When the distention of the bladder can be clearly felt above the pubes, the sur geon may a curved trochar di rectly into its cavity, about an inch above the bone, as in the paracentesis abdomi nis. He should remember to direct the point of the instrument in the axis of the bladder; and not to urge it forwards when the resistance to the point ceases. Then the stilet should be withdrawn, and the canula pushed onwards. The latter part must be confined in its situation, and should remain in the bladder until the natural passage is re-established : or, af ter a few days. an elastic catheter way be introduced through it, and the canula withdrawn. If the bladder cannot be felt so distinctly, the surgeon may dissect down to its surface before he penetrates it with the trochar.
In operating from the rectum, a long curved trochar should be employed. The two first fingers of the left band serve as a direction to the instrument, which is firmly held in the right; and should be passed through the very middle of the projection caused by the distended blad der, care being taken to accommodate its direction as much as possible to the axis of the bladder. After forty-eight hours the canula may be withdrawn, and the ar tificial opening will serve until the natu ral passage is restored.
In women, the bladder should be tap ped above the pubes, although it might be done from the vagina.
If the surgeon should not be called in until the urethra has ulcerated, and the urine becomes diffused, it will be his duty to make free incisions, particularly in the perineum, for the discharge of that fluid, and to use those general means which arc likely to allay the constitutional irritation. He must then wait until the operations of nature have separated the sloughs caus ed by the urine, endeavouring, however, to introduce an elastic catheter, where he should allow it to remain. Poultices, fomentations, and the warm bath, should be resorted to, if there are any appear ances of inflammation ; and abscesses, or accumulations of urine, should be opened early and freely.
Incontinence of urine. Sometimes this fluid dribbles away without any sensation of the patient. Here paralysis of the bladder is the cause, and may be induced in various ways, as from injuries of the spine, over distention of the organ, &c. In the latter case, the urine should be carefully drawn off at regular intervals ; cold bathing, bark, blistering the sacrum or perineum, electricity, tincture of can tharides internally, &c. will be of service.
Sometimes thepatient can hold his urine to a certain degree, when an irre sistible propensity to evacuate it comes on. Here irritability of the bladder is the cause, and may be induced by bad piles, fistula in ano, &c. Opium, the warm bath, fomentations, diluting drinks, &c. may be resorted to, when no obvious cause appears.
Imperforate vagina. Sometimes the la
bia have their opposite surfaces grown together, leaving perhaps merely a small opening, through which the urine is im perfectly discharged, but marked with a line, showing the proper distinction. This may be congenital, or the effect of disease. Sometimes a thin membrane closes both the meatus urinarius and va gina in newly born children. In both these cases the use of the knife is neces sary ; and lint should be interposed be tween the divided surfaces. There is another form of the same mal-formation, in which the vagina alone is closed; and no symptoms appear until puberty, when the menstrual discharge does not flow. The uterus swells, and at last a kind of labour pains come on. Here the mem brane must be divided to discharge the accumulated menses, and the edges of the cut kept asunder.
Imperforate anus. The part may either be closed by a membrane, or be too con tracted to allow the feces to be evacuated. It may be rightly formed at its outer part, but terminate in a cul de sac ; or there may be no vestige whatever of anus. In the first species, a division of the mem brane is the remedy; and in the second, a dilatation of the contracted part by the crooked bistoury. If an obstruction; should be discovered within the gut, it may be perforated with the trochar, in troduced according to the course of the intestine. The latter species is attended with very little hope of saving life. The surgeon may cut in the situation of the anus, and follow his dissection along the sacrum, in order to find the end of the gut, which, when found, should be punc. tured.
Fistula in any. Any formation of mat ter near the anus is very likely to termi nate in this complaint ; the suppuration extends in the fat and cellular substance round the rectum, and sinuses form, hav ing small external apertures, and seldom healing without an operation. The com mencement of the disorder may be a phlegmonous abscess, attended with con siderable sympathetic fever ; or it may have a more erysipelatous character, spreading more widely, being more su perficial, and attended with depression of the powers of the constitution. The former is seen in young, strong, and healthy subjects; the latter in weakened, intemperate, and unhealthy constitutions. The parts in the neighbourhood of the disease are often affected ; and hence re tention of urine, stnuigury, prolapsus and tenesmus, piles, &c. are produced. The complaint sometimes begins in an indu ration of the skin near the anus without pain. This hardness gradually softens and suppurates. The matter may either point in the buttock, at a distance from the anus, or near this latter part, or in the perineum. It may escape from one open ing, or from several. Sometimes there is not only an external aperture, but ano ther internal one, communicating with the cavity ..:•he intestine.