The principles and practice of modern surgery

by Roswell Park

The attempt will not be made here to picture nor go into a minute description of the various forms of the cystoscope. Their use, like that of the ophthalmoscope, requires special aptitude and training. With the latter they are of great value; without them they confuse and complicate. The cystoscope may be used for ordinary purposes of inspection, for aid in introducing the ureteral catheter, or even for photographic purposes, for it is now possible with the latest instruments to photograph the image thus obtained of the bladder interior. To one not accustomed to viewing the field seen in such an instrument these revelations are of little interest. To the expert, however, they may be made of the greatest value. Without further description, then, allusions made below to the use of the instrument must presuppose some familiarity with it, and the advantages and even necessity of securing special training in its use.

CONGENITAL MALFORMATIONS OF THE BLADDER.

The lesser malformations of the bladder include mainly irregularity in shape or the formation of diverticula, which are not extremely rare. These are especially likely to be met during hernia operations. I have repeatedly in operating for inguinal, and once in operating for femoral hernia, found a diverticulum of the bladder complicating the situation. Its possibility, then, should be borne in mind. It may be thin and lie in such close relation to the hernial sac as to be mistaken for the latter. When opened urine will escape and contaminate the wound. It would probably be best to close the bladder opening and discontinue the operation rather than run the risk of contamination of the peritoneal cavity, postponing further work for a few days. As the result of allantoic defects a double bladder may be met, each perhaps having one ureter opening into it. More or less complete partitions in the bladder are more frequently met. These conditions could not be appreciated previous to opening the viscus or the use of the cystoscope.

More complete forms of acquired vesical hernia may be found in such conditions as cystocele, common in women after perineal lacerations, and frequently constituting a most serious condition.

Ectopia or Exstrophy of the Bladder.

—By far the most serious and extensive of the congenital malformations are those constituted by more or less complete defects of the anterior portions not alone of the bladder, but of the abdominal wall which should cover it, and which are known as ectopia, exstrophy, or extroversion of the bladder. Of this condition there are different degrees, from a small cleft just behind the symphysis pubis, to that which is complicated by prolapse of the remaining posterior wall, the umbilicus being situated just above it, while the pubic arch itself is defective or rudimentary. Thus in the male there is usually epispadias of a more or less rudimentary penis, while in the female the clitoris is cleft and the vulva more or less opened, the urethra being defective or entirely wanting, the vagina often small, and the uterus generally infantile. Extreme cases of this condition constitute one of the most serious and deplorable congenital defects which are not inherently fatal. Obviously, with these conditions, there is constant escape of urine, usually with complete mechanical impotence, although in the female the ovaries are usually present, and practically always the testicles in the male. In the latter the opening of the seminal ducts may be frequently seen on the floor of the urethra, more or less concealed by folds of cystic mucous membrane. The condition is much more frequent in males than in females. The prostate is usually at least rudimentary and may be wholly wanting. Occasionally the testicles are undescended. Double uterus has also been seen in these conditions.

Regarding its causes there is but little known. Doubtless these have to do with allantoic defects, but the allantois is such a temporary organ that there would seem to be some other contributing cause not yet recognized.

Among its most distressing features are not only the lack of control of urine, but the irritation of the exposed mucous surfaces consequent upon friction with clothing, or decomposition of urine and consequent uncleanliness. There is, therefore, nearly always ulceration, with extreme irritability and more or less constant suffering. It is not strange, then, that for its relief surgeons have taxed their ingenuity, or that adult patients, finding the conditions unbearable, are willing to submit to even extreme measures.

Treatment.

—So many operative measures have been devised that it is impossible to include them all. First of all the procedure should be adapted to the particular case. Much will depend, for instance, upon the extent of the defect in the abdominal wall, or in the pubic arch, and in the male upon the rudimentary condition of the penis or the extent of the urinary canal.