CONGENITAL ANOMALIES.
Fissure of the Anterior Wall.—The most frequently observed con genital anomaly of the bladder is a fissure in the anterior wall. This is produced by defective union of the right and left halves of the body in early embryonic life, and varies in degree all the way from a failure in the development of the anterior urethral wall to a fissure involving the lower part of the anterior bladder wall, or one extending up the anterior abdominal wall a variable distance, reaching as high even as the umbilicus.
In the mildest form of this defect, in which the anterior urethral wall alone is involved, there is incontinence of urine, the clitoris is divided into right and left halves, but there is no separation of the symphysis pubis. In two cases related to me by Dr. C. P. Noble, of Philadelphia, the other genital organs were normal. • In the more extensive eases involving the anterior wall of the blad der there is often an eversion, or exstrophy, of the bladder walls through the opening. In these cases the ureteral orifices may readily be seen with the urine discharging intermittently from them. The ureters are frequently found to be dilated.
I will briefly indicate the line of treatment without going into detail. Where there is a simple slit-like defect, the sides of which can be approximated without difficulty, the appropriate operation is a denudation of the margins of the openings and approximation by suture. Where the defect is more extensive, and a urethra exists,
the best plan of treatment will be by sliding flaps, taken from the neighboring portions of the abdominal walls, over the exposed por tion and uniting them by their edges.
Double Madden—Cases of division of the bladder into two halves are exceedingly rare, and as a rule found only in very young chil dren. The only adult case on record is that related by Gerard Blasius, of Amsterdam, in his " Observationes Medicce Rariores," published in Amsterdam, in the year 1700. His eighteenth observa tion, on page 59, is as follows : " A divided urinary bladder. Second case. Seen on the tenth of January, 1657, at the post-mortem ex amination of a patient who died of phthisis. The exterior of the bladder exhibited simply a depression throughout its length, but the interior was divided into two cavities by a thick membrane extending down to the urethra, into which each cavity emptied. Each cavity was provided with but one ureter. It was possible by dissection to separate the bladders completely." The condition found is well shown in his twelfth figure on page 114.
Other cases similar to this are those in which vertical septa are found dividing the bladder less completely.