The patient was referred to me February 28, 1903, by the family physician living in one of the suburbs of New York, and gave the following history;
E.C., aged twenty years, born in New York State, of Irish parentage; father and mother both living, also four brothers and four sisters, all of whom, as far as she knows, are strong and well and normal in every way.
Patient has never menstruated; was strong and well till four years ago; weighed 120 pounds, but has gradually lost flesh year by year, and now weighs only 99 pounds.
She was educated in the public schools and graduated from the grammar school two years ago ; has a weak stomach and occasional attacks of indigestion.
She has never had any girl love affairs or been attracted passionately by any girl, but has been attracted by boys; says that "that thing" (the clitoris) began to develop to a noticeable degree when the hair began to develop on the pubes, fourteen to fifteen years of age; played with it some at that time and experienced pleasurable sensations therefrom; has erections at times and at first feels that it is pleasant, but eventually dis appoints and annoys her; wants to get rid of “the growth.”
In deportment the patient was somewhat shy and modest, and gave the impression that she did not care to reveal the facts she had stated, but was determined to get relief, and had decided to go through whatever ordeal was necessary to secure it. She came to my office alone, and heavily veiled to conceal the growth of hair upon her lip, face, and chin. In appearance she showed feminine taste in dress, which was neat and in good style.
PHYSICAL EXAMINATION.
- Height, 5 feet 17 / 8 inches.
- Weight, 100 pounds at present.
- Gait, feminine in character.
- Voice, feminine, with occasional male tendency.
- Hair growth on the head coarse, abundant, and black; eyebrows black and heavy, meet between the eyes
hair on upper lip well developed; on chin well developed; also strong growth in front of ears to angle of jaw. Growth is sparse between angle and chin. Chin is square and jaw heavy, otherwise face is female type; features are small; eyes are brown.
- Arms not well developed, hair growth abundant.
- Hands medium in size ; fingers square and strong , with large joints .
- Neck larger than normal for a female.
- Mammary Gland . No mammary development; neither fat nor glandular tissue, strictly male type.
- Areola dark brown and about 14 inch in extent from nipple. It is encircled by small black hairs.
- Abdomen. Longitudinal hair line well developed from one inch above umbilicus to pubic hair, which is very thick. There is no transverse abdominal hair line.
- Spine .No deformity. Lower Extremities. Hair growth excessive.
- Pelvis flaring . Measurements : Interspinal , 271 / 2 cm . ; inter crestal , 281 / 2 cm . ; external conjugate , 18 cm .
- Heart, normal.
- Lungs, normal.
On examining the genitals the enlarged clitoris with prominent glans, as shown in Fig . 1, obtruded itself and became erectile on the slightest touch.
It was surrounded with a corona of hair and surmounted on the mons veneris with a luxuriant tuft.
An excessive growth of hair covered all the surrounding parts and ex tended down on to the thighs.
The clitoris measured three inches in length and three and a half inches in circumference.
The fore skin could be drawn forward on to the glans , but retracted strongly in erection.
The clitoris was restricted in its action as in chordee hy a broad frenum, which reached from near the glans down to the under surface of the symphysis and disappeared with in a little opening one - quarter of an inch in diameter, the urogenital cleft.
A narrow strip of mucous membrane ran along the free border of the frenum as in cases of hypospadias . The clitoris was impervious and the meatus urinarius could not be discovered. Below the introitus was a broad perineum reaching to the anus.
The vaginal opening took a Peaslee sound readily to the depth of four and a half inches and the caliber of the canal seemed to enlarge at the distal end . Under bimanual manipulation with finger in the rectum no internal generative organs could be out lined except a cord - like extension from the upper end of the vagina.
(my note - the fuck?)
The patient insisted that “the growth” was a great annoyance, that it made her different from other girls, and she wanted it taken off. When asked if she preferred to be made like a man or woman, said decidedly "a woman.” Accordingly she was sent to the Polyclinic Hospital, and the operation was done March 11, 1903, in the presence of the class and some invited guests.
