shortest cut compatible with the work to be done; the object to be sought being removal of the tumor or correction of any visceral lesion without bruising the tissues. There should be no pulling or straining upon any abdominal or pelvic organ or growth. For simple oophorectomy a two-inch incision is amply sufficient, while an eight inch one would be wholly unjustifiable. The surgeon should feel, not see, what he is doing in the pelvis in such cases,

DR. R. H. GOODIER of Hannibal, read a paper entitled: "The Physiology of Quickening." This term is usually defined as simply the period of pregnancy when motion of the foetus is first perceptible, without any explanation as to the cause of this motion or reason why it appears at this particular time. What is it? This query has been variously but not very satisfactorily answered. It occurs from the 12th to the 18th week of pregnancy -some say as early as the 10th week, but in the latter cases it is probably purely imaginary. By some it has been claimed that this symptom marks the point where life begins in the foetal existence; but this is obviously not true since there has been cell-life and cell-movement from the very first day of fecundation. This, however, is sentient movement, muscular contractions on the part of the foetus that until now has remained quiescent. Now it occurs as the result of a direct stimulation from the blood. The explanation of the differ ence of time in its appearance is therefore easily made by the extent of placental development; as soon as the placenta reaches a certain stage of growth this direct stimulation is effected. Quickening may then be said to comprehend the physiological process of establishing the foetal circulation, and its sequence: foetal movement. This may be present as early as the 12th week if the placenta grow rapidly or delayed until the 18th if it develops very slowly.

DR. I. N. LOVE said: As one who has for years been engaged in teaching in the department of physiology or allied branches I feel like complimenting the author of this paper, and congratulating the members of this association, upon the excellent character of the ad

dress just read. There is a scarcity of such papers. As chairman of the section of Physiology in the American Medical Association some years ago 1 could not get enough essays to make the section a success-authors do not like to write upon physiological subjects. This is a mistake for physiology is practically the basis of all scientific medicine, particularly in regard to rational therapeutics. For having departed from the usual rut of papers presented before this and kindred bodies the essayist deserves our thanks. Certainly there is nothing in his assertion to be controverted; so discussion is not possible.

DR. W. H. MAYFIELD, of St. Louis, reported "Three hundred and thirtyone Lacerations of the Perineum with Operations, and Remarks Thereon," presenting a number of oil paintings representing an operation claimed original-so performed as to give no traction on the perineal muscles when completed and to allow complete abduction of the thighs during convalescence. He insisted upon deep dissection in every case so as to restore a muscular perineum instead of one consisting of only mucous membrane. skin and cicatrix as so often secured by the methods of Tait and Emmett. This operation has been recently declared original with Bergmann-but it is a St. Louis product. He advocated double operation at one sitting-that is, repair of tears of the cervix and of the perineum at the same sitting instead of in two operations. All work should be done under constant irrigation of bichloride solution. When the gut is also torn, the operation must be done in two steps-one to close the rectum and one to repair the perineum. He declared rupture of muscular tissue of the perineum frequently torn through during labor without injury to skin or mucous membrane. Such cases require surgical treatment just as much as do other ruptares of this region. Vaginal tears far up that organ are also quite often produced and should also be sought and corrected in every perineorrhaphy-otherwise the ultimate results will not be satisfactory. Even small lacerations of the perineum should be repaired as they may give rise to pronounced nervous pheromena. Excessively dilatable vaginas

are sometimes met and should be subjected to colporrhaphy if not perineorrhaphy. By timely operation in such cases the surgeon might oftentimes prevent the occurrence of certain sequelae which ultimately requires removal of the tubes and oraries with their consequent unsexing of the patient-often described as a mutilaring operation. For this reason perineoplasty offers a vast and not sufficiently worked field in operative surgery. By closer attention to this work much suffering might be averted by preventing some of the distressing sequelae, the chief of which are (1) nervous phenomena; the cause often overlooked; giving rise to neurasthenia if nothing worse, (2) Interrerence with the physical function of the vagina, giving rise to martial infelicity, domestic unhappiness and too often permanent separation of people who might be rendered happy by the surgeon, and (3) Prolapsus of the uterubladder and rectum with their attendant discomfort.

