HX00017906 inttjfCitpofllfttigork College of |3l)pgician£! anb ^urgeong ILibrarp t)Ii. B. QUEL. 257 East lit'oadivay, NEW YORK, THE DISEASES OF THE MALE ORGANS OF GENERATION BY THE SAME AUTHOR THE OPERATIONS OF SURGERY Intended for Use on the Dead and Living Subject alike, by those- preparing for the Higher Examinations, and by those recently appointed on a Hospital Staff Si:a>ND EDITION, WITH 235 ILI.LSTKATIONS, 8V() THE DISEASES OF THE MALE ORGANS OF GENERATION W. H. A. JACOBSON, M.Ch. Oxon., F.R.C.S. ASSISTANT-SURGEON GUy's HOSPITAL SURGEON ROYAL HOSPITAL FOR CHILDREN AND WOMEN WITH EIGHTY-EIGHT ILLUSTRATIONS PHILADELPHIA P. BLAKISTON, SON & CO, 1012 WALNUT STREET 1893 lie /«•=? JACOBO FREDERICO GOODHART D.M. CUJUS SINGULAREM MORUM SUAVITATEM DULCEDINEM COMITATEM TAM MITI INGENIO CONJUNCTAS OMNES AGNOSCUNT AMICUS AMICISSIMO Digitized by the Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/diseasesofmaleorOOjaco PREFACE. Since 1880, when Mr. Holmes requested me tore-edit Sir G. M. Humphry's article on the " Diseases of the Male Organs of Gene- , ration " for the third edition of the System of Surgcri/, my attention has been drawn to these subjects. It will be seen that in one point the title of my book is not correct ; the necessary limits of space have prevented my entering into many details connected with the Prostate which might have been included in a completer attempt than this. Messrs. Churchill have allowed me to make use of the illus- trations in Mr. Curling's work, and also some of those in Mr. S. Osborn's books on Hydrocele and Diseases of the Testicle. To Messrs. Longman I am indebted for permission to introduce three illustrations from vol. iii. of the System of Surgery. My best thanks are due to two old dressers — G. Bellingham Smith, F.R.C.S., for much help in hunting up references, and A. E. Norburn, M.B., for the care with which he has corrected the proof-sheets, and for the painstaking labour involved in compiling •each Index. Finally, without the help of my brother, C. L. Jacobson, I could not have found the time needed for consulting many of the German writers referred to, W. H. A. JACOBSON. 66 Great Cumberland Plack, W. CONTENTS. PART I. DISEASES OF THE TESTICLE. CHAP. PAGE I. Development ANT) Transit of the Testicle. — i. How is the transit of the testicle brought about ? — 2. Why does this transit from the abdomen to the scrotum take place ? — 3. Pathological conditions which may follow on deficiencies or errors in the de- velopment and transit of the testicle 1-20 II. Congenital Abnormalities and Defects op the Testicle AND its Annexa.— Section I. Abnormalities in Develop- ment. — Polyorchism. — Anorchism. — Monorchism. — Chief defi- ciences in the seminal apparatus : (i) Absence of the testicle only ; (2) Absence of the testicle, the epididymis, and a portion, more or less extensive, of the vas deferens ;■ (3) Absence of the whole apparatus ; (4) Absence of all, or part of, the excretory apparatus, the testicle being present ; (5) Bilateral anorchism. — Section II. Abnokmalitiesin the Transit op the Testicle. — (A.) Incomplete transit or retention of the testicle. — Varieties, (B.) — Malplaced transit or ectopia testis. — Varieties. — Causes of abnormalities in the transit of the testicle. — ^Question of the func- tional efficacy of a retained or ectopic testicle. — Complications of a retained or ectopic testicle. — Treatment of the complications. — Orchidopexy. — Section III. Abnormal Position op the Tes- ticle in the Scrotum. — Inversion of the testicle. — Varieties. — Eeversion of the testicle 21-96 III. Hydrocele. — Section I. Acute Hydrocele. — Classification of hydrocele.— Section II. Hydijocele of the Tunica Vagi- nalis, Common or Vaginal Hydrocele. — Causes, — Charac- ters of the fluid. — Changes in the tunica vaginalis. — Condition of the testicle and epididymis. — Symptoms. — Diagnosis. — Com- plications. — Accidents. — Treatment : (A) Palliative. — Tapping. CONTENTS. lAP. r.VOE Accidents.— Acupuncture ; (B) Radical cure.— (i.) Introduction of stimulating substances. — (ii.) Iodine. — Complications. — (iii.) Carbolic acid.— Complications.— (iv. ) Silver nitrate. — Antiseptic incision.— Antiseiitic incision with partial excision of the sac. — Choice of operation. — Seton and other methods. — Section III. Congenital Hydrocelk. — Source of the fluid. — Symptoms.— Diagnosis. — Complications. — Treatment. — Section IV. Infan- tile Hydrocele. — Symptoms. — Diagnosis. — Treatment. — Sec- tion V. BiLOCULAR HVUROCELE. HYDROCELE EN BiSSAC. Infantile Hydrocele with Prolongation into the Abdo- men. — Symptoms. — Treatment. — Section VI. Fatty, Chylous, Milky Hydrocele. — Causation. — Theories. — Symptoms.^ Treatment.— Section VII. Encysted Hydrocele of the Tes- ticle. — Varieties: (i.) Encysted hydrocele of the epididymis. — Pathology. — (A) Small cysts. — (B) Large cysts, often contain- ing spermatozoa. — Pathology. — Explanations; (ii ) Encysted hydrocele, situated between the tunica albuginea and the tunica vaginalis, or in the tunica albuginea itself. — Symptoms of en- cysted hydrocele. — Diagnosis. — Treatment. — Section VIII. Hydrocele of a Hernial Sac. — Symptoms. — Diagnosis. — Treatment.— Section IX. Fibrous or so-called Cartilagi- nous Bodies, Attached or Free, in the Cavity of the Tunica Vaginalis. — Varieties. — Origin. — Symptoms. — Treat- ment 97-214 IV. HiEMATOCELE. — Varieties. — Section I. Hematocele of the Tunica Vaginalis. — Question of spontaneous origin. — Ques- tion of origin in injury, or in a pathological condition of the tunica vaginalis. — Interior of vaginal hajmatoceles. — Contents. -^Site and condition of testicle. — Causes. — Symptoms. — Com- plications. — Diagnosis. — Treatment: (A) Palliative; (B) Radi- cal. — Incision. — Incision and scraping. — Decortication. — Cas- tration.— Section II. Encysted H.f.matocele of the Testi- cle. —Diagnosis.— Treatment. — Section III. Parenchymatous OR Intea-Testicular H.ematocele. — Section IV. Hemato- cele IN the Substance of the Epididymis. — Section V. Combined Abdominal and Scrotal Hematocele. Bilo- CULAR Hematocele 215-247 V. Inflammatory Affections of the Testicle and Epididymis. — Section I. Epididymitis. — Section II. Epididymitis or Epididymo-Orchitis op Urethral ORiGiN.-Causes.— Patho- logical anatomy. — Symptoms. — Varieties. — Complications. — Termination. — Abscess in the testicle. — Treatment of acute and sub-acute epididymo-orchitis. — Inflammation op the Tes- ticle and its Immediate Surroundings due to General CONTENTS. xi ■CHAP. PAGE Diseases, often Infectious. — Mumps. —Nature of the orchitis. — Typhoid fever. — Nature. — Scarlet fever. — Orchitis complicating influenza.— Inflammation of the testicle and its immediate surroundings in malaria and ague. — Gouty orchitis. — Goiity orchitis proper. — Gouty epididymo-orchitis. — Eheu- matic. orcliitis. — Orchitis and acute tonsillitis. — Epididymo- orchitis from strain. — Section III. Orchitis Proper. — Causes. — SequelEe. — Treatment. — Syphilitic Affections of the Testicle and Epididymis: (A) Acquired. — i. Syphilitic Orchitis, Syphilitic Sarcocele. — Two forms. — (a) Dif- fuse interstitial orchitis. — Pathology. — (;8) Gummatous orchi- tis. — Pathology. — Condition of the tunics and annexa of the testicle.— Terminations.— 2. Syphilitic Epididymitis. (B) Orchitis due to Hereditary Syphilis. — Clinical course of syphilitic orchitis. — Prognosis. — Treatment .... 248-320 VI. Tubercular Disease op the Testis and its Appendages.— Ways in which the testicle and its appendages become the seat of tubercle. — Mode of entrance of the bacilli. — By the blood- vessels. — Question of infection during coitus. — Predisposing conditions : i. Hereditary taint ; ii. Injury ; iii. Mixed in- fection ; iv. Venereal excitement; Morbid anatomy: (i) Naked-eye changes. — A. Epididymis. — B. Testis. — C. Tunica vaginalis. — D. Vas deferens. — E. Vesiculse seminales. — F. Pros- tate ; (2) Microscopical appearances. — Acute tubercular disease of epididymis and testis. — Symptoms : A. Of the more chronic form ; B. Of the acute. — Diagnosis. — Course. — Prognosis. — Complications. — Treatment : (A) Medical or palliative ; (B) Operative : (i) Opening and scraping out abscesses ; (2) Use of the cautery; (3) Castration. — Tuberculosis of the testicle in infants 321-375 VII. Fungus or Hernia Testis. — Varieties: (i.) In tubercular dis- ease; (ii.) In syphilitic disease ; (iii.) In malignant disease . 376-383 VIII. New Growths op the Testis, Epididymis, and Tunica Vagi- nalis. — Classification : Section I. Carcinoma.— (a) Encepha- loid. — Starting-point. — Naked-eye appearance. — Generalisation. Microscopical appearances. — (/3) Scirrhus. — Sub-varieties of encephaloid. — Section II. Sarcoma. — Starting-point. — Naked- eye appearance. — ^Geneialisation. — Microscopic appearance. — Sub-varieties. — Clinical history of Carcinoma. — Sarcoma. — Dia- gnosis. — Prognosis. — Treatment. — Lymph adenoma. — Enchon- deoma : A. Uncombined ; B. Mixed.— Fibroma.— Myxoma. — Myoma. — Osteoma. — Cystic Disease. — Two groups : A. More innocent ; B. More complicated and malignant. — Naked- eye and minute anatomy.— Starting-point. — Course. — Prognosis. xii CONTENTS. C.IAI', PAGE -TfiliATOJiATA. — Varieties : A. More complicated one. — Foetal inclusion ; B. Simpler forna of dermoid cysts. — Clinical history. Prognosis. — Treatment 384-432 IX. Growths of the Tlnjca Vaginalis. — Lipoma. — Fibroma. — Sarcoma.— Castration 433-442 X. Lesions op Nutrition. — Hvpertrophy. — Atrophy. — Two conditions: (i.) Atrophy [iroper ; (ii.) Arrest of development . 443-451 XL Irritable and Neuralgic Testicle 452-456 XII. Masturbation. — So-called Spermatorrhcea. — Seminal Emissions. — Sexual Hypochondriasis. — Continence and Sexual Hygiene 457-477 XIII. Impotence. — Sterility. — Physiological facts and practical results. — A. Impotence. — Varieties: (i.) Atonic; (ii.) Physi- cal; (iii.) Symptomatic; (iv.) Organic. — Sterility'. — Varie- ties: (i.) Azoospermia; (ii.) Aspermia ; (iii.) Male-mission . 478-498 PART II. DISEASES OF THE CORD. I. Inflammatory Affections. — Acute and chronic. — Hydro- cele: (i.) Acute; (ii.) Diffuse or infiltrated ; (iii.)' Encysted 49S-507 II. HiEMATOCELE OF THE Cord.— Diffuse.— Encysted . . . 50S-512 III. New Growths.— Lipomata.