View attachment 1900483
Fig . 1 . (ABOVE) - Appearance before operating. The round black spot below the clitoris shows opening to vagina. From its upper border a strip of mucous membrane extended to the glans along the free border of the frenum. Mucous membrane covered the median line of perineum for two inches toward the anus; shows light in the picture.
Operation .
— With the patient under ether and the parts shaved and sterilized, by a little steady pressure I gradually insinuated my little finger into the urogenital cleft to its full length and then the index finger, being careful to dilate* rather than tear.
(*first use of the word dilate in relation to neo-vag?!?!?!)
At the depth of two and a half inches a strong constricting band of dense, resisting tissue was encountered, through which my finger was forced with difficulty. With the tissue put upon the stretch by bearing down with this finger strongly on the perineum two lateral incisions (one on either side) were made with scissors from the outer edge of the canal to and including the constricting band . The depth of these incisions went only through the vaginal sheath.
By firm pressure first with one finger in the urogenital cleft and then with two these incisions were torn deep into the tissues, resisting strands being snipped as they presented. In this way the caliber of the cleft was enlarged to a diameter of two and a half inches.
At this juncture the meatus urinarius was searched for and discovered just under the internal border of the symphysis pubis, and a catheter passed, demonstrated the position of the bladder and the presence of urine.
View attachment 1900484
Fig. 2. (ABOVE) — The clitoris after removal, the skin having been dissected.
The skin adjacent to the vulva was so harsh and bristled so with hair that it was not available for filling in the lateral gaps in the mucous membrane of the vagina.
The only apparent resource was to allow them to fill up by granulation, when suddenly the thought occurred to me, Why not use the skin covering the clitoris? This was soft and delicate and free from hair.
It was therefore decided upon.
A longitudinal incision was made along the dorsum of the clitoris and another along the ventral surface, and a circular incision just back of the corona of the glans.
These flaps were carefully dissected off down to the base of the clitoris and left attached. The base of the clitoris was transfixed inside the flap with chromic gut and cut away. ( Fig .2.) The flaps of skin with their bases still attached were drawn down into the urogenital cleft and stitched in position on either side by catgut sutures, care being taken to make them reach in as far as possible by dragging down the skin upon the mons veneris and abdomen and holding it in place by firm straps of adhesive plaster passed around under each thigh.
The clitoris measuring three and a half inches in circumference, afforded two flaps, each one and a half inches wide, growing broader at the base.
These together with the anterior and posterior strips of membrane of the cleft made a vaginal canal of goodly proportions. The strip of mucous membrane on the under surface of the frenum was saved, drawn up and stitched to the stump of the clitoris.
The purpose of this was to give support to the urethra and maintain its normal position. It also made a vestibule beneath the stump of the clitoris. The stump was covered with the skin from the mons as it was drawn down by the adhesive plaster.
View attachment 1900485
Fig.3. (ABOVE) — Glass tube in place during convalescence; the
patient's hand holds the tube. (First dilation!)
There was considerable hemorrhage from the lateral incisions, but no large vessels were incised, and what hemorrhage occurred was controlled by applications of adrenalin chlorid. The vaginal canal was packed moderately full of iodoform gauze, sufficient pressure being made to smooth out the skin flaps and bring their entire surface in contact with the underlying tissue.
(my note - exactly like SRS today, fascinating)
A self - retaining catheter was inserted into the bladder.
The dressings were removed on the fourth day and a glass tube substituted in the vagina to maintain pressure upon the flaps and secure its calibre, as shown in Fig .3.
The entire wound healed! by first intention and the patient left the hospital at the end of four weeks .Fig. 2 shows the exact size of the clitoris after being stripped of skin and removed.
View attachment 1900486
Fig .4. (ABOVE) - Photograph three weeks after operation.
Fig .4 shows the condition at the end of four weeks. The vagina closed snugly, but readily admitted two fingers and permitted of further dilatation by slight pressure. Later digital and specular examinations revealed a small cervix at the head of the vagina, which took a small sound to the depth of one and three - quarter inches. A small gland could also be made out on the left side, but it had more the feel and shape of an enlarged lymphatic, although it may be a rudimentary ovary
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TLDR - Penile inversion of a hermaphrodite in 1903. That's one for the history books.
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