Bischoff, Peters); and, 3. Those who assume portions of each theory, and reject others: Involutionists, adherents of the theory of pre-menstrual discharge of the ova, dependence of menstruation on ovulation-Schroeder, Simpson-believers in total independence of ovulation and menstruation-Goodman, whose article does not refer to the anatomical changes in the uterus, and the temporal relations of ovulation and menstruation. As only the four gentlemen mentioned above have declared their adherence to Dr. Williams' theory, it is evident that thus far, not the modern desquamationists, but the old involutionists, are in the majority; for the greater portion of the profession must be considered to belong to that party. While in this respect no innovation has been made, the new theory of pre-menstrual ovulation and impregnation, and the total independence of menstruation and ovulation, appears, on the other hand, to have been received with general favor, and to be steadily gaining ground. -American Jour. of Obstetrics.

ART. II.-Extrophy of the Bladder. By C. B. KING, M. D., Pittsburg, Penn.

William J. Kilpatrick, aged thirteen, was admitted to the Western Pennsylvania Hospital, at Pittsburg, April 10, 1874, for congenital deficiency of anterior wall of abdomen and bladder.

The posterior wall of the bladder projects forward, and forms a tumor about the size of a goose's egg, oval in shape, measuring 2 inches across from side to side, and 24 inches from above downwards. In the erect position the tumor protrudes 11 inches, and measures around the oval from side to side 4 inches. No hernia. Pubes wanting 24 inches. Penis epispadic, about the size of an almond, and covered with an imperfect prepuce. Scrotum quite small, and contains two well-developed testicles. For some time previous to the operation, the patient was put upon tonics and nourishing diet, with gentle out-door exercise. May. 3-He took an ounce of castor oil, which operated freely. The following morning the lower bowel was washed out by

enema, and the patient being put under the influence of ether, a horse-shoe-shaped incision was made; beginning about one and a half inches to the left, and a little above the penis. This incision was carried down close to the left thigh, then across the perineum to the opposite thigh just in front of the anus, and then upward to a corresponding point on the right side. The flap was dissected up, laying bare the testicles. An oval incision was made in the flap to allow the penis to drop through. Another incision, beginning about three-quarters of an inch above the starting point of the first incision, was made through the skin of the abdomen and extending around and about one-half inch above the upper edge of the bladder to a corresponding point on the opposite side. The skin was dissected up about three-quarters of an inch. The first flap was then turned up over the bladder, and its edges placed beneath the last flap, and held in position by eight silver wire sutures secured by perforated shot.

As the walls of the abdomen were found to be very thin, the sutures were only passed through the two flaps, and thus differed from Prof. Pancoast's "tongue and groove suture," in having but two raw surfaces together instead of four. The urine flowed freely over the raw surface under the upper flap, but I did not fear urinary infiltration, as the opening made in the lower flap for the penis was large enough to allow free escape for the urine.

The skin remaining between the ends of the first and last incisions was now pared, and the raw surfaces united by two interrupted wire sutures on each side. The testicles being exposed, I attempted to close the large wound in the perineum by drawing the edges of the skin together, but the testicles still remained uncovered. The raw surfaces were dressed with lint spread with carbolized cerate. The knees were crossed and bandaged together, and the thighs flexed upon the abdomen, by placing him in a half-sitting position in bed with a pillow under his knees to relieve the flaps of tension. As soon as he recovered from the effects of the anaesthetic, he was given an eighth of a grain of morphia, which was repeated at 3 and 6 P. M.

At 7 P. M. (six hours after the operation), pulse 112; temparature 101° F.; suffers but little pain.

5th.-8 A. M., pulse 122; temperature 101°. Slept well during the night. Feels comfortable. 8 P. M., an erythematous blush has made its appearance, extending toward the left groin. Is very sensitive to the touch, and has the appearance of urinary infiltration. Pulse 128; temperature 102°.

6th.-8 A. M., rested well all night; blush not extending. Pulse 132; temperature 101°.

7th.-8 A. M., blush has disappeared. Rested well during

night. Takes nourishment well. Pulse 130; temperature 101°. 8th.-8 A. M., pulse 130; temperature 100°. Dressings removed, and union found to be complete throughout. The bladder is very much protruded from accumulation of gas in the bowels. He was given fövj ol. ricini, followed by an enema, which acted well, and relieved distension.

9th.-8 A. M., pulse 124; temperature 100°. Rests well, and feels hungry. All the stitches but three were removed. The swelling, being much greater than was expected, caused three of the stitches to cut through, allowing the urine to escape through the openings.

10th.-Remaining stitches removed, and bladder washed out through a small catheter.

13th.-Openings from the cutting through of stitches, through which the urine escaped, have entirely closed. Eats and sleeps well; suffers no pain. Flaps cicatrizing at edges.

25th.-Large quantities of mucus collect in the bladder, causing distension, and have to be removed with a syringe. Is sitting up to-day for the first time.

June 17th.-Has been walking about the ward since May 27. Flap has nearly cicatrized over the whole extent.

25th.-Flaps and perineum completely cicatrized, the cicatrix in the perineum being quite small. By pressing the fold of skin above the penis against the latter, he can retain his urine for two and a half hours. The greatest difficulty in the treatment of the case was caused by the very free secretion of vesical mucus, which distended the bladder and prevented the free escape of urine. No pain or inflammation was caused by the urine, which was allowed to flow over the exposed testicles and raw surface of the perineum, but it appeared to hasten cicatrization.

The boy at this date (April 25, 1875) is doing well. He is able to walk erect; he runs and jumps with ease; and by the use of a shield, the urine is collected in a bottle fastened to the inside of his boot, thus preventing his clothing from becoming soiled.-Trans. Amer. Med. Asso.

Dr. Andrews, of Illinois-I would like to ask the gentleman what is to become of this boy when he arrives at the age of puberty, and this integument which has been taken from the pubes and placed so as to serve for the inner lining of the bladder is covered with hair? In my opinion it may give him a great deal more trouble in the future than would his former condition. It may do very well for the boy, but I think not one here would be willing to perform such an operation.

Dr. King, of Pennsylvania-The trouble which Dr. Andrews thinks is liable to follow this operation, i. e., irritation of the bladder, is obviated by the urine acting as a depilatory. Dr. Pancoast, of Philadelphia, to whom belongs the honor of first performing this operation, and Dr. Wood, of London, both hold this view.

Dr. James R. Wood, of New York—I am delighted with the result which my friend Dr. King has reported. I have seen the cases of my namesake in London, and they are not more favorable than this. As far as the accumulation of hair is concerned, there is no trouble to be feared. I know objections have been made by many surgeons to the operation, but the comfort accruing to the patient is beyond description, and this, together with previous successes, should warrant its being performed. An operation which I performed some time ago resulted very favorably, and in every case where the operation has been performed by intelligent surgeons it has proven successful; the result being hailed both by surgeon and patient with delight. You all know the success of the somewhat similar operation for vesico-vaginal fistula as performed by Dr. Sims, of New York, to whom womankind is so much indebted; and it is to the young men of our profession, Mr. Chairman, we must look to perform these operations. They require study, thought, and labor, which the older men of the profession have either not the time or are not willing to bestow. There are poor wretches to-day travelling over this country with protruding bladders, exhibiting themselves to the medical classes and eking out a most miserable existence; and these men are not operated upon, simply because you and I, and others, have not the time or inclination to qualify ourselves to do it. Mr.