Journal : Photographic review of medicine & surgery ; vol. 2., no. 5.
Philadelphia : J. B. Lippincott & Co., 1871-72.
Description : pp. 43-45,  pl. ; ill.: 1 photo. ; 24 cm.
Photograph : mounted albumen.
Subject : Bladder — Deformity.
IN the Transactions of the College of Physicians, published in the American Journal of the Medical Sciences for July, 1871, page 154, will be found a short account of two cases of Extroversion of the Urinary Bladder successfully operated on by the writer. The result being best shown by means of photography, it has been deemed proper to republish it, with a short account of the operation. One case only will be shown and alluded to, as in all respects the other is a parallel, both prior and subsequent to the operation.
The little patient here represented was six years and a half old at the time of the operation, and presented the following appearance : A deficiency of the lower and anterior part of the abdominal wall existed, so that the mucous surface of the posterior wall of the bladder was exposed and on a level with the surrounding skin. The lower portion of the bladder was partially concealed by the penis, which was short, inclined upwards, and flat upon its upper surface, where it presented a slight median longitudinal groove. The mucous membrane of the bladder was continued along the upper surface of the penis to the glans penis, which was flatter than usual. There was the usual well-marked deficiency of the pubic symphysis, likewise a double scrotal hernia. On either side, in the bottom of the hernial sac, could be felt a testicle.
The condition of the little fellow from early infancy had been most melancholy. The urine constantly spread itself from the surface of the bladder over the surrounding skin, thereby scalding it, and producing constant inflammation. The bladder and penis were incrusted with urinary salts. Every motion of the bowels, or the slightest collection of flatus in the portion of bowel contained in the hernial sacs, gave violent pain. Sleep could only be obtained on his hands and knees, or by lying on the back with the legs and thighs strongly flexed.
The operation has the merit of originality, and in brief the following were the steps of my procedure. The object was to cover in the bladder as much as possible, and at the same time so to fashion the flap as to guide downward and in one direction the flow of urine. In the first incision the knife was introduced at the raphé of the perineum below the herniæ and scrotum. Anterior to the verge of the anus, one and a half inches, a similar incision was made on the opposite side, which joined the first. This flap was then carefully dissected up, completely denuding the hernia; of their cutaneous covering. Both these incisions were continued in a curvilinear direction upwards over the outer third of Poupart's ligament. When the dissection was effected to the root of the penis, a valvelike incision was made in the flap, which allowed the penis to slip through. In this manner the flap obtained was amply sufficient to cover in the bladder. An incision was then made across the abdominal wall, and a trap-door flap dissected up. The lower flap was then inverted, so as to bring its cutaneous surface in contact with the mucous wall of the bladder. The edges of the lower flap were then carefully beveled, and by means of the tongue and groove suture of Prof. Pancoast it was brought under the trap-door flap and there firmly fastened. These steps constituted the operation. Owing, however, to a giving-way of portions of the flap, certain parts of the operation had to be twice reviewed. In the second case, only slight surgical interference was requisite at one point of the flap after the primary operation. The local dressing immediately after the operation was the oxide of zinc ointment, benzoated and softened down with oil of sweet almonds to the consistence of thick cream. As the result of these operations, the boys are to-day enabled to eat and sleep well, have no pain, and are more comfortable in mind and body. A urinal can now be worn, which collects the water as it flows from the bladder. The cicatrization of the flaps has cured the herniæ, the testicles being within the abdominal cavity. These operations may therefore be justly claimed as among the most successful performed for the relief of this distressing deformity.
PHILADELPHIA, 1218 Walnut Street.