392 



BLADDER, ABNORMAL ANATOMY. 



Walthcr, and one of Quatrefages;* and there 

 are still one or two others, about which some 

 doubt exists. What proportion these cases 

 would bear to those in which the separation 

 was demonstrated, it is almost impossible to 

 determine, because there can be no doubt that, 

 of the numerous recorded cases, many of the 

 descriptions appertained to the same indivi- 

 dual, the total number of cases being in my 

 opinion much less than is supposed. It is 

 easy to explain how this source of error has 

 been introduced. The unfortunate persons 

 who are subjected to this infirmity are often 

 objects of general curiosity. They wander 

 from town to town for the purpose of obtaining 

 a livelihood by exhibiting themselves to me- 

 dical societies and to private individuals, and 

 the history of a single person may thus be 

 found repeated in the different periodicals of 

 the same and even of different countries. 



To determine the mode in which this vice of 

 conformation is effected is very difficult. We 

 cannot admit that Duncan'sf explanation of the 

 mode of its formation is correct, because it is 

 opposed to every principle which we are ac- 

 customed to recognize as presiding over the 

 developement of our organs. He attempted 

 to prove that an obstacle to the expulsion of 

 urine affords a satisfactory explanation of this 

 phenomenon, and he believed that the bladder, 

 by its distention, removes the bones of the 

 pubis from each other, ruptures the hypogas- 

 trium, and then disorganises itself. We should 

 have conceived that a very little reflexion would 

 have removed from his mind so singular an 

 opinion. The disease is almost always conge- 

 nital, although during intra-uterine life the 

 fetus can have but little urine to void, and 

 cannot, consequently, have a distended blad- 

 der. Duncan himself, however, strangely 

 enough states the case of a little boy who was 

 affected by the disease, although the urethra, 

 placed in front of the root of the penis, 

 strongly curved towards the anus, allowed of 

 the easy passage of the renal secretion. And 

 there are cases on record well authenticated, 

 where no separation of the pubis existed. 

 Isenflamm also states that the disease was 

 manifested, in his experience, ten weeks after 

 birth. The opinion of Duncan, theiefore, 

 cannot, it is apprehended, be sustained. 



Those persons who believe this disease to be 

 a primitive monstrosity are divided into two 

 classes. The one suppose it to be merely an 

 organic deviation, in which the urethra is 

 placed above instead of gliding beneath the 

 pubis. This, however, is not the prevailing 

 doctrine; that which has obtained the most 

 general currency is based upon the theory of 

 arrested development. Supposing that the 

 two moieties of the body do not, until late, 

 meet upon the median line anteriorly, they 

 say, if, by any cause, the sides of the hypo- 

 gastric parietes cease to advance, the one to- 

 wards the other, during their allotted time, 

 the bladder will pass between them, and will 



* Theses dc Strasbourg, 1832. 

 f Edinburgh Med. and Sur^. Journal for 1805. 



soon lose its anterior moiety, supposing this 

 moiety to be already formed, from whence the 

 fungous state which it offers after birth. So 

 powerful are the authorities by which this mode 

 of explaining the phenomena is supported, so 

 completely is it said by the ardent supporters 

 of teratology to be in consonance with its 

 principles, that it would appear to be almost 

 heretical to support a somewhat different view 

 of the subject taken by M. Velpeau. He be- 

 lieves that extrophy of the bladder is not 

 simply owing to an arrested development, 

 first, because in the normal state the bladder 

 is neither split nor open, neither anteriorly nor 

 posteriorly; secondly, because the pubic circle 

 is completely formed before the bladder is per- 

 ceptible; thirdly, because the aspect of the 

 fissure that the urinary sac should present 

 never exists ; and, fourthly, because the theory 

 in question has for its support only such ana- 

 logies as do not appear to us to have been 

 completely established. If an hypothesis be 

 required, it appears to be more in conso- 

 nance with observation to assume that this 

 vice depends upon an alteration of the abdo- 

 men, either pathological or purely mechanical, 

 contracted during embryo life. The parietes 

 of the abdomen are extremely attenuated and 

 fragile up to between the second and third 

 months, and for some time beyond this the 

 parietes do not acquire any thing like the 

 density below that they do above the umbilicus. 

 At this time the space is so small between the 

 umbilicus and the sexual organs, that the 

 smallest fissure may become the origin of a 

 large ulceration, and such lesions are seen at 

 all degrees. Indeed it is scarcely possible to 

 set forth the variety of lesions to which the 

 young fetus is subject : fetuses have been 

 seen in which the parietes of the abdomen 

 were alone destroyed. In one of three months 

 the bladder was already comprised in such a 

 perforation, and the borders of the whole weie 

 so jagged, thin, and unequal, that it could be 

 referred to nothing else than a laceration. It 

 is held in this place, therefore, that extrophy is 

 frequently a disease, or the effect of a diseases, 

 but not a monstrosity ; an ulceration, a perfo- 

 ration of the penis or of the hypogastrium, 

 being the common point of origin. The 

 bladder is only secondarily altered. If the 

 fetus continues to live, the borders of the de- 

 stroyed bladder are united to the circumference 

 of the abdominal opening, or, at least, to the 

 posterior surface of the remaining portion of 

 the hypogastrium. The cicatrisation once ef- 

 fected, the rest is explained by the mucous 

 nature of the organic septum, which occupies 

 the place of the pelvic or abdominal parietes. 

 The umbilicus may or may not be implicated 

 in the loss of substance ; the pubes, which are 

 commonly destroyed, and not simply sepa- 

 rated as has been believed, may be also pre- 

 served ; and the vesical tumour may in some 

 cases only occupy a space of a few lines, 

 whilst in others it may implicate a great por- 

 tion of the hypogastrium. 



Those organs which are normally in relation 

 with the pubis present certain anomalies in 



