numerous attacks of epididymitis on both sides, and who yet furnish semen
containing abundant spermatozoa. Tn other cases the inflammation may be
so slighl that the patients have only a trifling amount of pain in the epididymis
and along the cord, with scarcely palpable enlargement of the lower end of
the epididymis, and yet they may be rendered permanently sterile. In some
eases the passage is not occluded, but narrowed. Tn these the number of
spermatozoa may be simply diminished. In some of them the spermatozoa
are alive and active, in others we see only a few dead spermatozoa in each
microscopic field. Tn addition there will be numerous pus cells and spermatin
crystals. The history of these cases is often as follows: The patient suffers
from a posterior urethritis, and sometimes, in addition, from a seminal vesicu-
litis. He furnishes a1 firsl blood-stained semen, and later semen containing
much pus. Upon the advent of double epididymitis the number of spermati
in the semen will rapidly diminish, and the few remaining will he found dead.
Soon even these will disappear, and the semen will consisl of a fluid which
may resemble normal semen in appearance, hut under the microscope no sper-
matozoa will he seen. There will he pus cells, blood cells, spermatin crystals,
granular detritus, epithelia, colloid granules, and occasionally indigo crystals.
These nun are temporarily or permanently sterile. I have hud a number of
such cases under observation throughout a series of years. In some of them
spermatozoa reappeared after six months; some have remained permanently
sterile. In one case spermatozoa reappeared after eighteen months. I have
never seen them reappear after two years or more. Tuberculosis and cancer
700 THE SEMINAL VESICLES AND THE SEMEN
of the lower genito-urinary tract may produce a semen poor in spermatozoa,
and later on their total disappearance.
Inflammation of the Seminal Vesicles — Seminal Vesiculitis. — Inflammation of
the seminal vesicles may be simple, gonorrheal, or tuberculous. The gonorrheal
inflammation may be associated with mixed infection and the formation of
abscess. The tubercular form is often associated with tuberculosis of the
prostate and epididymis. The gonorrheal variety is much the most frequent.
Simple Catarrhal Inflammation of the Seminal Vesicles. — Simple catarrhal
inflammation of the seminal vesicles is believed to occur, and to be associated,
with dilatation of the vesicles. The condition is believed to result from an
unhygienic sexual life, sexual excesses, masturbation, or prolonged sexual ex-
citement without gratification. These patients are usually neurotic and neu-
rasthenic subjects. They often have a congested and oversensitive posterior
urethra, sometimes a slight degree of catarrhal posterior urethritis. In some
of these cases the secretion of the prostate is increased in amount, and the
individuals observe that after urination, during straining at stool, and during
sexual excitement a certain quantity of opalescent, sticky fluid escapes from
the meatus. This fluid they usually believe to be semen. They consider that
they are suffering from constant seminal losses, or, as they call it, spermator-
rhea. In this idea they are sometimes encouraged by reading quack medical
literature. They are often partly impotent, and have premature ejaculations
and other disturbances of the sexual function. They may complain of pain
or of a sense of fullness in the perineum ; of pain in the sacrum and of ab-
normal sensations in the glans penis and testes. They often have frequent
urination and slight ardor. Upon rectal examination the seminal vesicles are
found tender, enlarged, and dilated.
Gonorrheal Inflammation of the Seminal Vesicles. — Gonorrheal inflamma-
tion of the seminal vesicles may be of a mild or severe type, and either acute
or chronic. It is probable that a large proportion of cases of acute gonorrhea
have, associated with a posterior urethritis, an inflammation of the seminal
vesicles, mild in degree, and not attended by any marked signs or symptoms.
In these cases the involvement of the vesicles usually passes unnoticed, and
gets well of itself. In another and much smaller group of cases the invasion
of the vesicles is of a fairly severe type, and gives definite signs and symp-
toms. The condition may get well under appropriate treatment, or become
chronic, or eventuate in the formation of an abscess. The signs and symptoms
of acute seminal vesiculitis do not differ much from those of acute gonorrheal
posterior urethritis and prostatitis. The patients suffer from painful and fre-
quent urination. They have frequent, painful, and often bloody, nocturnal
emissions. Defecation is painful. In some cases there is a rise of tempera-
ture. There is burning, throbbing pain in the perineum and rectum. The
urine is purulent, and has the characters observed in acute posterior urethritis.
