Section Iii. of the Testicles.

=Congenital Anomalies.= There is no sufficient evidence of the presence of more than two testicles. They are both absent when the entire sexual apparatus is wanting, and in some rare cases they are imperfectly developed, or only one may exist.

It not unfrequently happens that at birth there is an apparent absence of one or both glands from an arrest or delay in their descent, so that they lie in the groin, the inguinal canal, or the lower part of the abdomen. Sometimes they wander into other situations, e. g., into the perineum close by the anus, and through the crural canal. If the descent does not take place within twelve months after birth it is rarely perfectly completed afterwards without being accompanied by hernia.

The organ is sometimes retroverted, so that the epididymis is placed in front.

The vas deferens may be absent to a greater or less extent, and even the epididymis has been found in great part deficient.

The vas deferens frequently terminates in a blind extremity before reaching the vesicula seminalis.

=Hypertrophy and Atrophy.= True hypertrophy of the testicles does not occur but when attacked with inflammation, or when the seat of morbid growths the glands may become greatly enlarged. Atrophy, congenital or acquired, is not unfrequent. The effect of old age is very gradual, the gland being often but very little diminished in size.

“The testicle atrophied from disease is not only of diminished size and weight, but is altered in shape, being uneven and irregular, and sometimes of an elongated form. There is little or no trace of the proper glandular structure, the organ being converted into fibrous tissue of a firm texture.

“The testicle in an advanced stage of wasting, not arising from disease of the gland, usually preserves its shape, but feels soft, having lost its elasticity and firmness. Its texture is pale, and exhibits few blood-vessels; the lobuli and septa dividing the lobes are indistinct, and the former cannot be so readily drawn out into shreds as before. The epididymis does not usually waste so soon, nor in the same degree as the body of the testicle. Fatty matter is also found in the glandular substance of atrophied testicles.”

=Inflammation.= The serous covering of the testes, the tunica vaginalis, is liable to acute inflammation, and is then affected as other serous membranes. It becomes thickened and injected with blood, and is coated with a variable quantity of fibrinous exudation. Serum is, at same time, effused into the cavity, and rendered turbid by flakes of fibrin. Adhesions between the opposing surfaces commonly form. The epididymis is apt to partake of the inflammation of the tunica vaginalis, and vice versa.

Orchitis and Epididymitis, may be acute or chronic, primary or secondary. In acute cases, the testis is congested, and of a darker hue than natural, although not much enlarged. The epididymis, especially its lower part, is much enlarged, and feels thick, firm and indurated. “The coats of the vas deferens are thickened, and the adjacent vessels injected. The tunica vaginalis is inflamed, and its cavity contains the usual effusions.”

Suppuration may occur more frequently in primary orchitis, rarely in the secondary form. The pus is liable to burrow and disorganize the tissue of the gland. By a subsequent absorption of the fluid part of the pus, there is often left a whitish mass resembling tubercular deposit, but distinguished from this by being contained in a cyst, and by the altered condition of the adjacent gland tissue. The epididymis not unfrequently remains enlarged, presenting a hard, knotty swelling at its lower part. “In old cases the epididymis acquires the density and consistence of cartilage, and sometimes even of bone.”

Atrophy of the gland is a frequent result of inflammation.

Chronic orchitis is characterized by the effusion of a yellowish, homogeneous-looking matter, in the substance of the testicle, within the tubuli. This deposit may shrink and contract, inducing gradual atrophy of the testis, or, by adhesions and ulcerative absorption, a fungous protrusion of the affected tissue may take place.

=Hydrocele.= Simple Hydrocele is a dropsy of the tunica vaginalis. The fluid is usually clear, and of a straw color, sometimes turbid, with albuminous flocculi, and not unfrequently contains shining particles of cholesterine. In old or very large hydrocele, it is often dark-brown or chocolate colored from disintegrated blood. Its quantity is sometimes very considerable. The position of the testicle may be altered by adhesions formed between the two layers of the tunica vaginalis; these latter may also produce a multilocular hydrocele. Simple hydrocele may occur with some of the other varieties to be mentioned, and also with inguinal hernia.

When serous effusion in the tunica vaginalis, is associated with chronic orchitis or other diseases of the gland, we have hydro-sarcocele.

In congenital hydrocele, the dropsical tunica vaginalis retains its fœtal communication with the peritoneal cavity.

Encysted Hydrocele. In this variety the fluid is contained in cysts, which may be situated (1) beneath the visceral portion of the tunica vaginalis, investing the epididymis; (2) between the testicular portion of the tunica vaginalis and the tunica albuginea, which are thus separated from each other; (3) between the layers of the loose or reflected portion of the tunica vaginalis. The two last mentioned varieties are of rare occurrence. The cysts have thin fibrous walls, a lining of tessellated epithelium, and contents usually clear, although sometimes mixed with various exudations of fibrin or even blood. Spermatozoa are very frequently found in the fluid of these cysts. Their presence is undoubtedly due, as pointed out by Cushing, to the rupture of a neighboring seminal duct. They are but rarely found in the fluid of common hydrocele.

