Matthews reports a case in the Medical Record, vol. 55, No. 21. He removed from a supposed girl, aged twelve, a testicle, being just below the external abdominal ring, under the skin of the left thigh. At the age of nineteen she was tall, slim, and pale. The external genitals, normal female. The face and pubes were free from hair. The vagina was one and threefourths of an inch deep. No trace existed of uterus, prostate gland, nor any trace of another testicle.

The following case came under my observation within the past year: Miss X., aged 14, a healthy and apparently welldeveloped child, was brought to my office by her mother for treatment of her throat, as for some weeks she had complained of "hoarseness." An intralaryngeal examination revealed no abnormal condition, the nares and pharnyx were also normal. I was at a loss to account for the alteration of voice described as "hoarseness,” and requested the mother to bring the child back in a few days. Upon the next visit I still was unable to explain the peculiar tone of voice, which no doubt was the normal change of the male voice at puberty. The mother incidentally stated that her daughter was ruptured, and had worn a truss for some time, and expressed a desire for medical treatment. Upon requesting the patient to stand, and placing my hand over the pubic region, I found a distinct bulging over both inguinal canals, with desided impulse upon coughing. Upon this hasty and imperfect examination I diagnosed hernia, possibly ovarian, into the canal of Nuck, and sent her to the hospital for operation. I did not see the patient again until she was brought into the operating room, where we discovered the following conditions: Both canals open and containing almondsized bodies freely movable; pubes slightly covered with hair; labia majora fully developed; "clitoris" enormously hypertrophied with well formed glans, the foreskin retracted and continuous with the labia minora. A slight groove, with elevations upon either side, was continuous from the frenum for three quarters of an inch to the meatus urinarius which was well formed and normal in appearance. Directly below this was the opening of the vagina, surrounded with well formed carunculæ. The vagina was one inch and a half deep, ending in a blind cul-de-sac. The hymen was apparently absent. A rectal examination, as well as a subsequent examination through the inguinal ring, revealed neither uterus nor prostate gland.

The body resembled more the masculine type, the mammary glands undeveloped, the curvature of the thighs alone bearing some resemblance to the female. The hands were large, but the feet small.

We were now confronted with a question which rarely falls to our lot to decide-that of determining the future sex nominally of an individual. I called for her mother to consult with her, but she had left the hospital. Nature had evidently given to this individual a preponderance of the masculine-a case of complete hypospadism with division of the urethra and scrotum and undescended testes. The patient had been reared and

educated as a girl, so the question before us was whether to perpetuate the mistake which had already been made, or to dis turb the social and domestic relations upon anatomical grounds. After a brief consultation with the physicians present it was decided that social and domestic considerations take prece dence. I therefore opened the canals, removed the testicles and treated as in ordinary cases of hernia. Three weeks later, with full consent of the mother, who had entirely agreed with the result of the previous consultation, I removed the "clitoris ” and united the upper parts of the labia minora, giving the parts a normal feminine appearance.

In inquiring into this case the mother informed me that soon after the child was born she noticed an irregularity of these parts and called the attention of the family physician to it, but upon his assurance that everything was normal she gave it no further thought. At the age of four years, according to the mother's account, the child became ruptured, necessitating the frequent attendance of the family physician to restore the part and adjust the truss. Chloroform was occasionally administered. The mother had detected no peculiarity in regard to the child's sexual preferences, but when closely questioned, said that her daughter could not be bothered with fellows.

The questions arising from the recital of this case are: the embryological development; the influence upon the organism of the early removal of the testes, and the proper treatment of these cases.

