MISCELLANEOUS SURGICAL ANOMALIES. 7 page

Musee Cluny in Paris, both the anus and vulva were protected by a steel

covering perforated for the evacuations. In the Orient, particularly in

India and Persia, according to old travelers, the labia were sewed

together, allowing but a small opening for excretions. Buffon and Brown

mention infibulation in Abyssinia, the parts being separated by a

bistoury at the time of marriage. In Circassia the women were protected

by a copper girdle or a corset of hide and skin which, according to

custom, only the husband could undo. Peney speaks of infibulation for

the preservation of chastity, as observed by him in the Soudan. Among

the Nubians this operation was performed at about the age of eight with

great ceremony, and when the time for marriage approached the vulva had

to be opened by incision. Sir Richard Buxton, a distinguished traveler,

also speaks of infibulation, and, according to him, at the time of the

marriage ceremony the male tries to prove his manhood by using only

Nature's method and weapon to consummate the marriage, but if he failed

he was allowed artificial aid to effect entrance. Sir Samuel Baker is

accredited in The Lancet with giving an account in Latin text of the

modus operandi of a practice among the Nubian women of removing the

clitoris and nymphae in the young girl, and abrading the adjacent walls

of the external labia so that they would adhere and leave only a

urethral aperture.

This ancient custom of infibulation is occasionally seen at the present

day in civilized countries, and some cases of infibulation from

jealousy are on record. There is mentioned, as from the Leicester

Assizes, the trial of George Baggerly for execution of a villainous

design on his wife. In jealousy he "had sewed up her private parts."

Recently, before the New York Academy of Medicine, Collier reported a

case of pregnancy in a woman presenting nympha-infibulation. The

patient sought the physician's advice in the summer of 1894, while

suffering from uterine disease, and being five weeks pregnant. She was

a German woman of twenty-eight, had been married several years, and was

the mother of several children. Collier examined her and observed two

holes in the nymphae. When he asked her concerning these, she

reluctantly told him that she had been compelled by her husband to wear

a lock in this region. Her mother, prior to their marriage, sent her

over to the care of her future husband (he having left Germany some

months before). On her arrival he perforated the labia minora, causing

her to be ill several weeks; after she had sufficiently recovered he

put on a padlock, and for many years he had practiced the habit of

locking her up after each intercourse. Strange to relate, no physician,

except Collier, had ever inquired about the openings. In this

connection the celebrated Harvey mentions a mare with infibulated

genitals, but these did not prevent successful labor.

Occasionally infibulation has been used as a means of preventing

masturbation. De la Fontaine has mentioned this fact, and there is a

case in this country in which acute dementia from masturbation was

cured by infibulation. In this instance the prepuce was perforated in

two opposite places by a trocar, and two pewter sounds (No. 2) were

introduced into the wounds and twisted like rings. On the eleventh day

one of the rings was removed, and a fresh one introduced in a new

place. A cure was effected in eight weeks. There is recent mention made

of a method of preventing masturbation by a cage fastened over the

genitals by straps and locks. In cases of children the key was to be

kept by the parents, but in adults to be put in some part of the house

remote from the sleeping apartment, the theory being that the desire

would leave before the key could be obtained.

Among some peoples the urethra was slit up as a means of preventing

conception, making a meatus near the base of the penis. Herodotus

remarks that the women of a certain portion of Egypt stood up while

they urinated, while the men squatted. Investigation has shown that

the women were obliged to stand up on account of elongated nymphae and

labia, while the men sought a sitting posture on account of the

termination of the urethra being on the inferior side of the base of

the penis, artificially formed there in order to prevent conception. In

the Australian Medical Gazette, May, 1883, there is an account of some

of the methods of the Central Australians of preventing conception. One

was to make an opening into the male urethra just anterior to the

scrotum, and another was to slit up the entire urethra so far as to

make but a single canal from the scrotum to the glans penis. Bourke

quotes Palmer in mentioning that it is a custom to split the urethra of

the male of the Kalkadoon tribe, near Cloncurry, Queensland, Australia

Mayer of Vienna describes an operation of perforation of the penis

among the Malays; and Jagor and Micklucho-Maclay report similar customs

among the Dyaks and other natives of Borneo, Java, and Phillipine

Islands.

Circumcision is a rite of great antiquity. The Bible furnishes frequent

records of this subject, and the bas-reliefs on some of the old

Egyptian ruins represent circumcised children. Labat has found traces

of circumcision and excision of nymphae in mummies. Herodotus remarks

that the Egyptians practiced circumcision rather as a sanitary measure

than as a rite. Voltaire stated that the Hebrews borrowed circumcision

from the Egyptians; but the Jews claimed that the Phoenicians borrowed

this rite from the Israelites.

