The patient, so far as the operation was concerned, had an uninterrupted recovery, but on the fifth day we found it very difficult to move the bowels. Some very solid substance obstructed the entrance of the nozzle of the syringe. Upon closer examination I found a hard fecal mass, and when we did succeed in removing it at all, it seemed to be mountainous in size and very antique from an odorific standpoint, notwithstanding we had given her, as we thought, the necessary purgatives before operating. A few days later we had trouble with stitch abscesses. After a few days we placed patient on her face and in twenty-four hours the abscesses were entirely healed. This is an idea of my own, and the first time I ever applied it was in a case of abdominal section for a gunshot wound about two years ago. It acted like magic then, and I believe it to be a good and harmless procedure, as these abscesses never form until long after peritoneal union, and to lie on the belly the bed acts as a support against abdominal hernia. This patient was sent home in five weeks perfectly well. I wish to say that the first patient developed no fever, and the second patient did not at any time have a temperature above 100° F. SOME REMARKS ON PLEURISY WITH EFFUSION.* Report of Cases. BY FRANK A. JONES, M.D. MEMPHIS. Chief of Clinic, East End Dispensary; Demonstrator of Physical Diagnosis, At our last meeting I reported eight cases of pleurisy with effusion. Since then I have had seven additional cases, making a total of fifteen seen at the East End Dispensary during the month of May and the first week of June. I do not purpose reading a paper on the subject, as all of us are familiar with the disease and its symptoms, but I wish to give my experience briefly from a clinical standpoint, as occurring in my service at the East End Dispensary, covering a period of something over two years. I have treated 8000 patients, and among that number I have had a great many cases of pleurisy with effusion, as evidenced by the physical signs and verified by aspiration with the hypodermic needle. My first observation is, that over 75 per cent. of these cases are tuberculous, as first advocated by Bowdwitch, of Boston, and confirmed by Osler, Anders, Wood and Fitz, and all other modern authorities whom I have consulted. * Read before the Memphis Medical Society, June 20, 1899. My next observation is, the disease is insidious in nature, a great many patients presenting themselves with virtually no symptoms except slight dyspnea and cough complained of mostly at night, with slight fever, when a physical examination reveals the pleurisy; and in 90 per cent. of my patients the effusion has been on the right side, filled from apex to base with a sero-fibrinous fluid. Further, I have watched my patients closely. The majority of those seen in the winter of '97 and spring of '98 have "shuffled off this mortal coil" by the phthisis route. Right here I wish to record a fact which has not been mentioned by textbooks. If any physician has seen the same thing in the negro I would be glad to have him state his experience. In nearly all of these patients succumbing to phthisis there has also been an acute nephritis, as evidenced by general dropsy and albumin in large quantities in the urine. My final observation is: there is but one treatment—aspirate and reconstruct your patient. I have given the salines and counter-irritants a fair and unbiased trial. In no patient did I get results desired. True, you can, in a measure, remove the serum with large doses of salts. The depleted blood calls upon the effusion to counterbalance the loss, thus removing it, but you run a great risk of impoverishing the patient in so doing. What your patient needs is more blood and better blood to generate a better metabolism, to produce a better nutrition, a better resistant force on the part of the patient. With your permission I will now report and present some patients. Milton Peoples, male, colored, aged 29. No history of previous pleurisy, pneumonia or la grippe. Had been in good health until a few weeks previous to coming to clinic. Physical signs marked dyspnea, diminished movement on right side, absence of vocal fremitus on palpation, flatness on percussion from apex to base, absence of respiratory murmur on auscultation; temperature 101° F.; pulse 100; slight cough. Aspirated with a hypodermic needle and withdrew some typical sero-fibrinous fluid. Aspirated May 8, and withdrew nearly a gallon of fluid-a washbowl half full at one sitting-patient showing no sign of collapse. Placed him upon iodide of potassium and syrup iodide of iron. At present he is doing fairly well. Cary Jones, male, colored, aged 20. Physical signs same as above patient. Clinical history: had what he termed "side pleurisy" two months previous to coming to the dispensary; temperature 102° F. Aspirated May 8 and withdrew half a gallon of fluid. Placed him upon iodide of potassium and syrup of the iodide of iron. At present patient seems cured. Richard Kight, male, colored, aged 31. History vague; no history of pneumonia or pleurisy; had acute articular rheumatism when he presented himself for treatment; temperature 102° F.; pulse 120, small volume. Dr. Francis aspirated and withdrew more than two-thirds of a gallon can full of fluid. Patient showed signs of collapse, respiration and pulse becoming rapid. I should have stated that all of the physical signs in this patient were positive. Placed him upon iodide of potassium and syrup of iodide of iron. Patient is now doing fairly well. Isom Boyd, male, colored, aged 30. Had pneumonia in December; was attacked 27th day of December last, and was confined to his bed over three weeks. When able to be out he noticed that his work as a street laborer unduly fatigued him. Had cough and dyspnea which harassed him at night. Weighed 190 lbs. when taken sick; weighed 175 lbs. when he applied for treatment May 16, showing that he had not lost much flesh, when we consider the attack of pneumonia and the time which elapsed between his attack and his coming to the clinic. When seen he stated that he had shortness "at de bres" and a "worrisome cough," and that he was "costic at de bowels," and that if he had something to give him "a free passage from de bowels" he would be all right. Found temperature and pulse normal, about 80 and full. Physical examination revealed the following: absolute fixation of left side of chest from apex to base, dyspnea moderate, cough irritable, absence of vocal fremitus on palpation, dulness on percussion everywhere, absence of supination on auscultation. Introduced hypodermic needle and withdrew pus. On May 17 Dr. E. M. Holder made incision in posterior axillary line in sixth intercostal space with a scalpel, and evacuated more than half a gallon of pus. There are some interesting features in this case. Here was a man with empyema. He had no fever when he applied for treatment; his pulse was normal. He has had no fever since the operation. Pulse has never been higher than 80. He does not show any evidence of a general sepsis, as is generally seen in empyemic cases. Never had to take his bed. Has lost but little flesh. The pleural cavity has drained well, Dr. Holder having used two rubber drainage tubes. Expansion is good; some retraction. Patient eats and sleeps well; is gaining strength rapidly and says he is about able to return to work. For the present he is all right. Has been taking large doses of iodide of potassium, syrup iodide of iron, and a good supply of nutritious food. Loomis mentions such cases. He says: "Not infrequently pyemic patients make no complaint which would direct attention to the pleura, and the pleural cavity may be found half full to two-thirds full of pus, without having given a single symptom of its presence." This is the first case of this nature that has come under my observation. I shall watch the future of all these patients, as experience has made me skeptical as to ultimate results. SOME CAUSES OF DYSENTERY-A CLINICAL STUDY. BY O. S. McCOWAN, MEMPHIS. The epidemic of enteric troubles now prevalent brings this class of diseases prominently before us, and perhaps it would be well for us to study them more carefully than we are in the habit of doing. I have had, under the direction of our visiting staff physician, Dr. J. H. Reilly, the privilege of observing several interesting cases in the hospital wards, and it is the object of this sketch to call attention to some of the interesting features, and especially to report the post-mortem findings in several, and in this way illustrate some of the causes of dysentery. The leading textbooks teach that enteric troubles are greatly influenced by atmospheric conditions, and this teaching seems to be borne out by the fact that they appear frequently as endemics and sometimes as epidemics, and that they are more prevalent during the summer months than any other season of the year. One of the most common forms of dysentery is that in which the ameba coli acts as the direct causative agent, and in which climatic influences play a very important part by |