The degree of incontinence varies with the size and the position of the fistula. If the opening is small and is situated in the upper part of the vagina, there may be perfect continence when the woman is in the erect position, as long as the urine remains below the level of the opening. Incontinence returns when the accumulation of urine becomes greater than this and when the woman assumes the recumbent posture. I have seen a woman with a fistula of this kind who was only troubled with incontinence at night. The secondary symptoms of vesico-vaginal fistula are due to the irritation of the urine. Unless the greatest cleanliness be observed, great suffering may result within a few weeks after the receipt of the injury. The vagina, the labia, and the inner aspects of the thighs become inflamed and excoriated. The mucous membrane of the vagina may become covered with an offensive phosphatic deposit. If the fistulous opening be large, the fundus of the bladder may prolapse into the vagina and become covered with a similar deposit. Secondary kidney disease, from infection of the ureters, may follow in time. As the result of disuse the bladder becomes contracted, and its walls become thickened from inflammatory infiltration, so that when the fistula is closed the capacity of the bladder is much less than normal. Disuse of the urethra results also in contraction, which may be so extensive as seriously to complicate treatment. Physical examination usually reveals the condition. The woman should be placed in the Sims, the genu-pectoral, or the lithotomy position, and the anterior vaginal wall should be examined through the Sims speculum. The examiner should, of course, determine that the involuntary flow of urine comes from the vagina, and not from the urethra. Women are often unable to tell accurately whence the urine escapes, and the single symptom of incontinence of urine is not pathognomonic of fistula. In most cases the fistulous opening may be readily detected, and a sound passed through the urethra may be made to emerge in the vagina. In the case of small openings, however, obscurely situated in the upper part of the vagina, and especially in case of vesico-uterine fistula, it may be difficult to demonstrate the presence of a fistula. In such cases the bladder may be filled with sterile milk, which may then be seen escaping into the vagina. This is a valuable method of diagnosis in the rare cases of uretero-vaginal fistula. _Treatment._--The method of curing vesico-vaginal fistula was taught to the world by Marion Sims, who operated successfully in 1849, and who published his first article upon the subject in 1852. Careful preparatory treatment before operation is usually necessary. Unless the vagina and the bladder are in a healthy condition beforehand, every method of operation is likely to fail.