—Myxo-lipomata. — Fibromata. —Myxomata.—Myxo-saecomata.— Sarcomata.— Myomata. 513-519 I V. Varicocele. — Pathological anatomy. — Causation. — Symptoms. — Complications. — Condition of testicle. — Treatment : (A) Pallia- tive, (B) Operative. — Antiseptic excision. — Risks and causes of failure 520-543 CONTENTS. xiii PART III. DISEASES OF THE SCKOTUM. :HAP. I'AGE I. Inplabimatory Affections of the Scrotum. — Section I. Chronic (Edema OF THE Scrotum.— Section II. Inflamma- tory (Edema. — Diffuse Inflammation. —Cellulitis. — •Erysipelas. — Gangrene. — Anatomical conditions predisposing to the above. — Causes. — Treatment. — Section III. Scrotal or Extra- Vaginal Hematocele 544-551 II. New Growths of the Scrotum. — Section I. Malignant Disease. — Epitlielioma. — Initial form. — Progress. — Extension to the lymphatic glands. — Question of diminishing frequency of this disease in England. — Question whether this disease is almost unknown out of England. — Treatment. — Section II. Melanotic Growths of the Scrotum. — Paget's disease . 552-564 III. Non-Malignant New Growths of the Scrotum.— Angeio- mata. — Sebaceous cysts. — Other forms of cystic disease. — Hydatid cysts. — Urinary cysts. — Fibromata. — Fibro-myxomata. Sarcomata. — Chondromata. — Osteomata. — Lipomata . . . 565-575 IV. Scrotal Elephantiasis. — Causes of endemic and other varie- ties. — Symptoms. — Treatment. — -Lymph-scrotum. — Affinities. — Treatment 576-588 V. Scrotal Fistula and Scrotal Calculi .... 589-590 PART IV. DISEASES OF THE VESICULJ] SEMINALES. I. Anomalies.— Atrophy S91-592 II. Inflammatory Affections.— Causes. — Symptoms. — Treatment 593-600 III. Dilatation and Cysts 601-602 IV. Concretions 603-604 V. Tubercular Disease 605-607 VL New Growths 608 xiv CONTENTS. PAIIT V. DISEASES OF THE PENIS. Division I.— Abnokaiahties in Development. niAP. PACiF; I. Absence. — Apparent Absence 609-611 J I. Torsion 61 ? III. Congenital Adhesion to Scrotum 613-614 IV. Double Penis • 615-616 v. Congenital Fistula . . 617-618 VI. Abnormalities in Shape and Size 62c Division II. — Anomalies and Diseases op the Prepuce. I. Phimosis. — Development of the prepuce. — Symptoms. — Sequelte. Circumcision. — Sequelse. — Acquired Phimosis. — -Paraphimosis. — Complications. — Treatment. — Section II. Deficient Deve- lopment OF THE Prepuce. — Congenital absence. — Congenital Division. — Shortness of the frsenum 621-645 II. Section I. Dilatation op the Prepuce.— Section II. Prepu- tial Calculi 646-649- III. Inflammatory Affections of the Penis. — Section I. Chro- nic CEdema. — Section II. Balanitis. — Balano-Posthitis. — Varieties : Venereal, Gouty, Catarrhal, Croupous, Diph- theritic, Diabetic. — Section III. Herpes Progenitalis, or Preputialis.— Section IV. Cutaneous Diseases of the Penis. — Lupus. — Eczema 650-666 IV. Acute Inflammatory Affections.— Cellulitis. — Erysipe- las.— Lymphangitis 667-669 V. Inplaaimation of the Erectile Tissues of the Penis. — Caveenitis.—Penitis.— Gangrene.— Section I. Caverni- tis.— Penitis.— Section II. Gangrene.— Causes, General and Local. — Symptoms. — Treatment ...... 670-677 VI. Section I. Chronic Induration op the Erectile Tissues OF THE Penis.— Section II. Formation op Cartilage and Bone in the Penis 678-683 VII. Acute Gouty Affection op the Penis . . . . 684-6S5 VIII. Neuralgia op the Penis 686-687 IX. GUMWATA OP the PeNIS . . . . . . . . 688-689 CONTENTS. x^r CHAP. PACE. X. Tuberculosis of the Penis 690-691 XI. Diseases of the Vessels. —Section I. Affections op the Blood-Vessels. — Nasvi. — Varicose veins. — Section II. Pria- pism. — Causes. — Relation to leukaemia. — Symptoms. — Treat- ment. — Section III. Dilatation of the Lymphatic Vessels 692-699> Division III.— New Growths of the Penis. I. Elephantiasis . II. Innocent New Growths. — Section I. Sebaceous Cysts.— Section II. Angeiomata. — Section III. Horns.— Section IV. Papillomata 700-706 III. Malignant Diseases.— Section I. Epithelioma.— Modes of commencement. — Course. — Extension to lymphatics. — Visceral metastasis. — Causes. — Symptoms. — Diagnosis. — The pre- cancerous stage. — Treatment: i. Amputation. — (A) Flap method. — (B) Circularmethod. — Kemoval by the cautery.— Objections. — Question of castration after amputation of the penis ; ii. Ex- tirpation of the penis ; iii. Removal of inguinal glands.— Sec- tion II. Growths op the Erectile Tissues of the Penis : i. Primary sarcoma ; Melanotic sarcoma ; ii. Secondary or metastatic sarcoma ; iii. Secondary or metastatic carcinoma . 707-745, PART I. DISEASES OF THE TESTICLE. CHAPTER I. DEVELOPMENT AND TRANSIT OF THE TESTICLE. As many points of much practical importance in the diseases of the testicle and its annexa are only to be explained by reference to its development and transit,* a short account of the above will first be given. And here two questions call for some attempt at an answer — i. How is the transit of the testicle brought about ? ii. Why does this transit from the abdomen to the scrotum take place ? "Without going into needless details a short sketch of the transit of the testis f will be given here, those points especially being alluded to in which the early history of the testis bears upon its diseases later on. The testis, like the ovary, is developed from a mass of foetal tissue, the genital or sexual eminence^ which appears on the front and inner part of the Wolffian body. The growth of this eminence is so rapid that by the seventh week it has equalled in * As, with the ordinary position of the foetus in utero, the passage of the tes- ticle out of the abdomen is contrary to gravitation, I have followed Mr. Curling in not employing the usual term " descent." t The difficulties which beset the elucidation of this subject— viz., (a) the in- sufliciency of the supply of specimens, especially in regular sequence at early dates ; {Ij) the difficulty of clearing up important points in specimens necessarily so minute and with tissues so delicate ; (c) the fact that many of the specimens procurable are too decomposed and damaged to admit of examination — are well known. Mr. Lockwood {Hunt. Led,., 1887) investigated this subject by means of sections, both longitudinal and transverse, of embedded embryos and foetuses. For much of the following account of the development of the testicle I am indebted to his investigations, at once amongst the most recent and the most careful which we have, and the work of a Surgeon as well as of an Anatomist. A 2 DISEASES OF THE TESTICLE. bulk, and by the tenth become larger than the Wolffian body itself. As the sexual eminence develops the Wolffian body withers, and is converted into the epididymis. Before the tran- sition cf the testicle both this body, which is developing, and the Wolffian body, which is withering, lie in relation with the lower and outer part of the permanent kidney, which is developed be- hind and independently of the Wolffian body. It is very im- portant to remember that before the testicle starts in its transit these organs are already so low down in the abdomen that the distance of the testis from the external abdominal ring is exceed- ingly small (Lockwood, siq^ira cif.). Important changes now take place aflfecting the mobility of the testis. By the four- teenth day in the rabbit, and by the sixth week in the human embryo, the Wolffian body has a well-marked mesentery attached to the dorsal wall of the abdomen, and there is, as well, an obvious constriction between the Wolffian body and the genital eminence. This mesentery, ultimately the mesorchium or mes- ovarium, becomes increasingly distinct, and the genital mass is commonly fastened to it by a narrow neck. Before the actual passage of the testicle takes place through the abdominal wall, this organ has attained a position upon the brim of the pelvis, and almost in contact with the hypogastric arteries and the abdominal wall, by a gradual process of develop- ment of the adjacent parts. The events which seem to participate in leaving the testis upon the brim of the pelvis are thus given by Mr. Lockwood in their proper sequence : — ( i ) Development of the mesonephros ; (2) Development of the genital eminence ; (3) Development and growth of the kidney behind the mesonephros and the genital emi- nence; (4) Development and growth of the pelvis behind the lower end of the mesonephros; (5) Alterations in the upper part of the mesonephros — i.e., its partial atrophy and probable incorporation with the supra-renal capsule ; (6) Growth of the lumbar spine. I have ouly space here to consider those which seem to be of the greatest practical importance. For full details the reader should refer to Mr. Lockwood's interesting Lectures. Development of the Genital Eminence. — This has been re- ferred to above. Development of the kidneys behind the mesonephros and the genital eminence. The permanent kid- neys, developed independently of the Wolffian bodies, start behind the lower end of tliese, and quickly grow forwards until they lie behind the middle third of the Wolffian body, and consequently DEVELOPMENT OF THE TESTICLE. 