A CASE OF EXTROVERSION OF THE BLADDER IN A FEMALE TREATED BY OPERATION. BY EDWARD BARKER, SURGEON TO THE MELBOURNE HOSPITAL, AND LECTURER ON SURGERY IN THE UNIVERSITY. COMMUNICATED BY T. HOLMES, F. R. C. S. Received June 14th.-Read June 28th, 1870. J. O. S, æt. 17, a native of the colony, a dressmaker, was admitted into the Melbourne Hospital on the 7th August, 1868, suffering from congenital extroversion of the bladder. Her general appearance was healthy, with an inclination to stoutness, and she was rather below the average height. On examination the following conditions presented themselves. The posterior portion of the bladder projected in the form of a round red tumour, larger than a walnut, covered with mucous membrane, in which the orifices of the ureters could be seen discharging urine. Just below the tumour was a circular orifice about the size of a sixpence, and on introducing the little finger into it, the uterus could be felt about half an inch from the surface. The clitoris was cleft: there were large excoriations about the groins and between the nates. There were no labia majora and no umbilicus. The horizontal rami of the pubes were wanting. (See Plate IV, fig. 1.) She had menstruated regularly but scantily. After she had been made fully aware of the uncertainty which attended the experiment to afford her relief, she warmly urged that an attempt should be made. Accordingly, on the 1st October, after she had been brought under the influence of chloroform, I commenced to operate by dissecting off the skin from two opposite portions of the abdominal walls, each about one inch broad and three inches long, on either side the protruded bladder, beginning a little above the position of Poupart's ligament, and two and a half inches from the linea alba. Folds of the integuments on each side. were pinched up and a handled needle passed through from about one inch beyond the external limit of denudation and coming out just in the inner boundary, then entering the opposite denuded band and passing out as it first entered, about an inch from the external limit; this needle was then threaded with iron wire and withdrawn. Three of these sutures were made and fastened to the clamp used by Mr. Hutchinson for lacerated perineum. The superficial parts were brought together by interrupted horsehair sutures. Deep incisions were then made through the integuments outside the clamps, and the parts were dissected upwards and a little inwards to relieve tension. Strips of adhesive plaster were then passed from one side to the other, and the whole was covered over with lint soaked in diluted sulphurous acid. She was then put into bed in a sitting posture, and a silver tube was passed from below upwards under the band of integument covering the bladder, and kept there to prevent any accumulation of urine, and an opiate was administered. She suffered a little sickness the next day from the effects of the chloroform; she did not have any more pain than might have been expected. Everything went on favorably, and the deep sutures were removed on the fourth day, when the parts appeared to have become firmly united. There was no irritation from the superficial sutures, which were allowed to remain for several days. longer. On the 23rd of October she had an attack of pneumonia, which lasted for a few days, but her health was not sufficiently established until the 19th of November, when I proceeded with the second portion of the operation by denuding as before opposite bands of the abdominal walls two inches in length, commencing about three quarters of an inch above the top of the united flaps and inclining inwards towards the median line; these were brought together and treated as before; they united very well with the exception of one point just above the middle suture, which suppurated and left a fistulous opening. I did not do anything further until the 14th of March, 1869, as I wished the parts to get as consolidated as possible, there being no hurry, as no urine flowed over the cicatrices or about the parts previously excoriated, and as she was able to continue wearing the tube. It is also desirable, in all cases, to avoid operating during the heat of summer in this colony, unless it is urgently required. The third portion of the operation consisted in closing the interval between the pairs of lateral flaps, which was done by denuding a part on each side between the bands resulting from the first and second operations and bringing them together with one deep and two superficial sutures. The opening left above the uppermost band was roofed in by denuding the upper edge of the flaps and part of the adjacent abdominal walls transversely, and joining them by sutures; they fortunately united, and I closed the fistulous opening before mentioned with the actual cautery. July 4th. She has been out of the hospital for several weeks, walks about and attends to her business, and can |