DR. I. N. LOVE: There can be no question as to Dr. Mayfield's claim to priority in the operation he advocates. This statement is made because recently another operator has declared himself the originator. Some of Dr. Mayfield's cases were reported to the St. Louis Medical society at least five years ago, long before anyone else had ever attempted this method. Justice to Dr. Mayfield demands recognition of his rights to whatever praise is deserved for this mode of treatment of lacerations of the perineum. This paper illustrates several important points. In the first place it demonstrates the advantage the surgeon has over the general practitioner. He comes with his pictures showing exactly what he does-we can see it; and he tells of the excellent results and can exhibit the perinei if we doubt his statistics; he can report a series of brilliant cures-333 casesmagical number!

DR. MAYFIELD: Only 331.

DR. LOVE: Well-still the luck of odd numbers. Just think of it! Three hundred and thirty-one cases of lacerations of the perineum without a failure in any case. It certainly is a marvellous record and can scarcely be du

DR. J. H. MCINTYRE: I wish to the enter a protest against double operation-that is repairing a laceration of the cervix at the same sitting as operation for a torn perineum. For in removing the stitches from the cervix the newly formed tissues between the raw surfaces of the perineum will be torn apart and all the work upon it come to naught. The cervix should be operated upon first; then when the sutures are removed the perineum can be repaired. In the latter operation our object should be only one thing. To restore the tissues to their normal state. All that is necessary is to lightly freshen up the edges and stitch together with silkworm gut; this can be done without much chloroform; it can be done with cocaine in some cases and in the cervix operation can be done with nothing but a good drink of whiskeythere being but little sensation in the os uteri. Little lacerations should not be operated upon-they are of no importance unless they produce some symptoms. I also object to the expression that "ovariotomy unsexesmutilates;" it does nothing of the kind-it rather improves the sexual appetite when already aroused by removing painful conditions which have rendered intercourse distressing. The constant irrigation of the vagina with bichloride solution during operation is wholly objectionable; if the vagina has been carefully cleansed the dryer it can be kept the better; and the bichloride tends to prevent healing by primary union. The use of the curved Hagedorn needle should also be criticized. In his early operations upon the perineum the surgeon will use a needle greatly curved, but as his ex

perience increases his needle will become gradually more nearly straight, until at last he will employ a needle which is entirely straight; the best being a common darning needle properly sharpened and tempered.

DR. EMORY LANPHEAR: That one surgeon should in the brief space of six or seven years operate upon more than three hundred lacerations of the cervix and perineum shows the great frequency of such tears and emphasizes the necessity for primary operation. By primary operation I mean repair of the injured tissues at the time of delivery. After removal of the secundines every accoucheur should carefully examine the os and perineum for lacerations and if any be found a little chloroform should be given and the rents sewed up with catgut. Much suffering might thus be prevented and subsequent confinement to bed or even a trip to the hospital be rendered unnecessary. I am therefore an earnest advocate of primary operation; and especially for the perineum. So far as the double operation is concerned it can readily be done by using chromicized catgut for the cervix and silkworm gut for the perineum. Personally I prefer to use silkworm gut for the cervix also, repairing the perineum at the time I remove the sutures from the cervix; I believe I get better results, but as a witness of some of Dr. Mayfield's work I can say he often gets just as good by the use of the catgut which does not have to be removed. I cannot think Dr. McIntyre does a good operation upon the cervix if he can operate with cocaine or whisky; I cut away all cicatricial tissue very deeply, in a way that no patient could stand without chloroform, so that when my work is completed there remains what appears to be a virgin os; I am sure no operator can do this without full anaesthesia. And in the perineum my object is always to bring muscle to muscle-so deep dissection is here likewise demanded; and for the same reason. Tait's flapsplitting operation is not advisable in most cases. From my own work I can testify to the correctness of Dr. Mayfield's position that every case of facerated perineum should be operated on that produces reflex nervous

symptoms, that impairs the physical integrity of the perineum to any marked degree or that allows of any prolapse of the rectum, bladder or uterus by reason of want of natural support-such cases are only too often neglected and suffer untold misery on account of the proneness of the attending physician to do nothing in the way of operative treatment.

