a false passage will be avoided. The walls of old false passages that have been kept open sometimes undergo changes similar to those of stricture, and therefore will grip an instrument after the manner of a stricture. The diagnosis in these cases is difficult, and must be made with great care.

False passages are produced most frequently by the use of small steel instruments, usually during an attempt to pass the instrument from the bulbous to the membranous urethra. The urethral walls in front of a simple stricture and in the course of a tortuous stricture are often so thinned and softened that they may easily be penetrated by a small steel sound, especially if force be used. When a surgeon has been unfortunate enough to make a false passage, he should recognize the fact, or he will continue and dilate the opening instead of the stricture. The perforation of the urethral wall by the point of an instrument gives the hand of the operator a sensation very different from that produced when the instrument passes through a strictured point in the urethra. The instrument is obstructed in its movements, but is not gripped as when it has entered a stricture. The direction of the handle shows that the point is not in the median line, and if the handle be depressed, it cannot be rotated as when the point is in the bladder. The finger on the perineum or in the rectum will probably distinguish the point of the instrument. On withdrawing the latter there is usually considerable hemorrhage.

The treatment of a recent false passage consists of rest, boric acid, urotropin, or salol internally, hygiene, and the avoidance, if possible, of all instrumentation of the urethra for two or three weeks. The damaged tissue usually becomes inflamed, causing a discharge of blood and pus for a few days, but under favorable circumstances. the wound heals in two or three weeks. Urethral fever, abscess, fistula, or even extravasation may result. Urethral Fever (Urinary Fever).-This much-dreaded

complication of stricture usually finds its exciting cause in instrumentation of the urethra. In some instances the urethral fever is apparently due chiefly to shock or to reflex influences, but in most cases it is undoubtedly the result of an acute toxæmia or septic infection. The urethra back of a stricture usually contains micro-organisms and their toxines capable of rapid absorption if the mucous membrane be even slightly cut, torn, or abraded, though there are evidences of such absorption in but a small minority of operations on stricture. Those cases in which nausea, syncope, or a chill occurs immediately after the insertion of an instrument into the urethra are undoubtedly due to nervous influence, and may result from the skilful passage of a smooth sound which has produced no damage to the mucous membrane. These instances undoubtedly differ widely from cases of urinary fever proper.

Some patients, usually those having damaged kidneys, lesions of the urethra or bladder, or septic urine, are peculiarly susceptible to chills and fever, which in a few individuals follow every attempt at urethral instrumentation. This susceptibility may suddenly develop during the treatment of a stricture, or it may as suddenly disappear. Occasionally this complication is one of the symptoms of a stricture, and disappears when the latter is properly treated. It occurs rarely after operations on the meatus, but it increases in frequency with the depth of the injury in the urethra, being most frequent after divulsion or internal urethrotomy of the deep urethra. In cases of old stricture, especially if complicated by bladder or kidney disease, the danger of a fatal termination is greatly increased.

The symptoms usually appear within twenty-four hours after instrumentation, frequently following the first urination. In other instances symptoms may not appear for two or three days. In typical cases there is a sharp chill, lasting from a few seconds to several hours, followed by fever of irregular duration, ranging from

100° to 105° F., and terminating in more or less profuse perspiration. The patient may be well in forty-eight hours, or a feeling of lassitude and malaise may remain for a few days. In very mild cases slight chills may be the only symptoms noticed by the patient. In severe cases the chill is sudden and violent, and is attended by great prostration. The skin is cold and livid, and there may be vomiting and profuse diarrhoea. Suppression of urine, uræmia, and death may occur within twenty-four or forty-eight hours. In yet other cases slight chills and mild fever may be followed by all the symptoms of septicæmia or of pyæmia, with a fatal termination.

The first chill may be followed by others without further exciting cause, and the fever may continue in an intermittent or remittent form. In these cases the symptoms do not conform in type and character to the first attack, but vary greatly. Finally, the fever may become chronic, and may simulate malaria except that the symptoms are more irregular and the disturbance of digestion and the impairment of nutrition are more. marked. The persistent forms usually occur in connection with disease of the bladder and the kidneys.

The treatment is chiefly prophylactic. The directions. already given for urethral instrumentation, including skilful and gentle manipulations, antiseptic precautions, and urethral hygiene, should be followed carefully. Of special value in this respect is the use of boric acid in doses of from 10 to 20 grains four times a day, its administration being begun forty-eight hours before operating and being continued for several days. In the case of some patients a chill may be prevented by a prolonged milk diet or by the use of morphine and pilocarpine just before operating. There is no specific treatment. for urethral fever after its development. The patient should be put to bed, and free perspiration should be encouraged by the use of blankets, hot-water bottles, hot drinks, and in some cases by the administration of jaborandi. If the urine is infected, urotropin should

be given in doses of from 5 to 8 grains, four times a day. Further treatment is purely symptomatic. Cardiac, and other stimulants and tonics are indicated in severe cases. Suppression of urine, marked albuminuria, or hæmaturia may call for dry cupping over the kidneys, hot vapor baths, large quantities of bland drinks, digitalis, etc.

Fistula. If fistulæ are small, they frequently close when the stricture is dilated. If they are larger and remain open, they should be treated on surgical principles.

Abscess has been considered in connection with Periurethritis. When complicating stricture of the deep urethra, external perineal urethrotomy is usually the best

treatment.

Extravasation of urine, if at all extensive, calls for prompt surgical treatment to secure free drainage and to prevent abscess, gangrene, and extensive sloughing of tissue. When the quantity of extravasated urine is slight, involving a small circumscribed region, is not enlarging, and is not interfering with micturition, incisions are not necessary. In such cases the treatment is directed mainly to the patient and to the stricture. Absorption of the extravasated fluid may be encouraged by rest and by the application of hot fomentations.

GONORRHOEA IN WOMEN.

GONORRHOEA in women has not been studied so long or so carefully as has the same disease in men. There is great diversity of opinion with reference to the frequency of its occurrence, its relation to other forms of inflammation of the organs involved, and the site of inoculation. Bumm and some other observers believe that gonococci never penetrate the vaginal epithelium, and that when found in a vaginal discharge they come from the cervix or body of the uterus. Other observers find that a vaginitis frequently is the first evidence of gonorrhoeal infection. It is certain that in the acute gonorrhoea of girls and young women vaginitis is usually the most prominent symptom. In older women, and especially in those who have borne children, the vagina is less easily inflamed, and the process is most marked in the endometrium of the neck and body of the uterus or in the urethra. In children infected as the result of criminal violence or by contaminated towels or other media, vulvitis or vulvo-vaginitis most commonly results. Practically there is little difference whether the site of infection be the vulva, the urethra, the vagina, or the uterine neck, since in the great majority of acute cases, excepting those of vulvitis in young children, the inflammation extends eventually to all of these regions, and also to the uterus, the Fallopian tubes, the ovaries, and the peritoneum. In the chronic forms the disease is most frequent in the vaginal portion of the neck of the uterus, in the pelvic organs, in the urethra, and in the glands of Bartholin.

In acute gonorrhoea of women the etiology, the modes of infection, the period of incubation, the development of

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