TWO CASES OF CONGENITAL CURVATURE OE THE PENIS, WITH HYPOSPADIAS AND ADHESION TO THE SCROTUM; SUCCESSFULLY RELIEVED BY OPERATION. BY R. F. WEIR, M. D., SURGEON TO THE ROOSEVELT AND ST. LUKE’S HOSPITALS, ETC. [.REPRINTED FROM 1HE N. Y. MEDICAL JOURNAL, MARCH. 1874 ] NEW YORK: D. APPLETON AND COMPANY, 5 4 9 & 5 5 1 BROADWAY. 1874. PROSPECTUS FOR 1874 THE MEDICAL PROFESSION Of the United States have universally indorsed the New York Medical Journal as one of the very best medical periodicals published in the world. THE New York Medical Journal, EDITED BY JAMES B. HUNTER, M. B., Assistant Surgeon to the New York State Woman’s Hospital, etc. The Contents of each number are— I. Original Communications from the very first writers of the Profession; articles which are widely circulated, and which leave their impress on the medical literature of the age. II. 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TWO CASES OF CONGENITAL CURVATURE OE THE PENIS, WITH HYPOSPADIAS AND ADHESION TO THE SCROTUM; SUCCESSFULLY RELIEVED BY OPERATION. BY R. F. WEIR, M. D., SURGEON TO THE ROOSEYELT AND ST. LUKE'S HOSPITALS, ETC. [REPRINTED FROM TEE N. T. MEDICAL JOURNAL, MARCH, 1874.] NE¥ YORK: D. APPLETON AND COMPANY, 5 49 & 551 BROADWAY. 1874. TWO CASES OF CONGENITAL CURVATURE OF THE PENIS, WITH HYPOSPADIAS AND AD- HESION TO THE SCROTUM; SUCCESSFULLY RELIEVED BY OPERATION. In the following cases there existed a triple malformation, hypospadias, curvature of the penis, and adhesion to the scro- tum. The rarity of the two latter conditions, which are gen- erally, if not always, associated with hypospadias, may be judged from the fact that Guy on, in his excellent work on the u Malformations of the Male Urethra,” 1 lias collected but four cases : one, on the authority of J. L. Petit, where curvature and adhesion were conjoined, and in which the penis was separated by operation from the scrotum, but the curvature remained; two others (Buisson,2 and Dupont3), where ad- hesion only existed, and in which liberation was easily effected by division of the fraenum-like band; and a fourth (Buisson4) where curvature only existed, and which is quoted by Guyon to show the superiorly of the method used in that and in the present cases over that suggested by Petit, who advised making a series of minute incisions in the contracted urethral band. Buisson, however, remarks that he has seen several simi- lar cases, but gives no particulars. In Petit’s own works,6 1 “ Vices de Conformation de l’Uretlire chez l’Homme,” 1863. 2 Buisson, “ Traitement de l’Hypospadias,” p. 536. * Dupont, “Moniteur des Ildpitaux,” February 4, 1853. 4 Buisson, op. cit. 6 “CEuvres completes,” edition 1837, p. 715. 4 however, besides the case alluded to above, where he did not operate himself, believing the case to be irremediable, is mentioned the post-mortem examination of a youth of ten or eleven years of age, afflicted with curvature of the penis and scrotal adhesions, whose case had been pronounced by him some time previously as being beyond the reach of sur- gical skill. The quaintness and interest of his description render it well worthy of translation. lie says : “ I first exposed one of the corpora cavernosa, opened it and passed into it a tube through which I forced in air, and the penis enlarged and curved downward; to retain this shape, I applied a ligature by which I kept in the air ; then I dissected the penis, and found that the whole urethra was very short, that it was, so to speak, ligamentous and incapable of being extended, having no cel- lular tissue. I separated it from the two corpora cavernosa very carefully, but with great difficulty; in spite of the sepa- ration, the corpora cavernosa lengthened only a very little, and the penis remained curved, which made me judge that the mal- formation of the urethra was not the cause of the curvature, and that the under part of the corpora cavernosa had some part in it. To examine it at leisure, I took the parts home with me, and, having separated the corpora cavernosa from the other tissues, I noticed that, on taking hold of them at each end, I could not stretch them out, and, on inflating them anew by the opening first made, they resumed the curved position, which I then attributed to a ligamentous band, which remained in the place whence I had removed the urethra. I cut off from this strip all that was possible without opening the corpora cavernosa, and I even cut transversely each of the fibres that I could not dissect off. In spite of this and all the air that I could force in, the corpora cavernosa preserved always the same curve. Having distended them for the last time, I retained the air by a ligature, and put them away to dry. Some time afterward I cut them, one longitudinally, the other transversely, and I perceived that their cells were nearly obliterated in the concave part of the curvature, and that by degrees they enlarged toward the con- vex part of the penis where they were the largest, either be- cause they were originally so formed, or that, having been 5 always compressed by the urethra and ligamentous band, they had remained small, not having the power of enlarging like the others.” To show that Petit did not carry his experimentation suf- ficiently far to develop practical results, I present a summary of Buisson’s operation in the case of curvature alluded to above. After describing the case, etc., he continues: “A fold of skin belonging to the inferior face of the penis was pierced valvularly by the point of a lancet and a tenotomy- knife introduced through the opening, so as to press its edge against the inferior surface of the penis, previously