water.

support of the catheter, which was not withdrawn during the whole after-treatment, but kept open by passing a small wire and by injecting a little warm Removed on the seventh day, along with the suture apparatus, it left a complete closure, and the urethra measured about an inch in length. The patient could now lie dry for several hours; the urine was then, for a few days longer, drawn off by catheter occasionally, until she could lie six or eight hours dry, and walk about for two or three hours at a time without any escape from the urethra, a result quite satisfactory, when we consider the complete destruction of the neck of the bladder. To obviate still further the remaining inconvenience, by increasing the retentive power of the bladder, we sought to afford a mechanical support to the cervix uteri and root of the urethra. The ordinary globe pessary seemed to answer best, and with a small scoop-shaped wire instrument, and a little instruction, the patient had no trouble in removing or replacing the pessary. We advised its removal at bedtime, and the use of astringent injections, the instru ment to be worn only when on her feet. This seemed to be the limit of surgical resources.

The nervous derangement in this case, and the constant pain at the neck of the bladder, had been due in great measure to endometritis, itself a consequence of the reflux of urine into the uterine cavity. Multiform sympathies, mental as well as physical, betray such irritation of its delicate lining membranes, and corre spond to the medical history of this patient. By months of a judicious treatment, with this indication

in view, she might have been restored to health and usefulness; but circumstances necessitated her returning home, and she was discharged September 7, after a thorough re-examination, and the completeness of the closures by our two operations having been verified in presence of several physicians. Five months afterwards, on revisiting New York, another examination, made in presence of Drs. Isaac E. Taylor and T. C. Finnell, attested the persistence of the improvement obtained, and permanence of the two closures. The general health was better than before, but pain was still complained of beneath the pubic arch.

Rents of the urethra, such as this case presented, are exceedingly troublesome. A catheter has to be worn throughout the after-treatment, to keep an outlet open for the urine, yet the weight of this catheter is very apt to compromise the closure of the rent. There is no way of raising and holding it quite steady at a fixed point by a sling, or other attachment to the exterior of the body, that can dispense with an intelligent and incessant vigilance. The stretching of a cord, the slipping of a knot, any loosening of the attachments of the sling, let the catheter down just so much so much upon the approximated edges of the rent, which it separates anew. A quarter of an inch of play suffices to spoil the results of an operation. Consequently a partial success can at best be expected, when the catheter is supported by these uncertain means, in connection with the simple interrupted suture. Only the upper angle of the rent is likely to remain closed. There is, however, one way of escaping this disaster; it is to dispense

with the catheter altogether, and to perforate the base of the bladder as an outlet for the urine during the process of reparation. Dr. Emmet (op. cit.), Case LXIV., on which he performed twenty operations with the interrupted suture, for the closure of a large opening in the base of the bladder, and re-establishment of a urethral channel, writes as follows:

"Thirteen sutures were used, but a gap was left in the line in front of the uterus for the urine to escape while the urethra was being afterwards extended."

In our case, an outlet already existed in the form of an enclosed vesico-vaginal fistule, and the preliminary step of a perforation in the base of the bladder was therefore unnecessary, if it had been desired. The closure of the rent by the simple interrupted suture should have preceded the final closure of the vesico-vaginal fistule, and in that way the catheter could have been dispensed with. A permanent cure of both lesions might in this way have been secured, but with the button-suture we could and did reverse this order, closing first the v. v. f., and afterwards the rent.

The question arises, whether our patient, after her second discharge by Dr. Emmet, who says nothing of the urethral rent, might not have produced it herself, by some misuse of instruments. We have met, in our somewhat extended experience, with so many injuries of this kind which had been ignored or passed unnoticed by other surgeons, that it would seem either that its bearing on the functions of the urethra and bladder was not appreciated, or else that it was regarded as irremediable by the forms of suture employed.

The application of the button-suture, as above shown in Fig. 2, cannot fail to strike every one as satisfactory. The edges of the rent are perfectly coaptated, and the outer end of the button, with a notch in it, is bent forward to receive the catheter and hold it steadily against the upper wall of the urethra, thus leaving the approximated edges of the rent on the opposite side free from all motion or pressure. The male elastic catheter, preferred in all cases, is especially adapted to this procedure. Nothing can fulfil more perfectly the important indications presented in the treatment of this injury, as the result in this and other cases proves.

The happy combination of the interrupted and twisted sutures, as embodied in this button-suture, could not be more beautifully illustrated. The result of its application in this operation is not more striking than in the first, which was performed for the closure of the remaining vesico-vaginal fistule, after three operations with the interrupted silver suture had failed in the hands of a surgeon whose skill is unquestionable.

It may be urged that the large original fistule had been already nearly closed before our button-suture operation; but, on the other hand, a miss was as bad as a mile to the patient, and the necessary removal of thinned cicatricial borders left the fistule enlarged to more than half its original size before the button-suture was applied. It might have been twice as much enlarged without in any way compromising the successful result.

The combination of principles embodied in the button-suture gives it a practical advantage over any other

employed, in the proportion of at least

to, or in

nine cases to four of average fistules closed. For the cure of patients, this difference in the results of the operations, severally, is still more important, because faith must be taken into the account, and the oftener a surgeon fails, the greater must be the reserve faith of his patient, in order to secure another chance of operating on her. Whatever be the surgeon's reputation, not more than half of his subjects will bear more than three or four operations. In the above case the limit of faith had been reached at the third operation, and the patient had gone home expecting to make no other effort to get cured. No persuasion, said she, could have induced her to undergo another operation; but a friend of hers who had been in the same condition, and had undergone five operations in the course of fourteen years, had at last been cured by our first application of the button-suture. To this fact she surrendered, and her faith has made her also whole after 17 years of suf fering.

With regard to our improved position, designated as the right-angle position upon the knees and chest, we have a word to say before concluding these remarks, for the difference between this and the knee-elbow position is not fully apprehended by the profession. Thus Dr. T. Gaillard Thomas, in reporting his case of "Vaginal Ovariotomy" (Am. J. Med. Sci., April, 1870), says that the patient "was placed in the knee-elbow position, secured upon the apparatus of Dr. Bozeman.' Now, if the patient were in the knee-elbow position, with her body and head declining at an angle of 45°