Upon rectal examination the prostate will be found swollen and tender, and
one or both vesicles will be found swollen, tender, and moderately hard. If
iXFLAMMATloX OF THE SEMINAL vi.h< LES 701
the contents of the seminal vesicle be expressed during this acute itaot the
patient's condition will be rendered much worse. The prostatitis and posterior
urethritis will !"• aggravated; an attack of epididymitis will often follow.
Chronic Gonorrheal Inflammation of the Seminal Vesich s. Many cases of
acute inflammation are followed by a chronic form. One of the tnosl mai
characters of this type is the tendency t<> repeated attacks of epididymitis.
The local and general symptoms are fairly marked, though tiny vary some-
what in differenl cases. These patients are nearly always sexual neurasthenics.
They may have imperfecl erections; they usually have premature ejaculations,
and the orgasm may be painful. The semen usually contains hi 1, or blood
ami pus in an even mixture. There is usually a chronic posterior urethritis,
and recurrent attacks of anterior urethritis are the rule. The patients complain
of pain of a neuralgic character, referred to the sacrum, tin- perineum, the
rectum, the testes, the inner surface of the thighs, and the hip. Much im-
portance has been given to this last symptom by certain observers. Pain during
defecation is common. Tn the early stages of the disease some of these indi-
viduals have a marked irritation of the sexual sphere. In some cases there is
a marked desire with partial impotence. Some id' these patients, on the other
hand, are able to copulate with great frequency, so that for a time their ex-
ploits excite wonder and admiration. Sooner or later, however, though the
sexual desire may continue, the power to gratify it diminishes, and may finally
he entirely lost. In these chronic cases physical examination will discover the
vesicles enlarged, thickened, and tender, sometime- markedly dilated. The
expressed secretion will contain pus, and sometime- blood.
Abscess <>f the Seminal Vesicle. — Tn the course of an acute or chronic semi-
nal vesiculitis, pyogenic infection with abscess formation may occur. The signs
and symptoms resemble those of prostatic abscess; hut it is to he borne in mind
that abscess of the vesicle may rupture into the peritoneum with fatal results,
or into the bladder or rectum, or into both, with the production of a recto-
vesical fistula. The symptoms of a beginning abscess are those of sepsis —
namely, a rise of temperature, a rapid pulse, a leucocyte count characteristic
of suppuration, prostration, etc Locally the patients suffer from painful'and
frequent urination, painful defecation, and burning, throbbing pain in the
perineum, rectum, and sacral region. Rectal examination will disclose a tumor
en the anterior rectal wall, above the prostate, as large as a goose egg, which
may fluctuate, or a diffuse inflammatory induration above the prostate, extend-
ing beyond the reach (d* the finger, and without definable limits.
Tuberculosis of the Seminal Vesicles. — Tuberculosis of the vesicles :
dom observed as a primary \'<>cu< of infection, hut is a frequent accompaniment
of tuberculosis of the epididymis and prostate. The vesicles become enlarged
and nodular. Later on there is softening with the formation of tuberculous ab-
scesses. These may rupture through the rectum, or into the bladder, or through
the skin of the perineum. The diagnosis is usually simple, on account of the
evident tuberculous disease of other portions of the genito-urinary tract.
CHAPTER XXXVI
THE SCROTUM, TESTIS, AND SPERMATIC CORD
ANATOMICAL REMARKS
The Scrotum
The scrotum hangs between the penis and the perineum. It is a some-
what pear-shaped hag of skin, narrower above, broader below. It exhibits a
median vertical furrow between the inclosed testes. Xearly in the median
line a narrow, white ridge can be seen upon the skin — the raphe" — representing
the line of fusion between the two halves of the originally divided scrotum.
The line is continued forward on to the penis and backward on to the peri-
neum. Upon either side are pear-shaped prominences corresponding to the
testes. The two halves of the scrotum are not quite symmetrical, since the left
testis hangs lower than the right. The raphe is directed from above downward
a little to the right of the median line.
The skin of the scrotum is thin, soft, and translucent. It is very vascular,
and when stretched numerous delicate veins can be seen in its substance. The
skin exhibits notable brown pigmentation, and contains thinly scattered hairs
as well as numerous sebaceous and sweat glands. The glands are visible as
whitish granules within the skin. On account of the presence of the dartos
tissue, consisting of unstriped muscle fibers, the skin of the scrotum is smooth
or wrinkled, according to the relaxed or contracted condition of this muscular
layer. The wrinkles or folds are transverse, and extend from the raphe later-
ally., concave upward, to the back of the scrotum. Under the influence of cold,
mechanical irritation, sexual excitement, or other strong emotion, the muscle
fibers contract, the wrinkles become more marked, and the entire scrotum
shortened so that it tightly incloses the testes. Under the influence of heat,
debility, and old age the scrotum is relaxed, and becomes smooth and longer.