Spencer and others say that in the early history of the Christian

religion, St. Paul and his Disciples did not believe in circumcision,

while St. Peter and his followers practiced it. Spencer mentions that

the Abyssinians take a phallic trophy by circumcision from the enemy's

dead body. In his "History of Circumcision," Remondino says that among

the modern Berbers it is not unusual for a warrior to exhibit virile

members of persons he has slain; he also says that, according to

Bergman, the Israelites practiced preputial mutilations; David brought

200 prepuces of the Philistines to Saul. Circumcision is practiced in

nearly every portion of the world, and by various races, sometimes

being a civil as well as a religious custom. Its use in surgery is too

well known to be discussed here. It might be mentioned, however, that

Rake of Trinidad, has performed circumcision 16 times, usually for

phimosis due to leprous tuberculation of the prepuce. Circumcision, as

practiced on the clitoris in the female, is mentioned on page 308.

Ceremonial Ovariotomy.--In the writings of Strabonius and Alexander ab

Alexandro, allusion is made to the liberties taken with the bodies of

females by the ancient Egyptians and Lydians. Knott says that ablation

of the ovaries is a time-honored custom in India, and that he had the

opportunity of physically examining some of the women who had been

operated on in early life. At twenty-five he found them strong and

muscular, their mammary glands wholly undeveloped, and the normal

growth of pubic hairs absent. The pubic arch was narrow, and the

vaginal orifice practically obliterated. The menses had never appeared,

and there seemed to be no sexual desire. Micklucho-Maclay found that

one of the most primitive of all existing races--the New

Hollanders--practiced ovariotomy for the utilitarian purpose of

creating a supply of prostitutes, without the danger of burdening the

population by unnecessary increase. MacGillibray found a native

ovariotomized female at Cape York who had been subjected to the

operation because, having been born dumb, she would be prevented from

bearing dumb children,--a wise, though primitive, method of preventing

social dependents.

Castration has long been practiced, either for the production of

eunuchs, or castrata, through vengeance or jealousy, for excessive

cupidity, as a punishment for crime, in fanaticism, in ignorance, and

as a surgical therapeutic measure (recently, for the relief of

hypertrophied prostate). The custom is essentially Oriental in origin,

and was particularly used in polygamous countries, where the mission of

eunuchs was to guard the females of the harem. They were generally

large, stout men, and were noted for their vigorous health. The history

of eunuchism is lost in antiquity. The ancient Book of Job speaks of

eunuchs, and they were in vogue before the time of Semiramis; the King

of Lydia, Andramytis, is said to have sanctioned castration of both

male and female for social reasons. Negro eunuchs were common among the

Romans. All the great emperors and conquerors had their eunuchs.

Alexander the Great had his celebrated eunuch, Bagoas, and Nero, his

Sporus, etc. Chevers says that the manufacture of eunuchs still takes

place in the cities of Delhi, Lucknow, and Rajpootana. So skilful are

the traveling eunuch-makers that their mortality is a small fraction of

one per cent. Their method of operation is to encircle the external

genital organs with a tight ligature, and then sweep them off at one

stroke. He also remarks that those who retain their penises are of but

little value or trusted. He divided the Indian eunuchs into three

classes: those born so, those with a penis but no testicles, and those

minus both testicles and penis. Curran describes the traveling

eunuch-makers in Central India, and remarks upon the absence of death

after the operation, and invites the attention of gynecologists and

operators to the successful, though crude, methods used. Curran says

that, except those who are degraded by practices of sexual perversions,

these individuals are vigorous bodily, shrewd, and sagacious, thus

proving the ancient descriptions of them.

Jamieson recites a description of the barbarous methods of making

eunuchs in China. The operators follow a trade of eunuch-making, and

keep it in their families from generation to generation; they receive

the monetary equivalent of about $8.64 for the operation. The patient

is grasped in a semi-prone position by an assistant, while two others

hold the legs. After excision the wounded parts are bathed three times

with a hot decoction of pepper-pods, the wound is covered with paper

soaked in cold water, and bandages applied. Supported by two men the

patient is kept walking for two or three hours and then tied down. For

three days he is allowed nothing to drink, and is not allowed to pass

his urine, the urethra being filled with a pewter plug. It generally

takes about one hundred days for the wound to heal, and two per cent of

the cases are fatal. There is nocturnal incontinence of urine for a

long time after the operation.

