ON A CASE OF CONGENITAL INVERSION OF THE BLADDER; CURE
SURGEON TO THE WEST NORFOLK AND LYNN HOSPITAL. THIS affection is so rare that it is passed over in silence by most authors of systematic works on surgery. The only recorded case which I have met with is that given by Mr. Crosse in the British and Foreign Medical Review (Oct. 1846, p. 319'), which is exceedingly interesting as showing the importance of careful diagnosis before attempting any operative measures on tumours of the genital parts in female children. In this instance, the patient,
... three years, had a tumour, to which a surgeon was about to apply a ligature, when Mr. Crosse, who happened to be present, fortunately discovered an aperture which he found to be the ureter. The operation was of course postponed SMM die. By firm pressure the inverted bladder was made to repass into its natural position, and consequently the child was saved from an untimely death. The report goes on to say that the prolapse of the bladder did not subsequently return; and the patient grew up to womanhood with no other inconvenience than a constant incontinence of urine. The following report of a very similar case may prove worthy of being recorded, more especially as operative interference, which does not appear to have been found necessary in Mr. Crosse's case, was here pursued with excellent results :-M. A. H-, aged two years and a half, a fine, healthy, but very irritable girl, was admitted into the West Norfolk and Lynn Hospital on the 10th of November, 1859. On examination, a vascular-looking tumour, about the size of a large Italian walnut, was found projecting between the external labia. When the little patient cried, the tumour became more injected, and increased considerably in size; at the same time, a gush of urine took place. On closer inspection, the mass was found to be seated at the orifice of the urethra. On making a little gentle pressure, the tumour receded under the finger, and presently disappeared altogether within the urethra, and the forefinger could be readily passed into the bladder. I had, therefore, no difficulty in diagnosing an inversion of the bladder. From the statement of the mother, it appeared that the child had been subject to incontinence of urine from its birth, and that from the time it was two or three days old, a small substance had been observed to protrude during a fit of crying or straining. Each effort of this kind was followed by a flow of urine, and the child's condition from this cause was truly pitiable. The thighs and labia were much excoriated, and the latter, as well as being swollen and indurated, were covered with numerous pustules. Until the age of two years, the tumour had receded as soon as the fit of straining was over; but latterly it constantly protruded more or less. After considering the various means which might afford a chance of improving this distressing condition, I resolved upon making use of the actual cautery, which seemed to me best adapted for narrowing the calibre of the urethra, and thus preventing the descent of the bladder. Accordingly, after putting the patient under the influence of chloroform, and having re placed the bladder within the pelvis, where it was retained by two stout probes, which served to keep the canal patent, s female sound, heated to a white heat, was applied to the tract * From the Transactions of the Provincial -'dedical and 8m gieal Associatiol vol ,xi., 1846. of the urethra. A small curved catheter with a bulbous extremity, which had been previously made by my direction, was then introduced and fastened in, and the patient put to bed. No constitutional symptoms followed, but there was considerable pain in passing urine. On the 17th, a small shred of slough separated. Patient can retain four ounces of urine when in the recumbent posture. Dec. 1st.---The catheter on being removed was found coated with a thick deposit of phosphate of lime ; urethral canal per. ceptibly smaller. After the expiration of a month, during which time there was destillation pretty constantly, with occasional power of retaining several ounces of urine, the cautery was again applied as before. The same manifest improvement followed. The child became much more comfortable and cleanly in person. The excoriations almost entirely disappeared, and the pustules healed. On three subsequent occasions (making five in all) the cautery was repeated after long intervals. The urethra became so much diminished as to admit only a No. 4 catheter; urine esoped only when patient cried or strained. After having been a patient of the hospital about eleven months, during the latter part of which she was an out-patient, coming in at intervals to be operated on, she was discharged. I have since learned that she continues well, with not the slightest evidence of prolapse, but with some degree of incontinence of urine. (Under the care of Dr. PITMAN.) Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdisscetionum historias, tam aliornm proprias, collectas habere tt inter se comparare.-MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium. THE sequence of disease shown in the following case is somewhat remarkable. The patient was admitted with rheumatism and disease of the heart, the symptoms of the latter being in some degree masked : bronchitic cough, followed by uleeration and sloughing of the tonsils, and later, by pneumonia of the right lung, proceeding to the third stage, that of puru lent infiltration, which ended fatally. The autopsy revealed, in addition, a diphtheritic exudation of the pharynx, soft palate, and larynx. There was a well-marked history of early syphilis. Rebecca T-, aged twenty-one, admitted Jan. 1st, 1862. She was brought to the hospital with rheumatic swelling of thehands, which had commenced four days previously, some heat of skin, and considerable fever. She had no pain in the chest; but a mitral murmur was audible, probably of old standing, as she had twice before suffered from rheumatic fever, the first attack dating seven years ago. She was ordered venesection t& twelve ounces, two grains of opium, and five of calomel at bedtime ; and a scruple of bicarbonate of potass and four drachms of liquor of the acetate of ammonia in a nitre draught every three hours. The following day her pains were relieved, and she was ordered one grain of opium and three of calomel at night. On the 3rd, she was looking pale and white, had a troublesome hacking cough, with some bronchial expectoration, and complained of pain in her right side ; for this, wine of antimony, twenty minims, was added to the draught, and on the following day increased to thirty, a blister at the same time being applied to the right side. On the 8th, her cough was relieved; but there being still some rheumatic pains lingering about her, she was ordered hydriodate and bicarbonate of potass thrice a day,.