In another degree of malformation the cavity is formed, and the uropoietic and generative organs are completely separated from each other; hut the rectum, being a distinct organ, is nevertheless in connection with one of the said parts, by means of a sort of canal. In the female sex this communication is found between the rectum and vagina (fistula ani vaginalis congenita); in the male sex between the rectum and urinary bladder (fistula ani vesicalis congenita). The transition towards the natural state is nearest when the rectum opens into the urethra ; to this condition, when it is complicated with an imperforate anus, Papendorp has given the name of atresia ani urethralis.
b. Congenitalfissure ofthe urinary bladder.— Without a cloaca, and with a perforate anus, the interior surface of the posterior part of the bladder may lie exposed on the hypogas tric region (prolapsus, inversio, fissio vcsiece).
It then forms a red, spongy tumor, situated somewhat above the separated pubic bones, and involving the umbilicus, so as to give the appearance of a deficiency of the um bilical cicatrix. In male children the ori fices of the vasa deferentia are to be found on the inferior part of the tumor. The ure thral orifices are papillary eminences on the naked internal surface of the bladder. The urine drops continually out of them, but may sometimes be seen to issue in a small stream. The pubic bones are widely apart, sometimes with an interspace of four inches. They have no intermediate cartilage, but are merely united together by a ligament, without form ino a synchondrosis. The consequence of this is a very peculiar reeling in the walk of the malformed subject, and a great disposition to inguinal hernia, due to the absence of suf ficient support at the interior surface of the body. The penis is fissured on its superior surface (epispadias). The testes are, even in adults, very small, and often retained in the abdomen or in the inguinal canals. The seminal vesicles, the prostate and the vasa deferentia, offer various deviations. In the female sex the labia majora and minora are separated and without a commissure at their upper part. The vagina is often closed or very narrow. The anus is more protruded than in the natural condition.
Sometimes the penis is epispadiac, with a well-formed urinary bladder. In such a case, Bonn found, nevertheless, the pubic bones apart, but united by a ligamentous texture. Although the continual dropping of the urine is a very annoyino. disturbance, which I contrived to remove annoying the means illustrated in figs. 603 and 604 , and although the generative organs are very incomplete, this malformation is not dangerous to life, which in several cases has been remarkably protracted.
c. Ectopia vesidc urinarice. — The smallest degree of deformity is when the urinary blad der remains intact, but lies in an opening in the wall of the hypogastric region. It is ecto pia vesicce urinarice, of which a representation is given in fig. 605.; and for more details I refer to my " Tabul ad illustrandum embryo genesin," etc., Tab. xxx.
d. Inversio vesicce uninarice. Prolapsus oe sica If the urachus mains open after birth, the urinary bladder may be expelled, and thereby inverted through it. R. Froriep (Chirurg. Kupfertafeln, Heft 67. Taf. cccxl.) has given an example of this malformation. It ought to he distinguished from the inversion of the bladder through the urethra, which is possible even in adult women (Voigtel).
If we take a general survey of all these cases of non-closure of the hypogastric region, it is evident that they are intimately connected with one another.
The cloacal disposition is the highest, the edopia of the urinary bladder the lowest, de gree of malformation, and therefore the latter is a distinct transition towards the natural con dition. The inversion of the urinary bladder
observed by Froriep has, as to its origin, no direct relation to the other forms. It is but an accidental effect of the remaining open of the urachus, through which the bladder chanced to become inverted, and the urine flowed away through the urethra if the child was held up right. From the gradual transition of one form into the other, I conclude that the origin of this malformation cannot well be attributed to a mechanical cause, as Duncan and Bonn have asserted nearly at the same time. They both consider it the effect of a preternatural accumulation of urine, causing a violent dis tension, and later a rupture of the bladder, of the urethra, of the hypogastric region, and of the pubic articulation. This theory had already, in the year 1816, a very strong oppo nent in my father (Verh. d. le kl. van het Koninkl. Nederl. Instit. D. II. B. 88). His chief arguments against it, to which I add my own, are : 1. That, if the urinary bladder bursts, as may happen in adults, the urine will be evacuated into the abdominal cavity, without fissuring the anterior wall. 2. That it is improbable that in some cases such an accumulation should fissure the whole apparatus, and in others re strict its effect to the corpora cavernosa, penis, and the urethra, as may be seen in simple epispadias (W. Vrolik, Bosson, Sals mann, Morgagni, and Oberteuffer). 3. That by an observation of Baillie is proved, that in fissure of the urinary bladder the posterior part of the urethra may remain intact and closed, while the corpora cavernosa are fissured at the anterior part of the penis. 4. That I have often found in the foetus atresia urethra com plicated with an unusual expansion of the urinary bladder and of the ureters, but with out the least sign of bursting or of producing the malformation in question. 5. That ectopia of the urinary bladder demonstrates that the anterior wall of the abdomen may be open, the urinary bladder remaining intact ; or the sup posed effect may exist, when the cause is absent. From all these and other remarks and observations I conclude that the origin of this malformation is not to be found in a mechanical cause, neither internal nor external (goose). I am much more inclined to ascribe all its different forms to arrest of develop& ment. My chief grounds for this opinion are the frequent coexistence of : — 1. The want of arterice hypogratricce (G. Vrolik); 2. Ab normal condition of the kidneys and the ure ters (Pinel, Cooper, Isenflamm); 3. Fis sured dorsal vertebra: (Littre, Revolat, Delfin, G. Vrolik); and many other malformations, as labium leporinum (Dupuytren, Meckel), con fluent toes (Saxtorph). The only question which remains is, what is the cause of this imperfect developement ? As to the cloacal formation, it is certain that it may be said to he an arrest at an earlier period of evolu tion ; but this is not certain with regard to the vcsica fissa. The origin of this can only be explained by an imperfect developement of the urinary bladder from the allantois. It is not improbable, as my drawing of the cloacal formation shows also, that the urinary bladder is formed by two half-parts, which approach each other anteriorly and posteriorly on the mesial line. if this junction does not occur, the different forms of vesica inversa will be formed. Atresia ani is, in the cloacal dis position, without doubt, an arrest of deve lopement at an early period of embryoge nesis; for previously the anus is closed. And epispadias shows that the penis is formed by two parts, which may remain separated from each other on the superior surface. Con sequently it appears, that the name of vesica inversa is as improper as that of vesica fissa. But I shall propose no other name, because we know sufficiently the meaning of it.