DR. EDWIN BORCK, of St. Louis. said: This operation should be called the "American operation" as it is distinctly and unquestionably of American origin. One question of Dr. Mayfield: From his unusual experience has he noted that the vagina of the typical American woman is much longer and higher than that of the typical German woman? It has been asserted that such is the case that there is a marked difference in the relative position of the vagina in the two races. If this be true it means we must freshen the edges and sew farther forward in the one woman than in the other.

DYSPEPSIA IN SCHOOL GIRLS.

Dr. Anthony finds that many highschool pupils suffer from a form of dyspepsia induced by irregularity of meals, mental over-work in their studies and insufficient exercise. In the case of a girl of 18 years reported in the New Eng. Medical Monthly, the appetite was variable, with distress after eating; with pain in the precordial region, tenderness on pressure of the stomach, tongue coated, marked distention of bowels, with occasional eructations of gas. Ordered a change in manner of living and relaxation from study, with regular meals of easily assimilated food. A tumbler of Londonderry lithia water to be taken, hot, just before retiring, one before breakfast, also to be taken hot, and enough cold water during the day to amount to three pints in the twentyfour hours. The effect was apparent within a week and at the end of a month she had gained five pounds in weight and there was a cessation of all dyspeptic symptoms.

This case is illustrative of a class, of which there are many among school girls, who do not need active medication, but who will be benifited by a systematic use of Londonderry lithia water and a regulation of habits.

AND

DR. W. J. WILLIAMS of Adel, Ia., read a paper. Title, "Diseased Conditions of the Ovum, Leading to a Watery Discharge from the Uterus." (See original department.) Discussion:

DR. VAN EMAN-I do not find any fault with the paper, but would simply say from every standpoint, it is something with which we are not familiar; in my own experience I have met or remember now of only two such cases; one of a woman with her fourth child, who had never had any trouble or any disease, and at five and one-half months, while taking a walk one evening away from home, she was very much astonished as well as frightened to find that she had a watery discharge. A few days in bed was all the treatment given, and she went to full term and delivered a healthy child. The other case was a young woman. About her third impregnation she went to the seventh month with several attacks of watery discharges, some four or five, and finally miscarried. She afterwards had another man, and I delivered her a child at full term without any trouble of any kind; as far as I know there was no history of any trouble afterwards with other babies. In the first place, the trouble was that she was unable to bear with her first husband a living child. Those two cases constitute my knowledge of the subject.

DR. HALL-I remember of one case I had a number of years ago; a lady who had frequent discharges of water which I attributed to some rupture of the membranes; possibly one of the variety that Dr. Van Eman speaks of. This case was threatened with miscarriage, and owing to the fact that she had frequent uterine contractions for two months, I kept her in bed and gave her opium to allay the pains. The mouth of the uterus was dilated to the size of a dollar for two months. I succeeded in keeping her to the

eighth month and delivering a child, not very healthy, but by treating it carefully saved its life. Now this case was to me at the time unique..

