CRYPTORCHIDISM. WITH AN ILLUSTRATIVE CASE. by Robert W. Johnson, M. D. Reprint from Transactions of the Medical and ChirurgicalFaculty of Maryland, 1884. BALTIMORE: JOURNAL PUBLISHING COMPANY PRINT, No. 35 Park Avenue, I 884. CRYPTORCHIDISM. WITH AN ILLUSTRATIVE CASE. Robert W. Johnson, M. D. The testicles perform so important a service in directing the formation of the male—his habits, instincts, and ambitions, his vices and his virtues, from the womb to the grave, that they may not inaptly be compared to the weights of the clock, whose func- tion it is to regulate its going, striking, and entire usefulness. With man or time-piece these essentials must be in working order or the machine runs down. So close is the connection between a lesion of the generative tract and mental anxiety that one does not need a long professional life to find that the old surgical axiom—“Nearer the body the greater the danger”—has a corollary which can be translated, the nearer the pubis the dearer the part. In fact, as I shall instance later, the least variation from the normal standard fastens such a lens on the mental eye of the deformed that he sees only his deformity, and that, too, magnified out of all reason. It is not surprising, therefore, to find that the Ancients, among whom there was probably as great a demand for theories as there is now, had some peculiar notions about the testicles. For instance, one testicle was supposed to beget males ; the other had the more aesthetic function of engendering woman. What was done by the third, in those rare cases of supernumerary testicles, I am unable to state. When one appreciates the vicissitudes of the descent of the testicle, the chance for a band of lymph to stop the way, or an inaccuracy existing between the size of the rings and the testicle which has to pass them, a faltering on the part of the guberna- REPORT OF THE SECTION ON PRACTICE. culum, or a mistep in the cremaster, I say when we weigh all these adverse odds we might be more surprised at finding the testicles in the scrotum than we are at their arrest in transitu. For the sake of clearness, I must now define the abnormalities of position. First, we have supernumerary testicle, with which we have nothing to do. Second, the class of monorchids, or persons having only one testicle in the scrotum, the other lodged in the abdomen, inguinal canal, perineum or thigh. Provided there is one healthy testicle in the scrotum, of course these persons can reproduce and will not demand our attention. The third class, much more rare are cryptorchids, or those who have no testicle in the scrotum. These may be subdivided into those who have no testicles, or anorchids, those whose testicles are both in the abdominal cavity, or inguinal canals, and finally, those who are a mixture of the latter classes, i.e., having one testicle in the abdomen and one in the canal. Marshall states that monorchids occur once in eight hundred examinations, and that he found but one cryptorcliid in twelve thousand recruits. Hunter saw it but once or twice in his long surgical experience, and even such observers as Ernest Godard, who have made the subject a specialty, are able to collect, from personal observation, a paltry half dozen or more thus deformed, though the literature of the subject is prolific, and, in most cases, I regret to say, not very exact, such important elements as the examination of the seminal fluid being frequently omitted. The empty scrotum has been found to exercise a marked influence on the general appearance of some cryptorchids. They are frequently described as effeminate, having a shrill voice, beardless or downy face, a restless eye, in fact, just on the border-land of hemaphrodism. Others are hypersensitive, and in the celebrated case of Sir Astley Cooper’s apprentice, his deformity preyed so on his mind that he committed suicide. It must not be thought that all cryptorchids are thus stigmatized in appearance and manner. Many, unless confessing their con- dition, would pass as ordinary or even well-formed men, and ROBERT W. JOHNSON, M. D. 3 among the curious histories of some is the fact that their wives never suspected their husband’s shortcomings, so perfect were they in every other particular. What are the causes of non-descent? Mostly mechanical. Either the testicle is too large to pass or the rings abnormally small. The gubernacula might be wanting, or as Curling suggests, the cremaster spasmodically contracted, paralysed, or undeveloped. Peritoneal bands may intercept, or, finally, the truss cut off the avenue to the scrotum. Rosen- merkel, Mayo and Curling find no shortening of the vas deferens to account for the deformity. Interesting cases of temporary absence of testicles are noted where from violent colic, fever, or blow, both testicles have been drawn up th 3 inguinal canal and kept there until the exciting cause has been removed, while it is not by any means uncommon to find new-born males whose testes do not appear until varying times up to one year after birth. The Hungarian children are spoken of as abnormally slow in this regard. It would take too much of the Society’s time if we discussed the varied conditions in which the testicle is found when not descended. One can run the gamut from a normal gland to none at all, and find authorities for each stage. Suffice it to say, that M. Cloquet found the left testis situated within the abdomen, the same size and as well formed as the right situated