SINUSES IN THE SUPRA-PUBIC REGION. Class 2.—Sinuses in the supra-pubic region leading into the blad der. These are of two kinds—(a) arising from abscess; (b) from wounds, surgical or otherwise. Abscesses in the supra-pubic region may be confined in the space known as the porta vesicce, and eventually open both into the bladder and externally, though they are apt to burrow considerably, and thus prove difficult to heal. Sometimes they are connected with caries of the pubic arch, or with disease of the symphysis. In the following case the course and treatment of these abscesses are illustrated : 1885 I saw, with Dr. H. W. Knowles, a woman aged about 20, under the following circumstances : Fifteen months pre viously she had some swelling and pain about the left groin. Three months, before I saw her an abscess formed above the pubes, which was opened externally, and found to communicate with the bladder. A sinus formed, which resisted all efforts to close it, including con tinual catheterism. When we saw her, the abdominal parietes were undermined, and urine welled up through the opening when the ca theter was removed. It was advised that the sinuses should be opened
up and the catheter again worn. This was followed with improve ment, but when the catheter was removed urine still escaped by the wound. Then we found, on further examination, that the urine had burrowed under the attachment of the left rectos muscle. This we divided close to the pubes, when the wound soundly healed.
Wounds and punctures made into the male bladder above the pubes, either accidentally or for surgical purposes, usually heal when there is nothing in the condition of the prostate or urethra to inter fere with the escape of urine by the natural passage, though they are sometimes tedious. Where there is a urethral stricture this must first be treated. A discharge of urine from the umbilicus, due to a congenitally unobliterated urachus, is occasionally met with. If there is any obstruction in front, such as a phimosis, or a. contraction in the urethra, this should be removed, and then an endeavor may be made to close the sinus by cauterization, or a plastic operation may be attempted, as already mentioned.