a bladder filled to over-repletion. Should the physician get his forceps in readiness and pass the catheter before their application, he finds that as soon as the bladder is relieved, the uterine contractions receive renewed energy, and the labor is soon ended without instrumental interference. CASE IV.-A lady, ætat 43, was in labor three days with her 13th child. There had been no trouble in her previous labors, and her physician referred the difficulty in this to an occipito-posterior position. Five weeks after her accouchement she was brought to me. I found a transverse vesico-vaginal fistula just behind the symphysis pubis, and extending entirely across the vaginal wall, through which the anterior wall of the bladder protruded in a constricted condition. The vagina was acutely inflamed, the labia much swollen and of a fiery redness, an eczematous condition existed along the inner surfaces. of the thighs nearly half way to the, knees, and the buttocks were in a similar state. After suitable treatment the fistula was closed with silver sutures; but owing to its great length, and the want of tonicity in the tissues, a few of the sutures cut out, leaving about an inch of the fistula ununited. This was successfully closed in a second operation. In this case we have a model example of inefficient obstetricy! The large fistula was obviously caused by long pressure of the fœtal head against the soft maternal structures. A tyro in the use of the forceps, with only a moderate knowledge of the mechanism of labor, ought to obviate results so distressing and disastrous. He is not worthy the name of physician who cannot use the forceps under such circumstances. CASE V. This occurred in a large primiparous negress, referred to me by Dr. Erickson. The labor was severe and protracted, and of long duration, when medical aid was received. Delivery was accomplished with the forceps by Dr. Crozier, in consultation. I found a utero-vesico-vaginal fistula, commencing on the left side of the cervix at the vaginal junction, and extending along the anterior cul de sac of the vagina into the bladder, above the vaginal insertion to the right. The fistula presented a sigmoid shape, and a flexible bougie, passed along the urethra into the bladder, could be made to appear to the left of the cervix by pulling the latter forward with a tenaculum. Figures 1 and 2, drawn from nature by my friend, Prof. Christopher Johnston, represent the course and character of the fistula, Fa in Fig. 1. In Fig. 2 the woman is represented in the genu-pectoral position, with Bozeman's spring and self-retaining speculum in position, and a flexible catheter passed along the urethra into the bladder, traversing the fistula, and appearing through the lacerated cervix on the left side. Eleven silver sutures were used in closing the fistula and lacerated cervix, which was successfully done at one sitting. Not a drop of urine passed into the vagina after the operation. I found it no easy task to pass the needles above the vaginal insertion on the right side, so as to include the bottom of the fistula. The sutures were removed on the eleventh day. During all this time a celluloid catheter was worn without removal, as there were no signs of vesical irritation; and, when removed, it presented a somewhat sigmoid shape, as represented in Fig. 3, strikingly resembling Sims' well-known sigmoid catheter. The catheter was straight when first introduced. The warmth of the bladder rendered it so flexible that it readily assumed the shape imparted to it by the vesical walls, thus attesting the versa *The engraver should have curved the urethral end of the catheter a little more downwards, thus presenting a still more striking resemblance to Sims' sigmoid catheter. FIG. 3. tile genius of the world's most ingenious and most original gynæcological surgeon in fashioning an instrument for conducting urine from the bladder as soon as the ureters convey it into that organ. Unless great care and skill are exercised in so shaping Sims' catheter as to prevent the vesical end from resting on the fundus of the bladder, great vesical irritation, bloody urine, and violent spasmodic efforts to dislodge it sometimes ensue, and thus defeat the operation, as actually happened in one of my cases. From this cause, the catheter not being properly balanced in the urethra and bladder, Dr. Emmet has known perforation of the bladder and death to result in one instance. It occurred to me that a celluloid catheter would fulfil every indication, and the result happily verified the conception. In reviewing these cases it does not appear that, with the exception of the first case, the fistula in the other cases resulted from the use of the forceps. Dr. Emmet, it will be remembered, has never seen a case of vesico-vaginal fistula which could be referred to instrumental delivery; but, on the contrary, all of his tabulated 161 cases resulted from delay in delivery after impaction had taken place, causing an obliteration, by pressure, of the circulation through the soft parts of the mother. Indeed, he goes so far as to claim that half an hour of this obstruction may cause the most extensive loss from sloughing. So long as the head recedes during the absence of pains, although the latter may be violent, and intermittently impel it against the soft tissues of the mother, there is little danger; this begins when impaction occurs. He lays down the fundamental rule, as the result of his large experience, that although she may not remain undelivered until that time, the latest point at which it is safe to leave a woman undelivered is, when the head ceases to recede after a pain. Dr. Fordyce Barker, however, considers this rule unsafe and uncertain, as, in many cases of normal labor, the head ceases to recede in the intervals of pain; and his rule is, to apply the forceps as soon as the head ceases to advance, while uterine contractions are sufficient to accomplish delivery, if this is to be effected in a natural manner. Dr. Emmet's rule and Dr. Barker's are nearly in harmony; for practically, when the head ceases to recede, it almost invariably ceases to advance. Another point of the greatest importance brought out by an analysis of Dr. Emmet's 161 cases of vesico-vaginal fistula is, that in seventy of the cases, the average time after delivery before separation of the slough took place was nearly ten days. In some cases the delay was much greater, and in others much less, while in fifty women the urine escaped immediately on the termination of the labor. But this fact does not of necessity prove that a slough had formed, which became loosened only as the child was extruded, as Dr. Emmet seems to believe; because the discharge of urine, at that moment, may only have indicated that pressure on the urethra was removed by the birth of the child. At all events, in seventy cases the average time of separation of the slough was ten days, and that shows that, in those cases, immediate death to the parts did not occur. The fistula in such cases is evidently the result of inflammation caused by detention of the head, which, if neglected, ends in ulceration and sloughing. Now, if while these changes are going on, the patient were carefully examined on a table, in a good light, with Sims' speculum, the mischief might certainly be detected and promptly treated. In any case, then, of severe and protracted labor in which we have reason to suspect that impaction of the head has laid the foundation for the initiation of inflammatory processes, this examination should be made. And above all, when, by the touch, the vagina is found to be hot, tumid, and tender upon pressure, and the discharges are muco-purulent, or it may be foetid, and shreds of mucous membrane apparent, ought a thorough exploration to be made. The histories of some of the cases related prove how much can be done by a simple treatment in furthering the restorative process when large destruction of tissues has already occurred. The bladder should, in its paralyzed condition, be protected from the strain of over-distension by the insertion of a soft and flexible or celluloid catheter, which would readily adapt |