Chapter IX

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Complete absence of the hymen is very rare, if we may accept the statements of Devilliers, Tardieu, and Brouardel, as they have never seen an example in the numerous young girls they have examined from a medico-legal point of view.

Duplication or biperforation of the hymen is also a very rare anomaly of this membrane. In this instance the hymen generally presents two lateral orifices, more or less irregular and separated by a membranous band, which gives the appearance of duplicity. Roze reported from Strasburg in 1866 a case of this kind, and Delens has observed two examples of biperforate hymen, which show very well that this disposition of the membrane is due to a vice of conformation. The first was in a girl of eleven, in which the membrane was of the usual size and thickness, but was duplicated on either side. In her sister of nine the hymen was normally conformed. The second case was in a girl under treatment by Cornil in 1876 for vaginitis. Her brother had accused a young man of eighteen of having violated her, and on examination the hymen showed a biperforate conformation; there were two oval orifices, their greatest diameter being in the vertical plane; the openings were situated on each side of the median line, about five mm. apart; the dividing band did not appear to be cicatricial, but presented the same roseate coloration as the rest of the hymen. Since this report quite a number of cases have been recorded.

The different varieties of the hymen will be left to the works on obstetrics. As has already been observed, labor is frequently seriously complicated by a persistent and tough hymen.

Deficient vulva may be caused by the persistence of a thick hymen, by congenital occlusion, or by absolute absence in vulvar structure. Bartholinus, Borellus, Ephemerides, Julius, Vallisneri, and Baux are among the older writers who mention this anomaly, but as it is generally associated with congenital occlusion, or complete absence of the vagina, the two will be considered together.

Complete absence of the vagina is quite rare. Baux a reports a case of a girl of fourteen in whom "there was no trace of fundament or of genital organs." Oberteuffer speaks of a case of absent vagina. Vicq d'Azir is accredited with having seen two females who, not having a vagina, copulated all through life by the urethra, and Fournier sagely remarks that the extra large urethra may have been a special dispensation of nature. Bosquet describes a young girl of twenty with a triple vice of conformation--an obliterated vulva, closure of the vagina, and absence of the uterus. Menstrual hemorrhage took place from the gums. Clarke has studied a similar case which was authenticated by an autopsy.

O'Ferral of Dublin, Gooch, Davies, Boyd, Tyler Smith, Hancock, Coste, Klayskens, Debrou, Braid, Watson, and others are quoted by Churchill as having mentioned the absence of the vagina. Amussat observed a German girl who did not have a trace of a vagina and who menstruated regularly. Griffith describes a specimen in the Museum of St. Bartholomew's Hospital, London, in which the ovaries lay on the surface of the pelvic peritoneum and there was neither uterus nor vagina; the pelvis had some of the characteristics of the male type. Matthews Duncan has observed a somewhat similar case, the vagina not measuring more than an inch in length. Ferguson describes a prostitute of eighteen who had never menstruated. The labia were found well developed, but there was no vagina, uterus, or ovaries. Coitus had been through the urethra, which was considerably distended, though not causing incontinence of urine. Hulke reports a case of congenital atresia of the vagina in a brunette of twenty, menstruation occurring through the urethra. He also mentions the instance of congenital atresia of the vagina with hernia of both ovaries into the left groin in a servant of twenty, and the case of an imperforate vagina in a girl of nineteen with an undeveloped uterus.

Brodhurst reports an instance of absence of the vagina and uterus in a girl of sixteen who at four years of age showed signs of approaching puberty. At this early age the mons was covered with hair, and at ten the clitoris was three inches long and two inches in circumference. The mammae were well developed. The labia descended laterally and expanded into folds, resembling the scrotum.

Azema reports an instance of complete absence of the vagina and impermeability and probable absence of the col uterinus. The deficiencies were remedied by operation. Berard mentions a similar deformity and operation in a girl of eighteen. Gooding cites an instance of absent vagina in a married woman, the uterus discharging the functions. Gosselin reports a case in which a voluminous tumor was formed by the retained menstrual fluid in a woman without a vagina. An artificial vagina was created, but the patient died from extravasation of blood into the peritoneal cavity. Carter, Polaillon, Martin, Curtis, Worthington, Hall, Hicks, Moliere, Patry, Dolbeau, Desormeaux, and Gratigny also record instances of absence of the vagina.

There are some cases reported in extramedical literature which might be cited. Bussy Rabutin in his Memoires in 1639 speaks of an instance. The celebrated Madame Recamier was called by the younger Dumas an involuntary virgin; and in this connection could be cited the malicious and piquant sonnet--

Chateaubriand et Madame Recamier.

"Juliette et Rene s'aimaient d'amour si tendre Que Dien, sans les punir, a pu leur pardonner: Il n'avait pas voulu que l'une put donner Ce que l'autre ne pouvait prendre."

Duplex vagina has been observed by Bartholinus, Malacarne, Asch, Meckel, Osiander, Purcell, and other older writers. In more modern times reports of this anomaly are quite frequent. Hunter reports a case of labor at the seventh month in a woman with a double vagina, and delivery through the rectum. Atthill and Watts speak of double vagina with single uterus.

