ci-devant sister. A certain number of cases are recorded in which a prolapsed uterus or an extroverted bladder has grossly imitated the male organ, but these cases are so easy of detection, and have so little claim to be classified with permanent anomalies of evolution in the sexual organs, that it is not necessary to dwell upon them.

150. True hermaphrodites, in general.—The existence of real hermaphrodites has always been doubted, and is still held in doubt by many eminent authorities. By true hermaphroditism we mean the existence in the same person of the essential organs of generation of the two sexes: either the generative glands—the ovary in the female, or the testicle in the male-or the generative passages, the Fallopian tubes, uterus, and vagina, in the female, or the vasa efferentia, vas deferens, seminal vesicles, and prostate in the male. The coexistence of the glands of the two sexes is termed true glandular hermaphroditism; the coexistence of the genital passages of the two sexes, true tubular hermaphroditism.19

As factors of secondary importance in the determination of sex may be considered the stature, form of skeleton, especially of the thorax, pelvis, and long bones; the muscular development, the subcutaneous fat, the hairy system, the larynx and voice, and also the hymen, labia minora, and prostate; but on these alone no diagnosis of sex can be based.

151. Mixed external and internal.- The mixed cases, in which the external organs are of one sex and the internal of the other, are few, and can scarcely be called hermaphrodites. One such is the case of Angelique Courtois, 20 in whom the single well-formed and undoubted testis had no excretory duct, but lay under the pervious, fimbriated end of the Fallopian tube. There were no ovaries, seminal vesicles, or prostate. A corresponding case is that of Buillaud and Manec.21 The patient had attained the age of sixty-two years, and had lived and been married as a man. The external organs consisted of a penis, with the orifice of the urethra at the base of the glans, and an empty scrotum. The internal organs were completely feminine, with the exception of the prostate gland, which occupied its usual position. It is not stated whether the menstrual function was performed.22

"This classification, and the com- "Jour. Univer. et Hebdom. de Méd., t. ments on true hermaphroditism, are X., p. 467. taken largely from the thesis of Guéricolas, presented to the faculty of Lyons in 1899: De l'Hermaphrodisme Vrai Chez l'Homme et les Animaux Superieurs.

20 Follin, Gaz. des Hôpit. Dec. 1851.

Cases of menstruation through the penis, or from an orifice at its base, when imperforate, are on record. One is reported by Dr. Harris, of Virginia, and another by Dr. Barry, of Connecticut, in which it was necessary to deter

152. True tubular.- As instances of the condition of true hermaphroditism of the tubular type the following may be cited:

1. The case observed by Petit, and communicated to the French Academy in 1820, of a soldier twenty-two years of age, who died of a wound. The penis was normal, the scrotum empty, the testicles occupied the position of the ovaries, and each was provided with an epididymis, a vas, and a seminal vesicle, which emptied into the prostatic urethra. From the same spot emanated the uterus, which was continued into two complete Fallopian tubes. The vagina was absent.

2. Kiwisch and Kolliker23 have described a case of great interest, of an individual who died at the age of thirty-three. The external genitals consisted of a perfectly normal penis, with a rugose but empty scrotum. Opening into the prostate, of normal size, were the two seminal vesicles and the vasa from the testes, each of which had an epididymis. Likewise, from the prostatic urethra arose a rudimentary uterus provided with tubes 334 inches long, with imperfectly developed fimbria. In the place of the ovaries were the ectopic testicles.

menses flowed from this orifice at regular periods. There was no external orifice of the vagina, the perineum was covered with hair, the labia majora were rudimentary, and on the right side there was a body like a testicle. The habitus was feminine, and there was no beard. An operation was performed to make an artificial vagina, and eight months afterwards she was married. (Neue Zeitschrift für Geburtzkunde, von Busch, 1836, Bd. 4, H. 2, p. 267.)

