BLADDER, ABNORMAL ANATOMY 



391 



in one of the two compartments no such mus- 

 cular investment is present. 



Exlrophy or extroversion. Extrophy of the 

 bladder was, up to a comparatively late period, 

 almost universally regarded as a hernia of 

 that organ; and it was not until about the 

 middle of the last century, and after Tenon 

 had dissected two such cases, that this opinion 

 was shown to be erroneous.* Tenon dis- 

 covered that there was a complete " absence" 

 or destruction of the whole of the anterior 

 parictes of the bladder ; and that the tumour 

 which is found at the hypogastrium is only 

 the posterior parietes of this sac, with the 

 " trigone " pushed forward by the abdominal 

 viscera, as if for the purpose of blocking up 

 the opening caused by the deficiency of sub- 

 stance below the umbilicus. On the surface 

 of the tumour which is there presented, and at 

 its inferior part, we see the urine almost con- 

 tinually exuding through two holes, pierced in 

 the centre of two small nipple-like eminences, 

 which are the orifices of the ureters. The 

 insertion of these conduits of the urine at the 

 inferior part of the tumour indicates that the 

 portion of the bladder, which appears upon 

 tlie exterior, is precisely that which, in the 

 natural state, is found most deeply situated in 

 the pelvic cavity, the internal surface of the 

 posterior and inferior portion of the organ. 

 The researches of anatomists have most posi- 

 tively confirmed these indications, by shewing 

 that in extroversion of the bladder the anterior 

 part of this organ is more or less completely 

 wanting, and that the posterior part is pushed 

 from behind forwards, through the large open- 

 ing which results from this absence, causing 

 a " hernia," either between the two pubes 

 and the two recti muscles, or, which is very 

 rare, only between the latter, the mucous mem- 

 brane being presented externally. IJy this 

 displacement the external posterior surface of 

 the bladder forms a concavity in which some 

 portions of the intestinal tube may be impacted, 

 as in a true herniary sac, especially when the 

 abdominal muscles and the diaphragm are 

 strongly contracted. The volume of the tu- 

 mour is on this account variable, not only as 

 between one subject and another, but in the 

 same subject at different ages. Thus in new- 

 born infants onlya slight projection is presented: 

 the tumour may not occupy a larger space 

 than from half an inch to an inch. In adults 

 it may project to the extent of two or more 

 inches and present a transverse diameter of 

 four or five. The tumour is then smooth and 

 frequently appears divided into two lobes. 



When extroversion of tlie bladder exists, the 

 umbilicus commonly is, as in the embryo and 

 the young foetus, not far removed from the 

 symphysis pubis, nor consequently from the 

 vesical tumour. The umbilicus is almost 

 always found immediately above the tumour. 

 Sometimes, however, the superior extremity of 

 the latter is observed beyond the umbilicus, 

 which is then entirely concealed ; and in con- 



Acr.il. dcs Sciences, 1761, torn, cxiv. in, 12 

 p. 67. 



sequence of this circumstance, some author 

 have believed that the umbilicus was not pre- 

 sent in infants affected with extrophy, and they 

 have drawn from this fancied absence phy- 

 siological consequences as erroneous as the 

 facts upon which they were based are ground- 

 less. 



This affection was until recently supposed 

 to occur only very rarely in the female; this 

 opinion, however, is incorrect. In many of 

 the cases on record the sex is not specified, 

 and it is not improbable that many women 

 may from a sense of shame be desirous of 

 concealing such a disgusting deformity. Even 

 with these reasons why the cases should be less 

 numerous, we have been enabled to collect 

 twenty-one examples. In women the affection 

 does not produce so much derangement in the 

 sexual functions as when it exists in man, 

 by whom, the penis being almost constantly 

 deprived of urethra, fecundation must be al- 

 most impossible. In the other sex, on the 

 contrary, the vagina being ordinarily free, 

 though more or less contracted, coitus may 

 have place, as in a well conformed female, 

 and fecundation may follow, as in the case 

 detailed by Drs. lluxham and Oliver and Mr. 

 Bonnet, of a woman who lived at Lantglasse 

 near Fowey ;* and that of Thieb.uilt, in \\hich 

 tlie delivery occurred through the perineum. 

 Among the anatomical varieties by which it is 

 accompanied, none are more singular than that 

 mentioned by Bartholin,t m which there was 

 neither anus nor penis, all the ingesta return- 

 ing from the mouth during forty years. 



It has been over and over again maintained 

 that this affection was incompatible with -long 

 life. The child of which llighmore speaks]: 

 was ten years old, and in good health ; the 

 case of which Montague speaks was at the 

 time a person of thirty ; that of Flajani || 

 was seventy. I3aillie,5[ Mowatt,** Innes,ft 

 and Labourdette4J all describe the cases of 

 adults. Quatrefages describes the cases of 

 a person of forty-nine and of another of forty- 

 six. 



Most authors who have written on this sub- 

 ject have strenuously maintained the constancy 

 of the separation of the bones of the pubis. 

 Duncan, even in spite of the case of Mr. 

 Coates, with the details of which he was fami- 

 liar, retained that opinion apparently unshaken. 

 We are in possession of the particulars of 

 cases in which no such separation existed, re- 

 corded by Coates,|||| Denman, Uoosc^U" 



* Phil, Transact, vol. xxiii. 1723, p. 408, 413, 

 and vol. xxxiii. p. 142. 



t Hist. Air-it, cent. iv. hist. 30, p, 293. 

 J Disquis. Anat. part iv. cap. 7. 

 Acad. tics Sciences, tome cxiv. iu 12:iio. 

 p. 67. 



|| Malattie Spettanti alia Chirurg. 178(5. 

 H Morbid Anat. p. 309. 

 ** Mem. do Desgrangcs. 



tt Arch. Gii'iicr. vol/ii. p. 206. 



Jt Journal do Sedillot. 



Theses dc Strasbourg, Uo. 1032. 



h|| V:.li,,: urgh Mi. I. Mid Sui'g. Journal, v, ! 



f^I DC uaiivo vcika; unuarix m\iis. 

 n 19. 



