practised. As the case improves the intervals between the treatments should be lengthened.

This local treatment should always be combined with the general treatment already prescribed-rest in bed if possible, a milk diet, and the administration of boracic acid internally.

Application through the Endoscope.-If the endoscope is used in the first place for diagnosis in a case of chronic cystitis, much time that might otherwise be wasted in unnecessary or useless forms of treatment may be saved. The condition of the parts may be accurately determined, and the proper form of treatment may be instituted. It may, for instance, be seen that deep ulceration is present, or that other lesions of the bladder are so extensive that the quickest plan of cure will be to proceed immediately to the formation of a vesico-vaginal fistula, without attempting to treat the disease by applications.

Applications may be readily made through the endoscope to any part of the interior of the bladder. Applications made in this way are most useful when the disease is localized. Stronger solutions may be used on the affected areas than when the application is made to the whole surface of the organ.

When the disease is limited to the vesical triangle or to local areas situated elsewhere, the inflamed spots should be touched with a solution of nitrate of silver (gr. v-xx to 3j). Much benefit is frequently derived from one such application, in connection with the general treatment already indicated. The applications may be made every few days. The procedure causes less discomfort to the woman as she becomes accustomed to it.

Cystotomy.-In cases of ulceration of the mucous membrane, or when the disease has resisted the milder forms of treatment, it may become necessary to perform cystotomy, to furnish an opening for the continuous drain of the urine, and to put the bladder at rest by relieving it from all functional action. This is a most valuable therapeutic operation in cases of obstinate cystitis.

In performing cystotomy the anatomical relations of the ureters and the internal orifice of the urethra must be kept in mind. It will be remembered that the ureters terminate in the bladder at points situated from 1⁄2 to 34 of an inch from the median line.

The course of the urethra is indicated by the anterior vaginal column, which is a single or double thickening

FIG. 188.-Illustration of the position of the incision in vaginal cystotomy, and the relations of the urethra and the ureters: A, anterior vaginal column; B marks the position of the internal urinary meatus; C and D mark the orifices of the ureters. The distance from C to D varies from 1 to 1 inches. C, B, D is approximately an equilateral triangle.

of mucous membrane traversed by short transverse folds or ridges. It begins near the external meatus and extends upward for about an inch. The internal meatus may be very approximately located by the upper end of this anterior vaginal column. The incision into the bladder should be made in the median line above this point.

The operation should be performed under the influence. of an anesthetic. The woman should be placed in the Sims or the dorso-sacral position. The anterior vaginal

wall should be exposed with the Sims speculum. A sound should be passed into the bladder, and its point should be pressed against the posterior vesical wall toward the vagina, at the position where the incision is to be made. The incision should be made into the bladder through the tissues fixed on the point of the sound. The opening may then be enlarged with the knife or scissors. The opening should be from 1 to 11⁄2 inches in length. In order to prevent spontaneous closure of the fistula, the mucous membrane of the bladder should be sutured to the mucous membrane of the urethra around the margin of the fistula.

The after-treatment consists in daily washing of the bladder with large quantities of sterile warm water or with the boracic-acid solution. The woman should be placed in the dorso-sacral position, and the fistulous opening should be exposed by the Sims speculum. The water should be introduced into the bladder through the urethra. Care must be taken to hold the edges of the fistula open, so that there may be a free channel of escape.

The patient should at first remain in bed. After the acute symptoms have disappeared she may get up and the frequency of the local treatments may be diminished. Various appliances have been introduced for receiving the continuously escaping urine. None of them, however, are satisfactory. They are difficult to keep clean, they cause pain, and they are liable to become displaced. The best method is to wear a vulvar pad of some absorbent material and to pay strict attention to cleanliness. The progress of the case may be determined by examination of the urine, and by examination of the vesical mucous membrane through the fistula or through the endoscope.

The time required for cure may extend from one to six. months.

When the vesical membrane has been restored to a normal condition the fistula may be readily closed.

Vesical Calculus.-Stone in the bladder is less com

mon among women than among men. This fact is probably due to the greater size and dilatability of the female urethra, on account of which small calculi may readily

pass out.

The symptoms and methods of diagnosis of vesical calculus are similar to those in the male. The stone may often be palpated by bimanual examination.

Treatment.-Small stones uncomplicated with cystitis may be crushed and removed through the urethra. Large stones should be removed by cystotomy. Whenever cystitis is present, it is advisable to perform cystotomy and to make a permanent fistula until the cystitis is cured, when the opening may be readily closed.

CHAPTER XXXVIII.

GONORRHEA IN WOMEN.

GONORRHEA in women has been considered disconnectedly in the preceding pages as one of several pathological conditions that affect the different parts of the genital tract. A more connected discussion of the subject will be of value, in view of the frequency of the disease, its often unsuspected or insidious character, and the serious and fatal lesions that it may produce. Lying between the two specialties of venereal diseases and gynecology, it is often ignored or slighted by both.

Acute gonorrhea in the female is much less frequent than in the male. It is rare in the gynecological dispensaries of Philadelphia to see acute gonorrhea of any part of the genito-urinary tract.

The disease is very often subacute or chronic from the beginning, and is not, as in the male, always preceded by a period of acute invasion, the symptoms of which necessarily attract the attention of the patient and the physician. For this reason gonorrhea in the woman is very often overlooked. We can as yet form no accurate estimate of its frequency. Certain lesions, such as pyosalpinx, which may be the remote result of gonorrhea, are often, especially by gynecologists, indiscriminately attributed to this disease without anything like sufficient evidence of such a causative relation.

The fact that the husband may at some time of his life have had gonorrhea, or even that the woman may have had gonorrhea, is no evidence that a pyosalpinx that appears in later years has been caused by this disease. There are many other causes of pyosalpinx besides gonorrhea. The frequent causative relation of sep