3. Odin24 describes the case of a laborer sixty-three years of age, whose autopsy showed a hypospadias (perineal), with the orifice of mine the sex on account of a denial of Marseilles. His patient was twentya person's right to vote. (Am. Journ. one years of age; the penis was of Med. Sci., 1847, July.) Prof. Simpson, the size of a boy's of twelve or fourof Edinburgh, states, that he has been teen years; it was imperforate and informed, on credible authority, of two the urethra opened at its base. The instances where, in males (?), the menstrual discharge was perfectly regular in its occurrence, and considerable in quantity. One of these persons was seventeen years of age, and the other had been married for several years, and his wife had no children. (Art. Hermaphroditism, Cyc. of Anat. and Physiol.) Dr. Blackman saw in the Northern Hospital at Liverpool, a sailor from the American merchantman Rappahannock. He says: "This person was about thirty years of age, and with the exception of the breasts, which were large, had the general appearance of а male. The penis, however, was short, and the scrotum somewhat cleft, so as to resemble in some respects the external labia of the female. At the time of my examination menstrual blood was passing through the penis, and we believe this was a regular monthly occurrence." p. 27. (Am. Journ. Med. Sci., July, 1853.) A case apparently similar in anatomical conditions to that of Suydam, above referred to, is reported by Dr. Coste, of

Other cases are reported by Forel, Bull. de la Soc. Méd. de la Suisse Romande, Lausaune, 1869, Vol. III., p. 53; cf. Guéricolas, thesis, Lyons, 1899. Gloninger, Amer. Med. Recorder, 1819, Vol. II., p. 371; and King, Canada Med. and Surg. Journ., 1867, Vol. III., p. 472. For still others, see Gould and Pyle's Anomalies and Curiosities of Medicine,

23 Kiwisch and Kolliker, Klinische Vorträge, Abth. II., Prag. 1849.

*Odin, Hermaphrodtisme Bisexuel (Lyon medical), t. XVI., p. 214, 1874.

the urethra in the vagina, or rather urogenital canal, in front of the hymen. The vagina ended in a uterus (there was no vaginal portion to this organ), which was rudimentary, and was continued upwards in a cord which led to a fleshy mass at the internal inguinal ring that appeared to be the partially developed testicle and epididymis and testicle. On that same side an imperforate tube led to an ovary-like body. On the opposite side there was a like fleshy mass at the external ring and the cord was much smaller, but the ovary and tube were like those on the opposite side. There was no microscopical examination made of the bodies in relation with the tubes and vasa, so that while they probably were ovary and testis respectively, they can not be considered so proved. But the genital passages are described as characteristic.

4. Klotz25 described the case of a Jew, twenty-four years old, with a hypospadias and rudimentary vagina, in which, in one side of the cleft scrotum, there was a testicle and vas deferens, on the other side of the pelvis was a uterus and Fallopian tube, which led to a cystic body in the representative of the other half of the scrotum. The microscopical examination of this cystic body failed to show any ovarian tissue, but the patient had given a history of monthly pains and enlargement in this body since the age of sixteen. Admitting that the existence of ovary and testicle was not proved, there remains no question as to the authenticity of the two canals.

5. Boeckel2 demonstrated to the Academy of Medicine of Paris, in 1892, the case of a young man of twenty years, operated on for congenital inguinal hernia. In that hernia were found a bicornute uterus, a Fallopian tube; and, on the other hand, an epididymis and a vas deferens.

6. Winkler27 found at the autopsy of a cryptorchid, a long and slender uterus provided with two tubes, one of which was closed, and the other better developed, with a fimbriated outer extremity. In addition there were two testes, each with more or less developed epididymis and vas deferens.

7. Giaccomini,28 in 1897, cites the case of a man operated on for inguinal hernia, with an ectopic testicle on the opposite side. At the operation were found, arising from the prostate, a bicornute uterus with the tube on one side, while on the opposite side the tube was

represented by a cord whose free extremity opened into the peritoneal cavity, near to rounded body. The external organs and habitus were distinctly those of a man.

8. Siegenbeek van Heukelom,29 in 1896 examined a preparation from an inguinal hernia operation on a man who had a normal penis, whose left testicle was felt in the scrotum, and whose right testicle was ectopic. He found in the specimen removed at the operation a uterus which led into a feminine genital canal, probably opening into the urethra. The uterus was continued into two horns, of which the left continuation was connected to the left testicle, which was fixed normally in the scrotum. The right horn of the uterus, on the contrary, opened freely into the peritoneal cavity. The uterus was supported by a broad ligament in which were inclosed, both on the right and on the left, the vasa deferentia.

