THE TREATMENT 
OF 
Extrophy of the Bladder. 
WITH SOME HISTORICAL NOTES AND GENERAL CONSIDER- 
ATIONS AND AN ACCOUNT OF A CASE. 
BY 
DAVID PRINCE*.M. D. 
Jacksonville, Illinois. 
READ BEFORE THE TRI-STATE MEDICAL SOCIETY OCT. 27, 1881. 
[Reprinted from the St. Louis Medical and Surgical Journal Nov1881.~\ EXTROPHY OF THE BLADDER. 
Plastic surgery requires a good conception of the means nec- 
essary to secure desired changes of form, and this conception 
must become well matured before it is put into practice; because 
from the nature of the case, the modeling cannot often be done 
over again. There is also required the most careful manage- 
ment of the attending wounds, in order to preserve the vitality 
of flaps and to secure their union in the new positions in which 
they are placed. To this end it is necessary to keep their nutri- 
tive action as near the physiological state as possible. Freedom 
from motion is the first condition. Freedom from contact with 
the septic influence of the atmosphere is the second condition. 
The early and frequent removal of the exudations in anticipa- 
tion of their decomposition, or afterward, through the failure of 
the first two conditions, is the third. When the first two condi- 
tions are complete, with tke best results, the third has no place 
for there is nothing irritating to be removed. 
For the first condition there arc plasters and sutures with 
fixedness upon splints and quietude of the whole body. 
For the second, there are, a blood-clot dried in the open air 
the dessicated exudations of lymph, the superposition of plasters 
and cotton, gauze, or other material to defend against septic 
influences while the drying influence of atmospheric contact is 2 
permitted. All these coverings may be increased in their efficacy 
by a coat of varnish over the blood clot or the dried crust of 
lymph (in what is called the open air dressing ) by carbolic acid 
10 per cent, in oil by dry salicylic acid, and by salicylic acid infil- 
trated into cotton.* 
For the third condition the irrigation and the bath are indi- 
cated. These may be of water, pure or medicated with salicylic 
and carbolic acid. 
It is one of the objects in publishing the case detailed in the 
following paper to give an account of the development of the 
utility of these agents in wounds in which the realization of 
the first two conditions cannot be anticipated or in which they 
fail from any cause. Where there is a strong probability 
of the failure of the first two, the third should be put into exe- 
cution as a primitive measure, before any mischief has 
occurred from the failure of the others. This probability of 
failure exists in all complicated wounds, involving a large 
extent of surface, especially, in parts not abundantly supplied 
with blood. 
Prof. Erichsen, of University College, London, speaking of 
extroversion of the bladder says :— 
“ The malformation is incurable. Operations have been 
planned and performed, with the view of closing in the exposed 
bladder, by plastic procedures, but they have never proved suc- 
cessful, and have terminated, in some instances, in the patient’s 
death. They do not, therefore, afford much encouragement for 
repetition. ”| 
The following description of this deformity by John Wood 
of King’s College, London, is brief and explicit. “In both 
sexes the pubic bones are widely separated. The symphyseal 
projection can be felt under the integument on each side of the 
genital organs. In both, the hinder wall of the bladder is seen 
as a red, vascular projecting tumor often ulcerated and discharg- 
ing muco-purulent fluid and blood, and surrounded by a cicatrix 
which, above, is blended with and obscures the umbilical mark. 
In the male, the penis is usually completely epispadiae, with the 
* Dissolve 100 grams of salicylic acid in two quarts dilute alcohol. 
Place in a jai 900 grams of cotton in the form of batting. Pour over 
this the alcoholic solution of salic\ lie acid. 
After several days remove the cotton and dry it. Preserve for the 
dressing of wounds where atmospheric filtration is desired, 
f Erichsen’s Surgery. American Edition 1859, p. 857. 3 
urethra open along its entire length. The corpora cavernosa 
are stunted, and fail to cover the urethra above, and they are 
connected below by an imperfect corpus spongiosum forming 
the lower part of the urethra. The glans penis is grooved 
above by the urethral gutter, bu-t perfect underneath and is pro- 
vided with a frenum and an abundant but split prepuce. The 
stunted penis is placed flat against the lower part of the bladder, 
usually covering by its roots the orifices of the ureters. The 
scrotum is perfect and contains the testes, and often an oblique 
inguinal hernia or a small ventral hernia is present. 
In the female, the clitoris is split and the anterior commissure 
of the labia minora are wanting, exposing more completely 
than in the male, the orifices of the ureters and laying open the 
urethra. The normal os uteri can be seen in the vaginal 
groove.* ” 
In 1869 Mr. Wood had operated in eight cases. Three 
methods were employed by him. 
First. Two lateral flaps were taken from the sides with their 
bases toward the groins with their raw surface touching the 
mucous membrane of the bladder—the success was imperfect. 