The raphe represents the line of union between the halves of the scrotum, and
is continued dorsad as a septum, separating the scrotum into two sacs. Thus
each testis with its coverings is lodged in a separate chamber. The wall of
the scrotal sac consists of the skin and the dartos tissue. The latter contains
unstriped muscle fibers running vertically, and is intimately adherent to the
former. On account of this intimate connection, transverse wounds of the
scrotum gape widely, resembling a loss of substance. The skin of the scrotum
is very elastic. Exudates, hernia 1 , and tumors may distend it to enormous
702
ANATOMICAL REMARKS
â– o;;
size. Owing to its extreme thinness the I in of the crotum readily becomes
aecrotic from mechanical and chemical insults, and Prom heat, cold, and in-
fection. The scrotum is attached to the coverings of the testis and spermatic
cord by a very loose meshwork of connective tissue, bo thai effusions and
dates readily accumulate in this space in fronl of the testis. Behind, the con
uection is firmer. Such accumulations, however, after they reach a certain
size, spread upward on to the abdominal wall, or backward into the perineum.
The scrotum is very vascular, lis blood supply is derived from the external
RIGHT INGUINAL CA
(OPINED)
CREMASTERIC
AND FASC
INTERCO
FASC
PERSISTENT SEROUS
CAVITY AROUND
CORO — EXCEPT ION *L
TUNICA VAGINALIS—
PARIETAL LAYER
INFUNDI8ULIF0RM
FASCIA
RIGHT HALF OF SCROTUM SKIN
LEFT HALF OF SCROTUM
Fig. 2:?.'>. — The Scrotum. On the lefl side the cavity of the tunica vaginalis has been opened; on the
ri>j;lit side only the layers superficial to the cremaster bave been removed. (Wocusey, Gerrish,
Testut.)
pudic and the superficial branch of the internal pudic arteries. There is a
free anastomosis between the two halves of the scrotum, and also at the rool
and base of the scrotum, between its vessels and those of the testis and cord.
The lymph vessels of the scrotum empty into the superficial lymph nodes of
the inguinal region.
704
THE SCROTUM, TESTIS, AND SPERMATIC CORD
The Testis and Spermatic Cord
The spermatic cord and testis are united by their coverings into a bundle —
slender above, at the external ring, almost wedge-shaped below — correspond-
ing to the situation and
shape of the testis. The
attachments of the testis
and cord to the scrotum
are for the most part loose,
so that upon incising the
scrotum it is very easy to
enucleate the testis without
the use of cutting instru-
ments except at its lower
pole, where it is attached
to the bottom of the scro-
tum by the scrotal liga-
ment. This structure rep-
resents the remains of the
gubernaculum testis, a rem-
nant of a fetal structure. The infundibuhform fascia (internal spermatic
fascia) is also adherent to the posterior border of the testis and to the
scrotum at this point. Even this attachment is not very firm, since by con-
ART. OF VAS
DEFERENS
VAS DEFERENS
SPERMATIC
ARTERY
PAMPINIFORM
PLEXUS
„INFUNDIB.
FASCIA
— LOOSE CONNECT-
IVE TISSUE
CREMASTERIC
LAYER
CELLULARTISSUE CON-
TINUOUS WITH SUB-
PERITONEAL TISSUE
Fig. 236.
oartos skin
•Transverse Section of the Right Spermatic
Cord. (After Woolsey.)
'spermatic cord -
tunica vaginalis propria
superior ligament of epididymis
sinus of epididymis
posterior border of testis M
inferior ligament of epididymis , - mh|
Y
tail of epididymis ..<
tunica vaginalis communis
head of epididymis
appendix of testis
appendix of epididymis
lateral surface
of testis
, anterior border
Vs of testis
Fig. 237. — The Testis Seen from the Side. (Watson and Cunningham, after Sobotta.)
ANATOMICAL REMARKS
705
siderable force 1 1 1 * - te~ti- may be dislocated <»n to the pubea into the perineum
or groin.