Diffused Hydrocele of the Cord, gives rise to an oval or oblong, irregular, circumscribed tumor, extending below and into the inguinal canal. “It consists in the enlargement of the cells of the areolar tissue, and their distension with a white or yellowish serous fluid. The inclosing fascial sheath is condensed and thickened, and at the lower part of the swelling, which is always the largest, separates it completely from the tunica vaginalis.”

Encysted Hydrocele of the Cord forms a tumor of oval shape, loosely attached to the vessels of the cord which pass behind it. Instead of a single cyst, there may be a number, forming a series along the cord.

=Hæmatocele=, is a tumor formed by an effusion of blood from the vessels of the testis or of the spermatic cord, into the cavity of the tunica vaginalis. It may be traumatic or spontaneous, and may attain a large size. Coagula are formed either in separate masses, or in firm layers, as in aneurism. Inflammation may be set up, leading to fibrinous and serous effusion, and to suppuration, or the blood may putrify and gangrene result. The tunica vaginalis is commonly thickened, the testicle unaffected, or in old cases atrophied from pressure.

Diffused Hæmatocele of the Cord results from the rupture of some vessels of the cord, in consequence of which blood is effused within the spermatic fascia. A tumor of enormous size may be formed should the bleeding continue, or recur after having been arrested. The usual cause is some strain or violent exercise.

=Varicocele= is a morbid dilatation of the spermatic veins. “The enlarged veins hang down below the testicle, and reach upwards into the inguinal canal; and when very voluminous, conceal the gland, encroach on the septum, and extend to the other side of the scrotum.” The left veins are more frequently affected than the right. In an advanced stage of the disease, the coats of the veins are thickened, and do not collapse when cut across. In cases of slight varicocele, the nutrition of the testis is not interfered with, but when large, it produces marked atrophy.

Morbid Growths.

=Cancer= is most frequently primary, and generally attacks the body of the testis in the first instance, the epididymis remaining for some time unaffected.

The scirrhus variety, characterized by its great induration, is rarely met with.

Encephaloid is the ordinary form; it commences as one or two masses among the tubuli, which it gradually destroys. The tunica albuginea is absorbed by degrees, gives way, and allows the growth to project into the scrotum and there freely vegetate. The scrotum is slow to be involved in the disease, but at first becomes distended, sometimes to the size of a cocoanut, and then gradually ulcerates. The spermatic artery and the accompanying veins become greatly enlarged. The cord may also be attacked with the disease, while secondary cancers spring up in various places. The lymphatic glands in the neighborhood become enlarged, especially those in the iliac fossa. The inguinal glands do not generally become affected until the skin has become involved in the disease.

Intermixed with the encephaloid are commonly found masses of a bright yellow color, supposed by some to be deposits of tuberculous matter, but by others, merely plastic matter undergoing fatty degeneration.

Colloid and melanotic cancers have rarely been observed in the testes.

The tunica vaginalis is said to have been attacked with cancerous disease, the testis remaining healthy.

=Cystic Disease of the Testis.= The cysts may be but few, or very numerous. The testis is proportionately enlarged, indurated, of a yellowish-white and opaque appearance, and studded with cysts varying in size. The contents are, in the younger cysts, a clear, amber-colored fluid; in the older ones, more thick, viscid, highly albuminous, and of a brownish color. The cysts are sometimes imbedded in solid stroma, probably of fibroid tissue; sometimes small masses of enchondroma are found between them. When of an innocent character, the cystic disease is characterized by the presence of tessellated epithelium in the cysts; when malignant, by the presence of nucleated cancer cells.

“Occasionally cystic tumors of the testicle are met with, in which the substance of the organ is atrophied or absorbed, and its place occupied by one or more large thin-walled sacculi containing fluids of different color and consistence, dark or fatty.”

=Tubercles= are not very unfrequent, and appear sometimes in the body of the gland, but oftener in the epididymis, whence they may spread to the testis. They occur as gray granulations, infiltrated or encysted, and varying in size from a pin’s head to a plum-stone. They are commonly found in all stages of development and disintegration in the same organ. Their presence in and between the tubuli produces inflammation, suppuration and disorganization of the structure of the testis, with which they become mixed, so as to form a cheesy mass of a dirty buff color. This may, by ulceration, perforate the scrotum, and protrude as a fungous growth of a pale, reddish-yellow granular mass. This disease of the testis is frequently found in connection with pulmonary tubercle, or general tuberculosis.

Tubercular syphilitic sarcocele, described by Hamilton, of Dublin, is a variety occurring in an advanced stage of constitutional syphilis.

“Cretaceous matter is occasionally met with in the testis, doubtless the residue of tuberculous deposit which has softened and undergone calcareous change.”

=Tumors.= Fibroid tumors of small size are sometimes found developed within the visceral layer of the tunica vaginalis, or within the substance of the cord.

Fatty tumors may be found, which have originated within the tunica albuginea, the dartos, or within the fibrous connective tissue of the cord.

Cartilaginous tumors of small size, originate with the substance of the gland, and are frequently associated with cystic disease or cancer.