Robb of Johns Hopkins Hospital reports a case of double vagina in a patient of twenty suffering from dyspareunia. The vaginal orifice was contracted; the urethra was dilated and had evidently been used for coitus. A membrane divided the vagina into two canals, the cervix lying in the right half; the septum was also divided. Both the thumbs of the patient were so short that their tips could scarcely meet those of the little fingers. Double vagina is also reported by Anway, Moulton, Freeman, Frazer, Haynes, Lemaistre, Boardman, Dickson, Dunoyer, and Rossignol. This anomaly is usually associated with bipartite or double uterus. Wilcox mentions a primipara, three months pregnant, with a double vagina and a bicornate uterus, who was safely delivered of several children. Haller and Borellus have seen double vagina, double uterus, and double ovarian supply; in the latter case there was also a double vulva. Sanger speaks of a supernumerary vagina connecting with the other vagina by a fistulous opening, and remarks that this was not a case of patent Gartner's duct.

Cullingworth cites two cases in which there were transverse septa of the vagina. Stone reports five cases of transverse septa of the vagina. Three of the patients were young women who had never borne children or suffered injury. Pregnancy existed in each case. In the first the septum was about two inches from the introitus, and contained an opening about 1/2 inch in diameter which admitted the tip of the finger. The membrane was elastic and thin and showed no signs of inflammation. Menstruation had always been regular up to the time of pregnancy. The second was a duplicate of the first, excepting that a few bands extended from the cervix to the membranous septum. In the third the lumen of the vagina, about two inches from the introitus, was distinctly narrowed by a ridge of tissue. There was uterine displacement and some endocervicitis, but no history of injury or operation and no tendency to contraction. The two remaining cases occurred in patients seen by Dr. J. F. Scott. In one the septum was about 1 3/4 inches from the entrance to the vagina and contained an orifice large enough to admit a uterine probe. During labor the septum resisted the advance of the head for several hours, until it was slit in several directions. In the other, menstruation had always been irregular, intermissions being followed by a profuse flow of black and tarry blood, which lasted sometimes for fifteen days and was accompanied by severe pain. The septum was 1 1/2 inches from the vaginal orifice and contained an opening which admitted a uterine sound. It was very dense and tight and fully 1/8 inch in thickness.

Mordie reported a case of congenital deficiency of the rectovaginal septum which was successfully remedied by operation.

Anomalous Openings of the Vagina.--The vagina occasionally opens abnormally into the rectum, into the bladder, the urethra, or upon the abdominal parietes. Rossi reports from a hospital in Turin the case of a Piedmontese girl in whom there was an enormous tumor corresponding to the opening of the vaginal orifice; no traces of a vagina could be found. The tumor was incised and proved to be a living infant. The husband of the woman said that he had coitus without difficulty by the rectum, and examination showed that the vagina opened into the rectum, by which means impregnation had been accomplished. Bonnain and Payne have observed analogous cases of this abnormality of the vaginal opening and subsequent accouchement by the anus. Payne's case was of a woman of thirty-five, well formed, who had been in labor thirty-six hours, when the physician examined and looked in vain for a vaginal opening; the finger, gliding along the perineum, came in contact with the distended anus, in which was recognized the head of the fetus. The woman from prolongation of labor was in a complete state of prostration, which caused uterine inertia. Payne anesthetized the patient, applied the forceps, and extracted the fetus without further accident. The vulva of this woman five months afterward displayed all the characteristics of virginity, the vagina opened into the rectum, and menstruation had always been regular. This woman, as well as her husband, averred that they had no suspicion of the anomaly and that coitus (by the anus) had always been satisfactory.

Opening of the vagina upon the parietes, of which Le Fort has collected a number of cases, has never been observed in connection with a viable fetus.

Absence of the labia majora has been observed, especially by Pozzi, to the exclusion of all other anomalies. It is the rule in exstrophy of the bladder.

Absence of the nymphae has also been observed, particularly by Auvard and by Perchaux, and is generally associated with imperfect development of the clitoris. Constantinedes reports absence of the external organs of generation, probably also of the uterus and its appendages, in a young lady. Van Haartman, LeFort, Magee, and Ogle cite cases of absence of the external female organs. Riolan in the early part of the seventeenth century reported a case of defective nymphae; Neubauer in 1774 offers a contrast to this case in an instance of triple nymphae.

The nymphae are sometimes enormously enlarged by hypertrophy, by varicocele, or by elephantiasis, of which latter type Rigal de Gaillac has observed a most curious case. There is also a variety of enlargement of the clitoris which seems to be constant in some races; it may be a natural hypertrophy, or perhaps produced by artificial manipulation.

The peculiar conditions under which the Chinese women are obliged to live, particularly their mode of sitting, is said to have the effect of causing unusual development of the mons veneris and the labia majora. On the other hand, some of the lower African races have been distinguished by the deficiency in development of the labia majora, mons veneris, and genital hair. In this respect they present an approximation to the genitals of the anthropoid apes, among whom the orang-outang alone shows any tendency to formation of the labia majora.

The labial appendages of the Hottentot female have been celebrated for many years. Blumenbach and others of the earlier travelers found that the apron-like appearance of the genitals of the Hottentot women was due to abnormal hypertrophy of the labia and nymphae. According to John Knott, the French traveler, Le Vaillant, said that the more coquettish among the Hottentot girls are excited by extreme vanity to practice artificial elongation of the nympha and labia. They are said to pull and rub these parts, and even to stretch them by hanging weights to them. Some of them are said to spend several hours a day at this process, which is considered one of the important parts of the toilet of the Hottentot belle, this malformation being an attraction for the male members of the race. Merensky says that in Basutoland the elder women begin to practice labial manipulation on their female children shortly after infancy, and Adams has found this custom to prevail in Dahomey; he says that the King's seraglio includes 3000 members, the elect of his female subjects, all of whom have labia up to the standard of recognized length. Cameron found an analogous practice among the women of the shores of Lake Tanganyika. The females of this nation manipulated the skin of the lower part of the abdomens of the female children from infancy, and at puberty these women exhibit a cutaneous curtain over the genitals which reaches half-way down the thighs.

