above the point of vaginal closure. This was done four months ago. I found that a portion of one ovary remained from the last abdominal operation, explaining the persistence of menstruation. As I cut off the womb a fountain of pus gushed from the cervical canal and deluged the pelvic peritoneum. The latter was cleansed by the dry method and the cavity closed without drainage. The layer of connective tissue joining bladder and rectum and obliterating the vagina was then punctured, and the purulent fluid remaining in the vagina evacnated. The woman made a good recovery. I have recently closed the vesico-vaginal fistula successfully, and the patient is now perfectly well. Appended is the list of ten operations by six physicians to which this patient was subjected before she was cured: Operation on the vagina during labor (Dr. G.); two plastic operations in the vagina (Dr. F.); a salpingo-oophorectomy (Dr. P.); operation for atresia of the vagina (Dr. M.); two unsuccessful operations on a vesico-vaginal fistula (Dr. M.); puncture of the hematocolpos through the rectum (Dr. L.); hysterectomy and discission of the vagina (Dr. H.); operation on vesico-vaginal fistula (Dr. H.). 1821 SPRUCE STREET. SO CALLED PUERPERAL ECLAMPSIA IN ITS RELATION TO INSANITY.' BY W. P. MANTON, M.D., Consulting Gynecologist to the Eastern and Northern Michigan Asylums for the Insane THERE is a tendency on the part of most of us to accept foreign statistics, especially those coming from Germany, as representing unqualifiedly the status of any given condition in this country, as well as in the country from which such statistics have emanated. The differences in the habite of life, the modifications due to environment, and the constitution of the peoples of other nations are either overlooked or ignored, and the results Read before the American Association of Obstetricians and Gynecologists, September, 1895. of investigations abroad credited as obtaining in the same degree in like conditions in the New World as in the Old. While foreign statistics of disease are exceedingly important and valu able to us in many ways, I am convinced that they are often misleading as regards corresponding conditions in our own country, and hence should be more generally looked upon as local contributions only to the sum total of our knowledge of a given subject. Some four years ago, in an able and elaborate paper by Olshausen on the puerperal psychoses, with especial reference to insanity as a sequel of eclampsia,' a greater importance was given to the latter disorder than the experience of the majority of American observers would seem to warrant. In the following brief communication I have summed up the results of my own researches in this matter, and I believe that, for this country at least, the figures presented represent more correctly the connection between the two disorders than do those of the authority referred to. An attempt to establish a relationship between two morbid somatic affections, the one acting as cause, the other appearing as effect, presupposes a knowledge of the etiology of the exciting agent. Of so-called puerperal eclampsia as a factor in the production of insanity this cannot be claimed; for, while the literature of this disorder is voluminous, our actual knowledge as to its origin is still indefinite and unsatisfactory, and any effort to trace the connection between the two diseases by arguments based on the various theories and hypotheses which have already been advanced as to its etiology must inevitably lead to disappointment and confusion. In discussing the relationship of these two conditions, therefore, we must acknowledge our ignorance concerning the primary etiological factors concerned in the production of eclampsia, and attempt the solution of the question of its bearing on insanity by confining our attention to the investigation of such facts as may be at our disposal. According to the latest statistics to which I have had access, those of Bidder,' in 60,583 deliveries eclampsia occurred 455 times, or once in about 133 labors. Of this number 79, or 17.3 1 Zeitschrift für Geburtshülfe und Gynäkologie, Bd. xxi., H. ii., p. 371, 1891. Archiv für Gynäkologie, Bd. xliv., 1893, p. 165. per cent, proved fatal; but as 31 of the women died of complicating disorders-sepsis and pneumonia-only 48, or 10.5 per cent, can be said to have succumbed to the convulsive attacks. These figures are much lower than those given by Goldberg,' who records a mortality of 24.7 per cent. Accepting Bidder's 10.5 per cent as the lowest mortality, we have left 89.5 per cent of eclamptic women to be accounted for as cured, that is, as recovered from the immediate effects of the convulsive disorder. We are informed by obstetrical writers, however, that, while recov ery from the primary disease may take place, other conditions, notably insanity, may follow in its wake; and as the original malady is one in which the nervous system is principally involved, it would be natural to suppose that the number of cases of mental breakdown would be not inconsiderable, as pointed out by Olshausen.' To ascertain this point I have had recourse to three sources of information: A. Statistics from private practice. B. Statistics from the lying-in hospital. C. The records of hospitals for the insane. A. Never having had a case of insanity following eclampsia in my own practice, I have collected 8,868 cases of delivery reported by eight competent