Examples of castration because of excessive cupidity, etc.,--a most

unwarranted operation,--are quite rare and are usually found among

ecclesiastics. The author of "Faustin, or le Siecle Philosophique,"

remarked that there were more than 4000 castrated individuals among the

ecclesiastics and others of Italy. The virtuous Pope Clement XIV

forbade this practice, and describes it as a terrible abuse; but in

spite of the declaration of the Pope the cities of Italy, for some

time, still continued to contain great numbers of these victims. In

France an article was inserted into the penal code providing severe

punishment for such mutilations. Fortunately castration for the

production of "castrata," or tenor singers, has almost fallen into

disuse. Among the ancient Egyptians and Persians amputation of the

virile member was inflicted for certain crimes of the nature of rape.

Castration as a religious rite has played a considerable role. With

all their might the Emperors Constantine and Justinian opposed the

delirious religion of the priests of Cybele, and rendered their offence

equivalent to homicide. At the annual festivals of the Phrygian Goddess

Amma (Agdistis) it was the custom of young men to make eunuchs of

themselves with sharp shells, and a similar rite was recorded among

Phoenicians. Brinton names severe self-mutilators of this nature among

the ancient Mexican priests. Some of the Hottentots and indigenous

Australians enforced semicastration about the age of eight or nine.

The Skoptzies, religious castrators in Russia, are possibly the most

famous of the people of this description. The Russian government has

condemned members of this heresy to hard labor in Siberia, but has been

unable to extinguish the sect. Pelikan, Privy Counsel of the

government, has exhaustively considered this subject. Articles have

appeared in Le Progres Medical, December. 1876. and there is an

account in the St. Louis Clinical Record, 1877-78. The name Skoptzy

means "the castrated," and they call themselves the "White Doves." They

arose about 1757 from the Khlish or flagellants. Paul I caused

Sseliwanow, the true founder, to return from Siberia, and after seeing

him had him confined in an insane asylum. After an interview, Alexander

I transferred him to a hospital. Later the Councillor of State,

Jelansky, converted by Sseliwanow, set the man free and soon the

Skoptzies were all through Russia and even at the Court. The principal

argument of these people is the nonconformity of orthodox believers,

especially the priests, to the doctrines professed, and they contrast

the lax morals of these persons with the chaste lives, the abstinence

from liquor, and the continual fasts of the "White Doves." For the

purpose of convincing novices of the Scriptural foundation of their

rites and belief they are referred to Matthew xix., 12: "and there be

eunuchs which have made themselves for the kingdom of Heaven's sake,"

etc.; and Mark ix., 43-47; Luke xxiii., 29: "blessed are the barren,"

etc., and others of this nature. As to the operation itself, pain is

represented as voluntary martyrdom, and persecution as the struggle of

the spirit of darkness with that of light. They got persons to join the

order by monetary offers. Another method was to take into service young

boys, who soon became lost to society, and lied with effrontery and

obstinacy. They had secret methods of communicating with one another,

and exhibited a passion for riches, a fact that possibly accounts for

their extended influence. The most perfect were those "worthy of

mounting the white horse," the "bearers of the Imperial seal," who were

deprived of the testicles, penis, and scrotum. The operation of

castration among these people was performed at one stroke or at two

different times, in the former case one cicatrix being left, and in the

latter two. The greater number--those who had submitted to the "first

purification," conferring upon them the "lesser seal"--had lost

testicles and scrotum. These people are said to have lost the "keys of

hell," but to retain the "key of the abyss" (female genitals). As

instruments of excision the hot iron, pieces of glass, old wire,

sharpened bone, and old razors are used. Only nine fatal cases

resulting from the operation are known. At St. Petersburg Liprandi knew

a rich Skoptzy who constantly kept girls--mostly Germans--for his own

gratification, soon after having entered into the "first purification."

Few of them were able to remain with him over a year, and they always

returned to their homes with health irretrievably lost. Women members

of the order do not have their ovaries removed, but mutilation is

practiced upon the external genitals, the mammae, and nipples. The

first ablation is obtained by applying fire or caustics to the nipples,

the second by amputation of the breasts, one or both, the third by

diverse gashes, chiefly across the breast, and the fourth by resection

of the nymphae or of the nymphae and clitoris, and the superior major

labia, the cicatrices of which would deform the vulva. Figure 232

represents the appearance of the external genital organs of a male

Skoptzy after mutilation; Figure 233 those of a female.

Battey speaks of Skoptzies in Roumania who numbered at the time of

report 533 persons. They came from Russia and practiced the same

ceremonies as the heretics there.