A corresponding development of the preputian clitorides, attaining the length of 18 mm. or even more, has been observed among the females of Bechuanaland. The greatest elongation measured by Barrow was five inches, but it is quite probable that it was not possible for him to examine the longest, as the females so gifted generally occupied very high social positions.

Morgagni describes a supernumerary left nympha, and Petit is accredited with seeing a case which exhibited neither nymphae, clitoris, nor urinary meatus. Mauriceau performed nymphotomy on a woman whose nymphae were so long as to render coitus difficult. Morand quotes a case of congenital malformation of the nymphae, to which he attributed impotency.

There is sometimes coalition of the labia and nymphae, which may be so firm and extensive as to obliterate the vulva. Debout has reported a case of absence of the vulva in a woman of twenty upon whom he operated, which was the result of the fusion of the labia minora, and this with an enlarged clitoris gave the external appearance of an hermaphrodite.

The absence of the clitoris coincides with epispadias in the male, and in atrophy of the vulva it is common to find the clitoris rudimentary; but a more frequent anomaly is hypertrophy of the clitoris.

Among the older authorities quoting instances of enlarged clitorides are Bartholinus, Schenck, Hellwig, Rhodius, Riolanus, and Zacchias. Albucasis describes an operation for enlarged clitoris, Chabert ligated one, and Riedlin gives an instance of an enlarged clitoris, in which there appeared a tumor synchronous with the menstrual epoch.

We learn from the classics that there were certain females inhabiting the borders of the Aegean Sea who had a sentimental attachment for one another which was called "Lesbian love," and which carried them to the highest degree of frenzy. The immortal effusions of Sappho contain references to this passion. The solution of this peculiar ardor is found in the fact that some of the females had enlarged clitorides, strong voices, robust figures, and imitated men. Their manner was imperative and authoritative to their sex, who worshiped them with perverted devotion. We find in Martial mention of this perverted love, and in the time of the dissolute Greeks and Romans ridiculous jealousies for unfaithfulness between these women prevailed. Aetius said that the Egyptians practiced amputation of the clitoris, so that enlargement of this organ must have been a common vice of conformation along the Nile. It was also said that the Egyptian women practiced circumcision on their females at the age of seven or eight, the time chosen being when the Nile was in flood. Bertherand cites examples of enlarged clitorides in Arab women; Bruce testifies to this circumstance in Abyssinia, and Mungo Park has observed it in the Mandingos and the Ibbos.

Sonnini says that the women of Egypt had a natural excrescence, fleshy in consistency, quite thick and pendulous, coming from the skin of the mons veneris. Sonnini says that in a girl of eight he saw one of these caruncles which was 1/2 inch long, and another on a woman of twenty which was four inches long, and remarks that they seem peculiar only to women of distinct Egyptian origin.

Duhouset says that in circumcision the Egyptian women not only remove a great part of the body of the clitoris with the prepuce, but also adjacent portions of the nymphae; Gallieni found a similar operation customary on the upper banks of the Niger.

Otto at Breslau in 1824 reports seeing a negress with a clitoris 4 1/2 inches long and 1 1/2 inches in the transverse diameter; it projected from the vulva and when supine formed a complete covering for the vaginal orifice. The clitoris may at times become so large as to prevent coitus, and in France has constituted a legitimate cause for divorce. This organ is very sensitive, and it is said that in cases of supposed catalepsy a woman cannot bear titillation of the clitoris without some visible movement.

Columbus cites an example of a clitoris as long as a little finger; Haller mentions one which measured seven inches, and there is a record of an enlarged clitoris which resembled the neck of a goose and which was 12 inches long. Bainbridge reports a case of enlarged clitoris in a woman of thirty-two who was confined with her first child. This organ was five inches in length and of about the diameter of a quiescent penis. Figure 149 shows a well-marked case of hypertrophy of the clitoris. Rogers describes a woman of twenty-five in a reduced state of health with an enormous clitoris and warts about the anus; there were also manifestations of tuberculosis. On questioning her, it was found that she had formerly masturbated; later she had sexual intercourse several times with a young man, but after his death she commenced self-abuse again, which brought on the present enlargement. The clitoris was ligated and came away without leaving disfigurement. Cassano and Pedretti of Naples reported an instance of monstrous clitoris in 1860 before the Academy of Medicine.

In some cases ossification of the clitoris is observed Fournier speaks of a public woman in Venice who had an osseous clitoris; it was said that men having connection with her invariably suffered great pain, followed by inflammation of the penis.

There are a few instances recorded of bifid clitoris, and Arnaud cites the history of a woman who had a double clitoris. Secretain speaks of a clitoris which was in a permanent state of erection.

