That urethral anomalies dispose to fissure of the bladder is demonstrated by the fact that in the male, where the urethra is much longer, and therefore more likely to suffer, vesical fissure is much more common than in the female. Thus Stadtfeldt found, among 14 cases of vesico-umbilical fistula, 12 in boys and only 2 in girls. It is interesting to note that Dr. Wunder of Altenburg, at the Zusammenkunft der osterlandischen Aerzte at Altenburg in 1831, presented two boys, aged respectively eight and eleven years, who both had inversio vesicle uritutrim congenita, and whose mothers were sisters. (Schneider.) The pelvic deformities to which we have alluded, the fissure and atro phy of the symphysis, the congenital luxation of both femora (as Voss has seen them with eversio vesicw), all occur as consequences of the same condition which causes the vesical fissure. The dilating bladder drives the horizontal rami of the pubes apart; the altered direction of the pubic bone and its atrophy leads to a lessening of the acetabular circumference, and a less perfect coaptation between it and the head of the humerus. (Voss.) fissure and fistula of the urachus are malformations which do indeed endanger embryonal life, but do not always lead to early death. Many of these children aro born alive, and they may even attain a considerable age. Lebert, in the Salpetriere at Paris, saw this deformity in an old woman. The red mucous membrane is usually very sensitive to the touch in the newly-born; and the urine may be seen trickling from the mouths of the ureters in its midst. The mucosa swells out as the in testines move about. If the opening is small, the mucous membrane may become inverted, either through the urachus, inversio vesicle per urachum, or through the vesical opening, i. v. per fissurum. If the orifice is very small, however, the trouble may subsist for years without inversion oc curring, as it did in Morgelin's case. If we replace the prolapsed mu cosa, and thus indirectly press upon the dilated ureters, the urine spurts out. Occasionally these persons can retain their urine to a certain extent. That occurs when there is umbilical hernia with the urachal fistula, and the posterior vesical mucous membrane is pushed by intestinal coils into the orifice of the fistula, and closes it for a time. Paget has described such a case, in which the hernial sac of the goose's egg-sized rupture was formed by the mucous membrane forming the posterior wall of the fistula; so no urine could escape when the hernia was prolapsed. If the patient desired to micturate, the hernial tumor receded as the first contractions of the bladder took place, and as it disappeared a fairly strong stream of urine came out of the opening. Then urine began to flow through the urethra, only coming through the umbilical opening again if the pressure was much increased.
And even with complete eversio vesicEe an occasional retainment of urine may be effected by the muscular tissue of the thickened bladder wall, it acting as a quasi sphincter. Thus Voss has recorded a case of a girl 2C months old whose urine did not easily flow off when lying quiet; her bladder wall was of an inch thick in its middle, and the mouths of the ureters ith inch long.
In more deeply situated vesical fissures the simultaneous oocurrence of inguinal hernia, as Bertet saw, may form a kind of cover for the fissure, and enable the patient to retain her urine. No such case is known to me.
As a rule the constant flow of urine keeps the lower margin of the fis sure red, eroded, ulcerated, painful, burning, and itching, and patient spreads a most unpleasant smell. It is remarkable that after a short time the epidermis spreads from the edges of the skin into the true mucous membrane. Sometimes we can see by observation of the mouths of the
ureters how completely independent of one another the two kidneys act; one secreting while the other is quiescent, or both acting at the same time. Occasionally the mucous membrane undergoes a change; fungous outgrowths appear, having a great tendency to bleed, and liable to be mistaken for malignant neoplasmata. Patients suffering from eversion of the bladder always have a peculiar, uncertain and unsteady gait, easily explained by the diastasis of the pelvic bones which accompanies it. Palette even noticed a marked limp. Of course the separation of the pubic bones alters the relations of the pelvic diameters to one another; the transverse will be considerably greater than the antero-posterior diameter; and this preponderance becomes greater as age advances, so that it may eventually become as 2 or 3 to 1 (Morgelin.) Females with vesical fissure may not only become pregnant, but may be delivered with out special difficulty, as the experiences of Huxham, 01liver, Bonnet,' Ayres, Litzmann, Giinzburg (2 cases) and Gusserow teach us. In Ayres's case, which was cured by operation, a prolapsus uteri occurred post par tum.
ago Tenon, Buxdorff and Castara recognized the tumor which they saw as the bladder; but they did not know that they were looking at its inner surface. Devilleneuve first had his attention called to it by the presence of the orifices of the ureters, and by the mucous membrane-like surface of the tumor. Bonn noticed that when he introduced his finger into the rectum, he could feel no bladder, but directly reached the inter-pubic space. The visible dribbling of urine from the surface, and the recognition of the mouths of the ureters and the thastasis of the pubic bones, ought to facilitate the diagnosis. Nor is the malady so extremely rare. In 12,689 new-born children with 27 mal formations, Sickel found it twice; I had one case among the 3,500 children that were born at the Dresden Institute from 1872-75. In 1833 Velpeau could mention over 100 recorded cases, and Percy claimed that he had met with over 20 persons so affected in his practice. I have alto gether seen it 5 times; 3 times in girls, 2 times in boys. Philipp has collected 21 cases of inversion of the bladder in girls. In Wood's 20 cases only 2 were in women.
Prognosis is decidedly unfavorable. Most children thus affected are sickly from birth, and die early. During life they suffer much from ulceration; and this, with the inevitable odor. renders the life of such as survive but a pitiful one. In addition to this only complicated and very burdensome apparatuses can be used to retain the urine; and operative treatment is difficult, very tedious, and only partially possible. But for cases in which the eversion is not complete, Ca8t3S of urachus fistula or simple fissure above or below the symphysis the prognosis is much bet ter, and treatment not unfrequently entirely successful.
has proved that out of 8 cases of fistula.of the ura chus treated by operative procedure, 7 are cured. He recommends in de pressed fistulte to freshen up the edges of the mucous membrane and the skin, and unite them with sutures. When the edges are fungoid a ligature or clamp must be applied. But it seems preferable to me to remove the abnormal growths, and proceed at once as first recommended. Occasionally after renewing the margins the introduction of 1 to 3 hare lip pins will cure the fistula in 2 to 4 weeks. (Paget.) M..Tacobi treated one case by pressure and another with the actual cautery, and was suc cessful in both.