CHAPTER XXXVIII

Sexual abnormalities-Hermaphroditism-Impotency-Sterility- Causes of impotency and sterility-Medico-legal relations of divorce.

SEXUAL ABNORMALITIES

THE question of sex may arise in connection with newlyborn children, as to whose sex there may be some doubt, and later in life the questions of sexual capacity and development of the sexual organs may require the consideration of the medical jurist in connection with sterility, impotency, and

rape.

Hermaphroditism is a term that is strictly applied to the presence of the organs of both sexes in the same individual; in its common acceptation it is frequently meant to designate all cases of doubtful sex. The embryo is at first hermaphroditic, both sets of organs being present; if growth and development in a new direction take place, the male organs are formed; but if, during their formation, aberrations or arrest of development occur, then a condition of the organs is produced in which the sex may be doubtful. For instance, an extreme form of hypospadias, in which the urethra remains open on the under surface, may cause the male organs to simulate abnormally formed female organs; the male organs may also somewhat resemble abnormal female organs if, with non-descent of the testicles, there is combined a cleft scrotum. In the early stages of development of the male organs, the part corresponding to the scrotum is divided by a fissure; if this fissure persist, then the commonest form of sexual abnormality

results the hermaphroditic form, with a predominance of the male characteristics.

So-called true hermaphroditism consists in the conjunction in the one person of parts of both the male and female generative organs, and is generally due to the persistence and development of the Wolffian and Müllerian ducts in the one individual. This form of hermaphroditism is classified by Sir J. G. Simpson as follows:

Lateral. Testicle on one side, and ovary on the other. Transverse.—External organs male, and internal female, or the reverse. (a) Ovaries with combined male and female passages. Vertical, or (b) Testicles with combined male and female passages.

double.

(c) Ovaries and testicles co-existing on one or both sides.

Ceccherelli relates a case of a living example of vertical hermaphroditism, the subject at the time of the examination being fourteen years of age. There was a hypospadic penis; the scrotum was divided and contained one testicle; between the folds of the split scrotum, or labia, the neck of the uterus could be felt. The breasts were well developed, and the female organs appeared complete. Menstruation had occurred regularly since the twelfth year of age, and the individual had had sexual connection as a woman. From the opening in the penis semen was ejected, a specimen of which was found to contain spermatozoa. Very frequently hermaphrodites are impotent and sterile owing to defective development.

IMPOTENCY AND STERILITY

By impotency is meant incapacity for sexual intercourse; by sterility is meant incapacity for procreation-e.g. a male whose semen contains no spermatozoa, or a female destitute of ovaries. In the female, incapacity for sexual intercourse (not 2 Lo Sperimentale, 1874.

Todd's Cyclopædia of Anatomy.

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sterility) can alone be adduced as a ground for divorce. In the male, also, the legal disqualification on the ground of impotency is incapacity for sexual intercourse. Impotency may depend upon physical or moral causes. The moral causes of impotency are not recognised by law, and therefore do not concern the medical jurist.

Physical causes of impotency and sterility in the male. 1. Extremes of age.

2. Congenital malformations.

3. Diseased conditions.

I. Extremes of age. The procreative power in males usually commences at puberty, with the full development of the sexual organs, especially the testicles. The non-arrival of puberty is therefore one of the causes of impotency. The exact age of male puberty varies, but, as a rule, it may be taken at from fourteen to seventeen years. The English law recognises fourteen years in the male, and twelve in the female, as the earliest ages at which marriage may be contracted. The rule for a medical man to follow, when examining a male of reputed sexual power, is not so much to pay attention to the age, but to carefully notice the condition of development of the sexual organs, as well as the general physical and moral development of the individual. The development of sexual power is generally accompanied by well-marked changes in the person, such as a change in the tone of voice, the growth of hair on the pubes, development of the penis, and general muscular development. Several cases of early paternity have been recorded; many have occurred in which boys at fourteen years of age have become fathers. The earliest recorded1 age of the development of the procreative functions in the male is the case of a boy who, when not quite thirteen years of age, impregnated a young woman, who confessed to leading him astray, and to allowing him to have intercourse at least a dozen times. The boy possessed well-developed generative

The procreative power in the male may continue to very advanced age; spermatozoa have been found in the semen of men over eighty years of age. The English law has placed no limit to the age when old men may marry, thereby tacitly admitting no limit, as far as old age is concerned, to the power of sexual intercourse.

II. Congenital malformations. The physical causes of impotency and sterility in the male resulting from congenital malformations are various forms of hermaphroditism, absence of the penis, malformations of the penis, and absence of both testicles. The subject of hermaphroditism has, already been discussed (see p. 241), and the fact of complete absence of the penis rendering a male impotent is obvious; the two last mentioned forms of congenital malformation are therefore the only ones to be dealt with in this section.

Malformations of the penis.-Extreme degrees of epispadias and hypospadias constitute mechanical impediments to impregnation. Epispadias is a cause of sterility, in that the semen is unable to reach the vagina. Hypospadias may or may not be an impediment to impregnation, according to its degree; if the cleft or fissure extend far back to the root of the penis or scrotum, then the semen is unable to reach the vagina; impregnation has, however, resulted from artificial transference of the semen to the vagina. Extreme degrees of epispadias and hypospadias may therefore be a cause of sterility in the male, although such a person is not impotent; since, however, such a person can eject semen containing spermatozoa, a medical jurist should employ great caution in expressing an opinion as to the possibility, or not, of impregnation under such conditions; this caution is necessary, as impregnation may occur from mere ejection of semen on to the vulva, without any propulsion of it into the vagina.

Absence of the testicles. If one testicle only be present in the scrotum, the individual is known as a monorchid. Such a condition may be due either to imperfect development, or to removal of one testicle by operation; in neither case does it

interfere with the capacity for procreation. The absence of both testicles from the scrotum, owing to their non-descent, does not necessarily produce sterility in the male, although the condition is very likely to lessen the procreative power, and may be an actual barrier to it; an individual possessing undescended testicles is known as a cryptorchid. Taylor and Stevenson relate the cases of two cryptorchids who were in possession of indisputable procreative functions. One of them, before he had reached the age of thirty years, had been twice married, and had had children by each wife, besides illegitimate children which were affiliated on him. The other had a well-developed penis, but the scrotum was absent and the testicles were undescended; this man had married when he was twenty, and had had two children by his first wife, and had married a second time when he was twenty-seven years of age.

Entire absence of both testicles renders a man sterile. If they are removed by operation from a man at the period of sexual activity, it is possible for fruitful intercourse to occur for a very limited period after such emasculation, but such power is eventually lost. This temporary retention of the procreative function is probably due to some seminal fluid remaining in the vesicles and ducts. The power of copulation should not be confounded with the procreative power. Although the removal of both testicles deprives a man of the power of procreation, it does not necessarily render him impotent. It seems to be generally admitted that eunuchs, or at least some eunuchs, possess the power of copulation to a great degree.

III. Diseased conditions.-Advanced disease of the testicles or of the penis may be a cause of impotency or sterility. Mumps may cause, as a complication, inflammation of the testicles, which may lead to atrophy of those organs. Severe general debility, due either to inherited weakness or to disease, may be the cause of temporary or permanent loss of the sexual functions. Diseases of the nervous system tend to derange or abolish the sexual function. Cerebral exhaustion, due to various diseases, blows on the head or spine which affect the brain and