BIRTH, SEX, PREGNANCY, AND DELIVERY.

BY

ANDREW F. CURRIER, M.D.

I. BIRTH.

Legal Obligation of Physicians with Reference to the Recording of Births -Determination of the Period of Development in New-born Infants, especially in the Still-born, with Evidence Relating to the Viability of the Latter.

THE importance of correct and accurate vital statistics both to the lawyer and the physician is self-evident. Indeed it is a matter in which the entire community is interested, for in the absence of accurate records of this character how can the status of a community as to population be ascertained? But there are other considerations which are of much greater significance in this connection-considerations which affect the material welfare of large numbers of individuals, and which depend in no small degree upon the faithfulness with which these records are made. The responsibility of physicians is, therefore, direct and decided in this matter, and should be appreciated from the very beginning of their career. The state rather than the church should be the custodian of such records, at any rate in so far as the material interests of the individual are concerned. The recognition of this fact has doubtless been an important factor in the formation and development of bureaus of vital statistics in connection with the systematic regulation of all matters which pertain to the public hygiene. One of the decided evidences of advancing civilization consists in the very general establishment of boards of health, and the development of sanitary science in all parts of the world. With increasing experience the work of such bodies is yearly becoming more perfect and valuable. It will continue in this direction, pari passu, with the importance which physicians attach to it, and the heartiness and intelligence of their coöperation. In New York the law requires the return of a birth-certificate to the local board of health or other official keeper of records within ten days after the birth of every child, whether alive or dead at birth; and a penalty of ten dollars attaches to neglect to fulfill this requirement. This is the duty of the physician if he were in attendance at a given birth; otherwise the return must be made by the midwife or other person who assisted when the birth took place. The importance of this subject should be emphasized by those who serve as instructors in

medical colleges, and in the examinations which candidates for license to practice are compelled to pass.

In France the following sections from the Civil Code appertain to the registry of births:

"ART. 55. Declarations of birth must be made within three days of accouchement to the proper civil officer; the child shall be shown to him.

"ART. 56. The birth of a child shall be declared by its father, or, in default of the father, by the physician, surgeon, midwife, officer of health, or other person who assisted at the accouchement, and if the mother were confined away from her own home by the person at whose house she was delivered. The fact of the birth shall be stated in proper legal form in the presence of two witnesses.

"ART. 57. The return of a birth shall specify the day, hour, and place of birth, the sex of the child and the names he has received, the first and second names, occupation, and residence of the father, mother, and witnesses."

"PENAL CODE, ART. 346. Every person assisting at an accouchement who shall fail to make the declaration as prescribed in Art. 56 of the Civil Code and in Art. 55 of the same Code shall be punished by impris onment of from six days to six months and by a fine of from 16 to 300 francs."

The father or head of the house must report the birth if present at the time; otherwise upon the physician, if one were present, devolves this obligation, if he assisted efficiently in the accouchement. The duty devolves upon him though the child is born upon his arrival, if it is still united by the cord to its mother and the placenta is still in utero or in vagina. The same obligation holds for still-born infants if they have passed the fourth month of fetal life. (Vibert, Précis de Médecine Légale, Paris, 1886, p. 645.) The determination of the period of development which has been reached by a new-born infant, whether it is mature or premature, whether it was living and viable at birth, are all matters of the greatest importance, and can usually be decided with a considerable degree of precision. These subjects are elaborated in the article upon Infanticide (q.v.).

II. SEX.

Hermaphrodism-Defective and Rudimentary Organs of the Genital Apparatus, and the Bearing of the same upon Matrimony and Fertility -Determination of Sex-Puberty and its Attendant Phenomena― Menstruation, Normal and Abnormal-The Menopause.

Hermaphrodism or hermaphroditism is a condition which has elicited a great deal of attention from the earliest times and has given rise to a great variety of opinions and speculation. The work of Klebs upon this subject is scholarly and rational, but that of Pozzi in his Traité de Gyné cologie, vol. ii., p. 1069, is more recent, and will be frequently referred to in this article. To go to the root of the matter in defining the term, we must have in a true hermaphrodite, as Pozzi correctly states, a being who has the genital organs of both sexes, with the possibility of functional activity of both sets of organs. The testicles and ovaries are the essential organs of reproduction in the male and female sexes respectively.

