Over one hundred cases collected in which marriage proved fruitless. It is more common than is usually credited. In the French army it occurs once in every three hundred recruits. The neg lect of these eases in childhood is repre hensible. When operating on infants great care must be used in the dissection of the urethra. Carl Beck (N. V. Sled. Jour., Dec. S, 1900).
In the other cases the treatment con sists in straightening the organ and the formation of a canal in the normal posi tion of the urethra. The straightening of the organ is accomplished by making one or more transverse incisions through the skin and any bands of tissue which tend to hold the organ in the abnormal position. It is occasionally necessary to carry the incision into the corpora caver nosa. The incisions should be united by sutures in a longitudinal direction.
According to Duplay's method, the subsequent steps are as follow: Second stage, the formation of a new meatus. If there is a well-marked depression through the glans, the free edges may be freshened, a small catheter laid in the groove, and the raw surfaces brought to gether and held in place by sutures or harelip-pins. This may be done at the same time that the organ is straightened. which will shorten the treatment. Third stage, the formation of a new canal. This should not be undertaken until some months after the organ has been straightened or until it is certain that the first operation has been successful. In carrying out the operation a catheter should be introduced through the canal forming the glans and passed into the bladder. It should lie in the groove representing the undeveloped urethra. An incision is then made parallel with and a little external to the catheter on either side, and the flaps dissected up somewhat, but not enough to cut off the blood-supply at the base. These flaps are then made to fold over the catheter, and are united with fine catgut sutures. It is not essential that the flaps should join. The skin external to the two in on the stretch, a long, narrow bistoury was pushed into its centre, in the situa tion of the dimple where the urethra should have opened; the knife was made to traverse the whole length of the penis, approximately in the line of the septum between the corpora cavernosa, and was made to emerge at the fistulous opening at the root of the organ; a tunnel was thus made in the position of the urethra. The knife was then withdrawn, and the bleeding was arrested by pressure with the fingers. Meanwhile a Thiersch graft was cut from the inner surface of the left upper arm, ten centimetres in length and two centimetres in width; the graft was then wrapped around an oiled bougie, with its raw surface exposed and fastened to the bougie by a catgut thread at either end. The bleeding from the wound in the penis having ceased, the bougie enveloped by the graft was inserted into the tunnel already made, so that one end projected from the opening in the glans and the other from the fistula at the root of the penis; the excess of bougie was cut off with scissors, the catgut thread at the anterior end of the graft was divided, and the circular edge of the tubular graft was stitched to the edges of the wound in the glans; i.e., the site of the future meatus.
A catheter was secured in the bladder and emerged at the fistula at the peno-scrotal junction, and through it all the urine escaped. On the third day the bougie was carefully withdrawn by the meatus, after cutting the catgut thread round the graft at its posterior end; the catheter was allowed to remain until the seventh day; thereafter the patient urinated by the fistula. On the tenth day the new urethra was dilated with boogies Nos. 15 and 10 (French scale) ; this was repeated every second day until a No. 19 was easily passed. At a later period the fistulous opening was closed by a plastic operation, and the patient then urinated by the meatus in the natural way. On separating the lips of the meatus, one could see the white epidermis lining the canal of the urethra. Taller (Ann. d. Mal. d. Org. Gen.-Urin., Apr., 'DO).
cisions should then be dissected up freely on each side, and the two flaps united in the middle line by fine mattress-sutures. Great care should be taken to keep the wound dry and prevent infection, as this would interfere with the success of the operation. The fourth step consists in joining the new canal at either extrem ity. The margins of the openings are freshened and the raw edges united by fine sutures over a catheter. It is not to be undertaken until the healing from the last step is complete.
According to the method of Anger, the third step is carried out by forming two flaps the length of which cor responds to the defect to be corrected. One flap has its base along one side of the urethral groove, and the other has its free margin along the opposite side of the groove. The flap with the base next to the groove is turned over the catheter and the free margin united to the base of the second flap by means of sutures armed with a needle on either end. The second flap is then drawn over the first and united to the on the opposite side.
In some cases it will be found advis able to make use of the redundant prepuce. For this purpose an incision is made through both layers on the dor sum corresponding with the corona. The glans is slipped through this in cision, and the mucous membrane sepa rated from the cutaneous surface from the incision toward the free border, and the raw surface thus formed made to cover over that which resulted from turning flaps over a catheter to form a new urethra.
Case of peno-serotal hypospadias in which Nov6-Josserand's operation was used. The glans was imperforate; the urethra opened on the inferior aspect of the penis, at the junction of the latter with the scrotum. The glans being put