Complete absence of the ovaries is seldom seen, but there are instances in which one of the ovaries is missing. Hunter, Vidal, and Chaussier report in full cases of the absence of the ovaries, and Thudicum has collected 21 cases of this nature. Morgagni, Pears, and Cripps have published observations in which both ovaries were said to have been absent. Cripps speaks of a young girl of eighteen who had an infantile uterus and no ovaries; she neither menstruated nor had any signs of puberty. Lauth cites the case of a woman whose ovaries and uterus were rudimentary, and who exhibited none of the principal physiologic characteristics of her sex; on the other hand, Ruband describes a woman with only rudimentary ovaries who was very passionate and quite feminine in her aspect.

At one time the existence of genuine supernumerary ovaries was vigorously disputed, and the older records contain no instances, but since the researches of Beigel, Puech, Thudicum, Winckler, de Sinety, and Paladino the presence of multiple ovaries is an incontestable fact. It was originally thought that supernumerary ovaries as well as supernumerary kidneys were simply segmentations of the normal organs and connected to them by portions of the proper substance; now, however, by the recent reports we are warranted in admitting these anomalous structures as distinct organs. It has even been suggested that it is the persistence of these ovaries that causes the menstruation of which we sometimes hear as taking place after ovariotomy. Sippel records an instance of third ovary; Mangiagalli has found a supernumerary ovary in the body of a still-born child, situated to the inner side of the normal organ. Winckel discovered a large supernumerary ovary connected to the uterus by its own ovarian ligament. Klebs found two ovaries on one side, both consisting of true ovarian tissue, and connected by a band 3/5 inch long.

Doran divides supernumerary ovaries into three classes:--

(1) The ovarium succentauriatum of Beigel.

(2) Those cases in which two masses of ovarian tissue are separated by ligamentous bands.

(3) Entirely separate organs, as in Winckel's case.

Prolapsus or displacement of the ovaries into the culdesac of Douglas, the vaginal wall, or into the rectum can be readily ascertained by the resulting sense of nausea, particularly in defecation or in coitus. Munde, Barnes, Lentz, Madden, and Heywood Smith report instances, and Cloquet describes an instance of inguinal hernia of the ovary in which the uterus as well as the Fallopian tube were found in the inguinal canal. Debierre mentions that Puech has gathered 88 instances of inguinal hernia of the ovary and 14 of the crural type, and also adds that Otte cites the only instance in which crural ovarian hernia has been found on both sides. Such a condition with other associate malformations of the genitalia might easily be mistaken for an instance of hermaphroditic testicles.

The Fallopian tubes are rarely absent on either side, although Blasius reports an instance of deficient oviducts. Blot reports a case of atrophy, or rather rudimentary state of one of the ovaries, with absence of the tube on that side, in a woman of forty.

Doran has an instance of multiple Fallopian tubes, and Richard, in 1861, says several varieties are noticed. These tubes are often found fused or adherent to the ovary or to the uterus; but Fabricius describes the symphysis of the Fallopian tube with the rectum.

Absence of the uterus is frequently reported. Lieutaud and Richerand are each said to have dissected female subjects in whom neither the uterus nor its annexed organs were found. Many authors are accredited with mentioning instances of defective or deficient uteri, among them Bosquet, Boyer, Walther, Le Fort, Calori, Pozzi, Munde, and Strauch. Balade has reported a curious absence of the uterus and vagina in a girl of eighteen. Azem, Bastien, Bibb, Bovel, Warren, Ward, and many others report similar instances, and in several cases all the adnexa as well as the uterus and vagina were absent, and even the kidney and bladder malformed.

Phillips speaks of two sisters, both married, with congenital absence of the uterus. In his masterly article on "Heredity," Sedgwick quotes an instance of total absence of the uterus in three out of five daughters of the same family; two of the three were twice married.

Double uterus is so frequently reported that an enumeration of the cases would occupy several pages. Bicorn, bipartite, duplex, and double uteruses are so called according to the extent of the duplication. The varieties range all the way from slight increase to two distinct uteruses, with separate appendages and two vaginae. Meckel, Boehmer, and Callisen are among the older writers who have observed double uterus with associate double vagina. Figure 150 represents a transverse section of a bipartite uterus with a double vagina. The so-called uterus didelphus is really a duplex uterus, or a veritable double uterus, each segment having the appearance of a complete unicorn uterus more or less joined to its neighbor. Vallisneri relates the history of a woman who was poisoned by cantharides who had two uteruses, one opening into the vagina, the other into the rectum. Morand, Bartholinus, Tiedemann, Ollivier, Blundell, and many others relate instances of double uterus in which impregnation had occurred, the fetus being retained until the full term.

Purcell of Dublin says that in the summer of 1773 he opened the body of a woman who died in the ninth month of pregnancy. He found a uterus of ordinary size and form as is usual at this period of gestation, which contained a full-grown fetus, but only one ovary attached to a single Fallopian tube. On the left side he found a second uterus, unimpregnated and of usual size, to which another ovary and tube were attached. Both of these uteruses were distinct and almost entirely separate.

Pregnancy with Double Uterus.--Hollander describes the following anomaly of the uterus which he encountered during the performance of a celiotomy:--

"There were found two uteruses, the posterior one being a normal organ with its adnexa; connected with this uterus was another one, anterior to it. The two uteruses had a common cervix; the anterior of the two organs had no adnexa, though there were lateral peritoneal ligaments; it had become pregnant." Hollander explains the anomaly by stating that probably the Mullerian ducts or one of them had grown excessively, leading to a folding off of a portion which developed into the anterior uterus.