3 opposite to the genital mass. Thus, as Mr. Lockwoocl points ont, it is wrong to speak of the testicle as developing in front of the kidney. The reverse is the case, as the kidney develops after the Wolffian body and genital mass, and behind them. Develop- ment and grovsrth. of the pelvis and spine, and th.eir relation to the kidney and testicle. The pelvis is developed in a mass of mesoblast opposite to the lower end of the Wolffian body, and the iliac cartilage grows upwards behind that organ. In a human embryo of the seventh week, examined by Mr. Lockwood, the main part of the genital mass was just below the kidney, and on a level with the iliac crest. But it must not be inferred from, this that any movement downward of the genital mass had taken place, its position here being explained partly by the growth upwards of the pelvis behind it, and partly, perhaps, by the lower part of the genital mass being about to take a greater share in the formation of the testis than the upper part. The growth of the lumbar spine. This is a factor to be taken into con- sideration in speaking of the influence which the growth of its surroundings may have upon the adjacent position of the testis. It is well known that the growth of the spinal column is so rapid that it far outstrips that of the spinal medulla. Mr. Lockwood observes that it is significant that whilst the spinal column, especially its lower part, is growing, the genital mass separates from the kidney. During this separation the kidney remains immobile, in front of the lumbar spine, and the sexual gland maintains its original relation to the pelvis, so that one important cause of the separation is, in Mr. Lockwood's opinion, the growth of the lumbar spine. While the testicle has, thus, by a gradual process of develop- ment and growth of itself and other parts attained a position on the brim of the pelvis, thus completing the first stage in its tran- sition — i.e., that of alterations in its position within the abdo- minal cavity — preparations are being already made, by the third month, for the second stage — i.e., the passage of the gland through the abdominal wall and its arrival in the scrotum. Chief amongst these preparations are the further development of the mesorchium, and of its ascending and descending processes — viz., the plica vascularis and the plica gubernatrix, the develop- ment of the gubernaculum, of the processus vaginalis, the cre- master, and, finally, that of the scrotum. Mesorchium, Plica Gubernatrix, and Plica Vascularis. — The mesorchium is a peritouical fold which unites the meso- 4 DISEASES OF THE TESTICLE. nephros, and afterwards the epididymis, to the back of the abdomen. At the third month it is prolonged upwards from the epididymis in a small triangular fold, and as this subsequently contains the spermatic vessels, Mr. Lockwood has called it the plica vascularis. The lower part of the mesorchium becomes continuous with a cord which, passing down outside the hypogastric arteries, ends in the abdominal wall. This cord is an early stage of the guber- naculum testis, and the downward prolongation of the mesorchium is the plica gubernatrix. This disappears below in a peritoneal pouch, the beginning of the processus vaginalis. The appearance of the mesorchium at about the end of the seventh month will be gathered from the accompanying sketch of Mr. Lockwood's (Fig. i). The base of the mesorchium was loosely fastened Fig. I. Drawing made from a seven or eight mouths" fcetus to show the fold (plica vascularis) which connects the testis with the ca3cum. T, Testicle, e, Epididy- mis. P, Psoas. V, Vas deferens. G, Plica gubernatrix, disappearing into the processus vaginalis. P Y, Plica vascularis. S, Spenuatic artery, i, Ileum. (Lockwood. ) along the psoas muscle, and its free edge ended upon the epidy- mis and testis ; its upper fold contained the spermatic vessels, and its lower the gubernaculum. Mr. Lockwood has pointed out* that the chief interest of the upper process of the mesorchium lies, at this age, in its adhesion on the right side to the caecum,, appendix, ileum, and mesentery, thus later on explaining its important bearing upon the pathology of congenital cascocele : on the left side it passes upwards to the sigmoid flexure.f * The " Morbid Anatomy and Pathology of Encysted and Infantile Hernia," Med. Chir. Trans., vol. Ixix., 1886. t According to Kocher [Kranlch d. Hoden. ; Pitha and Billroth, Handbh. d. Chir. § 1200), Treitz had already drawn attention to this important point. DEVELOPMENT OF THE TESTICLE. 5 In a foetus of the sixth or seventh month, Mr. Lockwood found that the pHca vascularis contained fibres of the gubernaculum in great abundance, these fibres probably reaching the above-mentioned organs, with which the plica is connected. It is by means of this connection of the fibres of the gubernaculum, through the plica vascularis, with the above viscera, that it comes about that when the lower end of the gubernaculum in a foetus of the seventh or eighth month is pulled upon, not only the testis and epididy- mis, but the above-mentioned viscera and the peritonaeum lining the back of the abdomen, glide down towards the inguinal canal and scrotum. But the production of hernia is not the only pathological condition in which the plica vascularis may play an important part. The causation of undescended testis is, in some cases, no doubt due to adhesions {vide infra, pp. 33, 39). Mr. Lockwood thinks that we may safely infer that these adhesions are sometimes not inflammatory, but, in reality, date to the plica vascularis, which has persisted to an unusual degree. Gubernaculum Testis. — This structure, first described by Hunter, is a compound one, containing the plica gubernatrix and the gubernacular cord. The former has been alluded to at p. 3. The latter is a fibrous structure, the nature and uses of which have been much disputed. While all are agreed that it passes upwards to be attached to the testicle, that it lies partly in the abdominal cavity, where it receives a peritoneeal covering ; that it passes through the inguinal canal to end outside, there is much diversity of opinion as to its structure, its lower attach- ments, the amount of muscular fibre in it, and how far it is capable of contraction, and thus how far it is potent in causing the transit of the testicle. It can first be made out in the human embryo at the tenth, and easily with the unaided eye at the twelfth, week. It gains its fibres from the different layers of the abdominal wall, thus possessing fibres continuous with the external spermatic fascia, from the external oblique, and the deeper muscular fibres of the abdominal wall. These last are by the seventh or eighth month distinctly striated. Thus, there is no doubt whatever of the muscular structure of the guber- naculum. Its iLfpc/r and lower attachments will next be men- tioned. Above, the gubernaculum is attached to the vas, the epididymis, and afterwards to the testicle as well. The import- ance of any failure of, or anomalies in, the development of these upper attachments of the gubernaculum and their bearing on 6 DISEASES OF THE TESTICLE. the non-transit of the testicle will be alluded to later (p. 40). Tlic attachmcitts of the guhernamilum helovj are also of much im- portance. They are numerous, but some are more transitory than others, and of less functional activity. ( i ) And amongst the earliest are attachments to the abdominal wall, the fibres of the lower end of the gubernaculum at the third month entering the abdominal wall, and interlacing with fibres descending from the external spermatic fascia and muscular layers. (2) Fibres, visible about the fifth month, attached to the pubes and root of the scrotum. (3) Fibres attached, in Scarpa's triangle, to the neighbourhood of the saphenous opening. Over-action of these fibres or weakness of others may explain crural ectopia of the testicle. This band is, according to Mr. Lockwood, transitory, being unrecognisable after the sixth month. (4) Perineal. These end in the neighbourhood of the anus (sometimes blending with the sphincter ani) and ischial tuberosity. They are often well marked, and have been met with not only in dissection, but also in infants the subjects of perinteal ectopia of the testis. The existence of these bands can be made known by the puckering of the skin near the anus when a testicle, the subject of perinseal ectopia, is pushed upwards, and by their requiring division before such a testicle can be transplanted into the scrotum (pp. 40, 91). (5) Scrotal. The remains of these fibres can be seen by the inver- sion of the scrotum which follows on any dragging of the testicle out of the scrotum in a child which is being operated on for radical cure of hernia. In later life, when castration is being performed, and the testicle is almost completely shelled out of the scrotum, the remains of these fibres passing to the fundus scroti still require division before the testicle comes away.* It is noteworthy that these lower attachments of the gubernaculum are not developed till a later date than the upper. Thus, at first the gubernaculum only reaches from the abdominal ■tvall to end above upon the testis and epididymis. Bramann showed (Arch, f. Anat. tind UnhvicJc, Hft. 3 and 4, 1884) that the guber- naculum had originally no attachment to the bottom of the scrotum by the fact that when the early gubernaculum is pulled * Kocher {loc. supra cit. ) thus describes the fate of this scrotal attachment of the gubernaculum. " The part which goes into the scrotum shrinks into a band-woven relic, which persists as a firm adhesion between the hinder and lower part of the testicle and the skin. The evidence of this may be ascertained in inflammation of the testicle, and in castration. " In one case of marked retraction of the testicle Godard observed a puckering in of the scrotum. DEVELOPMENT OF THE TESTICLE. 7 upon from within, the abdominal wall is raised up and dimpled, but the scrotum is not pulled up with it. With regard to the structure of the guhernaculum, which has been much disputed, it is, in its completer form, somewhat com- plicated, consisting, as it does, of a central cord of connective tissue, of muscular fibres derived from the abdominal wall, and of a tubular sheath of peritonaeum. The muscular fibres are, of these, the most important. They are probably of two kinds. Thus, fibres ascending from the innermost layers of the abdominal wall, along the guhernaculum, immediately below its peritonseal covering, were recognised by Hunter long ago in such animals as the hedgehog. In the human foetus their presence can be re- cognised at the third month, by the seventh or eighth they are abundant and distinctly striated. The existence of another kind of muscular fibres at an earlier stage has been made probable by Mr. Lockwood. Thus, he describes at the third month fibres with a decided likeness to unstriped niuscular tissue, and probably of that nature. The above brief remarks on the structure of the gubernaculum lead up to the question of its function, a question even more dis- puted than its structure. Many observers {e.g. , Prof. Cleland) have considered that in the descent of the testicle, the gubernaculum plays no active part ; others have thought that while it is in- capable of contracting, the shortening of its connective tissue in the later months of intra-uterine life may help in the descent of the testicle. Finally, others, like Mr. Curling, have held that the foetal gubernaculum corresponds to the cremaster of later life, and that it plays an important part in the passage of the testicle. Mr. Curling found that on laying open the inguinal canal and gently pulling upon the gubernaculum, its muscular fibres could be traced into three processes, each having a distinct attach- ment. The external or broadest is connected to Poupart's liga- ment in the inguinal canal : the middle forms a lengthened band, which, escaping at the external abdominal ring, passes to the bottom of the scrotum, where it joins the dartos ; the internal has a firm attachment to the os pubis and sheath of the rectus (Fig. 2). As the attachnients of the muscle of the gubernaculum and those of the cremaster in the adult are exactly similar, Mr. Curling entertained no doubt of the identity of the two muscles. He lield that the fibres proceeding from Poupart's ligament, and the internal oblique, tend to guide the gland into the inguinal canal ; those attached to the os pubis to draw it outside the abdominal 8 DISEASES OF THE TESTICLE. ring; and the process extending to the bottom of the scrotum, to direct it to its final destination.