The Coverings of the Cord and Testis. — The Cremasi r. — The cre-
master consists of voluntary muscle fibers, continuous above with the internal
oblique muscle. It forms an incomplete muscular sheath for the cord and
testis, ;i sort of sling, :i rr:i i m< ■« I in separate arched bundles bound together
and covered by a thin layer of connective tissue at the sides and in fronl of,
I. ut qo1 behind, the cord ;in<l testis. The contraction of the cremaster, under
control <>\' the will, raises the testis in the scrotum. Cinder strong sexual ex-
citemenl the testes are drawn well up to the abdominal rintr, >" that the o.n-
tracted scrotal sac appears empty. A similar contraction is observed in attacks
of renal colic. The contraction in this ease is usually limited to the affected
side. The cremasters may be made to contracl by scratching the skin of the
groin ( the cremasteric reflex ).
The Infundibuliform Fascia. — The infundibuliforra fascia corresponds with
the same fascia in the groin. Together with the remains of the gubernaculum
testis, it anchors the testis at
the lower part of the scrotum :
thus effusions into the tunica
vaginalis testis may be safely
tapped in front and through
the upper part of the tumor.
Loose Areolar Tissue. —
Loose areolar tissue, contin-
uous with the subperitoneal
connective tissue, connects the
infundibuliform fascia with
the tunica vaginalis and unites
all tl ther structures of the
cord into a bundle. The in-
fundibuliform fascia, together
with tin's loose connective-
tissue layer, was described by
( looper, and is known as the
fascia propria of Cooper. It
spermatic
— cord
(+ cremaster)
lateral surface
tunica vaginalis
propria
superior extremity
appendix
of testis
head of
epididymis
appendix of
-"' epididymis
,mcdial surface
nterior border
• tunica vaginalis
â– * communis
was noted by him that these j-,,. 238 [hi testis lnd Idjacenh Stri - ewkd
layers became firm and thick- SSL)" 1 F *° KT ( ^ atson : "" 1 Cunningham ' : "'" s
ened in ancient and large her-
nia?. " Besides the (external) cremaster. two collections of imstriped muscle
fibers are known as cremaster muscles, one of them in the cord (internal
cremaster), the other in the subserous layer (middle cremaster)" (Woolsey).
The Testis. — Position. — The testicles bang suspended by their cords in the
lower pari of the scrotum, the lefl somewhat lower than the right They are
freely movable in the scrotum, and readily >li|> oul <d' the way of danger when
706 THE SCROTUM, TESTIS, AND SPERMATIC CORD
pressed upon. The testis hangs so that its long axis is not exactly vertical.
The upper pole is directed somewhat forward and a little outward.
Size. — The testis is on the average 1^ inches in length, 1^ inches in depth,
and rather less than an inch in thickness. Its weight is from 5 to 8 drachms.
In childhood the testis remains small, but grows very rapidly to its full size
at puberty. If one testis is congenitally absent, the other increases in size
beyond the normal. If one testicle is lost during early manhood, the other may
undergo hypertrophy. I have seen men whose testes were much larger than
the average, but I do not know whether they were unusually active sexually
or not.
Consistence. — The consistence of the testis is uniformly firm and elastic ;
firmer in strong, well-nourished men, softer in feeble individuals and the aged.
Continence and repeated sexual excitement render the testes firmer. The sur-
face of the testis is smooth; any inequality suggests disease.
Development. — In early fetal life the testis is developed in the abdominal
cavity from the tissues of the genital ridge, and afterwards becomes connected
with certain of the tubules of the Wolffian body (epididymis). It comes to
lie behind the peritoneum at the level of the lower pole of the kidney, opposite
the second lumbar vertebra. It sometimes possesses a short mesentery (mesor-
chium). To the lower end of the testis is attached a bundle of unstriped
muscle fibers (the gubernaculum testis). These pass downward; some of them
are attached to the internal abdominal ring, others to the bottom of the scro-
tum. Traction upon the testis by this structure has been thought to account
for the descent of the testis. There are, however, but few facts in support
of this supposition, the causes of the descent being really obscure. The testis
differentiates itself as a distinct organ during the second month of pregnancy.
During the third month it begins to descend and reaches the internal abdom-
inal ring during the sixth month. During the following two months it passes
through the inguinal canal, accompanied by a covering of the layers of the
abdominal wall, including the pouch of peritoneum (processus vaginalis), which
subsequently comes to form the tunica vaginalis testis. At the eighth month
it reaches the external abdominal ring, and at birth has descended to the
bottom of the scrotum. This situation, then, is a sign of the maturity of
the fetus, though not absolute.
