Dilatation of the colon frequently occurs as a transient affection, and

by its action in pushing up the diaphragm may so seriously interfere

with the action of the heart and lungs as to occasionally cause

heart-failure. Fenwick has mentioned an instance of this nature.

According to Osler there is a chronic form of dilatation of the colon

in which the gut may reach an enormous size. The coats may be

hypertrophied without evidence of any special organic change in the

mucosa. The most remarkable instance has been reported by Formad. The

patient, known as the "balloon-man," aged twenty-three at the time of

his death, had had a distended abdomen from infancy. Postmortem the

colon was found as large as that of an ox, the circumference ranging

from 15 to 30 inches. The weight of the contents was 47 pounds. Cases

are not uncommon in children. Osler reports three well-marked cases

under his care. Chapman mentions a case in which the liver was

displaced by dilatation of the sigmoid flexure. Mya reports two cases

of congenital dilatation and hypertrophy of the colon (megacolon

congenito). Hirsohsprung, Genersich, Faralli, Walker, and Griffiths all

record similar instances, and in all these cases the clinical features

were obstinate constipation and marked meteorismus.

Imperforate Anus.--Cases in which the anus is imperforate or the rectum

ends in a blind pouch are occasionally seen. In some instances the

rectum is entirely absent, the colon being the termination of the

intestinal tract. There are cases on record in which the rectum

communicated with the anus solely by a fibromuscular cord. Anorectal

atresia is the ordinary imperforation of the anus, in which the rectum

terminates in the middle of the sacral cavity. The rectum may be

deficient from the superior third of the sacrum, and in this position

is quite inaccessible for operation.

A compensatory coalition of the bowel with the bladder or urethra is

sometimes present, and in these cases the feces are voided by the

urinary passages. Huxham mentions the fusion of the rectum and colon

with the bladder, and similar instances are reported by Dumas and

Baillie. Zacutus Lusitanus describes an infant with an imperforate

membrane over its anus who voided feces through the urethra for three

months. After puncture of the membrane, the discharge came through the

natural passage and the child lived; Morgagni mentions a somewhat

similar case in a little girl living in Bologna, and other modern

instances have been reported. The rectum may terminate in the vagina.

Masters has seen a child who lived nine days in whom the sigmoid

flexure of the colon terminated in the fundus of the bladder. Guinard

pictures a case in which there was communication between the rectum and

the bladder. In Figure 140 a represents the rectum; b the bladder; c

the point of communication; g shows the cellular tissue of the scrotum.

There is a description of a girl of fourteen, otherwise well

constituted and healthy, who had neither external genital organs nor

anus. There was a plain dermal covering over the genital and anal

region. She ate regularly, but every three days she experienced pain in

the umbilicus and much intestinal irritation, followed by severe

vomiting of stercoraceous matter; the pains then ceased and she

cleansed her mouth with aromatic washes, remaining well until the

following third day. Some of the urine was evacuated by the mammae. The

examiners displayed much desire to see her after puberty to note the

disposition of the menstrual flow, but no further observation of her

case can be found.

Fournier narrates that he was called by three students, who had been

trying to deliver a woman for five days. He found a well-constituted

woman of twenty-two in horrible agony, who they said had not had a

passage of the bowels for eight days, so he prescribed an enema. The

student who was directed to give the enema found to his surprise that

there was no anus, but by putting his finger in the vagina he could

discern the floating end of the rectum, which was full of feces. There

was an opening in this suspended rectum about the size of an

undistended anus. Lavage was practiced by a cannula introduced through

the opening, and a great number of cherry stones agglutinated with

feces followed the water, and labor was soon terminated. The woman

afterward confessed that she was perfectly aware of her deformity, but

was ashamed to disclose it before. There was an analogue of this case

found by Mercurialis in a child of a Jew called Teutonicus.

Gerster reports a rare form of imperforate anus, with malposition of

the left ureter, obliteration of the ostia of both ureters, with

consequent hydronephrosis of a confluent kidney. There was a minute

opening into the bladder, which allowed the passage of meconium through

the urethra. Burge mentions the case of what he calls "sexless child,"

in which there was an imperforate anus and no pubic arch; the ureters

discharged upon a tumor the size of a teacup extending from the

umbilicus to the pubes. A postmortem examination confirmed the

diagnosis of sexless child.