* In the transit of the testicle to the bottom of the scrotum, the gubernaculum, including its Fig. 2. This and the next figure show Mr. Curling's viows on the cremaster. Diagram to show the relations of the cremaster before the descent of the testis. I, The kidney. 2, The testicle. 3, 3, The peritonasum. 4, Vas deferens passing dowu into the pelvis by the side of the bladder. 5, The bladder. 6, The abdominal ring. 7, 7, Poupart's ligament. 8, Pubic portion of cremaster. 9, Pibi'es of cremaster ai-ising from Poupart's ligament. 10, Portion of the gubernaculum attached to the bottom of the scrotum. (Curling. ) peritoneal investment and muscular fibres, undergoes the same change as that which takes place in certain of the Rodentia at the access of sexual excitement, its muscular fibres being gradually Fig. ^. Diagram of the testicle immediately after its arrival in the scrotum, the cremaster being everted, i, The testicle. 2, The shortened gubernaculum. 3. 3> The peritonseum. 4, Portion of the cremaster arising from Poupart's liga- ment. 5, Pubic portion of the muscle. (Curling.) everted, until v^hen the transit is completed it forms a muscular envelope external to the process of peritoneum which surrounds the gland and front of the cord. They are thus enabled to acquire * Kocher is in agreement with Mr. Curling as to the existence and function of these three lower attachments of the gubernaculum. Mr. Lockwood holds a somewhat different opinion as to their action. He considers that the scrotal attachment is not powerful enough to draw the testicle into its final resting- place, and thinks that it is by means of its well-attached perinaeal fibres that the gubernaculum is able to effect its purpose, the scrotal band merely influencing the final position of the gland. DEVELOPMENT OF THE TESTICLE. 9 the new functions of elevating, supporting and compressing the gland. It v/ill be seen that the chief points in favour of the guberna- culum playing an active part in the transit of the testicle are its undoubtedly muscular structure, the fact that its lower fibres are attached in regions — viz., the perinaeum, &c. — into which the testicle is occasionally displaced, and its analogy with the cremaster in many of the lower animals. The processus funiculo-vaginalis. — This is the pouch of peri- tonaeum which paves the way for the passage of the testis before this organ makes its start,* eventually becoming the parietal layer of the tunica vaginalis. The exact date of its appearance is uncertain. Mr. Lockwood thinks that a dimple in the peri- tonaeum at the lower end of the plica gubernatrix, found in a foetus of the sixteenth week, was the early stage of the processus.! In a foetus of the fifth month, Mr. Lockwood has found the process to be a funnel-shaped canal, wide above and pointed below, ending at this date in the midst of the muscular fibres of the internal oblique and trans versalis. Later on, when it has descended lower it becomes more capacious below. The same authority believes that this process is produced from without by the traction of the gubernaculum which is attached to it, not by any force acting from within the abdomen. Later on, when the processus funiculo-vagiaalis closes, this commences at two spots near the internal abdominal ring, and just above the testicle. Obliteration commences at the former spot first and descends, and a little later above the testicle, the change ascending, until nothing- is left of the peritonseal vaginal process save a fibrous cord ; which continues to shrivel, and the detached lowest part of v/hich per- sists as the tunica vaginalis. The Cremaster. — While the anatomy of this muscle, its attachments externally to Poupart's ligament, and internally to the pubes, with its intermediate loops descending on the cord or even on the testicle, is agreed upon, its origin is still disputed. * That the formation of the funiculo-vagmal canal is independent of the migration of the testicle is shown by the fact that the canal may exist, though the transit of the testicle may not have taken place. Bramann (Arch. f. Jilin. Chir., March 1890, Ed. xl. S. 157) proved the existence of the canal in five crypt- orchid infants. Again, though the testicle may not liave migrated, the vas deferens may have passed in front of it along the above canal, and be found in the scrotum. t Kollikor and Bramann say that the process begins at the third month, and Weil at the end of the second. lo DISEASES OF THE TESTICLE. On this point there are two main views. ( i ) That the cremaster is formed out of the striped muscular fibres which ascend upon the gubeinaculum from the abdominal wall. This view origi- nated with Hunter, who saw these fibres in the ram become inverted when the gubernaculum was seized beyond the abdomi- nal wall and pulled downwards. Mr. Lock wood considers that while these ascending fibres may help slightly to draw the testicle down, the ascending cremaster in the human embryo is so trivial, that perhaps it ought to be looked upon as a mere survival of a muscle, more active and better developed in some of the lower animals. (2) With regard to this view that the cre- master is an appendage of the internal oblique which is displaced downwards to the scrotum by the testicle in its transit, the above authority considers that it is not borne out by his section- specimens. The cremaster develops long before the transit of testis, and indeed before the funiculo-vaginal processus has appeared. Towards the end of the seventh month of intra-uterine life, this process is so far ahead of the testicle tliat it must have anticipated it in any action that the testicle might have had in carrying down the cremaster. It would be more rational to attribute the formation of the muscle to the gradual advance of the peritonaeal pouch rather than to that of the sexual gland (Lockwood). The Scrotum. — Of the two apertures in the foetal perinseum, the anterior or urogenital one, situated below the rudimentary penis or clitoris, as the case may be, has on either side of it a fold of skin. If the sex prove female these folds remain separate, the labia majora, but if a male be developed they fuse along a median raphe to form the scrotum. This takes place between the third and fourth months, the scrotum being thus formed long before the transit of the testicle is accomplished, and quite inde- pendently of it. The chief structures concerned in the migration of the testicle having been considered, it remains to recapitulate briefly the causes of this migration and the points of practical importance which may result when this migration is prevented or irregular. We have seen that the testicle is developed in the lumbar region on the inner side of the Wolffian body or primitive kidney. This position it occupies for about three months. By the tenth week the genital mass is actually a testicle, the tunica albuginea and tubuli seminiferi having appeared, and this organ, together with the Wolffian body, or, as it is becoming, the epididymis, lie CAUSES OTF THE TRANSIT OF THE TESTICLE. ii just below the kidney,* and upon the venter of the iliac cartilage. It will be at once recognised that the testis is from the first placed much lower down, and that thus the distance which it has to traverse in its migration is, to begin with, less than is usually- realised. At the twelfth week the position of the testicle is about the same, but its mesentery is now longer and more developed. During the next few months complete and exact evidence as to what happens to the testicle is not at hand, but while it is probable that it undergoes little change itself, it is certain that its other surroundings are undergoing marked development, and that important structures — e.g., the gubernaculura, funiculo- vaginal process, &c. — concerned in the transit of the testicle and its final reception when the transit is completed, are growing rapidly. The exact date of the entrance of the testicle into the inguinal canal is not yet known. At the end of the sixth, or during the seventh, month it traverses this region, from the seventh to the eighth month it reaches the external abdominal ring, and by the end of the eighth, or during the ninth, month the testicle has usually reached the bottom of the scrotum. Causes of the Transit of the Testicle. — While these are sti^l matters of controversy, and while no wholly satisfactory explanation of the transit has been given, it is most probable that the following may be assigned as the most important factors : — 1. The original position of the testicle is very low down to begin with. 2. The unequally rapid growth of certain of the surround- ings of the testicle, which bring about concomitant changes in the position of the gland itself — e.g., the growth of the lumbar spine, and that of the iliac part of the pelvis in an upward direction (p. 3). 3. Possibly pressure exerted by some of the adjacent vis- cera. Thus, Bramann considers that the fact that the left testicle is a little the first to start is due to the pressure of the expand- ing sigmoid which is gradually filling up with meconium. 