When 18 years old she commenced menstruating, but rather irregularly; she had three normal pregnancies, the last one of which was 10 years ago.

At about the age of 24 (two years before the last pregnancy), she noticed that without any apparent cause, and without any leucorrhoea, urination became more frequent, and soon the urine itself became cloudy. At certain times she had painful attacks, which appeared to be located in the right kidney; these attacks had all the typical character of intermittent pyonephrosis, and were accompanied by nausea, vomiting and suppression of urine. After 24 or 48 hours these attacks would cease.

In the first place they were separated by an interval of two or three months, but soon these attacks became more frequent, the patient having from one to two a week for the last six years. At this time she underwent nephrectomy of the right kidney; this kidney was transformed into a kind of cystic pocket about the size of a head. Following the operation there was a tendency to anuria, and then the urine became more abundant, but was still cloudy. The general condition rapidly improved.

A

year after the operation there was a new painful attack, and this time in the left kidney; a year after, another attack; then, 18 months after, a third one. There was nausea and vomiting with oliguria accompanying each attack.

For the last year the attacks have occurred at closer intervals, and for the last two months they have occurred every week. The last attack took place on September 16, and was also more painful than usual, and with complete retention of urine. Catheterization, which was done twice at an interval of twelve hours, did not withdraw a single drop of urine.

She was then brought to the Necker Hospital in the service of Professor Le Dentu. On the 20th of September we performed lumbar nephrotomy on account of the persistence of the symptoms of total anuria and the uræmic condition of the patient.

Before the operation the kidney could be felt easily the size of a child's head and formed a tumor which considerably descended below the false ribs and was very accessible by simple or combined abdominal palpation.

The operation was very simple; it was performed according to the usual technique of lumbar nephrotomy, and we came down upon a large uro-pyonephrotic pocket. On the convex border of

the kidney we made an incision of a few centimetres in length, which went through a thin layer of renal tissue and gave issue to a cloudy urine but no true pus was found. The pocket immediately sank in and we could see that a good amount of renal tissue still remained. No calculi. Without trying to catheterize the ureter on account of the general condition, we sutured the anterior lip of the kidney and for drainage down to the pelvis of the organ we used two large drainage tubes. The dressings were then applied.

The whole operation had not taken more than 20 minutes. The after-results of the operation were good. In the evening the patient, who had been kept up by champagne and artificial serum, came out of the stupor that she had presented before the interference. The pains had disappeared: the renal secretion was abundant, and the dressings which were frequently changed were soaked each time. The ulterior results were very simple, and at the end of a few days the patient was taken into the wards of Prof. Guyon. The treatment was continued as before and the general condition improved considerably, when one day on account of an irrigation which distended the pocket, the patient, who up to that time had been perfectly apyretic, had a temperature of 40° C. The next day she was well again.

The question that now comes up is regarding the passage of the urine by the natural passages, which has not as yet occurred. The ureter appeared completely closed to the passage of any urine. Should the ureter be catheterized, and in the first place should we have tried to reëstablish the passage of the urine by catheterization of the ureter instead of performing nephrotomy? We do not think so; catheterization of the ureter, which has been so well improved upon by Albarran, is excellent when the condition of the patient is not serious; and it is an excellent diagnostic and therapeutic means of cure. But it is not absolutely without danger; certain accidents have occurred in some cases. Given the condition of our patient, it appeared to us that this would have been bad. Evacuation of the pocket, even if it could have been produced, would have been slow, and the condition of the patient indicated that something should be done immediately, and lumbar nephrotomy acted in this case much as an artificial anus would in the case of intestinal obstruction.

The patient will have a lumbar fistula all her life, and the

experiments and communications of Guyon and Albarran particularly, which have been related at this session, have demonstrated the importance of tension of the kidney.

This woman was in a state of anuria and was consequently uræmic on this account; it was necessary, at any price, to avoid the return of this renal tension; a permanent fistula of the kidney appeared to us necessary, and we are therefore occupied in constructing an apparatus which will collect the urine as it comes away in order to avoid any permanent soiling.