The Liver.--The Ephemerides, Frankenau, von Home, Molinetti, Schenok,

and others speak of deficient or absent liver. Zacutus Lusitanus says

that he once found a mass of flesh in place of the liver. Lieutaud is

quoted as describing a postmortem examination of an adult who had died

of hydropsy, in whom the liver and spleen were entirely missing. The

portal vein discharged immediately into the vena cava; this case is

probably unique, as no authentic parallel could be found.

Laget reports an instance of supernumerary lobe in the liver. Van Buren

describes a supernumerary liver. Sometimes there is rotation, real or

apparent, caused by transposition of the characteristics of the liver.

Handy mentions such a case. Kirmisson reports a singular anomaly of

the liver which he calls double displacement by interversion and

rotation on the vertical axis. Actual displacements of the liver as

well as what is known as wandering liver are not uncommon. The

operation for floating liver will be spoken of later.

Hawkins reports a case of congenital obliteration of the ductus

communis choledochus in a male infant which died at the age of four and

a half months. Jaundice appeared on the eighth day and lasted through

the short life. The hepatic and cystic ducts were pervious and the

hepatic duct obliterated. There were signs of hepatic cirrhosis and in

addition an inguinal hernia.

The Gall-Bladder.--Harle mentions the case of a man of fifty, in whom

he could find no gall-bladder; Patterson has seen a similar instance in

a men of twenty-five. Purser describes a double gall-bladder.

The spleen has been found deficient or wanting by Lebby, Ramsay, and

others, but more frequently it is seen doubled. Cabrolius, Morgagni,

and others have found two spleens in one subject; Cheselden and

Fallopius report three; Fantoni mentions four found in one subject;

Guy-Patin has seen five, none as large as the ordinary organ;

Hollerius, Kerckringius, and others have remarked on multiple spleens.

There is a possibility that in some of the cases of multiple spleens

reported the organ is really single but divided into several lobes.

Albrecht mentions a case shown at a meeting of the Vienna Medical

Society of a very large number of spleens found in the mesogastrium,

peritoneum, on the mesentery and transverse mesocolon, in Douglas'

pouch, etc. There was a spleen "the size of a walnut" in the usual

position, with the splenic artery and vein in their normal position.

Every one of these spleens had a capsule, was covered by peritoneum,

and exhibited the histologic appearance of splenic tissue. According to

the review of this article, Toldt explains the case by assuming that

other parts of the celomic epithelium, besides that of the

mesogastrium, are capable of forming splenic tissue. Jameson reports a

case of double spleen and kidneys. Bainbrigge mentions a case of

supernumerary spleen causing death from the patient being placed in the

supine position in consequence of fracture of the thigh. Peevor

mentions an instance of second spleen. Beclard and Guy-Patin have seen

the spleen congenitally misplaced on the right side and the liver on

the left; Borellus and Bartholinus with others have observed

misplacement of the spleen.

The Pancreas.--Lieutaud has seen the pancreas missing and speaks of a

double pancreatic duct that he found in a man who died from starvation;

Bonet speaks of a case similar to this last.

There are several cases of complete transposition of the viscera on

record. This bizarre anomaly was probably observed first in 1650 by

Riolanus, but the most celebrated case was that of Morand in 1660, and

Mery described the instance later which was the subject of the

following quatrain:--

"La nature, peu sage et sans douse en debauche Placa le foie au cote

gauche, Et de meme, vice versa Le coeur a le droite placa."

Young cites an example in a woman of eighty-five who died at

Hammersmith, London. She was found dead in bed, and in a postmortem

examination, ordered to discover if possible the cause of death, there

was seen complete transposition of the viscera. The heart lay with its

base toward the left, its apex toward the right, reaching the lower

border of the 4th rib, under the right mamma. The vena cava was on the

left side and passed into the pulmonary cavity of the heart, which was

also on the left side, the aorta and systemic ventricle being on the

right. The left splenic vein was lying on the superior vena cava, the

liver under the left ribs, and the spleen on the right side underneath

the heart. The esophagus was on the right of the aorta, and the

location of the two ends of the stomach was reversed; the sigmoid

flexure was on the right side. Davis describes a similar instance in a

man.

