fistula. Winckel alone holds the opposite view; he believes that they do not always close after the first operation because the recto-vaginal septum is very thin, the surfaces to be freshened are narrow, and the rectum cannot be completely disinfected. The reader had likewise had a case in which various methods failed. In this case, the vagina being wide and relaxed, he performed colporrhaphy, instead of dividing the septum below the fistula. Only at the bottom of the wound was the fistula united by catgut sutures which, however, did not pass through the rectal mucosa. The operation succeeded. In his second case, the vagina being likewise wide and loose, he at once freshened the surfaces according to Hegar's method; the fistula was situated about midway between the middle and lower portions. The advantages of this operation are: broad freshened surfaces are obtained, the vaginal side alone is freshened, and the rectum not touched, the rectovaginal septum is reinforced and a barrier interposed to prevent the entrance of the rectal contents into the vagina, and finally the relaxation of the vagina is removed. The method will not be feasible in every case. Not every vagina is relaxed, and not every fistula, especially if large, will be suitable for it; but then most fistulæ are not very large. Finally, only fistulæ situated in the median and lower thirds are liable to be benefited by the operation; those higher up, only if the vagina is very loose.

DR. MUELLER.-In many cases, the same cause which led to the formation of the fistula prevents both the closure and colporrhaphy; cicatricial degeneration of the posterior wall taking place. Otherwise he held the operation to be good, since it permits broad surfaces to be freshened and a double row of sutures to be inserted.

DR. HIRSCHBERG thought the method was nothing but a broad, flat freshening, such as Wilms performed for vesico-vaginal fistulæ. If this freshening is to be extended into a colporrhaphy, dropped running catgut sutures should be employed because the entire wound surface could thus be better united.

DR. SCHAUTA had never observed cicatricial alterations in his cases. The case is different with vesico-vaginal fistulæ caused by long-continued pressure. Recto-vaginal fistulæ are due to excessive distention; cicatrices need not occur.

DR. KUESTNER (Jena) read a paper on

PERINEOPLASTY.

He first emphasized the necessity of stitching every perineal laceration, be it ever so small. The anterior portions of the perineum support the anterior vaginal wall; where they are defective, slight descensus takes place also on the posterior wall, owing to the great succulence at the time the laceration takes place. Leucorrhea, pruritus, and nervous disturbances, due to perineal wheals, may likewise ensue. Where retroflexion of the uterus is present, perineoplasty is still more strongly indicated, as no pessary would otherwise stay in place. Among 57 cases of perineal

laceration, retroflexion was present in 23 (40%). The reader then considered the methods of operation usually practised (triangular and flap operations), and declared himself in favor of that of Freund, because most perineal lacerations are not median, but run upward along the rugous column into one or two points. Freund's is preferable to Bischoff's method because it reproduces natural conditions, and a frenulum is formed. In the reader's 57 cases the laceration was nearly median in 14, in 4 of these, there was also a median tear in the cervix; these cervical lacerations complicated 21 cases. If the two-pointed method is the best for partial perineoplasty, it is undoubtedly so for the total operation. All failures are due to the unnatural features of the methods, parts being forced to adhere that do not belong together. The advantage of Freund's method is, that it renders possible the anatomical reunion of the parts. For suture material, silver wire or silk wormgut is to be recommended. Catgut does not hold long enough; Czerny's silk is good, but it drains both out of and into the wound; slight suppurations may occur as the consequence of the capillary attraction of the silk sutures. Silk worm-gut does not share this quality, and the reader has not observed any suppuration with it. DR. KORN (Dresden) read a paper on

PERINEOPLASTY.

