When extroversion of the bladder exists, the umbilicus commonly is, as in the embryo and the young foetus, not far removed from the symphysis pubis, nor consequently from the vesical tumour. The umbilicus is almost always found immediately above the tumour.
Sometimes, however, the superior extremity of the latter is observed beyond the umbilicus, which is then entirely concealed ; and in con sequence of this circumstance, some author have believed that the umbilicus was not pre sent in infants affected with extrophy, and they have drawn from this fancied absence phy siological consequences as erroneous as the facts upon which they were based are ground less.
This affection was until recently supposed to occur only very rarely in the female ; this opinion, however, is incorrect. In many of the cases on record the sex is not specified, and it is not improbable that many women may from a sense of shame be desirous of concealing such a disgusting deformity. Even with these reasons why the cases should be less numerous, we have been enabled to collect twenty-one examples. In women the affection does not produce so much derangement in the sexual functions as when it exists in- man, by whom, the penis being almost constantly deprived of urethra, fecundation must be al most impossible. In the other sex, on the contrary, the vagina being ordinarily free, though more or less contracted, coitus may have place, as in a well conformed female, and fecundation may follow, as in the case detailed by Drs. lluxham and Oliver and Mr. Bonnet, of a woman who lived at Lantglasse near Fowey and that of Thiebault, in %%inch the delivery occurred through the perineum. Among the anatomical varieties by which it is accompanied, none are more singular than that mentioned by Bartholin,t in which there was neither anus nor penis, all the ingesta return ing from the mouth during forty years.
It has been over and over again maintained that this affection was incompatible with long life. The child of which Ilighmore speaksi was ten years old, and in good health ; the case of which Montagne speaks§ was at the time a person of thirty ; that of Flajani was .seventy. Mowatt, Innes,tt and Labourdette,tt all describe the cases of adults. Quatrefages §§ describes the cases of a person of forty-nine and of another of forty six.
Most authors who have written on this sub ject have strenuously maintained the constancy of the separation of the bones of the pubis. Duncan, even in spite of the case of Mr. Coates, with the details of which he was fami liar, retained that opinion apparently unshaken.
We are in possession of the particulars of cases in which no such separation existed, re corded by Coates,1111 Denman, Itoose,1111 Walther, and one of Quatrefages;* and there are still one or two others, about which some doubt exists. What proportion these cases would bear to those in which the separation was demonstrated, it is almost impossible to determine, because there can be no doubt that, of the numerous recorded cases, many of the descriptions appertained to the same indivi dual, the total number of cases being in my opinion much less than is supposed. It is easy to explain how this source of error has been introduced. The unfortunate persons who are subjected to this infirmity are often objects of general curiosity. They wander from town to town for the purpose of obtaining a livelihood by exhibiting themselves to me dical societies and to private individuals, and the history of a single person may thus be found repeated in the different periodicals of the same and even of different countries.
To determine the mode in which this vice of conformation is effected is very difficult. We cannot admit that Duncan'st explanation of the mode of its formation is correct, because it is opposed to every principle which we are ac customed to recognize as presiding over the developement of our organs. lie attempted to prove that an obstacle to the expulsion of urine affords a satisfactory explanation of this phenomenon, and he believed that the bladder, by its distention, removes the bones of the pubis from each other, ruptures the hypogas trium, and then disorganises itself. • We should have conceived that a very little reflexion would have removed from his mind so singular an opinion. The disease is almost always. conge nital, although during intra-uterine life the fcetus can have but little urine to void, and cannot, consequently, have a distended blad der. Duncan himself, however, strangely enough states the case of a little boy who was affected by the disease, although the urethra, placed in front of the root of the penis, strongly curved towards the anus, allowed of the easy passage of the renal secretion. And there are cases on record well authenticated, where no separation of the pubis existed. Isenflamm also states that the disease was manifested, in his experience, ten weeks after birth. The opinion of Duncan, therefore, cannot, it is apprehended, be sustained.