4. The Gubernaeulum. — After what has been already stated it must be sufficient to say here that it is only rational to believe that this structure plays an important part in the transit of the * The separation of the testicle below from the true kidney above is in part brought about by the growth of the lumbar spine {vide supra, p. 3), the dcvclop- rnoiit of the kidney, and that of the pelvis. 12 DISEASES OF THE TESTICLE. testicle. Thus, muscular tissue, both striped and unstriped, and con- nective tissue are here present.* Above, it is attached to organs — e.g., testis, epididymis, and vas deferens, which do descend normally, and occasionally to others — cjj., peritoneum and intestine (Fig. 7), v^hich may descend abnormally in hernia. Below, it is attached on either side of the external ring (to the pubes and to Poupart's ligament), through which the testis passes, and, lower still, though this has been much disputed, to the fundus scroti. While the above are the normal attachments of the gubernaculum below, it has other attachments, some of which are occasionally well de- veloped {e,.g., in the perinteum) in places to which the testicle is occasionally found to pass abnormally. Again, there is the fact that if traction be made upon the gubernaculum in a foetus in which the transit of the testicle through the abdominal wall has not begun or is not yet completed, the testicle will be seen to move in a downward direction. 5. The presence, ready prepared, of a passage with, smooth walls, the funiculo-vaginal process, the open mouth of which is situated close to the testicle before it passes out of the abdo- men, and the lower end of which reaches into the scrotum. The presence of this structure, as it were, invites the testicle to change its position from an intra- to an extra-abdominal one, and it must require the exertion of very slight force, whether traction from below or pressure from or changes in the surrounding struc- tures above, to start the testicle thus situated. And the very slightness of these forces probably accounts for the comparatively long time taken — from the end of the sixth to the ninth month — in the completion of the transit of the testicle. 6. Before leaving the causes by which this transit is brought about it is right to add that the ones above given acquire some negative value owing to the weakness and inadequacy of the other factors which have been advanced. I have only space to refer to some of these, (a) The weight of the testicle. Prof. Sappey (Anat. Dcscript., torn. iv. p. 584) dismisses this owing to the minuteness of the organ, which is only 3 millimetres in dia- meter, and because, as he says, if it acted at all tliis factor ought to have kept the testicle in the abdomen, as the pelvis is usually the highest part of the foetus. (/3) Contractions of the abdo- * How far the action of the gubernaculum is due to the contraction of its smooth or striped muscular fibre, and how far to its connective tissue becoming- shortened, when fibrous, is uncertain. CAUSES OF THE TEANSIT OF THE TESTICLE. 13 minal muscles and diaphragm, of which proof is entirely wanting, (y) The view of Prof. Carus, according to which the testicle in some mysterious way had the power of making way through the abdominal wall by depressing some of its layers. This theory, which, in Prof. Sappey's words, makes the testicle move with the power and after the fashion of a projectile, is purely specu- lative, is based upon no proof, is contrary to the researches of Hunter upon the gubernaculum, and he might have added, takes no account of the fact that the testicle finds a canal ready developed for its transit and with its upper opening placed close to it, and, as it were, inviting it to enter. (S) Finally, there is the view of Mr. Bland Sutton * that the descent of the testes is in every respect to be regarded as a hernia of those bodies, and that in the first place it probably originated as such, thus coming into the category of inherited pathological conditions. While it is extremely difficult to criticise the observations of so brilliant and experienced an observer as Mr. Sutton, I am obliged to dissent from the arguments which he advances in favour of the above view. The following are the chief reasons which induce him to " regard the descent of the testicles as of the nature of a perpetuated hernia " : — ( 1 ) " They leave the abdomen at a region where hernia would be most likely to occur — viz., at points of least resistance." Now while it is probable that the foetal testicle finds a weak spot ready for it to leave the abdomen (vide supra, p. 1 2), it seems to me that there is no real comparison between a testicle which, submitted to gentle coaxing pressure by the parts around, and also gently pulled upon from below, finds at this spot a weak place and a smooth-walled pouch ready to hand for its transit, and a piece of intestine or omentum forced out later on in life, either after repeated straining, or because the peritonseal process is imperfectly obliterated, and the abdominal contents are now sub- mitted to such constant strains as those entailed by crying, &c. (2) " The more erect the posture assumed by the animal, the greater is the liability to hernia. Hence, mammals, like the kangaroo, monkeys, &c., present descended testicles, whilst in mammals which habitually maintain the horizontal j)osition, like the monotremata, porjjoise, &c., the testicles are renal in position." I do not know whether in the above use of the word " hernia," Mr. Sutton refers to hernia of the testicle. But certainly hernia, * Introduction to General Patlioloyy, p. 374. 14 DISEASES OF THE TESTICLE. in its actual sense — i.e., protrusion of intestine or omentum — is by no means unknown in animals which usually " maintain the horizontal position " — e.g., the dog and horse. (3.) "Hanging by the mesorchium, pendulous in the body cavity, the testicles are in the most favourable position possible to become herniated in all conditions involving increased strain on the abdominal position." To this I should reply, that while it is probable that in some cases the foetal testicle is thus pendu- lous, I believe that such a condition is usually met with in testes which have not left the abdomen, that it is not present as a rule judging from dissections and other means of investigating the foetal testis. Again, there is no reason whatever to believe that the foetal abdomen is ever "in conditions involving increased strain on the abdominal parietes," at least before parturition, and by this time the testicles have usually reached the scrotum. (4.) "Descended testes are certainly not an advantage to the animal ; perhaps the reverse of this is true." I have later (p. 18) tried to show that while this may be true of most animals, it is not so in the case of man. The diJBEerent pathological conditions -which may foUo-w on deficiencies or errors in the development and transit of the testicle, — To enumerate these, we must go back to an early date, for while the most important abnor- malities follow on the second stage of the migration of the testicle, especially on its passage through the abdominal wall, there are others connected with the first stage, while the testicle is stationary within the abdomen, and others earlier still, which are explained by its development while it is still in relation with the Wolffian body. And at this point it may be convenient to give the following list* of the various structures which are more or less connected in their development with the Wolffian bodies. In the Male. In the Female. The genital mass . ^^^^.^^^^ becomes I Epoophoron of Wal- deyer. Parova- rium of Kobelt. Organ of Eosen- m tiller. * The first part of this is given by Mr. Lockwood. Wolflaan body be- ] Epididymis and its comes — y vasa efferentia or A. Its sexual part j coni vasculosi. PATHOLOaiOAL SEQUELS OF DEVELOPMENT. 15 B. Its urinary part In the Male. A. Paradidymus oi\ Waldeyer, or organ of Giral- des. B. Vasa efferentia. In the Female. Paroophoron of Wal- deyer. Wolflaan duct becomes 'Almost entirely dis- Vas deferens. Eja- appears. In some culatory Duct. Ve- animals it per- sicula seminalis. I sists as duct of Gaertner. Duct of Muller ^Almost entirely dis- appears. A trace persists as the hydatid of Mor- gagni. Another part forms the prostatic vesicle. Fallopian tube. Va- gina and uterus. 1 . Fusion of the Testicles : Synorchis. — An instance of this exLremely rare condition in which not only the testicles retained in the abdomen, but also the kidneys and the supra-renal capsules were fixed together in the middle line, is recorded by Cruveilhier (Traits d'Anat. Path. G4n.^ t. i. p. 301). Mr. Lockwood {loc. supra cit. p. 50) met with one instance in a human embryo, at about the fifth week of intra-uterine life, in which, while the upper ends of the Wolffian bodies and the genital eminences were normal, the lower ends of the former bodies were fused together in the middle line. He considered that if this foetus had come to maturity, the testicles must have become fused together also. 2. Persistence of Foetal Relics. — It will be seen later on (Encysted Hydrocele), that at or near to the same spot where encysted hydroceles occur with especial frequency — i.e., in the neighbourhood of the head of the epididymis — we have the three following relics of foetal structures. This fact, together with the frequency with which cysts arise in this neighbourhood, makes it very probable that encysted hydroceles sometimes originate in enlargement of hitherto quiescent foetal relics, (a) Vestiges of the duct of Muller persisting as the hydatid of Morgagni. (/3) Vestiges of some of the urinary tubules of the Wolffian body forming the organ of Griraldos. (y) liemains of i6 DISEASES OF THE TESTICLE. some of the above same tubules persisting as the vasa aberrantia of Haller.