Herrick mentions transposition of viscera in a man of twenty-five.

Barbieux cites a case of transposition of viscera in a man who was

wounded in a duel. The liver was to the left and the spleen and heart

to the right etc. Albers, Baron, Beclard, Boyer, Bull, Mackensie,

Hutchinson, Hunt, Murray, Dareste, Curran, Duchesne, Musser, Sabatier,

Shrady, Vulpian, Wilson, and Wehn are among others reporting instances

of transposition and inversion of the viscera.

Congenital extroversion or eventration is the result of some congenital

deficiency in the abdominal wall; instances are not uncommon, and some

patients live as long as do cases of umbilical hernia proper. Ramsey

speaks of entire want of development of the abdominal parietes.

Robertson, Rizzoli, Tait, Hamilton, Brodie, Denis, Dickie, Goyrand, and

many others mention extroversion of viscera from parietal defects. The

different forms of hernia will be considered in another chapter.

There seem to be no authentic cases of complete absence of the kidney

except in the lowest grades of monstrosities. Becker, Blasius, Rhodius,

Baillie, Portal, Sandifort, Meckel, Schenck, and Stoll are among the

older writers who have observed the absence of one kidney. In a recent

paper Ballowitz has collected 213 cases, from which the following

extract has been made by the British Medical Journal:--

"Ballowitz (Virchow's Archiv, August 5, 1895) has collected as far as

possible all the recorded cases of congenital absence of one kidney.

Excluding cases of fused kidney and of partial atrophy of one kidney,

he finds 213 cases of complete absence of one kidney, upon which he

bases the following conclusions: Such deficiency occurs almost twice as

often in males as in females, a fact, however, which may be partly

accounted for by the greater frequency of necropsies on males. As to

age, 23 occurred in the fetus or newly born, most having some other

congenital deformity, especially imperforate anus; the rest were about

evenly distributed up to seventy years of age, after which only seven

cases occurred. Taking all cases together, the deficiency is more

common on the left than on the right side; but while in males the left

kidney is far more commonly absent than the right, in females the two

sides show the defect equally. The renal vessels were generally absent,

as also the ureter, on the abnormal side (the latter in all except 15

cases); the suprarenal was missing in 31 cases. The solitary kidney was

almost always normal in shape and position, but much enlarged.

Microscopically the enlargement would seem to be due rather to

hyperplasia than to hypertrophy. The bladder, except for absence of the

opening of one ureter, was generally normal. In a large number of cases

there were associated deformities of the organs of generation,

especially of the female organs, and these were almost invariably on

the side of the renal defect; they affected the conducting portion much

more than the glandular portion--that is, uterus, vagina, and Fallopian

tubes in the female, and vas deferens or vesiculae seminales in the

male, rather than the ovaries or testicles. Finally, he points out the

practical bearing of the subject--for example, the probability of

calculus causing sudden suppression of urine in such cases--and also

the danger of surgical interference, and suggests the possibility of

diagnosing the condition by ascertaining the absence of the opening of

one ureter in the bladder by means of the cystoscope, and also the

likelihood of its occurring where any abnormality of the genital organs

is found, especially if this be unilateral."

Green reports the case of a female child in which the right kidney and

right Fallopian tube and ovary were absent without any rudimentary

structures in their place. Guiteras and Riesman have noted the absence

of the right kidney, right ureter, and right adrenal in an old woman

who had died of chronic nephritis. The left kidney although cirrhotic

was very much enlarged.

Tompsett describes a necropsy made on a coolie child of nearly twelve

months, in which it was seen that in the place of a kidney there were

two left organs connected at the apices by a prolongation of the

cortical substance of each; the child had died of neglected malarial

fever. Sandifort speaks of a case of double kidneys and double ureters,

and cases of supernumerary kidney are not uncommon, generally being

segmentation of one of the normal kidneys. Rayer has seen three kidneys

united and formed like a horseshoe. We are quite familiar with the

ordinary "horseshoe kidney," in which two normal kidneys are connected.

There are several forms of displacement of the kidneys, the most common

being the "floating kidney," which is sometimes successfully removed or

fixed; Rayer has made an extensive study of this anomaly.

