Dohrn's second case belongs to a still higher grade of persistence of 3Ialler's ducts, as also Leopold's case, which we figure. (Fig. 49.) Through the great, penis-like development of the genital tubercle, the differentiation from a female is made. The individual was brought up a female, but had the habits of a male, as also hair on the upper lip, cheeks and chin. The voice was that of the male, the pomum adami markedly projecting, the mammas very fiat. The external genital organs consisted of a penis 21 inches long. The glans and the under surface were cleft.
The anterior opening led into a bladder, the lower (vagina masculina) was blind. There was no scrotum, but two large, thick labia, in the side of each of which were organs which felt like testicles. The most remarkable thing, however, was that this individual stated that at the age of seven teen menstruation set in, and, although not profuse, recurred every four weeks up to the age of forty-six. Leopold pronounced this individual a male. To explain the menstruation, it is to be noted, that Klebs has stated that periodical hemorrhages not only may occur from well-formed male organs (Rayer), but especially in case of hypospadias, and in ease of rudimentary sexual glands. This sufficed to lead Leopold to pronounce the case as one of male pseudo•hermaphroditism. Still the two sexual glands may have been herniated ovaries, and in addition there may have existed an arrested development of Muller's ducts; or else they were tes ticles, and the individual made false statements in regard to menstruation. Why this individual should have menstruated is certainly not apparent. That he had made other false statements was apparent from his history.
Leopold had previously recorded a similar case, where the individual at the age of twenty-five was married as a female. She had never men struated. There existed simply a cul-de-sac instead of a vagina, the clit oris was small, and in general the appearance of the external genitals sim ulated that of the female. In the labia were two round, almond-shaped bodies. There is no post-mortem history.
Veit records two similar cases of Oldham's where the malformation was due to herniated ovaries in individuals who had never menstruated. Leopold, finally, speaks of Ricco's, Steglehner's, and Giraud's cases. We will only mention here that Ricco's pseudo-hermaphrodite had never menstruated, that Steglehner's had simply menstrual molimina, and that in connection with Giraud's no reference is made to this function. Both of these latter were dissected and determined to be males, notwithstanding many suggestions of the female sex in their external appearances.
We now proceed to speak of those cases where not alone the vagina, but where from Milller's ducts bad been formed a more or less rudiment ary uterus masculinus. Here belong those instances where the uterus forms a cavity in the posterior bladder wall, or else both uterine comma exist but the tubes are lacking, and finally where the male individual, al though possessing testicles, has also complete development of 3Iiiller's ducts with tubes and fimbrim.
The figures 50 and 51 represent the genitals of a six months child which was considered a male because the genital glands were proved to be testicles, but still it possessed a vagina, uterus, and tubes.
The diagnosis of the sex is often very difficult, and yet of very great importance to the individual. In general, where there is ground for doubt, it is better to lean towards the male sex, since the various develop mental anomalies in the male have always a special likeness to the female genitals. And again, examination per rectum by determining the pres ence of a prostate, an organ without an analogue in the female, will fre quently settle the question.
The testicle and epidydimis in a cleft scrotum, suggestive of labia, in crease the probability, of course, that the individual is a male. It is not to be forgotten, however, that hernia of the ovary in one of the labia, associated with impervious vestibule, may suggest a male although the individual is a female. A further important appearance is a vagina ex tending from the uro-genital sinus. We have already referred to this in adults. If the canal is very short (as in Dohrn's case) it should suggest a vagina masculina. Examination per rectum clears up the diagnosis, in case the internal genital organs are present, the vagina being usually very short and the internal genitals being directly in connection with it. In after-life the sexual tendency serves to clear the diagnosis. These pseudo hermaphrodites, when they have been reared as females, often possess no special sexual leaning and allow themselves to be married to males, al though themselves really of the same sex (cases of Dolan, Leopold, Steglehner and others). Ejaculation of semen or typical menstruation are valuable factors in differential diagnosis. In not a single case, as yet, however, have spermatozoa been found in hermaphrodites, the ejacula tions consisting simply of such a fluid as even females secrete on irrita tion of their sexual organs. We exclude, of course, all cases of hypos padias, where naturally a fructifying fluid is present.