* 3. Conditions Associated with the Mesorchium, and its two parts, the Plica Vascularis and the Plica Gubernatrix. — Over-length and looseness of the mesorchium may perhaps keep the testis loose in the abdomen and so prevent its entering the inguinal canal. And the same result may be brought about in a different way by adhesions resulting in some cases from foetal peritonitis, in others from the existence of persistent and im- peding relics of the plica gubernatrix, 4. Conditions Associated with the Gubernaculum. — These may be (ct) imperfect development of this structure, and, espe- cially, in all probability, deficiency of its muscular fibres. (&) Im- perfect attachment of the upper fibres of the gubernaculum to the testicle, epididymis, and vas deferens. Thus, all these upper attachments may be wanting, or those to the epididymis and vas deferens may be present, but not those to the testicle. Thus, while the latter remains in the abdomen, the two former may be moved down towards or into the scrotum, (c) The upper attachments of the gubernaculum into the peritonaeum and to certain viscera — e.g., the csecum — may, as pointed out by Treitz and Mr, Lockwood, bring about by traction hernial sacs, and such hernia as csecoceles.t (d) The lower attachments of the gubernaculum. Deficiency of these, especially the scrotal, may prevent the full migration of the testicle. On the other hand, over-development of some other of these lower attachments — e.g., the perineal — may land the testicle in abnormal sites. 5. Imperfect Development of the Inguinal Canal and the External Abdominal Ring. — This is supposititious only. 6. Won-development of the Scrotum. 7. Conditions Associated with the Puniculo -vaginal Pro- cess. — If this be deficient the paving of the way for the migration * Luschka (Virchow, Arch., Bd. vi. S. 310) having found this vas aberrans con- verted into a cyst, suggested that it might occasionally form an encysted hydro- cele. Mr. Lockwood {loc. supra cit., pi. ii. fig. 36) figures a very interesting specimen in which four such vasa aberrantia were present. t Mr. Lockwood points out that this condition will be helped by the fact that there is much difference in the degree of closeness with which the peritonaeum is attached to the anterior and posterior wall of the abdomen. Thus, to the anterior wall the peritonseum is bound so closely as to be incapable of much displacement or of taking part in the formation of hernial sacs. To the posterior wall, on the other hand, the attachments of the peritoneum are much less -close, and being underlaid by abundant loose areolar tissue and fat, are easily displaced and thrown into folds. EXPLANATION OF TRANSIT. 17 of the testicle will be much interfered with. So also, later on, imperfect obliteration of it may lead to congenital or infantile hydrocele, hydrocele of the cord, and to different forms of hernia. The fact that this process comes down independently of the testicle also explains the fact that a hydrocele may exist below, while the testis is retained above. 8. If tlie sub-peritonseal fatty tissue which, aceompanies the funiculo-vaginal process towards the scrotum persist, it may develop, later on in life, into the well-known lipomata of the cord.* (ii) Why does the Testicle pass out of the Abdomen ? — When we consider that this seems to favour hernia, by leaving a weak spot, and exposes the testicle to injuries which it would have escaped, if, as in other animals, it had remained in the abdomen, we may be sure that there are excellent reasons for its transit. They are chiefly two, and are connected with (A) its diseases in man, and (B) its functions. But before I speak of these, I would point out that the extent to which the transit of the testicle in man favours the production of hernia and exposes the organ to injury is apparent rather than real. We certainly see congenital hernia and infantile hydroceles frequently enough in the children of the poor, and it is impossible to deny that the weakly or imperfect closure of the congenital canal does play a part in predisposing to the production of hernia. But it is very seldom that this alone is responsible. Other causes, and more powerful ones, are also present — e.g., premature birth, by which in- sufficient time has been given for perfect development, injudicious feeding giving rise to intestinal disturbance, liability to catarrh of the respiratory organs, producing cough thus early, and constantly taxing the closure and obliteration of the parts concerned in the transit. Phimosis, again, is another very common cause of hernia-production in these children, and one frequently over- looked. So, too, witli regard to the risk of exposure to injury which the extra-abdominal position of the testicle entails, this again is far more apparent than real. In the first place, while inflam- mation of the ejjididymis and testis from urethral causes — e.g., gonorrhfjea — is very common, traumatic inflammation of the testis * This subject will be found treated under Part II. Diseases op the Cord. See also a paper in the Patholorjical Society's Transactions, vol. xxxvii. j). 451, by Mr, J. Hutchinson, jun. B 1 8 DISEASES OF THE TESTICLE. is infinitely rare. To meet injuries, there are certain especial pro- visions made. (i) The mobility of the testis, from its pendent position, and serous membrane. (2) The position of the testis, one being at a lower level than its fellow, so as to slip readily beneath it, out of harm's way, as in the frequent action of cross- ing the thighs. (3) The contractile power of some of its cover- ings — e.g., the dartos and cremaster. It has been stated above that the reasons of the transit of the testicle in man are mainly two. (A) Those connected with its diseases, and (B) Those which go hand in hand with the peculiarities in the structure and functions of the organ. (A) The transit of the testicle in man certainly anticipates the frequency of certain diseases of this organ in him. I have only space to allude to two especially — viz., acute inflam- mation and tubercular disease. With regard to the most frequent form of inflammation, gonorrhoeal or urethral epididymitis, it is easy to see what would have been the results if the testis had remained in the abdomen, no longer easily got at, with such surroundings as the peritonaeum. The rapidity with which acute pain, swelling, redness, and the implication of the scrotal tunics follow, all point to what would have happened ; and if there were any doubts on this point they would be removed by the case at p. 62, in which a retained testis was the cause of fatal peritoneal inflammation, set up by an injury. So, too, with regard to tubercular disease. With the organ situated externally, we are able to attack small deposits with a sharp spoon, and when the disease is more extensive we are able to give much, and sometimes permanent, relief by castration. It is easy to see how different would have been the results if the testicle had had its permanent home behind and close to the peritonaeum, say in the iliac fossa. The softenings of tubercular deposits, the formation of adhesions to neighbouring parts and viscera, would have borne a very different aspect. We should have had to face a fresh and graver source of peritonitis, and the testis would now have been a starting-point of as grave and as often fatal mischief as the vermiform appendix. The above argument, that the transit of the testicle is of obvious advantage to man, in that it allows diseases of these organs to be more efficiently dealt with, has been criticised by a very brilliant writer, Mr. Bland Sutton, on the following grounds {Introduction to General Pathology, p. 375) : " It is a weak argu- ment, for the same line of reasoning would apply to the kidneys, EXPLANATION OF TRANSIT. 19 the lungs, and other viscera." To this argument I would reply, that where certain special conditions make such a position desirable, the lungs or their equivalents are found more externally placed. In man alone certain diseases are found very frequently to attack his testicles or their appendages, and therefore these organs alone are found, in the normal condition, permanently outside his body ; certain disadvantages which this position entails being largely, at all events, made up for by certain definite pre- cautions to which I have already drawn attention. The extra- abdominal position of these organs is by these means rendered compatible with long and healthy life, a result which certainly could not have been secured if the other organs referred to by Mr. Sutton had been outside man's body. The kidney, no doubt, is liable to acute inflammation, but more rarely than the testicle, and in a form far more amenable to medical treatment, and far ' less liable to spread to other parts than we have reason to believe would be the case with acute inflammation of the testis if this organ had also been, all life long, intra-abdominal. With regard to the disadvantages which the transit of the testicle entails, I have not made light of them, but I have pointed out how, in fact, these disadvantages — that of exposure to injurv, for instance — are met. With regard to other disadvantages, man, no doubt, by the position of his testicles, is rendered liable to hydrocele and haematocele, while other animals are, by the intra- abdominal position, rendered free of the risk of such diseases. But with regard to this point it must not be forgotten that man is, from his habits, less liable to the above diseases than animals would have been, and that he alone is able to secure efficient treatment for such affections when they occur. Such a sentence as, " Carefully considering the evidence, those animals with the testicles lying normally under the kidneys are in a more satis- factory condition than those having the organs normally lodged in the scrotum," entirely, I think, loses sight of the fact that with this particular position in man goes his liability to certain special disorders of his testicles. So far we have been concerned with the pathological argument. (B) Prof. Cleland pointed out that the structure and function of the testicle supply another argument for its extra- abdo- minal position. Thus, he believes that tlie scrotal site, the .pendent position, and the arrangement of the blood-supply to the testicle, are all associated with the fact that the testicle is the most complicated of all glands, its secretion the most elaborate. 