The kidney may be displaced to the pelvis, and Guinard quotes an

instance in which the left kidney was situated in the pelvis, to the

left of the rectum and back of the bladder. The ureter of the left side

was very short. The left renal artery came from the bifurcation of the

aorta and the primitive iliacs. The right kidney was situated normally,

and received from the aorta two arteries, whose volume did not surpass

the two arteries supplying the left suprarenal capsule, which was in

its ordinary place. Displacements of the kidney anteriorly are very

rare.

The ureters have been found multiple; Griffon reports the history of a

male subject in whom the ureter on the left side was double throughout

its whole length; there were two vesical orifices on the left side one

above the other; and Morestin, in the same journal, mentions ureters

double on both sides in a female subject. Molinetti speaks of six

ureters in one person. Littre in 1705 described a case of coalition of

the ureters. Allen describes an elongated kidney with two ureters.

Coeyne mentions duplication of the ureters on both sides. Lediberder

reports a case in which the ureter had double origin. Tyson cites an

instance of four ureters in an infant. Penrose mentions the absence of

the upper two-thirds of the left ureter, with a small cystic kidney,

and there are parallel cases on record.

The ureters sometimes have anomalous terminations either in the rectum,

vagina, or directly in the urethra. This latter disposition is realized

normally in a number of animals and causes the incessant flow of urine,

resulting in a serious inconvenience. Flajani speaks of the termination

of the ureters in the pelvis; Nebel has seen them appear just beneath

the umbilicus; and Lieutaud describes a man who died at thirty-five,

from another cause, whose ureters, as large as intestines, terminated

in the urethral canal, causing him to urinate frequently; the bladder

was absent. In the early part of this century there was a young girl

examined in New York whose ureters emptied into a reddish carnosity on

the mons veneris. The urine dribbled continuously, and if the child

cried or made any exertion it came in jets. The genital organs

participated but little in the deformity, and with the exception that

the umbilicus was low and the anus more anterior than natural, the

child was well formed and its health good. Colzi reports a case in

which the left ureter opened externally at the left side of the hymen a

little below the normal meatus urinarius. There is a case described of

a man who evidently suffered from a patent urachus, as the urine passed

in jets as if controlled by a sphincter from his umbilicus. Littre

mentions a patent urachus in a boy of eighteen. Congenital dilatation

of the ureters is occasionally seen in the new-born. Shattuck describes

a male fetus showing reptilian characters in the sexual ducts. There

was ectopia vesicae and prolapse of the intestine at the umbilicus; the

right kidney was elongated; the right vas deferens opened into the

ureter. There was persistence in a separate condition of the two

Mullerian ducts which opened externally inferiorly, and there were two

ducts near the openings which represented anal pouches. Both testicles

were in the abdomen. Ord describes a man in whom one of the Mullerian

ducts was persistent.

Anomalies of the Bladder.--Blanchard, Blasius, Haller, Nebel, and

Rhodius mention cases in which the bladder has been found absent and we

have already mentioned some cases, but the instances in which the

bladder has been duplex are much more frequent. Bourienne,

Oberteuffer, Ruysch, Bartholinus, Morgagni, and Franck speak of vesical

duplication. There is a description of a man who had two bladders, each

receiving a ureter. Bussiere describes a triple bladder, and Scibelli

of Naples mentions an instance in a subject who died at fifty-seven

with symptoms of retention of urine. In the illustration, B represents

the normal bladder, A and C the supplementary bladders, with D and E

their respective points of entrance into B. As will be noticed, the

ureters terminate in the supplementary bladders. Fantoni and Malgetti

cite instances of quintuple bladders.

The Ephemerides speaks of a case of coalition of the bladder with the

os pubis and another case of coalition with the omentum. Prochaska

mentions vesical fusion with the uterus, and we have already described

union with the rectum and intestine.

Exstrophy of the bladder is not rare, and is often associated with

hypospadias, epispadias, and other malformations of the genitourinary

tract. It consists of a deficiency of the abdominal wall in the

hypogastric region, in which is seen the denuded bladder. It is

remedied by many different and ingenious plastic operations.

