The testicle is originally formed by differentiation from the Wolffian bodies, at a level above the pelvis. Its migration from its original location into the pouch where it normally belongs is known as the descent of the testicle. When it fails to appear at the external ring it is spoken of as retained testicle, and when detained outside the ring above its proper level the condition is referred to as incomplete descent, these being purely arbitrary terms. The reasons for incompleteness of the descent are as little understood as those for its completion, and have but little reference to clinical surgery.
The surgical anatomy of the testicle may be only briefly considered here. Each is essentially a double organ, consisting of the testis proper, the secreting portion, with its more or less complete double peritoneal covering (originally peritoneum), and the epididymis, or conducting portion, variable in size, and corresponding to the parovarium in the ovary in respect that it is subject to cystic degeneration. The pathway made by the testicle as it passes from the abdominal wall should be completely obliterated. When unobliterated it facilitates the occurrence of hernia, while when partially obliterated cystic dilatations of the enclosed portions (hydroceles of the cord) occur. The lowermost portion of the accompanying peritoneal pouch is normally left as a closed sac, which constitutes the cavity of the tunica vaginalis testis. In the ordinary standing posture the epididymis occupies toward the testis proper the same relative position that the heel does toward the anterior part of the foot, i. e., it lies to its posterior and inner sides. While both portions of the organ may be involved in acute or chronic diseases, each of them may be by itself involved with a minimum of disturbance of the other.
RETAINED TESTICLE, OR CRYPTORCHIDISM.
As above indicated failure in descent varies in degree from complete absence from sight and touch to a presentation of the testicle at a point where it can be both seen and felt but still at too high a level. Ordinarily the condition is symptomless, its only signs being those above rehearsed. Strange to say the condition sometimes passes unrecognized until adult life is reached. Commonly it is early discovered. Pain is felt only when friction or traumatism lead to the same unpleasant sensations which would be produced by pressure upon a normal organ. Thus a testicle retained at the external ring may be irritated by the clothing, and has been many a time mistaken for an incomplete hernia, upon which a truss pad has been applied with inevitably resulting suffering. While accompanying malformations in other parts of the body may be found it does not follow that the individual may not be otherwise perfectly developed.
It is usually held that an incompletely descended testicle is more or less functionless; often it is at least more or less atrophied. Its functional capacity varies. It is usually more or less surrounded by a cavity formed from the peritoneum. While the condition is ordinarily one of minor importance, it has been established by numerous observations that retained testicles are relatively prone to undergo malignant degeneration.[73]
[73] In the pathological museum of the University of Buffalo I deposited specimens illustrating this fact, one testicle forming a tumor as large as the patient’s head, the other as large as a cocoanut. These were both successfully removed from an adult, and without the patient developing any subsequent evidence of malignant infection. It is thus important in every case of intrapelvic tumor in the male to examine the scrotum and be sure that both testicles are in their proper position.
Treatment.
—The proper early treatment of cryptorchidism has been a matter of dispute, some advising to leave the condition entirely untouched so long as it be not troublesome; others that early intervention should be practised. If the organ be simply displaced and not otherwise diseased, whatever be done may be limited to freeing it from its abnormal surroundings and restoring it as nearly as possible to the position where it belongs. If it be actually diseased it should be removed. What may be accomplished will depend much upon its movability and its blood supply.
Thus Keetley would liberate the testicle, when retained within the inguinal canal, by division of the latter and lengthening of the cord by blunt dissection, with division also of the lateral portions of the gubernaculum near the pillars of the external ring and as far as possible from the testicle. By traction upon this it is then often practicable to bring the testicle down, without undue tension, to the lower part of a new scrotal pouch, which is formed by making for it a nest, as it were, with the finger, with an opening at its lower extremity, through which forceps are thrust, passed upward and made to seize the end of the gubernaculum, or through which a suture may be passed for the same purpose. By means of this device the testicle is now drawn downward into the scrotal pouch, where, being once present, it is held by sutures, both direct and those which close the pouch above it. It is then advisable to close the inguinal canal, as after a hernia operation. In order to prevent upward traction on the scrotum it is necessary to attach its lower end to the skin of the thigh, by a suture which should remain for several days. If this be done on both sides the limbs should be snugly bandaged together and movement of all kinds prevented. Complete separation of the scrotum from the thighs should not be permitted for several weeks, unless unavoidable.
Beck recommends an incision from the external ring three inches downward along the cord, after which he opens the pouch of the testicle, lifts it from its bed, pulls it down, carefully dividing all bands of connective tissue or peritoneum which tend to immobilize it. It is then deposited in a scrotal pocket, in which it is held by a flap dissected from the outer margin of the inguinal ring, and turned downward in such a way that it can be attached to the opposite layer in semilunar shape. Thus a band of aponeurotic tissue is made to surround the testicle “like a necktie,” the organ being retained as in a buttonhole, the length of the flap being determined by the extensibility of the cord. The inguinal canal is then closed as after any other procedure.