Now, could we have tried to reestablish the passage of the urine by the ureter? Catheterization of the ureter by the bladder could be tried a little later and would tell us what has become of the ureter which is attached to the kidney, which alone takes care of the urinary excretion in the patient, but it is possible that catheterization would prove useless; what should especially be watched for a long time is the perfect drainage through the lumbar region, because recently a very instructive accident happened in this respect. The primary drainage having been replaced, the drainage tubes acted less regularly, and for three days there was fever and the general condition changed; the new drainage extending down very deeply avoided this incomplete retention which had occurred and now the patient is well again.

The conditions were particularly delicate in this case, and the observation pleads in favor of the combination which has already been upheld by one of us at the first meeting of this association in 1896, that we should restrict ourselves in such cases to a lumbar nephrotomy performed rapidly with a minimum of surgical traumatism.

SOCIETY TRANSACTIONS.

AMERICAN ASSOCIATION OF OBSTETRICIANS AND
GYNECOLOGISTS.

CONSERVATION OF THE OVARY.*

(Concluded from March number.)

DR. JOHN M. DUFF, of Pittsburg.-There were certain points brought out in the paper and discussion which are of very considerable importance. I shall not attempt to discuss the doctor's paper at length. One of the statements made in the paper, and referred to by gentlemen who have preceded me in the discussion, was that in a large percentage of the cases in which the ovary was removed there was a deteriorated condition of the woman, particularly with reference to neuroses, and that mentality becomes defective. It seems to me, this is a serious assertion to make, if it is not true, to go out to the profession and to the world. If it is true, we should endeavor to ascertain the facts positively, and act in accordance with them. My experience has not been so extensive as some of the Fellows, yet I feel that I am justified in saying that, as far as my ability to discern is concerned, in the cases in which I have removed the ovaries I have not noticed any subsequent ill effects to any great extent. On the other hand, I have had good results from carrying out this procedure. Every case must be studied by itself. All of the conditions should be taken into consideration. Many of our statistics are erroneous because they do not deal with like cases. If we judge according to those statistics our opinion thus formed will be equally erroneous.

I reported a case before the meeting of the American Medical Association this year upon which I operated, doing a vaginal hysterectomy, removing the uterus and tubes, in which the woman was in perfect health mentally before the operation, but she became a raving maniac afterward. At first she became hysterical, then maniacal, developed suicidal tendencies, and had to be watched for a considerable length of time. One year elapsed before she recovered so as to be able to attend to her

This discussion, which as published is complete in itself, was called forth by the paper by Dr. Sherwood-Dunn, read at the meeting at Niagara Falls, Aug. 17-20, 1897, and published in the ANNALS for November, 1897, Vol. XI, No. 2.

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ordinary household duties. In all of the operative work I have done this is the only case in which I have had a result of that kind.

In another case in which I did a vaginal hysterectomy nymphomania developed, the woman having had no sexual desire prior to the operation. After the operation she could hardly be satisfied in that direction. I have had two or three other cases in which the sexual appetite developed, but not to the same extent as in this one. On the contrary, I have had patients who were mentally feeble prior to operation, who have improved rapidly immediately after it. The two cases reported in my paper before the American Medical Association this year are illustrative of this condition. One lady had been under the care of several physicians, and they had determined that her mental condition was such that she would have to be sent to an asylum. Her father and brother insisted that an operation be performed, because of the fact that she had ovarian and uterine disease. I felt myself that an operation was necessary, notwithstanding her mental condition, without much hope of benefiting her. She was a skeleton, practically speaking, when she was brought to the hospital. I did a vaginal hysterectomy, removing the uterus and appendages. At the end of a few weeks she left the hospital in comparatively good health, and was apparently sound mentally. Within four months she went to Northern New York on a hunting expedition with her husband, and when she returned in the fall and I saw her she had gained thirty-eight pounds in weight, and expressed herself as perfectly well.

Four months ago I operated on another woman, and until the day of the operation she would not remain in a room by herself for five minutes at a time. It was necessary to have some one with her, because it was feared that something would happen to her. Her mental condition was weak and memory defective. She returned to her home in West Virginia four weeks after the operation, expressing herself as feeling good. She had insomnia before the operation. The third night after operation she began to sleep, and slept well at nights until the time she went home. Her husband sent me word two or three days ago regarding her condition, and he said only on two occasions since her arrival home had he noticed anything wrong with her, when she manifested mental disorder.