Abnormalities in the Descent of the Testis. — The testis may be ar-
rested in its descent at any point in the abdomen, at the internal ring, in the
inguinal canal, or at the external ring. Testes retained at the external ring
usually descend completely before puberty; those arrested in the canal may
do so. When the testes do not emerge from the canal, the condition is known
as cryptorchism ; if but one testis descends, as monocryptorclusm. One testis
may remain totally undeveloped ; such an individual is a monorchid. If both
testicles are absent or rudimentary, the individual is an anorchid. These last
are usually feminine in appearance, and have an undeveloped penis. A re-
tained testis is usually, but not always, atrophic and functionless. In certain
ANATOMICAL REMARKS 707
cases the testis may be absent, and yel an epididymis and v&s deferens may
descend to the bottom of the scrotum. A testicle may be presenl in tin- abdo
men, bul no epididymis or v&s. In these no descenl takes place. The causes
for failure of descenl arc for the mosl pari obscure. Such failure may well
be due to undue shortness <>f the Wolffian < 1 1 1< * t (vas deferens) during embry
onic life. It lias also been attributed to peritoneal adhesions between testis
and other pelvic viscera or intestine, and t<» interference by the aponeurosis
of the external oblique muscle. Failure of descenl is better explained by
assuming a reversion t<> a lower type, since in many animals the testis remains
permanently in the abdomen, and in others only descends during the Beason
of nit.
The Coverings of the Testis. — The testis is covered by it- tunica pro-
pria, or tunica albuginea, and by the tunica vaginalis.
Tunica albuginea. — The tunica albuginea is a dense white layer of fibrous
tissue which invests the organ, sends prolongations into its interior forming
spaces for the lodgment of the glandular substance, and forms the mediastinum
testis posteriorly and above, through which the hlood-vessels pass to and from
the testis and the straight tubules emerge carrying the spermatozoa to the
epididymis. The tunica albuginea is tough and unyielding, so that sudden
increased intratesticular tension is accompanied by severe pain, much greater
than is true of the epididymis. Thus, orchitis is more painful than epididymi-
tis. When the tunica is incised, testicular substance protrudes through the
gap. If dirty or infected, or if the wound he old, it may he mistaken for
granulation tissue, and upon this assumption has been many times curetted
away or pulled out The entire testis has thus been ignorantly removed. An
acute abscess or other inflammatory process which ruptures may, by increased
tension, cause the extrusion of the entire substance of the testis.
Tunica vaginalis testis. — The tunica vaginalis is a closed serous sac sur-
rounding the testis almost completely. It represents the remnant of the pro-
cessus vaginalis. Along the posterior border at the line of attachment of the
epididymis and at the insertion of the gubernaculum at the lower pole the
investment is incomplete. The visceral layer is reflected from the testis on to
the epididymis laterally, covering it in part. Mesially the reflection passes
directly into the parietal layer without including the epididymis. Normally,
parietal and visceral layers are in contact, only enough serous fluid being
present for lubrication. An accumulation of serous fluid in the sac constitutes
a hydrocele. Along the uncovered posterior border of the testis the efferent
tubules emerge to the head of the epididymis. Below, the blood-vessels pass
i" and from the testis, and at the lower pole the gubernaculum is attached.
Normally, the entire canal of the processus vaginalis above the testis i- closed
at or shortly after birth. Its walls atrophy to a slender tihrous cord, someti
traceable ;is far as the internal abdominal ring to end in a dimple on the
peritoneal surface at this point. In some cases the canal remains patent
throughout, encouraging the formation of a congenital hernia and constituting,
708 THE SCROTUM, TESTIS, AND. SPERMATIC CORD
if fluid accumulates in the sac, a congenital hydrocele. In other cases the
vaginal process is closed above and below, but remains open at one or more
intermediate points, constituting a monolocular or multilocular encysted hydro-
cele of the cord respectively. Hydrocele of the canal of Nuck in females has
a similar origin.
The anatomy of the secreting substance of the testis is not important from
a diagnostic point of view, and is consequently omitted.
The Epididymis. — The epididymis is applied to the testis along its pos-
terior border, and overlaps it slightly at the top and laterally. It begins above
as a larger part — the globus major — which receives the efferent tubules from
the testis (vasa recta) ; these dilate and collect into convoluted cones (coni
vasculosi), which empty into the single canal of the epididymis whose convo-
lutions form the central part or body of the organ. Below is the globus minor,
or tail of the epididymis, beyond which the canal becomes thick-walled and firm
and is known as the vas deferens. The body of the epididymis is but loosely
attached to the testis, and is movable upon it, possessing a short meso-epidid-