A true hermaphrodite must have organs with the anatomical peculiarities of both ovaries and testicles. Pozzi declares that there does not exist a single incontestable example in which this condition has been realized; but he, as well as Klebs, has evidently overlooked the case of Heppner (quoted by Garrigues in Mann's System of Gynecology, vol. i., p. 269), which was that of a child which died at the age of two months and was found by post-mortem examination to have a hypospadiac penis or enlarged clitoris, a cleft scrotum, a sinus urogenitalis and Rosenmüller's organ representing parovarium and epididymis, a prostate gland, both testicles, vagina, uterus, Fallopian tubes, both ovaries, round and broad ligaments. The ovaries contained Graafian follicles with ova, and the testicles had seminal canals. Among plants and many of the lower orders of invertebrate animals the condition of true hermaphrodism is common enough. Bland Sutton states (Transactions London Pathological Society, 1885, pp. 509, 510) that among the vertebrates it occurs in the cod and herring, and that an ovo-testis is very common in the toad and frog. Hermaphrodism is usually classified as true and spurious, the former of which must be exceedingly rare, making due allowance for any cases which may not have been reported. Pozzi has examined many specimens which have been regarded as examples of hermaphrodism in the Musée Dupuytren and elsewhere, as well as the available literature, and has found them all spurious.*

Instead of true and spurious hermaphrodites it would seem more practical to follow Pozzi in classifying them as gynanders and androgyns, according as the peculiarities of the female or the male sex predominate. In gynanders there may be menstruation, well-developed mammæ, uterus and ovaries, and the possibility of impregnation. In androgyns menstruation is absent, the breasts are of the male type, uterus and ovaries are absent, and there is a possibility that they may beget offspring. In both

* Plenty of cases are recorded in legal and medical literature as veritable instances of hermaphrodism. Lukomsky's case (quoted by R. Guiteras in Morrow's System of Genito-urinary Diseases, Syphilology, and Dermatology, vol. i., p. 50) was that of an individual thirty years of age, with penis two inches long, without urethra, below which was a scrotum with two testicles. Below the scrotum was a normal vulva, with labia majora, labia minora, and clitoris, the urethral opening being below the clitoris. The vagina was three inches in depth and terminated in a normal uterus. The patient had never menstruated. When coitus was practiced with a female a whitish fluid was ejected through the vaginal slit. Whether ovaries were present is not known; hence the evidence is inconclusive.

Wharton and Stillé (Medical Jurisprudence, 1884, vol. iii., p. 140) narrate several cases of varying degrees of importance and authenticity, including the following: Kiwisch's case was thirty-three years of age, had a normal penis, with rugose but empty scrotum, a normal uterus in proper position, a rudimentary vagina opening into the prostatic portion of the urethra, Fallopian tubes, three and three-quarter inches long, with imperfect fimbria, normal round ligaments, no ovaries, testicles with epididymis and efferent duct leading to the inguinal ring and finally opening into the prostate gland, the latter being of normal size and provided with vesicula seminales on either side.

Ackley and Blackman's case was twenty-six years of age, with the general appearance of a man, but with very broad hips. Painful discharge of blood had occurred from the penis at monthly intervals. There was a large penis, also an empty scrotum, pervious Fallopian tubes, ovaries, testicle on each side above the ovary, with excretory ducts leading from them, vagina opening into the neck of the bladder, and prostate gland. The inner surface of the vagina was covered with blood when examined post mortem. The same specimen was examined by J. B. S. Jackson, who found no trace of the os externum uteri, no vaginal portion of the cervix uteri, and a vagina only

varieties the individual may act as the male or female agent in copulation, and it may be impossible to determine the sex without abdominal operation or post-mortem examination. In gynanders the clitoris may

be so much enlarged as to serve the functional purpose of the penis; in androgyns the penis may be very small, the scrotum bifid, and the opening of the urethra so large as to admit the penis in the copulative act. The accompanying figures from Pozzi's work show the difficulties which may be encountered in attempting to determine the sex in such

OV

Fig. 60.-c, Clitoris; b, connecting bridge from clitoris to meatus urinarius; mu, meatus urinarius; ov, orificium vagina. (Pozzi.)