20 DISEASES OF THE TESTICLE. and, a further point, that its secretion is not always to be made use of, but only to be discharged, and that rapidly, at somewhat uncertain periods. JSTow, surrounding the testis we have the dartos and cremaster muscles, and the tunica albuginea, that dense tough capsule, which, like the sclerotic, is protective, while allow- ing of very little expansion. Further, the vessels are peculiar as well as the tunics — viz., a long artery which is said by some not to diminish in diameter as it descends, and then, with its branches, becomes tortuous. The veins, too, are large and numerous, and without valves, or only imperfect ones. Now, from its pendulous position, the free arterial supply, and the fact that the venous current is slow (the veins having no valves, and being weakly supported), the testicle structure is almost, as it were, in a bath of slowly moving blood, slow from the tortuous artery and its branches, and the condition of the veins. If this be so, there must be some arrangement to meet the trouble that would arise from the constant collection of seminal fluid resulting from this hath of blood. This is afforded by the structure of the tunica albuginea. From its density and want of elasticity it can expand but little, and so admits but a limited amount of fluid at a time. Thus, when the seminal tubules are full there is no more room, and no more blood can get in, and thus no more secretion can take place, the seminal fluid, if not required, being partly absorbed in 'situ, and partly along the vas deferens. If, on the other hand, the tubules are empty, the pendent position and the arrangement of the blood-supply of the testis allow of the blood rapidly filling the vessels, and thus the testis is best disposed for fresh secretion. If the testis had been in the abdomen the loose pendent position, on which much of the peculiarity of its blood supply depends, would have been impossible, as the testicle would have been liable to be caught up by, and entangled in, coils of intestine. ( 21 ) CHAPTEE II. CONGENITAL ABNORMALITIES AND DEFECTS OF THE TESTICLE AND ITS ANNEXA. Just as t-wo complete stages, Development and Transit are included in the early history of the testicle, so two distinct groups of anomalies, those connected Avith its development, and others -with its transit, have to be considered. How closely the above ; two stages are related is shown by the fact that any fault in the development of the testis will interfere with its migration, and, inversely, a faulty transit must of necessity prevent the proper development. Congenital Anomalies of the Testicle. , K T . fin excess. Polyorchismus. ( Anomalies m J ,., a i,- , I T J c • I Absence. Anorchismus. A. Anomalies in ^^^^'"- ^^^ ^^^^^^^^^-j Fusion Synorchismus. Development. Anomalies in f In excess. Hypertrophy. \ size. [in deficiency. Atrophy. /^ At some point of its normal course. / Testicle undescended. J ^ Retention. _ Trf^+r.TM"Q Outside its normal course. B. Anomalies in) Ectopia. y Ectopia. Migration. testicle descended. *■ Inversion. (Monod and Terrillon, p. 2.) Section I. ABNORMALITIES IN DEVELOPMENT. Supernumerary Testicles. Polyorchismus. — The instances given of these are unreliable. Thus, in every* case in which an " additional testis " has been submitted to careful * Perhaps an exception must be made here for the case which Blasius ( Ohn. Anat. Prod., 1674, PI. vi. Fig. 8) has recorded as one of "testis triplex." Here two testicles are described and figured as having been found, post mortem, on the right side. On this side arc; two spermatic arteries and veins : on the left these vessels are single. It is impossible to juake out from the jjlate whether the testicles had ever descended. The description is extremely short. No mention 22 DISEASES OF THE TESTICLE. test — i.e., during life by operation, e.g., tapping, or after death by dissection — its existence has been explained by some well-known pathological condition. Thus, it has been found to be an encysted hydrocele,* an omental hernia,t a fibrous tumour of the cord or tunica vaginalis.l In the verification of these conditions, the absence of testicular sensation,§ and the facts that no cord can be traced to them, and that they are not congenital, are the best guides. However closely a body in the scrotum may seem, in size, shape, and sensi- tiveness, to correspond to an additional testis, it must not be accepted as one unless operation or an autopsy allow an oppor- tunity of complete investigation,] | including the use of the micro- scope. In some a bifurcation of the vas deferens has been appa- rently made out.lF This is probably fallacious. It is noteworthy that Mr. Curling, in his examination of a patient supposed to have is made of the vasa deferentia, and we have, of course, no microscopical examina- tion. As is so frequent in the descriptions of these cases by the old writers, the subject of this abnormality is said to have been " valde libidinosus." * This, from its rounded outline, and its close connection with the testis, may be mistaken for a small additional testis. Some years ago a man presented himself at my out-patients at Guy's Hospital as " the man with three testicles." The third testicle was here an encysted hydrocele, and disappeared on tapping. ■f Even Morgagni was deceived by a piece of omentum " which had descended into the scrotum wrapped up in its proper sacculus of peritonaeum," and had the candour to allow it. (Seats and Causes of Diseases, vol. ii., "Dis. of the Belly," P- S45-) t In the Museum of St. Thomas's Hospital is a specimen showing that the body supposed during life to have been a third testicle is really a fibrous tumour attached to the tunica vaginalis. § Not even this is decisive. Thus, I have twice had patients with encysted hydroceles who, owing to the intimate connection of the hydrocele with the testis, spoke of testicular sensation being present in the swelling. II Thus, in the cases of supernumerary testicle recorded in the Lancet, 1865, vol. ii. pp. 448, 473, 501, there is no proof beyond that of external examination. So, too, with the three cases of polyorchismus recorded Lond. Med. Record, 1884, p. 170 and Oct. 1881. They appear to have been met with in Bulgarian and Russian soldiers. In the first, it was thought that two testes, one lying above the other, were present in the right half of the scrotum. In the second, two testes were made out in the left scrotum, each appearing to have an epididymis and cord. In the course of a gonorrhoea the patient had left epididymitis, which only attacked the lower of the two testes. The patient stated that the upper left testicle descended when he was eight. In the third case, four testes are said to have been present in a normally developed scrotum. ^ Thus, in a case of Dr. F. Hewett's, in which two testes were thought to be pre- sent on the left side, it is stated that " the vessels, &c. of the two glands on the left side united to form a single spermatic cord above the smaller gland, in which, on manipulation with the fingers, two of its constituents, of firmer feel and structure than the rest, could be isolated, being most probably the deferent ducts of the glands." ABN0RMALITIES IN DEYELOPMENT. 23 two testicles on the right side, the lower of which proved to be an encysted hydrocele of the testis, found that " something like a vas deferens even could be traced to the lower tumour, but compres- sion of it produced scarcely any uneasiness." One fallacy must always be remembered, and that is, that the structures in the cord may sometimes be easily separated into two bundles, one formed by the spermatic vessels, the other by the vas deferens and its artery. In cases where the penis is double the number of the testicles is not increased. While there is no case of supernumerary testicles in man, which, having been submitted to the necessary tests, can be con- sidered absolutely reliable, it would appear probable from Com- parative Anatomy that such a case may in future, though very rarely, be verified. Thus, veterinary surgeons, when castrating calves and colts, occasionally meet with this condition. Anorchism. Monorchism. Absence of one or both Testicles. — These conditions, though more frequently met with* than the preceding one, are rare. Several possible fallacies must be remembered before an apparent instance of this anomaly can be accepted as such. Thus, retention of the testicle, imperfect development, and extreme atrophy of the gland, have all been described as instances of its absence. Cases diagnosed on the living, without the confirmation of an autopsy, are subject to suspicion. But it is not only the above fallacies, and mistaking apparent for real absence of the testicle, which have led to errors, but further confusion has arisen from forgetting that with absence of the testicle may co-exist absence of parts of its annexa and excreting apparatus, or these may be present and the testicle itself absent. Accordingly, this will be the most convenient place for describ- ing other deficiencies in the seminal apparatus, which may occur either independently of, or together with, anorchism or mon- orchism. The following varieties have been thus classified by i'rench writers : f I. Absence of the Testicle only. 2. Absence of the Tes- * Thus, Gruber, of St. Petersburg (Zeitsch. der Jc.Jc. Gesellschaft. der Aertze in Wien; Ciiniita.tt's Juhresbericid, 1868), has collected 31 cases. In eight of these the absence of tlie testis was bilateral. t MM. Gossolin and Welther, Nouv. Dkt. de, Med. et de Chir. Fred., t. xxxv. Monod and Terrillon, p. 6. 24 DISEASES OF THE TESTICLE. tide, the Epididymis, and a portion, more or less extensive, of the Vas Deferens. 3. Absence of the Whole Apparatus. 4. Absence of all or part of the Excretory Apparatus, the Testicle being present. 5* Bilateral Anorchism. As the testis and epididymis are looked upon as forming a single organ, it might naturally be supposed that, if the testis were absent, its excretory duct would also be wanting. This is not always so. When it is remembered that, at a certain period of embryonic life, the epididymis and testis are developed separately, it is easy to understand that only one of the two structures may be absent. 