was passed very superficially as to the inferior denuded surface-barely beneath it so as to escape the possibility of obstructing the vesical outlet for the urine. The second figure of Plate II, represents the appearance after the parts were brought in apposition, and the wires were twisted.

There was nothing special in the after-treatment requiring notice, save that the vesical pain and tenderness from which the patient suffered for the first few days, I found best relieved by washing out the bladder twice in the twenty-four hours, with warm water and laudanum.

The stitches were removed on the eighth day, and the cure was found o be complete. In a most grateful letter received from her husb few days since, I learn that Mrs. R. continues perfectly well, and rejoiced at the removal of the painful and disagreeable infirmity from which she had suffered for more than fifteen years.

A word or two in conclusion. No one can doubt, considering the anatomical relations between the ureters and the vagina, especially as shown by the illustration from Dubois, found on a previous page, the possibility of such a lesion as we have described occurring. Nor would any one after a careful investigation of our case, a thorough examination of the fistula, for a moment doubt the fact of its occurrence.

The existence of a uretero-uterine fistula has more than once been established, not only by symptoms observed during life, but also by actual post mortem examination. Now the antecedent improbability, the anatomical difficulty, is no greater of a uretero-vaginal than of a uretero-uterine fistula in each instance the natural outlet of a portion of the urine is closed, and it finds a new route to the exterior. In the case which we have reported, the urine traversed its abnormal channel for a certain distance in the vesico-vaginal septum before emptying into the vagina, just as in some cases of uretero-uterine fistula, a direct and immediate perforation into the uterine cavity has not been made.

As to the instances of uretero-vaginal fistula resulting from badly performed operations for vesico-vaginal fistulæ, I have never met with such; but that they might occur in this way, can be readily conceived, and the statement of Dr. Savage, op. cit. is distinct as to their having thus happened: my friend, Prof. H. R. Storer, in a recent letter to me, also states that the only examples of this kind he has ever known, had such origin.

I believe that, as stated in the first part of this paper, there is here recorded the first case of uretero-vaginal fistula as a primary lesion; and that there should be added an eighth variety of genito-urinary fistula occurring in the female, to the excellent classification given by Da Costa Duarte.

Case of Spontaneous Evolution. By JOHN LEWIS, M. D., Ogden, Ind. I was called to see A- M- an unmarried female about twentytwo years of age, and in her second labor, at 8 o'clock, P. M., September 4th, 1865.

About two years previously she had been delivered of twins, one being born naturally while the other, still-born, was brought to light by two physicians with a "pot-hook," which, during traction, slipped and probably caused a vesico-vaginal fistula.

The patient had a severe chill two days previous to my first visit, and another the day following. I found her in bed, countenance indicating severe pain, skin hot and feverish, bowels constipated. Labor pains had been in progress for several hours; os uteri dilated to the size of a dime, but firm and unyielding. Administered a cathartic, quinine and morphine.

Sept. 5th. Patient vomited almost incessantly since my last visit, ejecting a large amount of greenish colored fluid; uterine efforts ceased before midnight; had another chill this morning. Treatment of preceding day continued.

Sept. 6th. Saw patient at 2 o'clock, A. M. Strong uterine pains commenced during the night. Vaginal examination discovered the left shoulder and side of the foetus forced down into the pelvic cavity; the face towards the sacrum of the mother; the head over, and the shoulder under the right ramus of the pubis; the os uteri beyond reach; external genitalia well relaxed. In about one hour the back of the foetus began to present at the pelvic outlet, and the shoulder to pass upwards above the pubis. Four hours afterward, the head and shoulder had receded so far as to allow the breech to sweep the sacrum of the mother. At 7 A. M., labor terminated in the delivery of a dead and decomposing child of ordinary size. Owing to the entire absence of the umbilical cord, by which to guide my efforts, there was some difficulty in removing the placenta which was undergoing disintegration. The uterus contracted well.

Sept. 7th. Lochia, very dark colored and offensive in odor. Patient has been feverish since delivery, but rested comfortably during the night. Sept. 11th. Convalescence progressing rapidly. Some tumefacation of breasts, and pain along the course of the right sciatic nerve; these, however, yielded to proper remedies, and recovery soon took place.

Dr. Denman was the first to give "to this peculiar change of position, effected by nature, the term of Spontaneous Evolution;" his idea was that labor terminated as in breech presentation. This idea was for some