In an occasional instance in which there is occlusion at the umbilicus

and again at the neck of the bladder this organ becomes so distended as

to produce a most curious deformity in the fetus. Figure 143 shows

such a case.

The Heart.--Absence of the heart has never been recorded in human

beings except in the case of monsters, as, for example, the

omphalosites, although there was a case reported and firmly believed by

the ancient authors,--a Roman soldier in whom Telasius said he could

discover no vestige of a heart.

The absence of one ventricle has been recorded. Schenck has seen the

left ventricle deficient, and the Ephemerides, Behr, and Kerckring

speak of a single ventricle only in the heart. Riolan mentions a heart

in which both ventricles were absent. Jurgens reported in Berlin,

February 1, 1882, an autopsy on a child who had lived some days after

birth, in which the left ventricle of the heart was found completely

absent. Playfair showed the heart of a child which had lived nine

months in which one ventricle was absent. In King's College Hospital in

London there is a heart of a boy of thirteen in which the cavities

consist of a single ventricle and a single auricle.

Duplication of the heart, notwithstanding the number of cases reported,

has been admitted with the greatest reserve by Geoffroy-Saint-Hilaire

and by a number of authors. Among the celebrated anatomists who

describe duplex heart are Littre, Meckel, Collomb, Panum, Behr,

Paullini, Rhodins, Winslow, and Zacutus Lusitanus.

The Ephemerides cites an instance of triple heart, and Johnston has

seen a triple heart in a goose.

The phenomenon of "blue-disease," or congenital cyanosis, is due to the

patency of the foremen ovale, which, instead of closing at birth,

persists sometimes to adult life.

Perhaps the most unique collection of congenital malformations of the

heart from persons who have reached the age of puberty was to be seen

in London in 1895. In this collection there was an adult heart in which

the foremen ovale remained open until the age of thirty-seven; there

were but two pulmonary valves; there was another heart showing a large

patent foramen ovale from a man of forty-six; and there was a septum

ventriculorum of an adult heart from a woman of sixty-three, who died

of carcinoma of the breast, in which the foremen ovale was still open

and would admit the fore-finger. This woman had shown no symptoms of

the malformation. There were also hearts in which the interventricular

septum was deficient, the ductus arteriosus patent, or some valvular

malformation present. All these persons had reached puberty.

Displacements of the heart are quite numerous. Deschamps of Laval made

an autopsy on an old soldier which justified the expression, "He had a

heart in his belly." This organ was found in the left lumbar region; it

had, with its vessels, traversed an anomalous opening in the diaphragm.

Franck observed in the Hospital of Colmar a woman with the heart in the

epigastric region. Ramel and Vetter speak of the heart under the

diaphragm.

Inversion of the heart is quite frequent, and we often find reports of

cases of this anomaly. Fournier describes a soldier of thirty years, of

middle height, well proportioned and healthy, who was killed in a duel

by receiving a wound in the abdomen; postmortem, the heart was found in

the position of the right lung; the two lungs were joined and occupied

the left chest.

The anomalies of the vascular system are so numerous that we shall

dismiss them with a slight mention. Malacarne in Torino in 1784

described a double aorta, and Hommelius mentions an analogous case. The

following case is quite an interesting anatomic anomaly: A woman since

infancy had difficulty in swallowing, which was augmented at the epoch

of menstruation and after exercise; bleeding relieved her momentarily,

but the difficulty always returned. At last deglutition became

impossible and the patient died of malnutrition. A necropsy revealed

the presence of the subclavicular artery passing between the tracheal

artery and the esophagus, compressing this latter tube and opposing the

passage of food.

Anomalies of the Breasts.--The first of the anomalies of the generative

apparatus to be discussed, although not distinctly belonging under this

head, will be those of the mammae.

Amazia, or complete absence of the breast, is seldom seen. Pilcher

describes an individual who passed for a female, but who was really a

male, in whom the breasts were absolutely wanting. Foerster, Froriep,

and Ried cite instances associated with thoracic malformation. Greenhow

reports a case in which the mammae were absent, although there were

depressed rudimentary nipples and areolae. There were no ovaries and

the uterus was congenitally imperfect.

There was a negress spoken of in 1842 in whom the right breast was

missing, and there are cases of but one breast, mentioned by King,

Paull, and others. Scanzoni has observed absence of the left mamma with

absence of the left ovary.