1. Absence of the Testicle only. — This is explained by the original independence in development of the testis and epididymis. Four or five cases have been recorded. The testis being absent the vas deferens is found to end in a small body, more or less closely resembling an epididymis. In most of the cases the epididymis has been met with in the scrotum. In one, a foetus of four months, a case of Godard's, the right testis was retained in the iliac fossa ; on the left side the testicle was entirely want- ing, the seminal apparatus commencing here in the epididymis, which, with the vas deferens and vesicula seminalis, was normally developed. Traced in the other direction, the vas has been found to run a usual course and end in a vesicula seminalis. In adults this contains mucus devoid of spermatozoa. 2. Absence of the Testicle, the Epididymis and more or less of the Vas Deferens. — This variety, much the most common, includes the greater number of the cases described as unilateral anorchismus. The portion of the vas deferens which persists presents itself as a cord which, starting from the vesicula seminalis, loses itself in a thread-like extremity in the neighbouring connective tissue, at a varying distance from its starting-point. In extreme cases, the vas ends close to the vesicula seminalis, the latter being in these cases remarkably small and atrophied.* More frequently, the vas deferens can be traced for a varying extent along its normal course between the vesicula seminalis and the scrotum. Thus, it has been found to end at the point * Cruveilhier, TraiU d'Anat. Path. G6n6r., t. iii. p. 24 ; TraiU cVAnat. Descr., 5th ed. t. ii. p. 358 ; Denonvilliers, quoted by Godard, Becherch. Teratol. sur I'Aj}- pareil Seminal de I'Homme, i860, p. 35 ; and Etude -far V Absence Congenitale du Testicule. Time de Paris, 1858, p. 39. ABKOHMALITIES IN DEVELOPMENT. 25 where it crosses the ureter * at the outer inguinal fossa of the periton8eum,t at the level of the external inguinal ring.J Lastly, in one case, the vas has been found to pass through the external ring and to end in the superficial parts after the manner of the round ligament. § In all these cases the scrotal part of the seminal apparatus was wanting. The part of the vas deferens present is usually normal in size and permeable to injection. The vesicula seminalis (as pointed out by Godard, merely a dilatation of the vas deferens) is only wanting when the terminal part of the vas is itself deficient. In otlier cases it has been the opposite end of the vas deferens, which, together with the testis and epididymis, has been wanting. Thus, in a case of Godard's {loc. 8wpra cit.), the testicle and epididymis were absent, the vas deferens began in the scrotum as a blind pouch and ran up, closely applied to the funiculo-vaginal process of peritonEeum, into the inguinal canal, where it came to an end. The vesicula seminalis on the same side was wanting. (c) Entire Absence of the Seminal Apparatus. — This variety is extremely rare. The extreme cases of the last-described variety (cases of Cruveilhier and Denonvilliers), in which the only part of the seminal apparatus present was the vesicula seminalis and a small part of the vas, lead up, naturally, to those cases where the entire seminal apparatus is deficient. Two such cases have been recorded. || {d) Absence, Total or Partial, of the Excretory Apparatus, the Testicle being present. — In this variety, as in number (6), more or less of the excretory apparatus is wanting, but the testicle itself is present. This abnormality is interesting, as it seems to prove an exception to the general rule by which any per- sistent obstruction to the outflow of the secretion of a gland leads to alteration in and finally atrophy of that gland. Not only does mal-development, but experiments also, prove this to be the case. Thus, Sir A. Cooper, Mr, Curling, M. Gosselin, have shown that * Pallington, quoted by Meckel, Handh. d. path. Anat., 1812, Bd. i. S. 6S5. t Zeitsclt. der h.li. G'esellschaft d. Aertze in Wien, t. xv. p. 42 ; and Oenter. 31ed. Jahrh., 1868, No. I. + Bastien and Legendre, Compt. rend, de la. 80c. de Bloloyie, 1859, p. 143 ; and (Juz. Mid. de Parin, 1859, No. 41, p. 649 ; Paget, Lond. Med. Gaz., 1841, vol. xxix. p. 817, a preparation taken from this case is in St. Bartholomew's Hospital Museum ; J. Cruveilhier, loc. supra cit. § Kipault, JJuU. de la i%c. Anat. de Paris, 1833, t. viii. p. 221. II Blondin, Anat. Topoyr., 1834, 2nd ed. p. 442 ; Velpean, Traite d'Anat. Vhlrury., 3rd ed. t. ii. p. 192. 26 . DISEASES OF THE TESTICLE. while section of the spermatic vessels letids to atrophy or slough- ing of the testis, division of the vas deferens does not prevent the testicle from continuing to secrete and maintain its normal develop- ment for a considerable time, certainly.* Probably, this peculiarity of the testicle is due to the arrangement of its blood-supply, by which the complicated secretion of the gland is always maintained in readiness without overflowing (p. 20). It is at all events interesting to note that in none of the cases recorded in which this mal-develo;^ment appeared in man, nor in any of the animals experimented on, is there any evidence of atrophy of the testicle followino' on engoroement and inflammation from the interference with the escape of its pent-up secretion, a fact in itself strongly confirmatory of Prof. Cleland's view above given. This abnormality may attack any part of the excretory appa- ratus. Tracing this from before backwards, it is extremely rare for the epididymis alone to be deficient.! When part of the epididymis is absent, it is the head that remains. Cases where more or less of this is deficient, together with part of the vas deferens^ are more common, or the vas deferens may alone be affected. § But if the terminal or urethral part of the vas is want- ing the vesicida semincdis will be absent also. As above stated, Godard believed that this was the only condition under which "■ As far as I know, the longest time in which the testis thus experimentally separated from its duct remained eEBcient was ten months. At this time the dog, the subject of the experiment, was killed. t Mr. Curling (be. supra cit., p. 7) mentions a specimen in St. Bartholomew's Hospital Museum, removed from a man aged fifty, in whom the testis was detained at the internal ring. The vas deferens terminated near the testicle, in a cid de sac. There was no trace of the epididymis. M. Godard could only find a single instance of the kind by Rhodius. According to MM. Monod and Terrillon, this case is very incompletely reported. { Brugnone (il/em. de VAcud. Hoy. des Scknce>i de Turin, 1786, 1787, p. 625) records a case of absence of the epididymis (except the head) and the greater part of the vas deferens. The urethral portion alone persisted, and the vesicula seminalis was present but empty. Godard quotes a very similar case (liccher. Tiratol., p. 87), but here the whole of the vas deferens was wanting, and the corre- sponding vesicula seminalis was absent also. Three more recently reported cases are quoted by MM. Monod and Terrillon from Miindemeyer, Zcitsch. f. Bation. Med., Bd. xxxiii., 1809 ; Reverdin, Bull, dc la fSoc. Anat., 1870, p. 325 ; and Mayor, ibid., 1876, p. 592. § Parise, Bull, de la Sue. Anat., 1837, t. xii. p. 38. Godard, loc. supra cit. Gosselin, Arch. Gen. de Med. 1847, t. xiv., p. 308, records a case in which the inguinal-scrotal portions of the vas deferens were wanting ; the corresponding vesicula seminalis was here present. Prof. Turner [Ed. Med. Journ., Jan. 1865) has published one in which the left testicle was retained in the abdomen, and the vas deferens was closed at its two extremities, at the one end having no con- nection with the epididymis, and at the other not opening into the urethra. ABNORMALITIES IK DEVELOPMENT. 27 the absence of the Acsicula would be present. This authority was disposed to look upon reported cases of this absence of the vesicula as due either to arrest of development or to atrophy from pathological causes. Cases of absence of the epididymis will be found recorded by J. Hunter, works edited by Palmer, vol. iv. p. 23. 5. Bilateral Anorchism. — Nearly all the above varieties of anorchism have been observed simultaneously on the two sides.* Thus, Fisher, of Boston (Amer. Journ. Med. Sci., Philadelphia, 1838, vol. xxiii. p. 352 ; and Zond. Med. Gaz., vol. xxviii. p. 817), and MM. Legendre and Bastien (Cotivpt. rend, de Ice Soc. de Biol., 1859, p. 144), have recorded cases of bilateral absence of the testicle and epididymis, each vas deferens and vesicula seminalis being intact; Godard {Ilech. Teratol., p. 54), one in which the testicles, epi- didymes, and the extra-abdominal part of the vasa deferentia were absent, the deep part of these canals and the vesiculse seminales remaining. Absence of the entire apparatus, including the vesi- culte seminales, seems to have been met with twice, by Kretzchmar (Arch. f. mediz. Erfitlirung, Leipzig, Bd. i. S. 349) and by Friese (Casper's Wochcmcrift, Dec. 1841; and Brii. and For. Med.-Chir. Ilev., vol. xiii. p. 527). A few points relating to the different varieties of anorchism call for notice. Its extreme rarity, especially when bilateral, is shown by Gruber, Professor of Anatomy in St. Petersburg. Writ- ing in 1868, he could only collect twenty-three cases of unilateral anorchism, and seven of the bilateral variety, all having been verified by autopsy. Very few have been added since. The left side seems to be somewhat more frequently the site of the deficiency, both in the case of the testicle and in that of its excre- tory apparatus. Co-existing" Malformations. — ( i ) State of external geni- tals. — (a) When the abnormality is unilateral, the correspond- ing half of the scrotum is usually present, but smooth and ill- developed. The raphe is present. The above asymmetry is the more marked in proportion as more and more of the excretory apparatus is wanting also.f The opposite testicle may be normal, it may be hypertrophied, or it may be ectopic. * According to MM, Monod and Terrillon, the only one of the above varieties which has not been met witli on both sides is that in which the testicle itself alone is absent. t According to Godard, in complete anorchism — i.e., when the testis and its excretory apparatus is entirely absent — the layers of ti.u scrotum consist only of 28 DISEASES OF THE TESTICLE. • (/3) When the anorchism is bilateral the external genitals are usually present, but in an extremely rudimentary condition. In exceptional cases — e.g., that of Friese {loc. supr