CHAPTER XV.

ANOMALOUS TYPES AND INSTANCES OF DISEASE.

Tumors.--In discussing tumors and similar growths no attempt will be

made to describe in detail the various types. Only the anomalous

instances or examples, curious for their size and extent of

involvement, will be mentioned. It would be a difficult matter to

decide which was the largest tumor ever reported. In reviewing

literature so many enormous growths are recorded that but few can be

given here. Some of the large cystic formations have already been

mentioned; these are among the largest tumors. Scrotal tumors are

recorded that weighed over 200 pounds; and a limb affected with

elephantiasis may attain an astonishing size. Delamater is accredited

with a report of a tumor that weighed 275 pounds, the patient only

weighing 100 pounds at death. Benign tumors will be considered first.

Pure adenoma of the breast is a rare growth. Gross was able to collect

but 18 examples; but closely allied to this condition is what is known

as diffuse hypertrophy of the breast. In some parts of the world,

particularly in India and Africa, long, dependent breasts are signs of

beauty. On the other hand we learn from Juvenal and Martial that, like

ourselves, the Greeks detested pendant and bulky breasts, the signs of

beauty being elevation, smallness, and regularity of contour. In the

Grecian images of Venus the breasts are never pictured as engorged or

enlarged. The celebrated traveler Chardin says that the Circassian and

Georgian women have the most beautiful breasts in the world; in fact

the Georgians are so jealous of the regular contour and wide interval

of separation of their breasts that they refuse to nourish their

children in the natural manner.

The amount of hypertrophy which is sometimes seen in the mammae is

extraordinary. Borellus remarks that he knew of a woman of ordinary

size, each of whose mammae weighed about 30 pounds, and she supported

them in bags hung about her neck. Durston reports a case of sudden

onset of hypertrophy of the breast causing death. At the postmortem it

was found that the left breast weighed 64 pounds and the right 40

pounds. Boyer successfully removed two breasts at an interval of

twenty-six days between the two operations. The mass excised was

one-third of the total body-weight.

Schaeffer speaks of hypertrophied mammae in a girl of fourteen, the

right breast weighing 3900 grams (136 1/2 oz.) and the right 3500 grams

(122 1/2 oz.). Hamilton reports a case of hypertrophied glands in a

woman of thirty-two, which, within the short space of a year, reached

the combined weight of 52 pounds. They were successfully excised.

Velpeau, Billroth, and Labarracque have reported instances of the

removal of enormously hypertrophied mammae. In 1886 Speth of Munich

described a hypertrophy of the right breast which increased after every

pregnancy. At the age of twenty-six the woman had been five times

pregnant in the space of a little over five years, and at this time the

right breast hung down to the anterior superior spine of the ilium. It

weighed 20 pounds, and its greatest circumference was 25 inches. There

was no milk in this breast, although the left was in perfect lactation.

This case was one of pure hypertrophy and not an example of

fibro-adenoma, as illustrated by Billroth. Warren figures a case of

diffused hypertrophy of the breast which was operated on by Porter. The

right breast in its largest circumference measured 38 inches and from

the chest-wall to the nipple was 17 inches long, the circumference at

the base being 23 inches; the largest circumference of the left breast

was 28 inches; its length from the chest-wall to the nipple was 14

inches, and its circumference at the base 23 inches. The skin was

edematous and thickened. Throughout both breasts were to be felt

hardened movable masses, the size of oranges. Microscopic examination

showed the growth to be a diffused intracanalicular fibroma. A peculiar

case was presented before the Faculty at Montpellier. The patient was a

young girl of fifteen and a half years. After a cold bath, just as the

menses were appearing, it was found that the breasts were rapidly

increasing in size; she was subsequently obliged to leave service on

account of their increased size, and finally the deformity was so great

as to compel her to keep from the public view. The circumference of the

right breast was 94 cm. and of the left 105 cm.; the pedicle of the

former measured 67 cm. and of the latter 69 cm.; only the slightest

vestige of a nipple remained. Removal was advocated, as applications of

iodin had failed; but she would not consent to operation. For eight

years the hypertrophy remained constant, but, despite this fact, she

found a husband. After marriage the breasts diminished, but she was

unable to suckle either of her three children, the breasts becoming

turgid but never lactescent. The hypertrophy diminished to such a

degree that, at the age of thirty-two, when again pregnant, the

circumference of the right breast was only 27 cm. and of the left 33

cm. Even thus reduced the breasts descended almost to the navel. When

the woman was not pregnant they were still less voluminous and seemed

to consist of an immense mass of wrinkled, flaccid skin, traversed by

enormous dilated and varicose blood-vessels, the mammary glands

themselves being almost entirely absent.

