Talk:Paper - Note on a case of bifid penis with penial hypospadia (1914)

NOTE ON A CASE OF BIFID PENIS, WITH PENIAL HYPOSPADIA. By J. A. Pires ve Lima, Professor of Topographical Anatomy in the Faculty of Medicine of Oporto, Portugal.

On the 23rd April 1914 there entered into the Santo Antdénio Hospital at Oporto a man from the town of Valenca, A. J. V., fifty-eight years of age, married, and employed as a farm labourer. Three days previous to his entry a bullock-cart laden with gorse ran over the external side of his thigh and gluteal region, producing serious internal injuries, which caused retention of urine and faces.

On the introduction of a catheter, it was noticed that there existed curious anomalies in the genital organs, which I had the opportunity of studying, and which I am going to describe.

On the mere inspection of the penis, this organ is found to be short and widening considerably from behind forwards, ending in a double well-developed and imperforate glans. On examining the ventral surface, it is seen that the copulating organ lacks urethra in its greater extent; this canal finishes in a larger and rounded meatus immediately in front of the scrotum, and on the anterior part of the body of the penis the urethra is represented by a large groove turned downwards.

By palpation I verified that the corpora cavernosa, joined behind, diverge in front, forming an acute angle, and separating from one another at the distal extremity of the body of the penis, which, owing to this, is wide and flattened in front.

The body of the penis measures 10 centimetres in circumference, not only close to the pubis, where it is cylindrical, but also close to the glans ; but here it is flattened, as I said, measuring in width, on the dorsal surface, 5 centimetres. The total length of the flaccid penis taken on that surface is 8°5 centimetres, of which 2°5 centimetres belong to the balanic part; on the ventral surface it measures only 6 centimetres in length, from the scrotum to the extremity of the glans.

The prepuce is double and very short, so that it cannot pass farther than the corona glandis, which is also double, with the consequent result that the double glans is totally uncovered.

On the median line of the dorsal surface, starting from the interstice between the two prepuces, there is a congenital scar, in the form of a raphe, 86 Professor J. A. Pires de Lima

2 centimetres long. On either side of the median line, as can be seen in fig. 1, there is a series of radiated folds.

In front of the sulci retroglandularis there is a double glans, each distinctly divided by a deep intermedian groove. Lach half appears as if it were a complete glans; they touch one another, and are both equal and symmetrical, so that it is sufficient to describe one of them only. Each one has the form of a triangular pyramid with its base turned towards

Fic, 1.—Dorsal surface. ~

the corresponding corpus cavernosum and a distal vertex. The internal surface is flat, and measures 2°5 centimetres from the extremity to the sulcus retroglandularis. The inferior surface is also flat and much smaller than the others, as the prepuce is more extensive on the ventral surface. The supero-external surface, regularly convex, presents wrinkles in some places. Both the corona and the sulcus retroglandularis have a normal appearance. As is natural, there is no sign of a frenum nor of Guérin’s valve.

The urinary meatus, which is wide and round, infundibuliform, is situated 2 centimetres away from the scrotum, and 4 centimetres from the distal end of the penis.

In front of the méatus, as can be seen in fig. 2, the urethral canal is Note on a Case of Bifid Penis, with Penial Hypospadia 87

represented by a deep groove, with its concavity turned downwards, and there can be seen some longitudinal folds. The scrotum, as well as the testicles, seems normal, and the patient has no other apparent anomaly, except convergent strabismus of the left eye. This genital malformation, according to the patient, did not affect his sexual functions. He has two daughters and three sons, two of whom are already married and have children. None of his descendants possess

Fie, 2.—Ventral surface,

any anomaly that resembles his.’ Hé does not think that any of his ancestors or relations have had any such malformations. As far as he knows, his parents were neither alcoholic nor syphilitic. His father was much older than his mother, and he must -have been fairly aged when A. J. V. was born, he being the youngest of four brothers.

