If there is a fissura vesicte superior or inferior, we must first ascertain whether the tension upon the edges of the cleft will be relieved by longi tudinal incisions through the skin some 1 to 2 inches distant. The edges may then be freshened and closed with a row of sutures. Unfortunately it is only in exceptional cases that we can obtain a complete cure by means of this operation.
In cases of actual inversion of the bladder, an operation was formerly unthought of, and our efforts were restricted to the applic,ation of appa rati to cover the vesical mucous membrane, and catch the urine. Such arrangements have been described by Fried, Stolte, Bonn, Lobstein, Rose, Stark, Jurin, Boyer, Breschet, Dubois, and others. A metallic capsule with a reservoir for urine attached to it is used, and the whole arrangement can only be of use when the patient is standing up. Wolfer mann has constructed an apparatus after Deunne, which, when the patient is recumbent, exercises an antero-posterior pressure upon the bladder, closing the vesical fissure and dilating the bladder, and making side-pres sure also upon the pubic rami, to draw them together. (See Fig 19.) Margelin's cases were three boys, and the penis was used to close the vesi cal fissure. Wolfermann's apparatus consists of (A) a metallic cup, pointed posteriorly, and fitting the perineum exactly, and reaching to just in front of the anus; (B) a metal plate extending from the upper edge of the vesical fissure down to the cup A, and united to it by a charnier, anti like it, covered with a solution of rubber; (C) spring-band, with pad, I), to approximate the pubic bones; (F) a belly-band to fix B; and (E) a reservoir attached t,o A, and hanging down between the legs. This ar rangement is said in three of Deunne's cases to have answered all the re quirements " as well as could be expected in a palliative apparatus for fissure of the bladder." In two cases the dilation of the bladder and the approximation of the pubes succeeded so well that there was no further obstacle to operative interference. Berend's apparatus is similar to this.
Gerdy in 1844. was probably the first to rectify by operation an everted bladder. Since be could not replace it, he attempted by a partial excision of the ureters to form a sufficiently large sac posteriorly; but the patient succumbed to peritonitis and nephritis. The proposition of Jules Roux,
in 1853, to form an artificial cloaca by separating the ureters from the bladder, and implanting them in the rectum, was indeed once successfully done by J. Simon; but the patient died twelve months later of peritonitis and exhaustion. His attempt to close the vesical fissure by means of skin flaps was unsuccessful, they becoming gangrenous on the fourth day. Ten years later, however, the attempt was more successfully made by John Wood and Holmes; and their results have been already criticised by Podra zk i, (Vol. III. Part II. of this book). The first surgeon who claims to have cured a female patient by this method was Ayres of New York. He took a long flap from the lower median part of the abdominal walls, turned the epidermic surface towards the cleft, and then united it to the skin at the edges of the vesical fissure. After Ayres, Wood operated once upon a girl eighteen months old, in whom the urogenital sinus was exposed by the vesical fissure, so that the cervix and os uteri were always wet with urine. W. took a flap from the skin above and on one side, turned their epi dermic surfaces to the bladder, and then covered both by a large flap from the other side; but the vesical mucous membrane pushed its way out below, bursting the delicate adhesions.
Ashhurst's case had greater success. He took from the skin below the navel a flap large enough to completely cover the defect (Fig. 20, A), turned it down, and covered its outer surface with the two side flaps B and C, so that their upper borders a b and a' b' met in the median line. The flaps were united by sutures, and on both sides of the upper one were passed soft iron wire sutures, which were then carried through the bases of the transplanted side flaps, and wound round small rolls of sticking plaster. Tension did not occur; the flaps healed by first intention; the last suture was removed on the eighth day, and the rest of the wound healed by granulation. Incontinence of urine persisted, however, in the upright position, so that the patient had to wear a urinal; when lying down, however, she could hold her water for two hours, and her general condition was greatly improved.