DEFECTS OF FORMATION OP THE BLADDER, OF THE URACHUS (Umbilical Fistula) Fleury described congenital absence of the urinary bladder in which death occurred from peritonitis in consequence of catheterization, which was made necessary by incontinence of the urine. Amongst the ex tremely rare conditions are to be mentioned a rudimentary reduplieation of the urinary bladder, witb its separation into several partitions.
Ectopia of the bladder (Figs. 11, 12. and 13 which occurs pre dominantly in persons of the male sex, and is generally combined with deformity, is of clinical importance. Ahlfeld characterizes this affection as "a fissure in the abdomen of an otherwise well formed foetus, which is lined with a bright red velvet-like skin the bladder membrane), which is constantly kept moist by the urine which trickles upon it. Below the fissure in t he abdomen and bladder are to he seen incompletely developed external genitals." The fiSSIIIT Of the abdomen and bladder may be accompanied by a complete separation of the bladder, and by an unnatural division between the two halves. To explain this anomaly, there have been brought forward theories of bursting and of incarceration.
Not. only the intestines, but other organs may participate in this deformity, thus Posenhaupt describes a fissure in the abdomen, blad der, and pubic bone with dislocation of tile kidney, absence of the right umbilical artery and two separate uteri. The affection may be healed during intra-uterine life. when it may be recognized by the presence of peculiar cicatricial bands (Kilister, Sonnenburg). It is of extreme clanger, because of the great liability to infection of the membrane, and it should be treated by an early plastic operation. Berger proved
statistically that the average duration of life is much shortened by this anomaly. Out of seventy one children, four of whom were still-born, thirty four died \Olen less than ten years olcl.
Patel described a cystic dilatation of the portion of the urachus which communicates with the bladder, in which the bladder was pressed upon by the urachus like a tumor with resulting retention of urine.
Fistula' al the urachas are in part congenital and in part acquired during intra-uterine life. According to Ledderhose, the first results from disturbances in the transformation of allantois into bladder and urachus. Another theory ascribes it to intra-uterine retention of the urine as a result of urethral strietures. Small umbilical fistula, of the urachus are not so very rare. -kn umbilicus which remains moist for a conspicu ously long time with surrounding excoriation, points to this anomaly, in the presence of which it may be possible to demonstrate a fine membrane lined with true epithelium, from which urine exudes. There often co exists deformity of the uret h r a (valvular blocking, strictures), and of the genitals. In undertaking to treat the condition we must con sider the possibility that urethral strictures may require simultaneous removal, bee flUSe after a pl as t ie closure of the fistula of the urachus, death may result from retention and from peritonitis. Even the use of a strong caustic in the fistula may endanger life in the same manner.