Evidently this is a case of hypospadias with penischisis. If the first of the malformations is common, ‘the same. is not the case concerning the bifidness of the copulating organ, which is very rare in man. Both have an embryological interpretation, as we will see, following closely the works of Tourneux (1) and Retterer (2, 3). 88 Professor J. A. Pires de Lima

During the third month of gestation, on the ventral surface of the genital tubercle there are two genital folds, disposed in the anteroposterior sense, which limit the genital suleus. The genital folds are joined together by their inferior free borders; the joining together begins to take place at the root of the penis, and then stretches progressively forwards to the vertex of the copulating organ. Thus originates the pars cavernosa of the urethra.

If there is a break in this process of adherence, instead of the normal urethral canal being formed a hypospadias takes place, and, according to the spot where the urethral evolution stopped, that hypospadias may be scrotal, penile (as in the present case), or merely balanic.

On the body of the penis, the superior angle of the genital sulcus disappears, owing to the junction of its lateral walls. On the glans, the lateral walls of the genital sulcus do not join completely on its dorsal surface, as is the case on the body of the penis; generally they adhere more especially on the posterior part of the glans, forming a mesodermic bridge (Guérin’s valve), which limits inferiorly Guérin’s sinus.

The anterior portion of the urethra has, consequently, the form of a vertical fissure on its dorsal surface, and it is wide on its ventral surface (fossa navicularis).

If the partial adherence of the lateral walls of the dorsal part of the balanic urethra continued as far as the extremity of the glans, a paraurethral fistula would be formed, which anomaly I have already had occasion to study in three individuals (4).

Retterer (2) considers the genital tubercle a dual organ, as being the result of the fusion of two even and symmetrical halves. The penis has, according to such views, the value of two formations which, developing one by the side of the other, joined together so as to form one single organ.

The junction of the two primitive halves of the penis did not take place completely in the present case. The two corpora cavernosa, joined at the prepubic angle, separated afterwards, ending each in an independent glans.

This disposition is to be found generally in the Monotremata and Marsupialia, as can be seen in the zoological treatise of Sedgwick (5); and some authors, like Albrecht, mentioned by Guinard (6), and Morselli (7), consider the bifidness of the penis, or penischisis, in man, where it is so rare, aS a regressive anomaly.

According to the investigations of Retterer (3) and other embryologists, the glans is not a mere expansion of the corpus spongiosum as was believed; the terminal and free end of the penis is rather constituted by the various elements which are to be found in the whole organ—that is, by the skin, by the corpora cavernosa, and by the corpus spongiosum. Note on a Case of Bifid Penis, with Penial Hypospadia 89

The cases of hypospadias, and especially the specimen which I have described, support the opinion of Retterer. It is true that, in my observation, the two parts of the double glans, on the whole well developed, are nevertheless flattened and, so to speak, atrophied on their ventral surface, which seems to show that the corpus spongiosum did not contrjbute normally as an element of formation.

Some recent works of anatomy still say that the glans is merely an expansion of the corpus spongiosum, superposed by its base on the anterior termination of the corpora cavernosa. However, I think Retterer’s views concerning the structure of the free extremity of the penis plainly demonstrated.

BIBLIOGRAPHY.

(1) Tourneux, “Sur le développement et l’évolution du tubercule génital chez le foetus humain,” Journ, de l’ Anatomie et de la Physiologie, 1889.

(2) Rerrerer, “Sur Vorigine et l’évolution de la région génitale des mammiféres,” Journ, de l Anatomie et de la Physiologie, 1890.

(3) Rerrersr, “Sur le développement du pénis et du clitoris chez les foetus humains,” Journ. de ? Anatomie et de la Physiologie, 1892.

(4) J. A. Pires pe Lima, “Sur quelques observations de fistules juta-uréthrales congénitales,” Seventeenth International Congress of Medicine, London, 1913, Section I., Anatomy and Embryology, part ii., London, 1914.

(5) Sepewick, A Student's Text-book of Zoology, tome ii., London, 1905.

(6) Guinarp, Précis de tératologie, Paris, 1893.

(7) Morseuut, L’ womo secondo la teoria dell’ evoluzione, Torino, 1911.