He had sifted the material of the Royal Lying-in Institute and reported on 35 cases of complete perineal rupture. Lacerations affecting only the sphincter ani were excluded. 33 patients or 94% were cured, i. e., discharged with complete continence. One patient, in whom a recto-vaginal fistula had remained behind, refused further treatment; in the other patient, full continence was not attained, although complete perineoplasty had been twice repeated. Of the 33 recoveries, 4 patients (11%) had to undergo a secondary operation (3 cases of closure of recto-vaginal fistula, 1 case of second complete perineoplasty). In 20 cases (57%), union by first intention; in 1 case, details are unknown; in 3 cases, rectovaginal fistulæ formed which closed spontaneously; in 3 cases, a perineo-rectal fistula was found which, however, was impervious to feces and gases. In 2 patients, the wound surfaces separated to some extent at the introitus vaginæ without impairing the result of the operation. Of the 20 closures by first intention, 14 were not sutured post partum, in 3 statements are defective; inversely, of 11 previously sutured, only 3 closed by first intention. In these cases, moreover, the rectal lacerations were small.

In all cases, the freshening was done according to the SimonHegar method, and the three-sided suture inserted in harmony therewith. The reader recommended to commence the freshening as high up in the vagina as possible, so as to obtain a thickening of the recto-vaginal septum from the topmost vaginal sutures down. Silk was the suture material in nearly all cases; only of late had

the running catgut suture found employment, good results having been obtained with it in recent lacerations (more than ninety per cent by first intention in a series of between three hundred and four hundred cases). The speaker, however, does not sew in the way recommended by Schroeder, which is very difficult; besides, he anticipates a more exact coaptation by retaining the three-sided suture. He, therefore, stitches with two threads, commencing the first suture in the vagina, where it extends to immediately above the end of the rectal laceration. Then the latter is united with a second thread which is knotted on the rectal mucosa. The vagina having been stitched down to the introitus (any desired number of turns being dropped), the perineum should be stitched only superficially. Deep perineal sutures should be avoided. The reader sees a certain advantage in his method, in so far as he is not forced to work with excessively long threads. Mention was made of a special case in which the reader closed a complete perineal laceration of seven years' standing according to this method, after a recent labor.

None of the thirty-five cases was operated upon before the lapse of two months, one patient having borne the laceration for twentythree years.

As regards the after-treatment, in none of the cases was the sphincter ani divided, nor was a tube inserted into the rectum. From the fourth day on, regular passages were provided for.

The discussion on the last two papers was postponed.

DR. HIRSCHBERG desired to make a correction. The expression "Simon-Hegar method” is erroneous; the three-sided suture had been made only by Simon.

DR. OLSHAUSEN (Halle) read a paper entitled:

NOTES ON THE CLINICAL INITIAL STAGE OF MYOMATA.

In a number of cases, the reader had observed symptoms which seem to precede the development of myomata. The patients suffered pains which increased during menstruation, but did not disappear in the intervals; exercise tended to intensify them. They had the character of inflammatory pains. The bladder likewise was frequently sensitive. A second group of symptoms were superadded in the shape of menstrual anomalies (profuse menstruation of an anticipating type). Finally, the uterus was always sensitive on pressure during examination. In all cases, accurate palpation could be performed, and other anomalies of the uterus could be excluded, especially the presence of myoma. These symptoms continued many months up to one or two years; then, on repeating the examination, enlargement of the uterus could be detected, and after further observation the development of a myoma could be demonstrated. Then the symptoms ceased, the pains and profuse hemorrhages disappeared, or at least moderated considerably. The symptoms admit of two explanations: either the first rudi

ments of the myoma were then present; or else, the irritation and the continuous congestion of the uterus were the primary conditions, giving rise to the development of the myomata. The latter explanation seemed the more plausible to the reader. In its favor is the fact that many patients come under observation in later years with myomata which are still small in size, and report that they have suffered with profuse menstruation for a very long time. These patients generally have been sterile for a long time, either primarily or secondarily. The view of the anatomists (Virchow, Cohnheim), that sterility produces myomata, does not satisfy him; but for many cases the view of the gynecologists does not seem much better, viz., those cases in which the myomata do not form until the end of the third decade of life, while the sterility is of long standing. He believes the first step to be the congested condition of the uterus; the consequent hemorrhages produce sterility by impotentia gestandi; after a further lapse of time, they lead to the development of myomata or to general hyperplasia of the uterus. He would be unwilling, however, to give a generally applicable explanation for the development of myomata.