/Second. One reversed lateral flap in combination with a 
smaller reversed umbilical flap, both turned with their cutaneous 
surfaces toward the bladder and covered by another larger 
lateral flap placed with its raw surface upon the exterior raw 
surface of the two reversed flaps. 
Third. A large umbilical flap turned down with its cutan- 
eous surface toward the bladder extending as far down as the 
root of the penis, covered by two lateral flaps from the 
groins with their bases toward the penis, scrotum and thigh and 
united in the median line over the umbilical flap and with their 
raw surfaces in contact. 
He adopted this third procedure in his last five cases, in 
each case covering the entire bladder by one operation. 
In the last two cases, a preputial covering was made by 
dissecting the skin of the scrotum and implanting it upon the 
penis previously peeled of a strip of integument on either side 
* Medico Churugical Transactions, Feb. 9, 1869. 
Lancet, Feby. 20,1869. 
American Journal of the Medical Sciences, April, 1869, p. 651. 
Half Yearly Abstract, July 1869 p. 193. 4 
of the fissure, in order to get a line of adhesion. With regard to 
the hairs which became covered by this inversion of integument 
it is said by Wood, and by Pancoast of Philadelphia, that they 
finally disappear in the continual bathing by urine. 
It is said that nitric acid taken by the mouth aids in cleaning 
the hairs and the surfaces from phosphates. 
Richard, a colleague of NAlaton, is said to have operated in 
1853. A central apron having been turned down, the raw sur- 
face of which was covered by a flap from the scrotum. Tho 
patient aged 24, died on the 9th day from peritonitis. In 1863, 
Mr. Holmes had operated five times. 
Extrophy of the bladder has been treated ( Boston Med. and 
Surg. Journal January 1876), by Dr. Henry J. Bigelow by the 
obliteration of the mucous membrane in order to get rid of the 
sensitive surface. For this purpose the mucous membrane is 
dissected up and integument is drawn over to cover the denuded 
surface. Ro attempt on this plan is made to form a pouch over 
the orifice of the ureters. A case is reported illustrated by lith- 
ographs. 
Dr. F. F. Maury ( American Journal of the Medical Sciences 
July 1871, p. 154) has practiced the expedient of elevating tho 
skin of the anterior portion of the scrotum to cover the imper- 
fect bladder. A hole is cut in the base of tho scrotal flap through 
which the penis is thrust. The raw surface of the flap is left 
exposed to the air to heal by granulation. Two cases reported 
were successful. 
What Wood calls his third method aided by the elevation of 
a portion of the scrotum are probably the best expedients for 
most cases. 
In 1858, a very successful operation was made by Dr. Daniel 
Ayers of Brooklyn N. Y. an account of which is here copied in 
some detail from a pamphlet of date 1859 and from Virginia 
Medical Journal January, 1859. 
Fig. 1 illustrates the nature of the deformity, and the plan 
of the operation. 
a. The posterior wall of the bladder, continuous with the 
abdominal parieties (there being no anterior wall for the blad- 
der) one inch and a quarter by two inches, and longer when 
standing. 5 
ft, ft. Nymph©, or labia minora, separated wide apart. 
c. Orifice of the vagina. 
d. Anus. 
Fig. 1. 
Dr. Ayer’s Case of Extrophy of the female bladder. Operation 1858. 
e. e. Labia majora. There was no trace of urethra or 
clitoris. There was a deficiency of the symphysis of the 
pubes, leaving the mons veneris without its natural osseous sup- 
port, and causing the thighs as shown in the cut, to stand apart in 
front to an unnatural degree. 
The patient, 28 years old, had borne a child at maturity; 6 
and had become afterwards afflicted with procidentia of the uterus, 
which appeared externally. 
Plan of the Operation.—A flap of the integument upon 
the anterior wall of the abdomen, was dissected from above 
downward corresponding with the figure, e, A, g, i, f. 
This flap was doubled upon itself, so that A, came to/ and 
i to k, in order to attach the borders e, A, and /, i. The 
triangle A, g, i would thus make that of j, e, k, but instead of 
this, it was turned up to make that of j, n, k. Thus, the blad- 
der had for the time, an anterior covering made of two layers 
of the same flap, the raw surfaces facing each other. A wide 
opening was thus left below, for the escape of the urine, to 
avoid urinary infiltration, and to afford room for swelling. 
The integument, on the outside of the line, e, A, g and of the 
line k, /, i, g was then cut under, and made to glide to the 
median line, so that the line, j, e came to the line, J, n and the line 
k, f to k, n, the borders of the triangular portion of the 
flap which had been turned up, and the lines, e, A, g and/, i, g 
were made to meet in the median line. Thus, no raw surface 
was left uncovered by skin. 
The parts united, in great part by adhesion. 
