DEVELOPMENTAL DEFORMITIES OF THE BLADDER The navel as well as the anus is usually nearer the symphysis. The malformation occurs in various grades. There may simply be a cleft in the most dependent portion of the bladder; so that Desault, Paletta, Coates and Gooselin saw cases in which under the relaxed. but not open symphysis there was a fissure I of an inch long. The cli toris may be cleft: (Fissura vesim inferior; Fig. 16.) In a more marked case, where the lower part of the abdominal cavity and the pelvis is nor mal, and the external genitals, urethra, and the lower half of the bladder in their usual condition, the cleft is higher up, near the navel: (Fissura vesicle superior; Fig. 17.) Closely related to this latter is patency of the urachus: (Fistula vesico-umbilicalis.) It may be open throughout its en tire length, and open externally at the navel ring. Finally, in the high est grade of fissure of the bladder the entire anterior vesical wa,11 seems to be absent. The lower abdominal region is usually shortened, the navel being approximated to the pelvis; the abdominal wall is cleft, anti the gap is filled with a swollen red mucous membrane which is continu ous with the external skin at the edge of the orifice. The mucosa of the bladder is wrinkled, thickened, moist, and shining; its edges may be dry and covered with a thick layer of epidermis. At the lower end of the bladder is the urethral orifice. The pubic arch is never completely closed; the imperfectly developed pubic bones are to 3 inches apart, and are only connected by a fibrous band. This diastasis of the pubis is found even in the new-born, as Dubois, Dupuytren, Mery, and Littre have shown. The urethra is usually entirely absent. The clitoris is bifurcated, each part being situated above the atrophied labium majus of that side, or it may be entirely absent. Below this is the hymen, with a vagina, or perhaps unperforated. The vagina may be absent, as in Herder's and Eschenbach's cases, or it may be, like the uterus, divided by a septum. Atresia of the vagina and imperfectly developed ovaries also occur with this, the most advanced form of vesical fissure. It may be called " eversia" or " extrophia vesica3." Occasionally the posterior bladder wall prolapses through the anterior opening, giving us inversio vesicm cum prolapsu per fissuram, which is to be distinguished from inv. v. c. prol. per urethram and i. v. c. p. per umclium, to be described later. As a rule they are much dilated, and can easily be found with the sound; Isenflamm found them dilated to 9i and 14 lines, Petit to 2 inches, Flajani and Bailie to 4 inches, Desnalt to 3 inches, and Littre to 21 inches with small calculi in them. Their course is usually altered, lying very deep in the pelvis, and then ascending to the bladder. But they are not always dilated. Bann in 1818 found them of normal length and diameter, and I have myself seen a case (1.c.) in which neither they nor the kidneys showed any change.
The six cases of Roser, Gosselin, Kleinedacher, Moller, Moricke, and Frommel are very rare and peculiar varieties of female epispadias. The external genitals, clitoris, frenum, and prepuce, were cleft, and between them was a deep furrow which led to an opening in the anterior vaginal wall behind the introitus. The urethra was absent or very defective.
In Willer's case ' there was an oval opening which stretched from the navel to the arch of the pubis, the muscular tissue, fascia transversalis, and peritoneum being intact; the clitoris was split, and the fissure ex tended down to the anus. The pelvis was split; the urethm was short and wide, and opened into a very small bladder. In the case of From mel's the anterior urethral wall was absent save a piece about Tair inch long, and the posterior wall was occupied by a vividly red tuberculated mucous membrane. The pelvis was normal.
understand the origin of these vesical malformations we must glance at the manner in which the bladder itself is developed. The allantois, the original urinary bladder of the embryo, originating as a blind sae proceeding from the intestine, is derived from the intestinal layer. It arises in consequence of the pressure exercised by the urine excreted by the primitive kidneys and collected in the cloaca. In the human sub ject it is only present for a short time, and is originally double. In the fourth week of pregnancy it has already disappeared; but it may retain its original double form beyond the usual time, in consequence of cer tain hindrances to its fusion. Rose and Creve think the absence of the symphysis ossium pubis is the hindering cause. Meckel considered the bladder to be originally a simple plate, which only became a cavity from the growing together of its edges. Duncan, and later A. Bonn, and after them B. S. Schultze, Thiersch and others, claimed that the cleft was due to atresia of the urethra with dilatation of the bladder, which first parted the two recti muscles, then separated the cartilaginous pubis, and even tually split the bladder. Klebs ' thought that there must be some more general cause existent, since it often occurred together with fissures and failures of development of other parts, such as fissura labii, anencephalus, spina bifida, etc.. E. Rose, on the other hand, explains every case of vesical fissure as being due to the persistence of the urachus, which has remained patent in consequence of disturbances of urethral development. He c,alls attention to the fact that in fresh preparations the edges of the bladder are smooth, and show no traces of cicatricial tissue. He only admits rupture as a cause when plain traces of it are present. Morgelin also was inclined to think that overfilling of the bladder would lead rather to a reopening of the urachus or a rupture into the peritoneal cavity than to a splitting of the anterior abdominal wall. He therefore assumes that the allantois must rupture before the abdominal wall is closed in front. On the other hand we must notice that Hecker (Klinik I. p. 122) extracted a fcetus with atresia ani vesicalis and an enormously dilated but whole bladder, when there was a cicatrised rupture of the abdominal walls; this would doubtless have rendered possible a future rupture of that wall, and of the bladder.