Further, the pelvic circumference may not unite, and there results a split pelvis, and also a split genital tubercle, and separation of all the organs developed from it: fissure of the clitoris, separation of the labia majors and minora.
The connection then between fissure of the abdominal wall and of the bladder, and absence of urethra with atresia of the anus and separation of the external genitals, is thus explained. We may also here mention the fact, although it does not belong to our subject, that through d inten sion of the allantois, the union and fusion of the internal genitals is inter fered with, since the distended allantois falls between Milller's ducts_ Herolies the explanation of bifid uterus and vagina.
Large fissures are almost always incompatible with life. Smaller ones, however, do not interfere with life, and can only be remedied by plastic operations. Let it be distinctly understood, however, that not every fissure of the lower abdominal wall or of the pelvic region, is due to trac tion on the omphalo-enteric duct or on the urachus. Only those fall in • this category which spring from the umbilicus downwards. All others, however, in which the defect is only below in the region of the bladder, and between which and the navel wide spaces of normal abdominal walls exist, can hardly be explained by traction exerted on the umbilical struc tures. Such cases occur, however, and to make clear my meaning, I refer to Bleinwtichter's observation of so-called lower fissure of the bladder (fissura vesica inferior). Similar cases have been recorded by Winckel, Gosselin, ROser, Moricke, Frommel.
In case of superior bladder fissure, however, the above explanation holds, seeing that, as the result of traction, an approximation of the um bilicus and of the symphysis occurs.
Defect of the bladder in its lower portion has been long described as epispadias, and this term is an excellent one. Epispadias in the male refers to cleavage of the penis at its upper portion. The corresponding organ in the female is the clitoris. This organ, therefore, in epispadias must be fissured, and the fissure must extend into the upper wall of the urethra. Recorded cases prove occasional prolongation of the fissure into
the bladder.
The prognosis of this affection has been much bettered, owing to the progress of plastic surgery. Roser's case and two from Schrader's clinic operated upon by Moricke and Frommel, were cured.
In Roser's case, a young girl of nineteen, troubled by incontinence of urine, had a fissure of the clitoris and of its prepuce. The halves were spread half an inch apart, and the nymphie were also separated. The region immediately below the symphysis was covered with smooth mucous membrane, and there existed an opening, patent for the finger tip, which was bounded below by the posterior wall of the urethra. The anterior wall was lacking.
Analogous cases have been reported by Gosselin and Testelin. In the latter's case the defect in the bladder opened into a canal two and a half inches long, right underneath the clitoris, and one inch above the mal opening of the urethra, and urine flowed indifferently through either. As explanatory of epispadias, the view held by Thiersch is the best, and applies equally to the female, although he enunciated it for the male. The uro-genital sinus is the anterior part of the genital furrow, and the posterior is the anus. In front the furrow is closed through fusion of the corpora cavernosa. For their union, however, the closure of the pelvic circumference is necessary. Thiersch claims that ordinarily this anterior closure occurs before division of the genital furrow into sinus nro-genitalis and anus. As the result of early closure the sinus uro genitalis is pulled forward, and thus a median septum is formed. In epis padias, however, the median septum is not formed, and the opening of the sinus uro-genitalis is so pulled forward that the corpora cavernosa do not unite and the anterior urethral wall is not developed.
Hypopasdias, or fissure of the urethra posteriorly, also occurs in the female. The posterior wall of the urethra is lacking, and the canal opens to a greater or less degree upwards in the vagina.