considered best, the catheter should be removed, cleansed of the adherent urinary salts, and reinserted; the track into the bladder will remain patulous for a short time. Should the obstruction be an enlarged prostate, and prostatec tomy be considered unwise, the patient may wear the suprapubic catheter for an indefinite time, withdrawing it every day or two for cleansing. Patients easily learn to remove and reinsert the catheter through the fistula; one elderly patient of mine wore the catheter in this way for six years. Another, who had a cancer of the prostate that prevented urination, secured entire freedom from urinary troubles during the last nine months of his life through this device. Other conditions in which the suprapubic catheter is useful are sometimes met, such as severe prostatic suppuration. In case the physician decides to make perineal section for an impassable stricture, a small curved trocar and canula can be passed into the bladder above the symphysis, and a filiform passed through the canula into the deep urethra as a guide; indeed, one is sometimes fortunate enough to pass the filiform through the stricture from behind, when it cannot be made to pass from in front. The Medical Fortnightly. TECHNIQUE OF OPERATION FOR PRIMARY BY DR. ROBERT W. STEWART. The gradual descent of a normal fetal head through a normal pelvis should not cause solutions of continuity in the soft parts, but narrowing of the bony parts of the pelvis and consequent pressure upon as well as stretching of these soft parts; the existence of old cicatrices in vagina or vulva, with the loss of elasticity; disproportion between fetal head and the canal through which it must be driven; the too rapid descent of the head; the failure of the head to flex at the perineum, and the consequent presentation of one of the greater diameters; the too rapid anterior rotation of the head in occipito-posterior positions; its failure to rotate completely, or, worse still, posterior rotations of the occiput-are all frequently met with, are all *Read at meeting of Obstetrical Society, of Cincinnati. deviations from the normal, and are all capable of producing more or less severe lacerations. Where instruments are used or other manipulations employed, the danger of producing tears is greatly increased. In short, it may be affirmed that but few. women escape at least the slighter tears, and many suffer griev ously from them, and the obstetrician is not always to blame. This affirmation is made in spite of the opinions of some obstetrical authorities. If it were not true, the gynecologist would have less work to do, at least in the way of plastic operations. Consequently, a very careful examination of the soft parts should be made immediately after the delivery of the child, in the interim between that and the expulsion of the placenta. This is easy of accomplishment, because the tissues are all distended and open to inspection. By separating the parts the larger lacerations are easily seen, but in order to avoid mistakes, the surfaces should be rubbed clean of blood with gauze sponges dipped in a solution of bichlorid of mercury (1.2,000) or lysol (1 per cent.); then by inserting the finger into the rectum and putting the vaginal tissues upon the stretch a complete view of the parts can be obtained. The result will be to show not only superficial tears, but the deeper and more important ones. To make this examination, the patient should be put upon her back and a strong light brought to bear upon the parts. The thighs should, of course, be flexed upon the abdomen. The degree of laceration should determine the subsequent procedures, for it is still a mooted question as to whether the purely superficial separation should be interfered with or not, for the good reason that most superficial tears will heal of themselves, and there is always a possibility of adding to the possibility of infection by adding stitch-holes to the already lacerated tissues. Per contra, it may be said that in this day of thorough asepsis the latter danger should not be a very great one. The rule should be that when the structures below the epithelium have been invaded it is safer to close the wound, especially those in the vagina, because stitching them does not give much pain. Where, however, the deeper structures are seriously wounded, and particularly where there can be no reasonable hope that the parts will be restored to their normal conditions by the natural process of healing, resort must be had to repair, the extent of which will necessarily depend upon the amount of damage which has been done. For those superficial wounds, those which go just below the skin or mucous membrane, a stitch or two will cause perfect closure; for those which involve fascia or muscle, the apposition of the edges should be made with all the care that one would exercise in bringing together the edges of any incised wound. It is of the utmost importance to make this coaptation particularly complete in the upper ends of the long tears, for thus the burrowing of the lochial discharge is prevented. Whenever the writer has been careless in these respects he has been chagrined at the poor results obtained. In his judgment, there are two factors which tend to produce bad results in the hands of even skilful obstetricians-failure to cleanse the wounds of blood and possible disease germs, and failure to bring the edges of wounds accurately together. In the hands of the incompetent or the careless, the opportunities for having bad results are practically too numerous to deserve mention. In very superficial tears the sutures should be made with chromicized catgut (ten-day), and may be running or interrupted. In the deeper wounds they should always be interrupted, for the simple reason that breaking of any part of a running suture lets down the whole structure, while the breaking of one interrupted suture does not invalidate the integrity of the whole, but only of a very small