In case of hypospadias the external genitals are less associated in the defect. In particular we do not find union of the labia or fissure of the clitoris. On the contrary, in many of the reported cases the clitoris was enlarged, and herein we have a great help in the diagnosis of the sex. In the hypospadiac male there exists, in addition to the greater or less fissure of the corpora cavernosa, a lessened development of the penis and a backward incurvation. Hypospadias is likely to lead to error as regards sex, and it has often happened that male hypospadiacs have been consid ered female and brought up as such, even indeed married. On the other hand females, on account of the development of the clitoris, have been reared as boys. (Cases of Debout, IIuguier, Jum(, Code, Engel, Hilde brandt.) In addition to cleavage of the clitoris as a consequence of epispadias, there are certain rare instances of fissure of the clitoris on record without epispadias which are very difficult to explain, for it is difficult to say what causes traction on the halves of the corpora cavernosa.
Herntaphroditism.—In these instances the sexual organs of the two sexes are combined in one individual. We already saw, when speaking of the development of the sexual organs, that in both sexes they originated from the same source. In short, every foetus is, at the outset, a herma phrodite, since it contains the essentials of the organs of both individuals, and it is apparently a matter of chance whether they will differentiate into the male or the female. And here there is a cardinal principle at stake. The foetus contains both Wolffian bodies and .Holler's ducts, and in the development into a male the former become epididymis and vesi culte seminales, the latter atrophying, even as the latter become converted into female organs, in which event the former retrograde. It is, how ever, an open question, whether a double formation, so to speak, of both sexual glands may occur, even as happens in case of other organs of the body. It so happens in case of hermaphroditic animals, and in the embryo of the higher mammals Waldeyer has found this duplex formation of the genital glands.
Klebs has made the following classification of hermaphrodites: 1. Bilateral, where on both sides of the individual there exist testicles as well as ovaries.
2. Unilateral, where, at least on one side, there is present ovary and testicle. Theoretically it would seem that then on the other side one or the other sexual gland should be present. We will see that in the only reported instance of this nature such was not the case.
3. Lateral, is double formation of the sexual glands, where on one side a different gland, and therefore different sexual development, is appar ent.
Of unilateral hermaphroditism there is not on record a single case. Bilateral hermaphroditism is very doubtful. We have to consider purely, therefore, instances of lateral hermaphroditism.
In all the hermaphrodites heretofore described, there was present the tendency towards development of one or another of the sexes. A simul taneous development of the Wolffian bodies and of Muller's ducts, and their accessories, has never as yet been met with. In the majority of herma
phrodites the tendency was unquestionably towards the male type. In most of the reported cases information is lacking as to whether one or another of the elements which go to form the internal genitals was in ex cess of the other, or if both were of tantamount importance. As a gene ral truth it may be stated that one sex seems to have gained the upper hand over the other, although remaining in a state of development a trifle below the normal.
As to whether, now, the sexual glands themselves, testicles and ovaries, have the power of determining differentiation of sex, or not, can obviously only be determined by observation of hermaphrodites. The results of extirpation in early extra-uterine life point to the fact that from the sex ual glands themselves emanates the stimulus necessary to the develop ment of the other sexual organs, but early enough extirpation of these glands to settle this point definitively is out of the question.
That man is working in a vicious circle who, from the presence of uterus and vagina, predicates at once the bodies felt to either side as ovaries. He holds that as certain which as yet lacks proof. There are many instances on record where, from the presence of tube and a one horned uterus, the conclusion has been drawn that an ovary also existed without subjecting it to careful microscopical examination. In those in stances where such an examination was resorted to, never has an ovary with Graafian follicles and ova been found. The reverse is true of testi cles, as the cases of Rudolph Stark and of Barlow prove.
For such reasons, then, Ahlfeld denies the existence of true herma phroditism in the human race, and Dohrn is in perfect accord with him. As to whether such positiveness is warrantable or not it is impossible to say.
The truth is, certainly, that as yet no instance has been noted where two functionating and fully developed sexual glands existed in one indi vidual. When all the genital organs bespeak a distinctive sex, and the whole individual bears the characteristics of a male, as in Meyer's and in Banon's cases, then it is certainly not to be expected that the other sex ual gland is also normally developed, but we would rather be justified in the belief that the ovary had not developed, or else had retrograded. Such is the opinion forced upon us by the latest results of microscopical examination by Klebs in Meyer's case. In the organ claimed to be an ovary by Meyer, Blebs found cells which do not exist in testicles, and similar to primordial ova, and further still he detected cylinders or de pressions suggestive of follicles. In the face of these findings, of course, no authority is entitled to absolutely deny the possibility of the existence of such cases. It is to be added, however, that the early structure of both testicles and ovaries are nearly similar, so that we should not lay overmuch stress on the certainty of anatomical differential diagnosis.