material left behind, such as dressings or unabsorbed ligatures; they therefore recommend that a thorough search be made for foreign bodies at the time any procedure for the closing of fistula is inaugurated.

EXSTROPHY OF THE BLADDER

This dreadful condition is a congenital one, and, fortunately, of very rare occurrence. It is due to non-closure of the abdominal cleft. It may be partial, so that only a slight fissure is left near

the urachus or at the lower angle of the cleft. If slight, stimulation of the edges or a slight plastic operation may result in closure. When complete in children so afflicted the anterior bladder-wall is absent, so that the posterior bladder-wall presents itself in the front of the abdomen. In males hypospadias coexists; hence such subjects, if they live to attain adult life, are so malformed that their genital organs are useless.

A great variety of operations have been performed for the at

tempted cure or relief of this distressing condition. So far as cure is concerned, these operations have all proved unsuccessful. The results so far as relief is concerned are, however, somewhat better. Only an outline of the operations for the relief of this condition will be given here. In a general way the operations that have been attempted may be divided into three classes:

Fig. 140.-Maydl's method for exstrophy of the bladder. The abdomen is opened by an incision around the upper part of the bladder, using one or two fingers introduced into the abdominal cavity as a guide; the sides of the bladder are then separated. The peri-ureteral portion to be incised is shown by the dotted line.

CLASS 1. This consists in separating the symphysis pubis in an attempt to fold and unite the two sides of the bladder-wall so as to make a complete bladder, an operation being performed at the same time for the relief of the hypospadias-in other words, to unite the borders of the bladder. There are several different modifications of this method.

CLASS 2. This consists of various methods of grafting skin from a neighboring part or from the intestinal region, transplanting also a portion of mucous membrane, with the idea of making a cavity that will act as a bladder.

CLASS 3.-Measures that consist in excising the bladder entirely and transplanting the ureters into the intestinal canal-generally

Fig. 141-Maydl's method of operation for exstrophy of the bladder. The sigmoid flexure is incised along its free border, and is then fastened to the peri-ureteral portion of the bladder with catgut sutures.

into the rectum. The writers have never had the opportunity of operating on a case of this kind, but one has been brought under their observation that was operated on according to the last-described method by Dr. Frank Hartley, of New York. The patient was alive several years subsequent to the operation, and the rectum seemed very tolerant to the urinary flow. This is the opera

tion of Maydl. The illustrations (figs. 140, 141, 142) furnish a clear idea of its nature. In this class also may be considered a series of operations that consist in transplanting the ureters into the penal gutter the method of Sonnenberg, of which two illustrations are given (figs. 138, 139). The bladder is entirely removed in this method and it necessitates the constant wearing of a urinal.

Fig. 142. Maydl's method of operation for exstrophy of the bladder. The peri-ureteral portion of the bladder is inserted into the opening in the sigmoid and the edges sutured together.

(These operations are described in considerable detail by Berger and Hartmann in their "Text-book of Surgery," vol. ix; they also commend the article of Katz, "Traitemente Chirurgical de l'Extrophie de Vessie," "Thèse de Paris," 1902-03, No. 535, G. Steinheil, editor.)

Also should be considered in this class the method of Segond,

illustrated in figs. 143, 144, 145. This method consists in dissecting out the wall of the bladder pretty well down to the attachment of the ureters; then doubling it over and attaching it to the penal gutter; then making a hole in the underlying prepuce and pushing the gutter through so that the prepuce makes a hood. The bladder flap should be trimmed to fit as

The under surface of the

Fig. 143. Segond's operation for exstrophy of the bladder. bladder-wall is pushed up and dissected along the dotted lines; it is then brought down upon the penal gutter.

the dotted lines in Fig. 143 show. The edges of the penal gutter should be freshened to unite them with the bladder flap. As much vesical tissue as possible should be left around the ureters when the flap is turned over. The upper border of the preputial hood can be united to and will help cover the opening in the