Other cases of double uterus with pregnancy are mentioned on page 49.

When there is simultaneous pregnancy in each portion of a double uterus a complication of circumstances arises. Debierre quotes an instance of a woman who bore one child on July 16, 1870, and another on October 31st of the same year, and both at full term. She had only had three menstrual periods between the confinements. The question as to whether a case like this would be one of superfetation in a normal uterus, or whether the uterus was double, would immediately arise. There would also be the possibility that one of the children was of protracted gestation or that the other was of premature birth. Article 312 of the Civil Code of France accords a minimum of one hundred and eighty and a maximum of three hundred days for the gestation of a viable child. (See Protracted Gestation.)

Voight is accredited with having seen a triple uterus, and there are several older parallels on record. Thilow mentions a uterus which was divided into three small portions.

Of the different anomalous positions of the uterus, most of which are acquired, the only one that will be mentioned is that of complete prolapse of the uterus. In this instance the organ may hang entirely out of the body and even forbid locomotion.

Of 19 cases of hernia of the uterus quoted by Debierre 13 have been observed in the inguinal region, five on the right and seven on the left side. In the case of Roux in 1891 the hernia existed on both sides. The uterus has been found twice only in crural hernia and three times in umbilical hernia. There is one case recorded, according to Debierre, in which the uterus was one of the constituents of an obturator hernia. Sometimes its appendages are found with it. Doring, Ledesma, Rektorzick, and Scazoni have found the uterus in the sac of an inguinal hernia; Leotaud, Murray, and Hagner in an umbilical hernia. The accompanying illustration represents a hernia of the gravid womb through the linea alba.

Absence of the penis is an extremely rare anomaly, although it has been noted by Schenck, Borellus, Bouteiller, Nelaton, and others. Fortunatus Fidelis and Revolat describe a newly born child with absence of external genitals, with spina bifida and umbilical hernia. Nelaton describes a child of two entirely without a penis, but both testicles were found in the scrotum; the boy urinated by the rectum. Ashby and Wright mention complete absence of the penis, the urethra opening at the margin of the anus outside the external sphincter; the scrotum and testicles were well developed. Murphy gives the description of a well-formed infant apparently without a penis; the child passed urine through an opening in the lower part of the abdomen just above the ordinary location of the penis; the scrotum was present. Incisions were made into a small swelling just below the urinary opening in the abdomen which brought into view the penis, the glans being normal but the body very small. The treatment consisted of pressing out the glans daily until the wound healed; the penis receded spontaneously. It is stated that the organ would doubtless be equal to any requirements demanded of it. Demarquay quotes a somewhat similar case in an infant, but it had no urinary opening until after operation.

Among the older writers speaking of deficient or absent penis are Bartholinus, Bauhinus, Cattierus, the Ephemerides, Frank, Panaroli, van der Wiel, and others. Renauldin describes a man with a small penis and enormous mammae. Goschler, quoted by Jacobson, speaks of a well-developed man of twenty-two, with abundant hair on his chin and suprapubic region and the scrotum apparently perfect, with median rapine; a careful search failed to show any trace of a penis; on the anterior wall of the rectum four lines above the anus was an orifice which gave vent to urine; the right testicle and cord were normal, but there was an acute orchitis in the left. Starting from just in front of the anal orifice was a fold of skin 1 1/2 inches long and 3/4 inch high continuous with the rapine, which seemed to be formed of erectile tissue and which swelled under excitement, the enlargement lasting several minutes with usually an emission from the rectum. It was possible to pass a sound through the opening in the rectum to the bladder through a urethra 1 1/2 inches wide; the patient had control of the bladder and urinated from every three to five hours.

Many instances of rudimentary development of the penis have been recorded, most of them complicated with cryptorchism or other abnormality of the sexual organs. In other instances the organ is present, but the infantile type is present all through life; sometimes the subjects are weak in intellect and in a condition similar to cretinism. Kaufmann quotes a case in a weakly boy of twelve whose penis was but 3/4 inch long, about as thick as a goose-quill, and feeling as limp as a mere tube of skin; the corpora cavernosa were not entirely absent, but ran only from the ischium to the junction of the fixed portion of the penis, suddenly terminating at this point. Nothing indicative of a prostate could be found. The testicles were at the entrance of the inguinal canal and the glans was only slightly developed.

Binet speaks of a man of fifty-three whose external genitalia were of the size of those of a boy of nine. The penis was of about the size of the little finger, and contained on each side testicles not larger than a pea. There was no hair on the pubes or the face, giving the man the aspect of an old woman. The prostate was almost exterminated and the seminal vesicles were very primitive in conformation. Wilson was consulted by a gentleman of twenty-six as to his ability to perform the marital function. In size his penis and testicles hardly exceeded those of a boy of eight. He had never felt desire for sexual intercourse until he became acquainted with his intended wife, since when he had erections and nocturnal emissions. The patient married and became the father of a family; those parts which at twenty-six were so much smaller than usual had increased at twenty-eight to normal adult size. There are three cases on record in the older literature of penises extremely primitive in development. They are quoted by the Ephemerides, Plater, Schenck, and Zacchias. The result in these cases was impotency.

In the Army and Medical Museum at Washington are two injected specimens of the male organ divested of skin. From the meatus to the pubis they measure 6 1/2 and 5 1/2 inches; from the extremity to the termination of either crus 9 3/4 and 8 3/4 inches, and the circumferences are 4 3/4 and 4 1/4 inches. Between these two we can strike an average of the size of the normal penis.

