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SURGERY. 
too late. It may be done from the peri- 
neum, pubes, or rectum. The two latter 
places are so much preferable to the for- 
mer, that we shall describe those operations 
only. When the prostate gland is enlarged, 
{and such a case often requires the para- 
centesis vesicie) the operation must be done 
above the pubes : if the patient should be 
fat, it would be preferable to puncture from 
the rectum. When all circumstances are 
equal, experience has not hitherto disco- 
vered any very decisive advantage in either 
of these methods over the othei’. 
When the distension of the bladder can 
be clearly felt above the pubes, the sur- 
geon may plunge a curved trochar directly 
into its cavity, about an inch above the 
bone, as in the paracentesis abdominis. 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 stil^t should 
be withdrawn, and the canula pushed on- 
wards. The tatter part must be confined 
in its situation, and should remain in the 
bladder until the natural passage is re-esta- 
blished : or, after a few days, an elastic 
catheter may be Introduced through it, and 
the canula withdrawn. If the bladder cannot 
be felt so distinctly, the surgeon may dis- 
sect down to its surface before he pene- 
trates it with the trochar. 
In operating from the rectum q long 
curved trochar should be employed. The 
two first fingers of the left hand serve as a 
direction to the instrument, which is firm- 
ly held in the right ; and should be passed 
through the very middle of the projection 
caused by the distended bladder, 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 with- 
drawn, and the artificial opening will serve 
until the natural passage is restored. 
In women the bladder should be lapped 
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 become diffused, it w'ill be his duty to 
make free incisions, particularly in the pe- 
rineum, for the discharge of that fluid, and 
to use those general means which are likely 
to allay the constitutional irritation. He 
must then wait until the operations of na- 
ture have separated the sloughs caused by 
the urine, endeavouring however to intro- 
duce an elastic catheter, where he should 
allow it to remain. Poultices, fomenta- 
tions, and the warm bath should be resorted 
to, if there are any appearances of inflam- 
mation ; 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 blad- 
der is the cause, and may be induced in 
various ways, as from injuries of the spine, 
over-distension 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 cantharides internal- 
ly, &c. will be of service. 
Sometimes the patient can hold his urine 
to a certain degree, when an irresistible 
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 batli, fomenta- 
tions, diluting drinks, &c. may be resorted 
to when no obvious cause appears. 
Imperforate vagina. Sometimes the labia 
have their opposed surfaces grown together, 
leaving perhaps merely a small opening, 
through which the urine is imperfectly dis- 
charged, but marked with a line, showing 
the proper distinction. This may be con- 
genital, or the effect of disease. Sometimes 
a thin membrane closes both the meatus 
urinarius and vagina in newly bom chil- 
dren. In both these cases the use of the 
knife is necessary; and lint should be inter- 
posed between 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. Tlie 
uterus swells, and at last a kind of labour 
pains comes on. Here the membrane must 
be divided to discharge the accumulated 
menses, and the edges of the cut kept asun- 
der. 
Imperforate anus. The part may either be 
closed by a membrane, or be too contracted 
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 membrane 
is the remedy ; and in the second, a dila- 
tation of the contracted part by the crooked 
bistoury. If an obstruction should be dis- 
covered within the gut, it may be perfo- 
rated with the trochar, introduced accord- 
ing to the course of the intestine. The lat- 
ter species is attended with very little hope 
of saving life. The surgeon may cut in the 