This case of Siegenbeek is of especial value from the precision with which his examination was made, and fully justifies the statement that "by the side of a masculine system in an individual in whom the external parts are distinctly masculine, there may exist a complete bilateral feminine canal."30

153. True glandular.- Instances of true glandular hermaphroditism are infinitely more rare, and in nearly all cases lacking in the authenticity of proof. The well known case of Catharine Hofmann, who was presented at nearly all of the clinics in Germany, and examined by Schultze, Friedreich, Virchow, and others, was at first believed to be a definite case of hermaphroditism, because, in addition to the evident menstruations which she had, spermatozoa were also found. However, she was accused of fraud as to the menstruation by Ahlfeld and Pozzi, who retracted the previous opinion, and considered the case as one of pseudo-hermaphroditism with perineoscrotal hypospadias. The absence of an autopsy did not permit the verification of the conditions of the internal organs.31

The case of Gast32 is more worthy of credence. It was that of a fetus born dead with exstrophy of the bladder. There was a uterus didelphys. The left uterus had a short, permeable tube with vibratory cilia, and, laterally, an ovary. On the same side there was a testicle distinct from the ovary, with a gubernaculum. The right

> Siegenbeek van Heukelom, Sur l'Hermaphrodisme Tubulaire et Glandulaire (Recueil des Travaux du Laboratoire de Boerhaave, 1899, t. II., p. 509). Guéricolas, Thesis, Lyons, 1899, p.

"Guéricolas, p. 42.

32 Gast, Beitrage z. Lehre von dem bauchblasen Genitalsspalt u. von dem Hermaphrodismus verus. Inaug. Dis., Berlin, 1884.

uterus had a very long tube but no ovary or testicle on that side. The microscopic examination of the ovary showed beyond question the presence of the ovules; that of the testicles showed the presence of the fine canaliculæ, lined with characteristic round and polygonal cells, the constituent parts of which, however, could not be made out. Debierre, Heppner, Perls, Reyter, and Blacker and Lawrence have no hesitation in calling the case one of unilateral glandular hermaphroditism.

A similar case has been published by Blacker and Lawrence, and two other cases of lateral or alternate hermaphroditism, one by Obolonsky in 1888, and one by Schmorl, which have passed the criticisms of many,33 but do not satisfy, in their precision, the demands of all.

Heppner3 in 1870, described the only case in which, so far as was known to Guéricolas, in 1899, there was proved incontestably the simultaneous presence of the sexual glands, male and female, in addition to the coexistence of certain more or less essential sexual organs. The subject was a premature infant, Paul B., born before term, and living seven weeks at the Saint Petersburg hospital for soundlings, to which he was admitted on the 19th of January, 1858. At the time of the autopsy the case was considered as one of spurius female hermaphroditism. It was found there some ten years later by Heppner, who made a searching examination of the specimen, with the following findings:

The external organs consisted in a hypospadiac penis, a scrotum, which was empty, and a urogenital canal opening just below the penis. Into the anterior part of this canal opened the urethra, and into the posterior part, the vagina. The urethra led into the bladder and was surrounded by the prostate. There were no seminal vesicles. The internal organs were represented by a uterus with a prominent cervical portion protruding into the vagina, and in every way normal. To it were connected the two Fallopian tubes, which were permeable, and opened into the peritoneal cavity by fimbriated ends, as normally. In the usual situation were the two ovaries, the left 13mm. long, the

"Blacker and Lawrence, Transactions of the Obstetrical Society of London, Vol. XXXVIII. A Case of True Unilateral Hermaphroditismus with Ovitestis in Man.

Obolonsky, Arch. f. Heilkunde, IX., 211, 1888. Beitrage z. pathol. Anat. des Hermaphrod. Hominis.

Schmorl, Virch. Archiv. B. 113, P. 229. Ein Fall von Hermaphroditismus.

"Heppner, Arch. f. Anat. u. Physiol. of Reichert and Dubois-Reymond, p. 679, 1870. Ueber den Wahren Hermaphroditismus beim Menschen.

For other instances of hermaphroditism, see Gould and Pyle's Anomalies and Curiosities of Medicine, p. 206.