In some instances the penis is so large as to forbid coitus and even inconvenience its possessor, measuring as much as ten or even more inches in length. Extraordinary cases of large penis are reported by Albinus (who mentions it as a cause for sterility), Bartholinus, Fabricius Hildanus, Paullini, Peyer, Plater, Schurig, Sinibaldus, and Zacchias. Several cases of enormous penises in the new-born have been observed by Wolff and others.

The penis palme, or suture de la verge of the French, is the name given to those examples of single cutaneous envelope for both the testicles and penis; the penis is adherent to the scrotum by its inferior face; the glans only is free and erection is impossible. Chretien cites an instance in a man of twenty-five, and Schrumpf of Wesserling describes an example of this rare anomaly. The penis and testes were inclosed in a common sac, a slight projection not over 1/4 inch long being seen from the upper part of this curious scrotum. When the child was a year old a plastic operation was performed on this anomalous member with a very satisfactory result. Petit describes an instance in which the penis was slightly fused with the scrotum.

There are many varieties of torsion of the penis. The glans itself may be inclined laterally, the curvature may be total, or there may be a veritable rotation, bringing the inferior face above and the superior face below. Gay describes a child with epispadias whose penis had undergone such torsion on its axis that its inferior surface looked upward to the left, and the child passed urine toward the left shoulder. Follin mentions a similar instance in a boy of twelve with complete epispadias, and Verneuil and Guerlin also record cases, both complicated with associate maldevelopment. Caddy mentions a youth of eighteen who had congenital torsion of the penis with out hypospadias or epispadias. There was a complete half-turn to the left, so that the slit-like urinary meatus was reversed and the frenum was above. Among the older writers who describe incurvation or torsion of the penis are Arantius, the Ephemerides, Haenel, Petit, Schurig, Tulpius, and Zacchias.

Zacutus Lusitans speaks of torsion of the penis from freezing. Paullini mentions a case the result of masturbation, and Hunter speaks of torsion of the penis associated with arthritis.

Ossification of the Penis.--MacClellann speaks of a man of fifty-two whose penis was curved and distorted in such a manner that urine could not be passed without pain and coitus was impossible. A bony mass was discovered in the septum between the corpora cavernosa; this was dissected out with much hemorrhage and the upward curvature was removed, but there resulted a slight inclination in the opposite direction. The formation of bone and cartilage in the penis is quite rare. Velpeau, Kauffmann, Lenhoseck, and Duploy are quoted by Jacobson as having seen this anomaly. There is an excellent preparation in Vienna figured by Demarquay, but no description is given. The Ephemerides and Paullini describe osseous penises.

The complete absence of the frenum and prepuce has been observed in animals but is very rare in man. The incomplete or irregular development is more frequent, but most common is excessive development of the prepuce, constituting phimosis, when there is abnormal adherence with the glans. Instances of phimosis, being quite common, will be passed without special mention. Deficient or absent prepuce has been observed by Blasius, Marcellus Donatus, and Gilibert. Partial deficiency is described by Petit Severinus, and others.

There may be imperforation or congenital occlusion of some portion of the urethra, causing enormous accumulation of urine in the bladder, but fortunately there is generally in such cases some anomalous opening of the urethra giving vent to the excretions. Tulpius mentions a case of deficient urethra. In the Ephemerides there is an account of a man who had a constant flow of semen from an abnormal opening in the abdomen. La Peyroma describes a case of impotence due to ejaculation of the spermatic ducts into the bladder instead of into the urethra, but remarks that there was a cicatrix of a wound of the neighboring parts. There are a number of instances in which the urethra has terminated in the rectum. Congenital dilatation of the urethral canal is very rare, and generally accompanied by other malformation.

Duplication of the urethra or the existence of two permeable canals is not accepted by all the authors, some of whom contend that one of the canals either terminates in a culdesac or is not separate in itself. Verneuil has published an article clearly exposing a number of cases, showing that it is possible for the urethra to have two or more canals which are distinct and have separate functions. Fabricius Hildanus speaks of a double aperture to the urethra; Marcellus Donatus describes duplicity of the urethra, one of the apertures being in the testicle; and there is another case on record in which there was a urethral aperture in the groin. A case of double urethra in a man of twenty-five living in Styria who was under treatment for gonorrhea is described, the supernumerary urethra opening above the natural one and receiving a sound to the depth of 17 cm. There was purulent gonorrhea in both urethrae. Vesalius has an account of a double urethral aperture, one of which was supposed to give spermatic fluid and the other urine. Borellus, Testa, and Cruveilhier have reported similar instances. Instances of double penis have been discussed under the head of diphallic terata, page 194.

Hypospadias and epispadias are names given to malformations of the urethra in which the wall of the canal is deficient either above or below. These anomalies are particularly interesting, as they are nearly always found in male hermaphrodites, the fissure giving the appearance of a vulva, as the scrotum is sometimes included, and even the perineum may be fissured in continuity with the other parts, thus exaggerating the deception. There seems to be an element of heredity in this malformation, and this allegation is exemplified by Sedgwick, who quotes a case from Heuremann in which a family of females had for generations given birth to males with hypospadias. Belloc mentions a man whose urethra terminated at the base of the frenum who had four sons with the same deformity. Picardat mentions a father and son, both of whom had double urethral orifices, one above the other, from one of which issued urine and from the other semen--a fact that shows the possibility of inheritance of this malformation. Patients in whom the urethra opens at the root of the penis, the meatus being imperforate, are not necessarily impotent; as, for instance, Fournier knew of a man whose urethra opened posteriorly who was the father of four children. Fournier supposed that the semen ejaculated vigorously and followed the fissure on the back of the penis to the uterus, the membrane of the vagina supplanting the deficient wall of the urethra. The penis was short, but about as thick as ordinary.