Micromazia is not so rare, and is generally seen in females with

associate genital troubles. Excessive development of the mammae,

generally being a pathologic phenomenon, will be mentioned in another

chapter. However, among some of the indigenous negroes the female

breasts are naturally very large and pendulous. This is well shown in

Figure 144, which represents a woman of the Bushman tribe nursing an

infant. The breasts are sufficiently pendulous and loose to be easily

thrown over the shoulder.

Polymazia is of much more frequent occurrence than is supposed. Julia,

the mother of Alexander Severus, was surnamed "Mammea" because she had

supernumerary breasts. Anne Boleyn, the unfortunate wife of Henry VIII

of England, was reputed to have had six toes, six fingers, and three

breasts. Lynceus says that in his time there existed a Roman woman with

four mammae, very beautiful in contour, arranged in two lines,

regularly, one above the other, and all giving milk in abundance.

Rubens has pictured a woman with four breasts; the painting may be seen

in the Louvre in Paris.

There was a young and wealthy heiress who addressed herself to the

ancient faculty at Tubingen, asking, as she displayed four mammary,

whether, should she marry, she would have three or four children at a

birth. This was a belief with which some of her elder matron friends

had inspired her, and which she held as a hindrance to marriage.

Leichtenstern, who has collected 70 cases of polymazia in females and

22 in males, thinks that accessory breasts or nipples are due to

atavism, and that our most remote inferiorly organized ancestors had

many breasts, but that by constantly bearing but one child, from being

polymastic, females have gradually become bimastic. Some of the older

philosophers contended that by the presence of two breasts woman was

originally intended to bear two children.

Hirst says: "Supernumerary breasts and nipples are more common than is

generally supposed. Bruce found 60 instances in 3956 persons examined

(1.56 per cent). Leichtenstern places the frequency at one in 500. Both

observers declare that men present the anomaly about twice as

frequently as women. It is impossible to account for the accessory

glands on the theory of reversion, as they occur with no regularity in

situation, but may develop at odd places on the body. The most frequent

position is on the pectoral surface below the true mammae and somewhat

nearer the middle line, but an accessory gland has been observed on the

left shoulder over the prominence of the deltoid, on the abdominal

surface below the costal cartilages, above the umbilicus, in the

axilla, in the groin, on the dorsal surface, on the labium majus, and

on the outer aspect of the left thigh. Ahlfeld explains the presence of

mammae on odd parts of the body by the theory that portions of the

embryonal material entering into the composition of the mammary gland

are carried to and implanted upon any portion of the exterior of the

body by means of the amnion."

Possibly the greatest number of accessory mammae reported is that of

Neugebauer in 1886, who found ten in one person. Peuch in 1876

collected 77 cases, and since then Hamy, Quinqusud, Whiteford,

Engstrom, and Mitchell Bruce have collected cases. Polymazia must have

been known in the olden times, and we still have before us the old

images of Diana, in which this goddess is portrayed with numerous

breasts, indicating her ability to look after the growing child. Figure

145 shows an ancient Oriental statue of Artemisia or Diana now at

Naples.

Bartholinus has observed a Danish woman with three mammae, two

ordinarily formed and a third forming a triangle with the others and

resembling the breasts of a fat man. In the village of Phullendorf in

Germany early in this century there was an old woman who sought alms

from place to place, exhibiting to the curious four symmetrical

breasts, arranged parallel. She was extremely ugly, and when on all

fours, with her breasts pendulous, she resembled a beast. The authors

have seen a man with six distinct nipples, arranged as regularly as

those of a bitch or sow. The two lower were quite small. This man's

body was covered with heavy, long hair, making him a very conspicuous

object when seen naked during bathing. The hair was absent for a space

of nearly an inch about the nipples. Borellus speaks of a woman with

three mammae, two as ordinarily, the third to the left side, which gave

milk, but not the same quantity as the others. Gardiner describes a

mulatto woman who had four mammae, two of which were near the axillae,

about four inches in circumference, with proportionate sized nipples.