part. Another reason for preferring the interrupted sutures is that there is less danger of damage from the nozzle of the syringe in the hands of careless or incompetent nurses. In this connection it may be permitted to say that more than once the writer has viewed with alarm and indignation vaginal stitching that has undoubtedly been plowed up by a strenuous or careless nurse. Inasmuch as the vaginal tissues have not only been torn, but also distended and driven forward by the descending part of the fetus, the sutures-the alternate ones, at any rate-should be inserted a quarter of an inch from the torn margin, pointed downwards or towards the vulva, brought out at the bottom of the wound, re-entered at this point, and brought out again opposite the point of entrance on the other side. The object of this procedure is to draw the tisues more nearly into their normal position, and thus to insure more perfect coaptation and union. The stitches alternate to these may be drawn across the wound from side to side, and including the bottom of the wound. Thus the wounds are closed down to the perineum, and frequently nothing else is necessary, for the integrity of the parts may be thus so completely restored as to necessitate at most a superficial stitch or two to bring the edges of the skin together. When, however, the tear is down to the muscle or into it, the perineum must be restored by passing sutures, preferably of silkworm-gut, from side to side, entering just outside the torn margin, then passing deeply into the so-called body of the perineum in order to get a good purchase, and thence to the other side and out upon the skin at a point opposite to that of entrance. In those cases in which the tear is complete, the rectal edges of the wound should be brought together before putting in the perineal sutures. This is best done by entering the needle high up near the angle of the tear and just above the rectal mucous membrane, pass the needle at an acute angle to line of laceration to the extent of a quarter of an inch at least, and deeply enough to get a firm hold upon the tissue; bring the needle out at the point indicated and thence across to a point a quarter of an inch beyond the opposite line of tear and at a height which corresponds to that of exit, thence deeply through the tissues to a point just above the mucous membrane and opposite to that of original entrance. Tie each suture when completed, leaving the knot in the rectum. This is to be continued until the rectum has been restored, and then the perineal sutures should be placed. After the work has been done as far as has been indicated, the parts should be practically in the normal position, and as far as sutures can put them the integrity of the parts should be restored. It may be necessary to put an occasional additional suture into the vagina to bring the torn edges more completely together, but if the work has been carefully done not many such stitches will be needed. After catheterization and a vaginal douche of lysol solution. (1 per cent.), the parts should be covered with aristol or some other antiseptic powder, an occlusion pad applied and held in place by means of a T-bandage. If the stitches have been accurately applied there will be no necessity for frequent douching; indeed, the less frequently it is done the better, for the reason that if the lochial flow has not been contaminated there is no danger of sepsis from that source, and if it has been contaminated no amount of vaginal douching will do any good. There remains but one question to discuss how soon should the perineum be repaired? The answer would appear to be, immediately, for by so doing the danger from sepsis is materially lessened. At the same time so many contingencies may arise to make immediate operation inadvisable that the work must be postponed. Postponement for twenty-four or even thirty-six hours makes no appreciable difference in the healing process, but, of course, it does make a great difference in the danger of infection. ST. LUKE AS A PHYSICIAN. It is generally understood that St. Luke was a very learned and skilful physician. One of the most pleasing references to this great physician may be found in a sermon by the Rev. Arthur B. Conger, Rector of the Memorial Church of the Good Shepherd, Rosemont, Pa., on St. Luke's Day, October 18, 1908, and published in the New York Medical Journal, November 15th. It is probable that St. Luke was a freed-man, or one of the Libertini, born in Lucania, in Southern Italy. He completed his medical studies at the great school of Tarsus, where he met St. Paul and "learned Christ." His writings in the New Testament, especially his original writings in Greek, showed that he was highly educated in the broadest sense of the words. He was designated by St. Paul as "the beloved physician." We know that St. Luke and St. Paul saw much of each other, especially at times when the latter suffered great physical pain. When St. Paul and St. Luke met at Troas, it was after the former had been detained in Galatea "by the infirmity of his flesh." Again, when they met on the road to Jerusalem, St. Paul had had "the sentence of death in himself," and supposed he was dying; but the ministrations of St. Luke were given with great care and zeal, and were attended by such excellent results that the great apostle Paul was able to continue his good work for many years thereafter. After referring to some of the incidents of St. Luke's life, the rector spoke as follows about members of the medical profession and their co-adjutors, the trained nurses: "Now, here, if you will permit me, I wish to find the fundamental relation of the priest to the physician. It is personal. It is founded upon appreciation of gifts and culture, of fidelity to duty, which, when necessary, is so self-sacrificing as to border upon, if it does not often reach, the heroic. If I may be pardoned for momentarily giving this sermon a personal note, I should like to grasp |