Gray mentions a curious case in a man afflicted with hypospadias who, suffering with delusions, was confined in the insane asylum at Utica. When he determined to get married, fully appreciating his physical defect, he resolved to imitate nature, and being of a very ingenious turn of mind, he busied himself with the construction of an artificial penis. While so engaged he had seized every opportunity to study the conformation of this organ, and finally prepared a body formed of cotton, six inches in length, and shaped like a penis, minus a prepuce. He sheathed it in pig's gut and gave it a slight vermilion hue. To the touch it felt elastic, and its shape was maintained by a piece of gutta-percha tubing, around which the cotton was firmly wound. It was fastened to the waist-band by means of straps, a central and an upper one being so arranged that the penis could be thrown into an erect position and so maintained. He had constructed a flesh-colored covering which completely concealed the straps. With this artificial member he was enabled to deceive his wife for fifteen months, and was only discovered when; she undressed him while he was in a state of intoxication. To further the deception he had told his wife immediately after their marriage that it was quite indecent for a husband to undress in the presence of his wife, and therefore she had always retired first and turned out the light. Partly from fear that his virile power would be questioned and partly from ignorance, the duration of actual coitus would approach an hour. When the discovery was made, his wife hid the instrument with which he had perpetrated a most successful fraud upon her, and the patient subsequently attempted coitus by contact with unsuccessful results, although both parties had incomplete orgasms. Shortly afterward evidences of mental derangement appeared and the man became the subject of exalted delusions. His wife, at the time of report, had filed application for divorce. Haslam reports a case in which loss of the penis was compensated for by the use of an ivory succedaneum. Parallel instances of this kind have been recorded by Ammann and Jonston.

Entire absence of the male sexual apparatus is extremely rare, but Blondin and Velpeau have reported cases.

Complete absence of the testicles, or anorchism, is a comparatively rare anomaly, and it is very difficult to distinguish between anorchism and arrest of development, or simple atrophy, which is much more common. Fisher of Boston describes the case of a man of forty-five, who died of pneumonia. From the age of puberty to twenty-five, and even to the day of death, his voice had never changed and his manners were decidedly effeminate. He always sang soprano in concert with females. After the age of twenty-five, however, his voice became more grave and he could not accompany females with such ease. He had no beard, had never shaved, and had never exhibited amorous propensities or desire for female society. When about twenty-one he became associated with a gay company of men and was addicted to the cup, but would never visit houses of ill-fame. On dissection no trace of testicles could be found; the scrotum was soft and flabby. The cerebellum was the exact size of that of a female child.

Individuals with one testicle are called monorchids, and may be divided into three varieties:--

(1) A solitary testicle divided in the middle by a deep fissure, the two lobes being each provided with a spermatic cord on the same side as the lobe.

(2) Testicles of the same origin, but with coalescence more general.

(3) A single testicle and two cords.

Gruber of St. Petersburg held a postmortem on a man in January, 1867, in whom the right half of the scrotum, the right testicle, epididymis, and the scrotal and inguinal parts of the right vas deferens were absent. Gruber examined the literature for thirty years up to the time of his report, and found 30 recorded postmortem examinations in which there was absence of the testicle, and in eight of these both testicles were missing. As a rule, natural eunuchs have feeble bodies, are mentally dull, and live only a short time. The penis is ordinarily defective and there is sometimes another associate malformation. They are not always disinclined toward the opposite sex.

Polyorchids are persons who have more than two testicles. For a long time the abnormality was not believed to exist, and some of the observers denied the proof by postmortem examination of any of the cases so diagnosed, but there is at present no doubt of the fact,--three, four, and five testicles having been found at autopsies. Russell, one of the older writers on the testicle, mentions a monk who was a triorchid, and was so salacious that his indomitable passion prevented him from keeping his vows of chastity. The amorous propensities and generative faculties of polyorchids have always been supposed greater than ordinary. Russell reports another case of a man with a similar peculiarity, who was prescribed a concubine as a reasonable allowance to a man thus endowed.

Morgagni and Meckel say that they never discovered a third testicle in dissections of reputed triorchids, and though Haller has collected records of a great number of triorchids, he has never been able to verify the presence of the third testicle on dissection. Some authors, including Haller, have demonstrated heredity in examples of polyorchism. There is an old instance in which two testicles, one above the other, were found on the right side and one on the left. Macann describes a recruit of twenty, whose scrotum seemed to be much larger on the right than on the left side, although it was not pendulous. On dissection a right and left testicle were found in their normal positions, but situated on the right side between the groin and the normal testicle was a supernumerary organ, not in contact, and having a separate and short cord. Prankard also describes a man with three testicles. Three cases of triorchidism were found in recruits in the British Army. Lane reports a supernumerary testis found in the right half of the scrotum of a boy of fifteen. In a necropsy held on a man killed in battle, Hohlberg discovered three fully developed testicles, two on the right side placed one above the other. The London Medical Record of 1884 quotes Jdanoff of St. Petersburg in mentioning a soldier of twenty-one who had a supernumerary testicle erroneously diagnosed as inguinal hernia. Quoted by the same reference, Bulatoff mentions a soldier who had a third testicle, which diagnosis was confirmed by several of his confreres. They recommended dismissal of the man from the service, as the third testicle, usually resting in some portion of the inguinal canal, caused extra exposure to traumatic influence.

