EXTROVERSION OF THE BLADDER.
Among the most distressing deformities to which the human body is liable is that where the roof of the urethra is absent in conjunction with fission and extroversion of the bladder. No more deplorable condition can be imagined, for not only does the individual, more frequently of the male kind, possess sexual desire he is unable to gratify, but the function of micturition is carried on in such a way as to be a constant source of personal distress as well as of annoy ance to others. Here not only are the parts fissured from the blad der downward, including the symphysis pubis, but the bladder pre sents the appearance of a fungating mass. The orifices of the ureters can generally be distinctly made out by the urine dropping from them, while the fissured penis projects at the base of the mass like a spout. The prostate is rudimentary. As already noticed, I can find no record of any male with this deformity who appears to have devel oped a large prostate. To remedy this condition various means have been employed. Of these I would mention certain plastic operations, having for their object the closing in of the protruding bladder so as to form a receptacle for the urine and a covering for the parts. To the late Mr. John Wood " we are indebted for what has been done in this direction, and a reference should be made to his papers by any one undertaking an operation of this kind. Various plans have been tried, having for their object the diverting of the urine by a fistulous track into the rectum, but I do not know of any results thus obtained which would induce me to repeat these procedures. An article on this point, containing a number of experimental observations, has recently been published by Dr. R. H. Reed." Mr. G. H. Makins " has re corded a case where, by means of a preliminary division of the sacro iliac synchowlrosis, he succeeded in diminishing the area above the pubes which required covering in by a subsequent plastic operation.
Such a proceeding, however, can only be resorted to in early life, Professor Trendeleuburg " placing the limit of age at five as being the most suitable. On reviewing what has thus been done for this class of deformities I am disposed to think that its relief will eventually work out most advantageously in the following way : By (1) the establish ment of a lumbar fistula with one kidney, preferably the right one, and (2) the removal of the opposite kidney as soon as the urinary fistula has been rendered permanent. In this way the whole of the urine would be voided through one fistula, means being taken to collect the excretion as it escapes. Dr. Gross " refers to a case mentioned by Mr. Henry Morris, "where about ten ounces of urine were passed daily into a receiver adapted to the loin, the patient suffering neither inconvenience nor discomfort." After the formation of one permanent lumbar fistula, the bladder surface being no longer saturated with urine, it would, I believe, be comparatively easy not only to close in the protruding mucous surface, but further, under these altered con ditions, to make a penis out of the fissured one which might permit of the performance of the sexual act. By the establishment of a sin gle renal fistula in accordance with such a plan, or some modification of it, as I have endeavored to indicate, there seems some hope of ameliorating the state of persons suffering in this way. To collect the urine as it drops from the lumbar fistula, an apparatus such as Dr. Meyer " suggests, in the shape of " a bustle" as worn by ladies, might be employed. Of mechanical appliances for the relief of the deformity under consideration, I can speak favorably of an apparatus made by Messrs. Tiemann & Co., of New York. It consists of a metallic or hard-rubber shield for application over the exstrophied bladder, to the lower extremity of which an elastic tube is attached leading to a bag buckled to the thigh for collecting the urine.