observers and published in current literature. In this number I find that eclampsia is noted as having occurred 33 times. In not a single instance is it stated that insanity followed the convulsive attacks. B. During the four years 1891-94, inclusive, 282 women were delivered in the wards of the Detroit Woman's Hospital, eclampsia occurring in two cases. Both of these recovered without symptoms of mental alienation.' This seems the more remarkable since of the whole number of patients confined 233 were unmarried.' C. During the same period (1891-94) there were admitted to the three principal asylums of Michigan with which I am connected 1,271 female patients. In this number the insanity was attributed to puerperal causes in 110 instances. In two cases only was eclampsia put down as the exciting cause, and one 1 Archiv für Gynäkologie, Bd. xli., 1891, p. 295; Bd. xlii., p. 87. These statistics have been introduced for comparison. 3 Both of these cases occurred during my own service. Statistics furnished by Dr. Jessie L. Herrick, Senior House Physician. of these patients was a readmission, the woman having recovered some years before from the original mental sickness.' While the number of cases which I have brought together in the above statistics is not large, it is sufficient, if the three different sources of information are considered, to enable us to arrive at a definite, and I believe accurate, conclusion regarding the relationship existing between puerperal eclampsia and insanity. The conclusion is that insanity as a sequel to puerperal convulsions is of such exceedingly rare occurrence in this country as hardly to deserve consideration in this connection. 32 ADAMS AVenue, W. THREE RECENT CASES IN GALL-BLADDER SURGERY.' BY EDWIN RICKETTS, M.D., WHEN We have a gall stone or gall stones in the bladder, cystic duct, or common duct, the biliary flow need not for a time be interrupted. When the stone is primarily engaged in the lower end of the gall bladder or in the common duct, then a pathological lesion begins. The stopping of the flow of the bile may be intermittent or constant enough to produce symptoms indicating tension. Then we can have an obstruction of the common duct due to external trauma, such as a blow received over the region of the liver. With this catarrhal condition of the common duct is usually found distention as the result of bile not being carried on through the gall ducts. Then we may have a solitary calculus engaged in the lower end of the gall bladder, causing thickening of its wall, with the periodical escape of infected or non-infected contents. It is claimed by some operators that gall stones are never preformed in the hepatic or common duct. If such is true we have some wonderful phe 'I am indebted to Drs. Edwards, Ostrander, and MacGurgan, of the Michigan; Dr. Morse, of the Eastern; and Dr. J. D. Munson, of the Northern Asylum, for examining the records of their respective institutions for these figures. Read before the American Association of Obstetricians and Gynecologists, September, 1895. nomena to account for, in which calculi were found post mortem in great numbers in the hepatic duct and liver substance and none in the gall bladder, cystic or common duct. As there is the possibility of finding one or more stones in the hepatic duct, I make it a rule to try to introduce a probe into the hepatic duct after the gall bladder has been incised, even though nothing but a catarrhal condition is found. The first successful probing of this kind was reported to the Southern Surgical and Gynecological Society at the last meeting in Louisville. CASE I.-Mrs. H., white, 52, German, and a patient of Dr. Campbell, of Vanceburg, Ky. Consulted me February 1st. 1895. While she had some pain in the region of the stomach, followed by attacks of diarrhea, she said that she had been but slightly jaundiced within the eight years. She was suffering from intestinal digestion with diarrhea; there was marked eructation of gas, and she said that it was seldom that her stools were other than grayish in color; there was no marked loss of flesh, nor did she ever have typical attacks of biliary colic. She said that it was seldom that she could take food without causing dull, heavy pain in the stomach. Three years previously Dr. Campbell had made a diagnosis of gall stone and urged surgical interference. There had been occasional attacks of vomiting that were severe enough at times to cause hematemesis. On examination I found a tender spot a little to the right of the median line and over the region of the gall bladder; on deep pressure a nodule could be felt; the pressure elicited much pain. Diagnosis of gall stone was made and surgical interference urged. The abdomen was opened on the following day, February 2d, and the gall bladder was found only moderately distended. Upon passing the finger down alongside of the bladder under the pylorus a stone could be felt through the wall. The bladder wall, which was thickened, was incised and quite a quantity of fluid removed. Passing the Tait alligator forceps (closed) well down into the bladder, the same being held up into the wound by catch forceps, the click was readily gotten, and, opening the blades with some difficulty, the stone, weighing one hundred and twenty grains, was dislodged. The small end of the olive-pointed probe was passed down into the common duct and an effort made to probe it, without success. Satisfying |