Venette gives an instance of four testicles, and Scharff, in the Ephemerides, mentions five; Blasius mentions more than three testicles, and, without citing proof, Buffon admits the possibility of such occurrence and adds that such men are generally more vigorous.

Russell mentions four, five, and even six testicles in one individual; all were not verified on dissection. He cites an instance of six testicles four of which were of usual size and two smaller than ordinary.

Baillie, the Ephemerides, and Schurig mention fusion of the testicles, or synorchidism, somewhat after the manner of the normal disposition of the batrachians and also the kangaroos, in the former of which the fusion is abdominal and in the latter scrotal. Kerckring has a description of an individual in whom the scrotum was absent.

In those cases in which the testicles are still in the abdominal cavity the individuals are termed cryptorchids. Johnson has collected the results of postmortem examinations of 89 supposed cryptorchids. In eight of this number no testicles were found postmortem, the number found in the abdomen was uncertain, but in 18 instances both testicles were found in the inguinal canal, and in eight only one was found in the inguinal canal, the other not appearing. The number in which the semen was examined microscopically was 16, and in three spermatozoa were found in the semen; one case was dubious, spermatozoa being found two weeks afterward on a boy's shirt. The number having children was ten. In one case a monorchid generated a cryptorchid child. Some of the cryptorchids were effeminate, although others were manly with good evidences of a beard. The morbid, hypochondriac, the voluptuous, and the imbecile all found a place in Johnson's statistics; and although there are evidences of the possession of the generative function, still, we are compelled to say that the chances are against fecundity of human cryptorchids. In this connection might be quoted the curious case mentioned by Geoffroy-Saint-Hilaire, of a soldier who was hung for rape. It was alleged that no traces of testicles were found externally or internally yet semen containing spermatozoa was found in the seminal vesicles. Spermatozoa have been found days and weeks after castration, and the individuals during this period were capable of impregnation, but in these cases the reservoirs were not empty, although the spring had ceased to flow. Beigel, in Virchow's Archives, mentions a cryptorchid of twenty-two who had nocturnal emissions containing spermatozoa and who indulged in sexual congress. Partridge describes a man of twenty-four who, notwithstanding his condition, gave evidences of virile seminal flow.

In some cases there is anomalous position of the testicle. Hough mentions an instance in which, from the great pain and sudden appearance, a small tumor lying against the right pubic bone was supposed to be a strangulated hernia. There were two well-developed testicles in the scrotum, and the hernia proved to be a third. McElmail describes a soldier of twenty-nine, who two or three months before examination felt a pricking and slight burning pain near the internal aperture of the internal inguinal canal, succeeded by a swelling until the tumor passed into the scrotum. It was found in the upper part of the scrotum above the original testicle, but not in contact, and was about half the size of the normal testicle; its cord and epididymis could be distinctly felt and caused the same sensation as pressure on the other testicle did.

Marshall mentions a boy of sixteen in whom the right half of the scrotum was empty, although the left was of normal size and contained a testicle. On close examination another testicle was found in the perineum; the boy said that while running he fell down, four years before, and on getting up suffered great pain in the groin, and this pain recurred after exertion. This testicle was removed successfully to the scrotum. Horsley collected 20 instances of operators who made a similar attempt, Annandale being the first one; his success was likely due to antisepsis, as previously the testicles had always sloughed. There is a record of a dog remarkable for its salacity who had two testicles in the scrotum and one in the abdomen; some of the older authors often indulged in playful humor on this subject.

Brown describes a child with a swelling in the perineum both painful and elastic to the touch. The child cried if pressure was applied to the tumor and there was every evidence that the tumor was a testicle. Hutcheson, quoted by Russell, has given a curious case in an English seaman who, as was the custom at that time, was impressed into service by H.M.S. Druid in 1807 from a trading ship off the coast of Africa. The man said he had been examined by dozens of ship-surgeons, but was invariably rejected on account of rupture in both groins. The scrotum was found to be an empty bag, and close examination showed that the testicles occupied the seats of the supposed rupture. As soon as the discovery was made the man became unnerved and agitated, and on re-examining the parts the testicles were found in the scrotum. When he found that there was no chance for escape he acknowledged that he was an impostor and gave an exhibition in which, with incredible facility, he pulled both testes up from the bottom of the scrotum to the external abdominal ring. At the word of command he could pull up one testicle, then another, and let them drop simultaneously; he performed other like feats so rapidly that the movements could not be distinguished.

In this connection Russell speaks of a man whose testicle was elevated every time the east wind blew, which caused him a sense of languor and relaxation; the same author describes a man whose testicles ascended into the inguinal canal every time he was in the company of women.

Inversion of the testicle is of several varieties and quite rare, it has been recognized by Sir Astley Cooper, Boyer, Maisonneuve, Royet, and other writers.

The anomalies of the vas deferens and seminal vesicles are of little interest and will be passed with mention of the case of Weber, who found the seminal vesicles double; a similar conformation has been seen in hermaphrodites.

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