She became a mother at fourteen, and gave milk from all her breasts. In

his "Dictionnaire Philosophique" Voltaire gives the history of a woman

with four well-formed and symmetrically arranged breasts; she also

exhibited an excrescence, covered with a nap-like hair, looking like a

cow-tail. Percy thought the excrescence a prolongation of the coccyx,

and said that similar instances were seen in savage men of Borneo.

Percy says that among some prisoners taken in Austria was found a woman

of Valachia, near Roumania, exceedingly fatigued, and suffering

intensely from the cold. It was January, and the ground was covered

with three feet of snow. She had been exposed with her two infants, who

had been born twenty days, to this freezing temperature, and died on

the next day. An examination of her body revealed five mammae, of which

four projected as ordinarily, while the fifth was about the size of

that of a girl at puberty.

They all had an intense dark ring about them; the fifth was situated

about five inches above the umbilicus. Percy injected the subject and

dissected and described the mammary blood-supply. Hirst mentions a

negress of nineteen who had nine mammae, all told, and as many nipples.

The two normal glands were very large. Two accessory glands and

nipples below them were small and did not excrete milk. All the other

glands and nipples gave milk in large quantities. There were five

nipples on the left and four on the right side. The patient's mother

had an accessory mamma on the abdomen that secreted milk during the

period of lactation.

Charpentier has observed in his clinic a woman with two supplementary

axillary mammae with nipples. They gave milk as the ordinary mammae.

Robert saw a woman who nourished an infant by a mamma on the thigh.

Until the time of pregnancy this mamma was taken for an ordinary nevus,

but with pregnancy it began to develop and acquired the size of a

citron. Figure 147 is from an old wood-cut showing a child suckling at

a supernumerary mamma on its mother's thigh while its brother is at the

natural breast. Jenner speaks of a breast on the outer side of the

thigh four inches below the great trochanter. Hare describes a woman of

thirty-seven who secreted normal milk from her axillae. Lee mentions a

woman of thirty-five with four mammae and four nipples; she suckled

with the pectoral and not the axillary breasts. McGillicudy describes a

pair of rudimentary abdominal mammae, and there is another similar case

recorded. Hartung mentions a woman of thirty who while suckling had a

mamma on the left labium majus. It was excised, and microscopic

examination showed its structure to be that of a rudimentary nipple and

mammary gland. Leichtenstern cites a case of a mamma on the left

shoulder nearly under the insertion of the deltoid, and Klob speaks of

an acromial accessory mamma situated on the shoulder over the greatest

prominence of the deltoid. Hall reports the case of a functionally

active supernumerary mamma over the costal cartilage of the 8th rib.

Jussieu speaks of a woman who had three breasts, one of which was

situated on the groin and with which she occasionally suckled; her

mother had three breasts, but they were all situated on the chest.

Saunois details an account of a female who had two supernumerary

breasts on the back. Bartholinus (quoted by Meckel) and Manget also

mention mammae on the back, but Geoffroy-Saint-Hilaire questions their

existence. Martin gives a very clear illustration of a woman with a

supernumerary breast below the natural organ. Sneddon, who has

collected quite a number of cases of polymazia, quotes the case of a

woman who had two swellings in each axilla in which gland-structure was

made out, but with no external openings, and which had no anatomic

connection with the mammary glands proper. Shortly after birth they

varied in size and proportion, as the breasts were full or empty, and

in five weeks all traces of them were lost. Her only married sister

had similar enlargements at her third confinement.

Polymazia sometimes seems to be hereditary. Robert saw a daughter whose

mother was polymastic, and Woodman saw a mother and eldest daughter who

each had three nipples. Lousier mentions a woman wanting a mamma who

transmitted this vice of conformation to her daughter. Handyside says

he knew two brothers in both of whom breasts were wanting.

Supernumerary nipples alone are also seen, as many as five having been

found on the same breast. Neugebauer reports eight supernumerary

nipples in one case. Hollerus has seen a woman who had two nipples on

the same breast which gave milk with the same regularity and the same

abundance as the single nipple. The Ephemerides contains a description

of a triple nipple. Barth describes "mamma erratica" on the face in

front of the right ear which enlarged during menstruation.

Cases of deficiency of the nipples have been reported by the

Ephemerides, Lentilius, Severinus, and Werckardus.

Cases of functional male mammae will be discussed in Chapter IX.

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.