PSEUDOHERMAPIIRODISNIUS MASCULINE'S Internal (more frequent than the feminine form). External genitals formed normally masculine. In the pelvis, beside normally or rudimentary formed Wolffian ducts and their derivatives, Ithillerian fibres are also found more or less developed: uterus with tubes, liga ments, and vagina. The latter opens either into the prostatic part of the urethra, or between the halves of the scrotum, in which latter case the urethra empties into the vagina. If a uterus is present, the tes ticles are very frequently located where the ovaries would lie in woman, The unilateral or bilateral chryptorchism stands in casual relation to the presence of a uterus in man.
B. External (the most frequent form of psetalohermaphroditism). The vulva is imitated in consequence of peni-serotal hypospaclias, with more or less rudimentary development of the hypospadiae penis. There are many cases where upon such a vulva, not the least variation from the normal vulva hints at a possible "erreur cle sexe," ease the vidual should have been christened a girl. In some cases there is hy pospaclias of the penis only, or the scrotum is only partly split, and the orifice of the urethra lies in its upper half, in other instances the scrotum is completely divided, and even little rudimentary labia pudendi are imitated by the split penile urethra. In most eases tlte false clitoris seems to be enlarged, but there are examples where the elitoris seems small even for a woman, and is therefore quite rudimentary in appear ance. The internal genitals are masculine in formation, analogous to the testicles. The eases fire very rare in which the penis is normal, and the scrotum alone shows a. split in its lower part, where the opening of a vagina appears to be located.
C. Complete.—Besides the seemingly feminine external genitals there are to be found more or less developed Mfillerian fibres, together with the presence beside the testicles of more or less developed Wolf fian ducts: i.e: Uterus with tubes and ligaments, a vagina which often empties into the urethra, or in common with the urethra into the sinus urogenitalis, which is persistent, or else the urethra empties into the vagina.
In the six recorded eases where a juxtaposition of hetero-sexual external genitals occurred: i.e. where scrotum and penis existed along with a vulva, there probably was, in the opinion of Neugebauer a split in the lower end of the vertebral column (dipygia). Hermaphroditism is of great theoretical interest in embryology, and in consideration of the many questions of civil and criminal law which may arise in con nection with the life ancl destiny of hermaphrodites. But setting aside all this, it was necessary for the present purpose to state in detail Neu gebauer's observations because tlte children's physician may often bc called upon to answer the query of parents as to the sex of a newborn child. (Three times in the last 4000 eases at the Berlin University
Polyclinic for Children' a decision was possible, if at all, only -1-ien the relations just discussed were fully understood).
If we remember that in masculine hermaphrodites the feminine appearance is simply imitated by peni-scrotal hypospadias (see chapter on the Male Genitals), it will be clear that the masculine SOX Call be established only by the presence of testicles, accessory testicles, and spermatic ducts. It is out of the question to consider the presence of the prostate, setting aside the difficulty of recognizing it by palpation, as a very important element in differential diagnosis. "The masculine sex is assured if it be possible to touch in the imitated labia pudendi symmetrical formations corresponding in size, shape, and consistency to testicles, and accessory testicles, even though the opening of a vagina, surrounded by hymen, should be found beneath the imitated feminine mouth of the urethra, and even labia pudendi minora as indications of the edges of the split penile urethra." Neugebauer from his experi ence does not approve of the dictum of Klebs that the presence of labia pudendi minora is decisive for the feminine gender. He says, "If in the newborn it be not possible to feel assured of having touched the testicles, and accessory testicles, the only proper thing to do is to declare until later that the sex is doubtful, to dernand a future repe tition of the examination, and finally even to postpone the decision until the individual has arrived at the age of puberty. But if the case is one with cryptorchism on both sides the opinion must certainly be postponed or else a serious error will be risked." The physician will the more readily decline to give a diagnosis which influences decisively the education of the patient, when he recalls those cases in winch a testicle of the masculine pseudohermaphrodite was erroneously' considered to be an ectopic ovary of a female, or those cases in the formations which (luring life WCIT bCliCIT(1 to be testicles were found at autopsy to be something entirely different, e.g., the case found by Iffichow to be a pre-inguinal hernia of the processus vagi nails peritonei. The laws of every state should recognize the fact that it is sometimes utterly impossible to determine the sex exactly, and should make allowance for doubtful sex (Unger).
Atresia ani and atresia urethra, are not rare among the deformities which complicate hermaphroditism, and it is important for the phy sician to be aware of this, since they require an immediate surgical operation.