This operation was performed on the 16th. of November, 
1858, and on the 7th. of December following, i, e„ after the 
lapse of just three weeks, the patient submitted to the second 
and final operation. 
The lower triangular flap, j, n, k was dissected from the 
recent temporary attachments both lateral and deep, and turned 
down over the vulva as indicated by the dotted line,/ e, k. 
Two incisions, j, I upon the right side and k, m upon the 
left were next carried from the external angles of the triangle, 
perpendicularly downward, just on the outside of the nympha;. 
The integument on the outside of n, j, l upon the right and 
n, k, m upon the left, was freely cut under, until these two lines 
could be made to approach each other, and coincide in a line 
drawn from n to c which was continous with the cicatrix previ- 
ously established from g to n occupying the lineaalba. The 
labia majora were thus made to approach each other, and the 
nymphie were concealed. 
A space was left for the urinary canal, which would admit 7 
the little finger, and the new-formed urethra was an inch and a 
half in length. 
During the operation, torsion and ice wore applied to several 
arteries which bled freely, after which the flaps were confined 
in the median line by interrupted sutures the most inferior one 
at l and m being made to include the point of the triangular 
flap c. Tho space between the sutures, was covered with patent 
lint soaked in collodion, and the labia majora were covered with 
strips of muslin saturated with collodion, the whole dressing 
being retained by threads of suture-silk, laced across in front. 
Adhesion was nearly perfect. 
After a year’s time, it was found that the weight of the 
abdominal contents, in the erect posture, caused the anterior 
fold of the vagina, alone, to descend a short distance, forming a 
pale oedematous tumor of the size of an “English Walnut.” 
The anterior fourchetto of the vulva remained firm and resisting 
and a perforated rubber pessary, introduced into the vagina 
retained the parts in position. 
T. Holmes, in 1863, had operated five times ; one flap from the 
groin everted and covered by a flap from the opposite groin. 
This is said to have been the plan of Wood in some of his ear- 
lier operations. 
Barker of Melbourne, Australia, is reported as having oper- 
ated. A flap from either side was made to glide over and meet in 
the median line; the raw surface being left to heal by granula- 
tion. 
Case.— Wm. St. John, aged 25, of stout build and in good gon- 
eralhealth is an opium eater, taking an ounce of laudanum at a time 
and two ounces in twenty-four hours. He has congenital extro- 
phy of the bladder and epispadias with shortening of the penis, 
so that tho expansion of the corpus spongiosum in the glans is 
nearly all that appears. 
The symphysis of the pubes is absent and the penis seems to 
lie between the pubic bones of the two sides. 
The transverse diameter from trochanter to trochanter is 261 
inches and the appearance of the pelvis is like that of a woman. 
The anterior wall of the bladder is absent, and the posterior 
wall fills an opening in the median line two and one-half inches 
(75 mm) in diameter. There is no umbibcal mark. The mucous 8 
Fig-, 2. 
3. The glans penis. 
4. The Scrotum showing numerous scars from old ulcerations occasioned by. 
the irritation of urinary contact, 
Wm. St. John. 
1. The junction between the the'mucous membrane and the skin above. 
2. Idle eminences at the exit of the ureters on the mucous surface. 9 
surface is convex, as if protruded by the pressure of the intes- 
tines from behind, and is exceedingly sensitive to touch. 
The little projections of the ureters are seen sometimes 
spirting small streams of urine and sometimes oozing a sluggish 
diminutive flow. 
On account of the spirting of the urine, the patient has 
invented a plate to be worn in front to arrest the stream and 
direct it downward. 
The prepuce and the frenum are developed, as well as the 
testicles and the scrotum, which latter is thickened by the con- 
stant irritation of urine. There is no hernial protrusion in 
either groin. 
The preparation for the operation consisted in a cathartic the 
night before, ten grains (.65 grms.) of sulphate of quinia in the 
morning with one ounce of laudanum (32 c. c.) and two ounces 
of whiskey and the addition of a hypodermic injection of £ gr. 
(.022 grms.) of morphia at the time of beginning the etherization. 
The operation was made Dec. 8, 1874 according to the third 
method of John Wood. 
A large apron was dissected from above downward and 
turned over with its raw surface anterior and outward. 
The exposed mucous surface was completely covered by this 
flap. 
A flap was then dissected from each inguinal region with its 
attached base downward. These flaps were brought to meet 
in the median lino where they were retained by sutures. 
The raw surfaces were freely bathed in ether for its supposed 
influence in favoring union by the first intension. 
The extensive raw surface above was dressed with ground 
slippery elm bark. 
On the 2nd. day the dressing was done in a bath, and 
repeated each day in the bath in which the patient remained 
during his pleasure; the temperature being regulated according 
to his sense of comfort. 
The amount of laudanum had to be greatly increased the 
patient taking from 4 to 6 ounces each day. 