Diffuse hypertrophy of the breast is occasionally seen in the male

subject. In one case reported from the Westminster Hospital in London,

a man of sixty, after a violent fall on the chest, suffered enormous

enlargement of the mammae, and afterward atrophy of the testicle and

loss of sexual desire.

The names goiter, struma, and bronchocele are applied indiscriminately

to all tumors of the thyroid gland; there are, however, several

distinct varieties among them that are true adenoma, which, therefore,

deserves a place here. According to Warren, Wolfler gives the following

classification of thyroid tumors: 1. Hypertrophy of the thyroid gland,

which is a comparatively rare disease; 2. Fetal adenoma, which is a

formation of gland tissue from the remains of fetal structures in the

gland; 3. Gelatinous or interacinous adenoma, which consists in an

enlargement of the acini by an accumulation of colloid material, and an

increase in the interacinous tissue by a growth of round cells. It is

this latter form in which cysts are frequently found. The accompanying

illustration pictures an extreme ease of cystic goiter shown by Warren.

A strange feature of tumors of the thyroid is that pressure-atrophy and

flattening of the trachea do not take place in proportion to the size

of the tumor. A small tumor of the middle lobe of the gland, not larger

that a hen's egg, will do more damage to the trachea than will a large

tumor, such as that shown by Senn, after Bruns. When a tumor has

attained this size, pressure-symptoms are often relieved by the weight

of the tumor making traction away from the trachea. Goiter is endemic

in some countries, particularly in Switzerland and Austria, and appears

particularly at the age of childhood or of puberty. Some communities in

this country using water containing an excess of calcium salt show

distinct evidences of endemic goiter. Extirpation of the thyroid gland

has in recent years been successfully practiced. Warren has extirpated

one lobe of the thyroid after preliminary ligation of the common

carotid on the same side. Green practiced rapid removal of the tumor

and ligated the bleeding vessels later. Rose tied each vessel before

cutting, proceeding slowly. Senn remarks that in 1878 he witnessed one

of Rose's operations which lasted for four hours. Although the operatic

technic of removal of the thyroid gland for tumor has been greatly

perfected by Billroth, Lucke, Julliard, Reverdin, Socin, Kocher, and

others, the current opinion at the present day seems to be that

complete extirpation of the thyroid gland, except for malignant

disease, is unjustifiable. Partial extirpation of the thyroid gland is

still practiced; and Wolfler has revived the operation of ligating the

thyroid arteries in the treatment of tumors of the thyroid gland.

Fibromata.--One of the commonest seats of fibroma is the skin.

Multiple fibromata of the skin sometimes occur in enormous numbers and

cover the whole surface of the body; they are often accompanied by

pendulous tumors of enormous size. Virchow called such tumors fibroma

molluscum. Figure 237 represents a case of multiple fibromata of the

skin shown by Octerlony. Pode mentions a somewhat similar case in a man

of fifty-six, under the care of Thom. The man was pale and emaciated,

with anxious expression, complaining of a tumor which he described as a

"wishing-mark." On examination he was found to be covered with a number

of small tumors, ranging in size from that of a small orange to that of

a pin's head; from the thoracic wall over the lower true ribs of the

right side was situated a large pendulous tumor, which hung down as far

as the upper third of the thigh. He said that it had always been as

long as this, but had lately become thicker, and two months previously

the skin over the lower part of the tumor had ulcerated. This large

tumor was successfully removed; it consisted of fibrous tissue, with

large veins running in its substance. The excised mass weighed 51

pounds. The patient made an early recovery.

Keloids are fibromata of the true skin, which may develop spontaneously

or in a scar. Although the distinction of true and false keloid has

been made, it is generally discarded. According to Hebra a true typical

keloid is found once in every 2000 cases of skin-disease. It is,

however, particularly the false keloid, or keloid arising from

cicatrices, with which we have mostly to deal. This tumor may arise

from a scar in any portion of the body, and at any age. There seems to

be a disposition in certain families and individuals to

keloid-formations, and among negroes keloids are quite common, and

often of remarkable size and conformation. The form of injury causing

the cicatrix is no factor in the production of keloid, the sting of an

insect, the prick of a needle, and even the wearing of ear-rings having

been frequent causes of keloid-formations among the negro race.

Collins describes a negress of ninety, born of African parents, who

exhibited multiple keloids produced by diverse injuries. At fourteen

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