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 ℥j). 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 ½ to ¾ of an inch from the median line. [Illustration: FIG. 192.--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 1½ inches. _C_, _B_, _D_ is approximately an equilateral triangle.] The course of the urethra is indicated by the anterior vaginal column, which is a single or double thickening 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 1½ 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.