On the 10th. day he was well enough to sing.—On the 12th 
day the adhesion was found to bo perfect the sutures having- 
been removed except a single silver wire remaining on each 
side. 
The first dressing was made with slippery elm but alterna- 10 
Fiy. 3. 
c. Gians penis. 
d. Scrotum. 
it. Granulating surface speckled with skin grafts. 
b. Flap united a little to the right of the apparaut median line 11 
tions were made with oxide of zinc until the zinc oxide was- 
given the preference. The zinc was never removed until lifted 
up Ky the pus accumulated beneath, so that it could be easily 
detached. 
Dec. 23 the 15th. day. Forty skin-grafts were applied. 
Dec. 26. Seventy-nine grafts were planted and the laudanum 
was reduced to two ounces a day. 
Feb. 3. the 26th. day the patient stood for his photograph 
(Fig. 3). Fifty-one grafts were implanted. The patient has 
completely recovered from the depressing influence of the oper- 
ation. 
Feb. 19th. 42nd day. A second operation was performed in 
order to lengthen the apron covering the bladder, by an attach- 
ment brought up from the scrotum. 
The dissection was carried sufficiently into the groins and a 
notch was made under the penis in order to enable the flap to 
rise readily into its position. It was attached above by a 
tongue and groove suture, a tongue of the upper margin of the 
scrotal flap passing into a groove made in the lower margin of 
the apron made by the first operation. 
The trial of this expedient recommended by Dr. Ashurst, 
and practiced by him in some of his operations, has not afforded 
inducement for its repetition. It is generally the case that 
plane surfaces can be brought into more perfect contact than 
those which are irregular. 
A considerable constitutional disturbance followed this oper- 
tion the pulse rising to 116 and the temperature to 101°F. 
The experience in the use of the bath acquired after the first 
operation led to its more protracted employment At the end of 
36 hours after, the operation he had been 32} hours in the bath. 
The following table shows the amount of time spent in the 
water on succeeding days. 
3rd. day 18 hours. 
4th. “ 14 “ 
5th. “ 14 “ 
6th. “ 14 “ 
7th. “ 18 “ 
8th. “ 22 “ 
9th. “ 16 “ 
10th. « 15 “ 
11th. « 16 “ 
12th. “ 15 “ 12 
After this date for many days the average time in the water 
was 12 hours from 9 A. M. to 7 P. M. the nights being spent in 
bed. An automatic irrigation with weak carbolized water was 
arranged so as not to require constant attention. 
Some sloughing occurred in the scrotal flaps and for the pur- 
pose of closing it, the third operation was made Feb. 24th, the 
75th day. On the 27, or the 3rd day from this operation he had 
been 50 hours in water. 
Not much constitutional disturbance followed but some addi- 
tional sloughing occurred. 
March 7th. or the 89th day, he was sitting up. March 22nd. 
or the 104th day, the fourth operation was made to close the fistu- 
lous opening in the scrotal flap occasioned by previous slough- 
ing. 
No union by adhesion followed this operation, but a good 
result was finally obtained by the repeated introduction of plas- 
tic pins for sutures. 
April 1st. the 117th day. The granulation and cicatrization 
subsequent to the fourth operation have produced a greatly 
improved condition. 
The testicles are supported b}' a scrotum of greatly reduced 
size so that they are much less in the way of the urinal which 
he now wears with much more comfort than before the operation. 
His urine is now entirely collected while in the erect posture. 
The cicatrization is not yet complete over the portion of the 
abdomen from which the great central flap was taken in the first 
operation. 
It was found impossible to reduce the supply of opium to any 
great degree while under surgical treatment, and he continued 
to take as an ordinary daily supply, two fluid ounces of laudanum. 
During the greater part of the time he took daily in one dose 
a drachm of tincture of chloride of iron combined with ten 
minims (.65 c. C.) of nitric acid taken in a glass of water. 
Quinine was freely during the greater part of the 
time of treatment. He went home in greatly improved condition. 
One of tho most important advantages which he has derived from 
the series of operations is the protection of the delicate mucous 
membrane from injury by his clothing. 
Fig. 4 illustrates his condition at the close of treatment. 
The use of the bath after complicated wounds is further exemplifi d 
in a report made to the Tri-State Medical Society last year and afterward 
published in the St. Louis Medical and Surgical Journal (Jan.— 
May, 1881. 
This report is also published and sold by Lindsay & Blakiston, Phila. 
as a pamphlet of 50 pages. 13 
Fig, 4. 
d. The scrotum reduced in size by the transfer of a portion of its integument 
to its new position above the diminutive penis. 
а. Cicatrix. 
б. The flap forming the anterior covering of the bladder. 
c. The Gians penis. PUBLISHED MONTHLY. 
1843. THE 1882. 
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