As to Development.-At about the end of the fifth week of embryonic life a small opening appears externally which receives the termination of the intestinal canal, the ureters and the different ducts of the sexual organs. At the beginning of the eleventh week the dual aperture is separated from that of the genito-urinary canal by the development of a transverse band. The genito-urinary canal is likewise separated by a similar process of division into a urinary and genital part, the former of which becomes the urinary bladder. At the external opening of this canal is soon observed two folds of skin, the rudiments of the labia majora in the female and the two halves of the scrotum in the male. Between and in front of these an erectile body appears surmounted by a gland and furrowed along its under surface. This body in the female is retracted into the genito-urinary canal and becomes the clitoris, while the margins

of the furrow are converted into the labia minora. In the male this sinus is closed at a very early period by the adhesion of the two folds of integument which bound it, forming the upper part of the urethra. The erectile body increases and becomes the penis, while the margins of the furrow at its under surface unite to form the spongy portion of the urethra. The condition of hypospadias arises from the incomplete closure of the edges of the original furrow. The so-called vagina is the inclosed urogenital sinus.

With reference to the influence upon the organism of the early removal of the testes, from my own experience I can offer no information, but in the majority of cases I am led to believe that the development of masculine characteristics is inhibited. As an interesting item in this connection I will give a brief resumé of an article that appeared some years ago in an American journal.

On the Lena river in eastern Siberia exists a religious community known as the Russian Skopzi. Dr. Sitlikoff was commissioned to make a searching investigation into the habits of this strange sect. He describes the courteous and kindly manner in which he was received, and goes on to give a detailed account of their methods of life, industries, etc., but it is only with the anatomical peculiarities that we are interested.

Most of the members join the sect at the age of eighteen and twenty, being induced to renounce the world from religious fanatacism, remorse, poverty, and some from melancholy produced by disease or abuse. The Russian peasant at twenty knows nothing that is elevating, and easily succumbs to the persuasion of the members of the sect to undergo mutilation to insure future happiness. As there are no children in the community the sect is kept up entirely by new male converts. According to the statements of the converts the operation of initiation to which they submit themselves is not so painful as one would imagine. Those who are to represent the male Skoptz have only their testicles removed; those who are to be called women have their testicles crushed like the spada of ancient Rome, and after absorption has taken place a perineal opening is made an inch and a half in length. The penis is clipped off close to the pubis, when all is healed the scrotum forms the labia and the contraction of the cicatrix caused by the removal of the penis simulates strongly the appearance of the

female genital organs. In speaking of the effect of the operation upon the younger members of the community Dr. Sitlikoff states that they grow up retaining all the freshness and much of the beauty of youth until late in life. They possess sweet voices and are quick to learn. The pseudo-girls are very fond of personal ornaments and bright colors, and so far as personal appearance goes, will compare favorably in looks with the average Russian girl. They retain the tone of voice they possessed in early youth, or at the time they were mutilated and received into the sect. The industry of these people is phenomenal. They seem to love one another and enjoy their lot in life as well or better than those upon their plane around them.

The Proper Treatment of Such Cases.-Admitting that this individual was essentially male, should we not consider the bearing that previous environment and education has upon determining the sexual classification. Incapacitated from the complete functions of either sex, and unable to exhibit but to a primary degree the office of either male or female, the position is somewhat unique. Where the condition is detected very early there can be no question as to the course to pursue, but when a mistake has been made and the child grown to maturity or entering upon nominal womanhood, the alteration of sexual classification is a matter of grave import. In this case, in which the associations and education had been that of a female, social chaos and ridicule or the removal to a distant part would have been the inevitable result. As the circumstances of the family would not admit of a change of residence, a decision was to be made between a perpetuation and intensification of the mistake or social ostracism. The question of means of livelihood also has a bearing here. Is the economic problem more complicated upon the male side or upon the female ?

Surgically. The testicles might have been replaced within the abdominal cavity and the canal closed. This would have probably resulted in atrophied organs, and the difference between atrophied glands and the absence of glands cannot be very great. Or we could have with difficulty closed the canal behind the testes and brought them further down, freed the clitoris and afterwards attempted a plastic operation for restoration of the urethra.

The girl-we call her now, since there are no testicles-is intelligent and ambitious, and as she has a desire for teaching,