Fig. 61.-c, Clitoris; ov, orificium vaginæ. (Pozzi.)

in some cases, but the common observation is that they are sterile; in fact but two cases occur to the writer in the literature of the subject in

four or five lines in circumference. No true ovarian structure was found. The testicles were normal in size and structure, but there were no vasa deferentia, vesicula seminales, or prostate gland.

Among recently reported cases may be mentioned one of Mr. Edgar Willett's, reported at the meeting of the London Pathological Society, February 6, 1894. The specimens presented were from a man who died, at the age of forty-four, of cerebral hemorrhage. The testicles were undescended; there was a well-developed uterus and vagina; the sexual glands, though occupying the situation of the ovaries, proved on microscopical examination to be the testicles, the membrana propria of the tubuli being very thick. There was a tunica vaginalis on either side of the scrotum, and the penis was well developed. The man wore a beard, was married, and had two children. The testicles were provided with vasa deferentia, which passed down by the side of the vagina toward the prostatic division of the urethra. The vagina narrowed as it perforated the prostate gland, and opened in the usual situation of the uterus masculinus. A closed Fallopian tube proceeded from the uterus on either side, terminating above the globus major of the epididymis in a body representing the usual hydatid of Morgagni. Mr. Stonham reported a similar case to the society a few years ago.

which they were observed to be fertile. (Cases are reported in which hermaphrodites have discharged semen containing living spermatozoa, while others have had ovaries in which were Graafian follicles and ova.) They must necessarily hold a peculiar position before the law. Their right of holding property and voting might be called in question. If they married the marriage might be annulled on account of their physical defects, and yet the law does not forbid their marrying. They may have inordinate or defective sexual desire. In the cases which one finds recorded, those who resemble females are in some instances excessively libidinous. This may be due to the exuberance of erectile tissue in the preternaturally enlarged clitoris, and the irritation to which that sensitive organ is continually exposed. In those who resemble males, on the other hand, an aversion to women and to the sexual act is sometimes reported. The absence of well-marked peculiarities which are common in the physical development of well-formed specimens of either sex is to be expected in individuals of such doubtful or blended sex as are hermaphrodites, but one does not see, in actual experience, the grotesque characteristics with which writers have been prone to clothe these unfortunates. One should not expect to find, on the one hand, a strong voice and a manly beard, or, on the other, well-rounded limbs and womanly breasts-these are the attributes of persons who are not physically defective; but one may sometimes see individuals with imperfect generative organs of one sex and well-marked peculiarities of figure and habit of the other. The precise determination of the sex in such cases is not easy. Hermaphrodites are not the only ones who possess peculiarities of the genital organs, but such peculiarities are often their chief distinguishing feature, and they will now be considered in detail, together with similar or related peculiarities in individuals about whom the sex is not doubtful.

The genital organs of the male are the penis and scrotum externally, the latter containing the testicles with their appendages, the epididy mides, and the spermatic cords, which connect the testicles with the seminal vesicles, the latter lying at the base of the bladder and serving as reservoirs for the semen. This fluid is conveyed from the testicles, where it is secreted, through the vas deferens, a tube contained in the spermatic cord, to the seminal vesicle, whence it is discharged in the act of copulation into a short tube called the ejaculatory duct, and thence into the urethra, the canal which extends through the entire length of the penis, terminating in the bladder, the reservoir of the urine. The penis is joined to the bladder by a trilobate structure called the prostate gland, through which the urethra passes, terminating in the bladder. The minute anatomy of these structures is not essential in this connection. The testicles are developed in the early months of fetal life on either side of the lower (lumbar) segment of the spinal column, from which position they gradually descend into the pelvis or bony basin which connects the body or trunk with the lower limbs. During the seventh month each testicle leaves the pelvis, passing down a canal in the anterior and lowermost portion of the abdomen known as the inguinal canal, and by the end of the eighth month it has reached its final destination in the scrotum.

In the female the external structures are the mons Veneris, which is composed mainly of fat, with its appropriate external coverings (skin and hair), and the labia majora, the latter presenting an elliptical appear