DR. FEHLING inquired whether the author had not observed that, in those cases in which the inception of myomata could be demonstrated, menstruation had been for many years previous surprisingly scanty, perhaps lasting only a few hours. He himself had observed some such cases, and believed that the menses had, for unknown reasons, failed to appear, and thus caused the development of the myomata.

DR. OLSHAUSEN had not observed any such cases, perhaps because he had not paid special attention to them.

DR. WINCKEL would reserve his reply to a future time, and called to mind cases in which myomata of many years' standing had been detected very late.

DR. OLSHAUSEN again stated that the pains were very intense and permanent in character.

DR. WIENER (Breslau) read a paper on

THE NUTRITION OF THE HUMAN FETUS.

He spoke of the various theories extant in reference to the nutrition of the fetus, and arrived at the conclusion that the liquor amnii is no physiological constituent of the fetal nutrition, but that the latter is furnished exclusively by the placenta. The nutriment of the fetus consists of maternal blood-plasma, and probably also of white blood-corpuscles. The difficulty which many authors had believed to find in the transition of the constituents of the blood, especially the albumin, has no existence, because the physical laws of diffusion and filtration deduced from dead membranes do not apply to living cells. Cohnheim calls the endothelium of vessels a living tissue or, if we like, organ, with an unknown, but undoubtedly very active nutrition. Most probably, the vascular endothelia take an active part in the imbibition of the constituents of the blood and in their distribution to the surround

ing tissues. A similarly active participation in the reception of the maternal blood contents and their distribution to the fetal blood can also be claimed for the epithelium of the villi, as Werth had formerly pointed out.

Of course, it is not necessary to assume that there should be any special transformation of the nutrient material, a sort of digestion by the epithelium of the villi. The presence of a so-called uterine milk in the human placenta appears very questionable to the reader; his examinations of hardened placentæ speak in favor of the fact that the intervillous spaces are filled with blood, and not with uterine milk.

The paper will soon be published in extenso.

DR. WINCKEL inquired whether all the intervillous spaces are filled with blood. (Answered in the affirmative.)

DR. FROMMEL referred to a paper by Davidoff, who observed that the epithelium of the intestinal mucosa was active in a process of proliferation or new formation of nuclei, and that these nuclei, which exactly resemble lymph-cells, reach the tissues and the lymph current. He inquired whether the author of the paper had observed anything similar. (Answered in the negative.)

DR. LEOPOLD.-Thus far the final proof has not been furnished that there is no blood in the intervillous spaces. He still maintains his former view that all the villi are bathed in blood. DR. SCHATZ (Rostock) read a paper on

TYPICAL PAINS OF PREGNANCY.

Occasionally the pains occur quite regularly for some time, stopping again after a while, to return weeks later. Now and then it may also be observed that agents which have a decided influence on the pains during labor are at other times quite inert; e. g., quinine, pilocarpine, electricity. Among fifty gravidæ, the reader had observed the typical pains of pregnancy in the last weeks before term in five cases. They probably occur regularly in preg nant females, but are not always perceived; they set in at definite intervals before labor and maintain a specific periodicity— not, as might be supposed, however, of a monthly character, which latter type seems to be not even the ordinary one. This irregularity calls to mind the menstrual period after delivery, in which the four-weekly type does not seem to be the prevailing one, but one of six, frequently also of three weeks. These pains last for some time, up to twelve or twenty-four hours. With reference to the periodicity, we are unable to assert that labor is influenced by the menstrual type. The types of labor and menstruation are similar, but the processes must be kept absolutely separate. Both are based on a factor which is congenital or existent in the organism. The main thing, in regard to the typical pains, is the existence of a centre which cannot be purely excito-motor, but must have associated with it an inhibitory centre. This conclusion is forced upon us in view of those cases in which ergot at first has no effect, then, in very large doses, produces pains which are,