raised against the pubis. The pressure of the instrument, aided by a slight transverse movement, divided the fibrous envelope of the corpora cavernosa nearly in the middle of the space be- tween the glans and the abnormal opening of the urethra. A slight sound, comparable to that resulting from the tissues divided in tenotomy, was heard, and the penis lengthened visibly. Nevertheless a deeper resistance was felt. I then directed the point of the knife upward toward the dorsum of the penis, so as to penetrate between the corpora cavernosa, and, turning its edge toward the septum, divided this com- pletely, and the restoration of the organ immediately became perfect.” This excellent result, as well as that obtained in the two following cases, disproves partially the doctrine of Eoubaud,1 who speaks of the incurability of this malformation, and calls the impotency with which it is associated absolute. Case I.—Isaac B., aged twenty-one years, was admitted into St. Luke’s Hospital January 4,1871 (service of Dr. "Weir), with the following congenital malformation of the penis, the other genito-urinary organs being normal: The penis was strongly curved downward, so that the glans presented at the base of the scrotum, and was apparently held there by the integument of the scrotum being continued over the dor- sum of the penis, a rajphe on each side marking the junction of the parts, and forming at the glans the free superior portion of the prepuce (see plate). The glans was uncovered and the urethra liypospadic, and opening about half an inch from the 1 “ Trait6 d’Impuissance et de la St6rilit6,” 1855, p. 167. 6 site of the meatus, from which place it could be traced into the perinseum as a short, tense band acting as the cord to the arc formed by the penis. This was demonstrated to be the urethra, and of normal diameter, by the passage of a No. Id English sound. The patient passed urine between the thighs, although, by raising the partially movableglans, he was enabled to throw the jet forward, and thus avoid wetting him- self. He contemplated marriage, and therefore asked for sur- gical relief. It was explained to him that, in the event of liberating the penis, the opening of the urethra would neces- sarily be carried farther back, and even might seriously inter- fere with procreation. Desiring the operation performed, he was on the 9th of January etherized, and an incision made on each side of the scrotum sufficiently far from the body of the penis to afford skin enough to cover the under surface when released, and the flaps dissected up to the penis. This consti- tuted the first step of the operation ; the second consisted in separating the urethra, with the corpus spongiosum, from the corpora cavernosa as far back as the posterior margin of the scrotum. This required but few cuts of the scissors, as the band wTas only about one and half inch long, and produced no effect upon the curvature of the penis. On stretching out the curved organ, the septum between the corpora cavernosa could be easily felt as a tense, thickened band, audits division constituted the third step in the operation. It Avas accom- plished by a tenotomy-knife, introduced, however, not so far as described by Buisson, and cutting freely the septum in its lower part and about half-way between the glans and scrotum. Immediately after this section was made, the curve was readily abolished and the deformity thoroughly overcome. The transverse incision made involved, however, the tissues of both corpora cavernosa, and gave rise to troublesome and persistent oozing of blood, only arrested by a ligature placed around an acupressure-needle. The skin-flaps were then united by a suture on the under surface of the penis, and the gaping edges of the scrotal wound brought together without tension; having, however, first carefully secured the mucous membrane of the urethra by line sutures to the integument at the posterior angle of the wound, that is to say, at the junc- tion of the scrotum with the perinseum. The penis was laid against the abdomen, without need of a retaining bandage, and cold-water dressings were applied to the parts. The result of the ease was exceedingly satisfactory, though at the situation of the needle there was tardy reparative ac- tion, not only from the presence of the ligature applied, but also from the frequent erections that ensued, enjoyed by the patient in spite of the pain therefrom. January 11th.—A small abscess appeared in the peri- nseum, running toward right nates, and caused bv a pocket at the end of the wound. It was relieved by incision. February 1th.—The wound had healed and the patient at his request was discharged from the hospital. At that time the penis, though not normally straight, was nearly so, and completely so, he informed me, when in a state of erec- tion ; and, when he subsequently called at my office, several months later, he expressed himself as being very well satisfied with the result, and that, too, in spite of the inconvenience of having to freely open liis dress in order to urinate; the jet, however, was thrown decidedly forward when the scrotum lifted up. The second ease was very similar. Case II.—In August, 1870,1 was asked by Dr. Orton, of this city, to see in consultation with him a young gentleman of about twenty-three years of age, who desired to marry, and whose condition clearly resembled the one narrated above. In him, however, the penis was free, having in early life been released by incisions apparently made on each side of the organ, the cicatrices of which were plainly to be seen. 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