DR. WILLIAMS-If I had my notes I could report at least five cases along these lines, embodying perhaps at least four of the different varieties mentioned. The point made by Dr. Hall is certainly the best treatment in these cases. Persons with these discharges need watchful care and in that way, I hope to hear favorable reports from cases one and two in which I have reported, in which, after the history of repeated discharges of slightly tinged water, without increase of size of the uterus, there was a difficulty in determining what the exact condition was. It might have been hydrosalpinx, or something of that kind, but we have a very nice distinction when you come to examine the cases carefully. We find the normal condition of the tubes in other cases, but after a while the uterus increases in size, and examination determines the fact that there is no foetus; careful examination determines the presence of water that is hydrometra. If this is allowed to go on and open sometimes in cases where they have a long ways to go after a doctor the latter comes too late, on account of hemorrhage. For there may be a tumor, and the separation of the mass that has been planted upon a weekly wall leads to a hemorrhage as in cases I have examined, where, after three or only part of the mass was expelled, in both cases exposing cysts as large as the end of one's finger; and yet the diagnosis had failed to have been made; in both cases the woman almost bled to death before the doctor arrived.

Paper read by Dr. J. E. Summers, jr., Omaha. Subject: "An interesting condition of the Intestines found during Operation for the cure of a Fecal Fistula." Discussed by DR. ADAMS.

"I am very much interested in the paper which the Doctor has presented to us. Iwill simply ask him a question in regard to whether he can determine whether the opening is in the small or large bowel and the probable location. I simply was interested in that from the fact that I had a case last July in which a lady had a femoral hernia (which was reduced. A few days after that there was a swelling in the femoral region. The swelling was thought to be a gland that had been injured in the reduction, but finally after incision got so that you could pass two fingers inside. In fact there was a most enormous opening there which ran down to the uterus; but she was put upon treatment and milk punch given to her. About a half hour after taking the punch she noticed the odor of alcohol at the opening. The question was whether the fistula connected with the stomach or lower down in the digestive tract. The lady is now perfectly sound and healthy. I did not use the knife in her case. She would never have gotten well if I had."

DR. ALLISON: About the first case: "I assisted Dr. Summers and it was somewhat embarrassing; there was considerable difference between the caliber of the gut above and below the constriction, and it was difficult to get the intestines to fit accurately over the same button at either end. This is one of the most trying features that I have noticed so far, and it occured to me at the time, that it might be possible for some individual to change the button in such a way that one side might be larger than the other and allow its wall to rise on the outside of the button in place of the anterior surface."

DR. ADAMS: "I have had some little trouble with fistulas. When you have a gut run through a mass of tissue, and when it is impossible for you, unless you have the whole abdomen laid open, to find the beginning and the end of the gut in order to put it together. When you have three, four and five inches of tissue, thrown out, causing the gut to be adherent and massed together, then have the gut running through it, you have something you could just as well keep

your fingers off and let her move her bowels from the side if she wants to." DR. SUMMERS closes the discussion: "I haven't anything, to say especially. In the first place a particular point to which I wanted to call attention was, that you would think, if you were to throw a quart of water or a pint of water, into the rectum and the water made its appearance at a fistulous opening that the opening was low down. The water in this case went into the lower part of the ilium. I spoke of not having made an analytical examination of the fistulous discharges, had I done so the location of the opening might have been determined.

In regard to the use of the Murphy button that Dr. Allison referred to, the difference in the caliber of the intestine above and below the fistulous opening, I had Dr. Allison's assistance in my first case in which I used the button. The condition of the intestine was practically the same, being due to the presence of a tumor of the intestine, so that obstruction was complete, even to the non-passing of gas. For some years I was led to believe that it was impossible to force water from the large intestine through into the small, without using so much pressure that you were apt to burst the large intestine, but once at a medical meeting, I took this position, backing it by a large number of experiments, when a country doctor told us that he had injected a pint or a quart of sweet oi into the rectum, and the patient vomited the oil, and there was no doubt about the way the oil went."

(TO BE CONTINUED)

The next issue of THE HERALD Will contain "PUERPERAL ECLAMPSIA,"by Dr. J. W. Young, Bloomfield, Iowa, and "ABORTION," Dr. Emmert, Atlantic, Ia.

Upon the Island of Formosa, a woman is not allowed to bear a child before her thirty-sixth year, and abortionists fulfill a social law by kicking the belly of a woman who becomes pregnant before the proper age. lest the population grow too large for the island.