in the scrotum. Mr. Curling, examining a specimen from the above mentioned apprentice of Sir Astley Cooper, finds both within the abdomen close to the internal rings, appearing to be nearly, if not quite, the natural size, and stated to contain semen. Dr. Bright finds a testicle in the abdomen smaller than natural; but ducts and secreting structure quite perfect. M. Cloquet finds a testicle in the left inguinal canal so small at forty years of age as not to be felt, flattened, elongated, and in a state of atrophy. Thus one might continue ad infinitum, without been able to elicit one general law, except this a priori, and, I think, a posteriori rule, i.e., testicles retained in the abdomen, ceteris paribus, have a better chance for health and natural function than when in the narrow confines of the inguinal canal, exposed as they are 4 REPORT OF SECTION ON PRACTICE. there, not only to blows, pressure from abdominal walls, constric- tion from belts, or what is worse for them, the misapplied truss, whose injudicious pressure prevents their natural function, and is probably the starting point of those malignant troubles that so often attack the testicle in this position. There is one point in favor of the inguinal locality that is not forthcoming in cryptorchids whose testicles remain within the abdomen, and that is their subjective influence. The man who finds his scrotum empty is likely to be much better satisfied if he can trace his testicles out a little higher up in the canal than he who finds no evidence of them at all, and it is really begging the question to appease a cryptorchid’s anxiety when he is told that his testicles are better in the abdomen than in sight, unless there are other means of proving to him that he possesses them anywhere. Interesting as the etiology and pathology of these curious deformities may be, there is another question that, from a prac- tical standpoint, far outweighs them, and that is, are cryptorchids sterile. Eight here must be drawn the distinction between sterility and impotence. Impotence is defined by Taylor as “Incapacity for sexual intercourse,” and we have too numerous witnesses to think for a moment that cryptorchids are impotent. On the contrary, as our table will show, they are sometimes Lotharios, and outstrip in woman’s estimation their better formed comrades. Sterility means inability to reproduce. With our present belief in the importance of the spermatozoa as factors of generation, we may lay aside that class of cryptorchids, or, as they are better termed, anorchids, who on dissection present no trace of testicle. These, fortunately for humanity, are very rare. Gruber has collected eight cases where this total absence of testicle was demonstrated by post-mortem examination. Cabrol, quoted by Geoff. St. Hilaire, is reported to have found in a soldier, hung for rape, an absence of testicles within and with- out, but whose semen filling the seminal vesicles contained spermatozoa. In the next sentence the author laughs him to scorn—a derision that the scientific researches of the present Robert w. Johnson, m. f>. 5 tend to reecho. Spermatozoa have been found days and weeks after castration capable of impregnating. Here the spring had ceased to flow, but the reservoirs were not yet empty. Comparative anatomy does not tell us that cryptorchids are necessarily sterile. We see animals with testicles normally in their belly creating after their kind, as the cetacea and elephant. Others find their natural habitat in the inguinal canals, as the rhinoceros and Sumatran tapir. Others again, in the perineum, as in civets. Some bring their testicles to the fore, either in the canal or to the rings, when there is a call for them during the rutting season, as in some rodents, so there would seem no sine- qua-non condition in the scrotum; yet it has been found that among animals whose testicles belong in the scrotum the cryptor- chids are usually sterile. Of whatever privileges the misplaced testicle may be deprived, there is no doubt that it can endure all the ills that its normal brother suffers. Epididymitis, orchitis, malignant growths,,]!ave been found existing in the retained gland, while some authors go so far as to claim that the position in the canal, exposed as it is to pressure and traumatism, is a prolific cause of sarcoma. Though I have no intention of wearying the reader with authorities or numerical deductions, I would present some results arising from the analysis of eighty-nine cases that I have been able to collect, mostly by means of the kindness and attention of Dr. Billings and his assistants in that invaluable library at Wash- ington : No. Age. Position of Testicles. Reporter. Fecundity. Remarks. i \dult. n abdomen. Dr. Marshall, Hints to Young Med. Officers in Army. Not noted. Never had appeared. 2 \dult. “ VIr. Hunter. Virile, [been found. Passions of a man. 3 Adult. “ near int. ring. sir Astley Cooper. Semen said to have Committed Suicide. 4 Adult. Mr. Wilson, Lect. on. Urin. and Gent. Organs, p. 408. No desire. Manly appearance. 5 8 years Mr. Curling on Testis, p. 106, Goddard. Not noted. Hernia on right side. 6 25 years Mr. Partridge, Communications to Pathol. Soc. No sperm found. 7 Adult. Mr. Partridge, Lancet, Jan , i860, p. 66. 4» 4 4 44 8 Adult. 44 Mr. Curling, Med. Times and Gazette, Feb. 23, 1861. 44 44 «4 9 30 years <4 Mr. Cock, Taylor’s Med. Jurisp. Reese, p. 686. Children. Twice married. 10 Adult. “ Virile. [no scrotum. IX 2