Chronic The testicle is liable to a form of inflammatory swelling of a distinct and chronic character, which occasionally succeeds acute orchitis but far more com monly arises spontaneously. The disease is of importance ; for, if unchecked, it tends to disorganise and destroy the gland. The chief anatomical character of this form of inflam mation is the deposit of a peculiar yellow, homogeneous, inorganic matter in the struc ture of the testicle. This substance when first formed is of soft consistence, but after wards becomes firm and solid, and so closely adherent and intimately blended with the proper structure of the organ as not to admit of separation without much difficulty. In some instances there is a single deposit of this substance in the centre of the glandular structure, as in the preparation from which the annexed woodcut was taken. In others several are interspersed throughout the tes ticle, portions of sound gland intervening. In a case of chronic enlargement of both testicles taken from a patient who died of ramollissement of the medulla spinalis, I found six or seven separate deposits of this yellow matter in the substance of the right testicle, and a single one only in the body of the left. The small masses as they enlarge coalesce, or the single one increases, until the whole testicle presents an uniform yel lowish-white appearance. The epididymis is frequently invaded at the same time by a similar kind of morbid deposit, which also tends to obliterate its tubular structure. This, however, is not, as some pathologists suppose, a constant occurrence ; for in the majority of testicles thus diseased that 1 have examined, the epididymis had entirely escaped. I have never succeeded in injecting this deposit, or in tracing vessels into it. But the vessels of the testicle generally are enlarged. Patholo gists have differed as to the particular tissue in which this yellow matter is deposited. Sir A. Cooper and Cruveilhier describes it to be seated in the areolar tissue between the tubuli; whilst Sir B. Brodie is of opinion, that it is secreted from their inner surface, as he discovered the yellow substance in the canal of the epididymis and also in the vas deferens which are continuous with the tubuli. I have had the opportunity of in specting a testicle affected with this disease, in what seems to me to be its early stage from which examination I think I have been able satisfactorily to confirm this opinion. The testicle was injected with red size, and a section then made of it. The surfaces of the tunica vaginalis were partly adherent, and about three drachms of serum were collected in one part of the sac. The body of the tes ticle was not much enlarged : it contained, however, an abundant deposit of a firm opaque matter. Near the anterior edge of the testicle this deposit appeared in the section like round isolated yellowish-grey bodies, separated from each other by portions of the sound structure of the gland : about the centre of the organ it assumed a beaded arrangement, and towards the mediastinum formed a number of closely set yellow lines or processes, radiating towards the posterior part of the testicle, where they were amalgamated into one uniform mass. Further examination perfectly satisfied me that this matter was lymph deposited in the tubuli seminiferi. The isolated and beaded appearances in the section resulted from breaks in the lymph thus deposited. The real seat of the effusion was very evident, from the arrangement described near the mediastinum. With a good lens some of the convoluted tubuli could be distinctly seen, filled with and dilated by the morbid deposit. A portion was carefully examined in the microscope with a similar result. The epididymis was much enlarged ; its head was filled with soft concrete matter, surrounding an irregular cavity with which a fistulous sinus com municated ; its tail contained a similar sub stance without any external opening. The various appearances described are depicted in the adjoining figure, which was taken from the recent specimen. Similar appearances to those noticed in this case have been described and figured by Cruveilhier, in his," Anatomic Pathologique."# He considers that the dis ease proceeds from the head of the epidi dymis towards the tail, and that the body of the testicle is affected only consecutively. I believe, myself, that the yellow deposit is the ordinary result of chronic inflammation of the testicle in whatever way produced ; but that the peculiar appearances noticed in the case just related and likewise described by Cru veilhier, — I mean the small isolated masses in the substance of the gland, and radiating towards the mediastinum, —are only observed in those cases in which the disease originates in the epididymis, and thence spreads to the body of the testicle, and in which the part is examined before the organ has become ex tensively diseased. These appearances are not often seen, because it is not often that it becomes necessary to remove a testicle in such a condition, which is indeed a curable one unless complicated with suppuration. Cruveilhier supposes that this matter is effu sed in the areolar tissue of the testicle, and radiates along the fibrous prolongations from the corpus Highmori. I feel satisfied, however, from my own observations, that he is mis taken, and that the interior of the tubuli is the original seat of the deposit. This yellow substance has been called the yellow tubercle of the testis; but, as it differs from tubercular deposit, the term is objectionable and liable to lead to error. It is evidently coagulable
lymph, which becomes more solid in the testicle than in most other parts, owing, per haps, to the condensation consequent on the firm resistance offered to any enlargement of the gland by the unyielding tunica albuginea. This disease is often accompanied with effu sion of serum into the tunica vaginalis, seldom amounting, however, to more than three or four ounces. Lymph also is sometimes de posited, and the sac may become partially, or totally obliterated by adhesions.
The peculiar matter effused in this disease under appropriate treatment undergoes com plete absorption, the testicle being left in a condition to perform its natural functions. It sometimes happens, however, that ulcera tion ensues in its tunics and integuments, and that a fungous-looking growth gradually pro trudes through the opening which is thus formed. This fungous growth is sometimes termed granular swelling ; it has also received the name of hernia testis, being formed in a manner very analogous to that of a hernia cerebri, in which the substance of the brain is protruded through an ulcerated opening in the dura mater. It appears that the yellow deposit after some time excites ulceration in some part of the tunica albuginea. The tunica vaginalis, and afterwards the skin, become adherent at this spot, and likewise inflame and ulcerate. The resistance afforded by the dense unyielding tunica albuginea being thus removed, the adventitious deposit gradually presses out the tubular structure, which forms a projecting tumour consisting:of the tubuli mixed up with this yellow substance, and also of ordinary granulations which spring up from the seminiferous structure. This projecting growth presents an ash or yellowish-white ap pearance, varied by irregular patches of a pale red hue, and sometimes of black. It is closely girt by the scrotum, the ulcerated edges of which are often thickened and everted. (fig. 651.) The mass often projects so much that scarcely any part of the organ is contained within the scrotum. Though this hernial growth occurs most frequently in an advanced stage of the chronic form of inflammation, it is developed in other diseases of the organ which occasion ulceration of the tunica albuginea, and thus afford an opening for the escape of its con tents. It is occasionally the result of an attack of acute inflammation supervening upon the chronic disease, and terminating in suppuration in the substance of the gland. In a case of this kind, in addition to the glan dular swelling, there are sinuses more or less numerous, which burrow in the interior of the organ, and discharge pus mingled with the yellow matter. An attack of orchitis, origin ally acute, going on to suppuration, is also liable to be followed by a fungous protrusion of the secreting structure of the gland. In the latter case, the growth is not so exube rant, and the seminiferous structure is more distinctly apparent, owing to the absence of the yellow matter ; but there are generally sinuses which furnish a purulent discharge, sometimes mixed with semen. Tubercular matter deposited in the testicle may also lead to suppuration, and the formation of a granu lar swelling.
A testicle after becoming somewhat en larged from chronic inflammation, often con tinues indolent and stationary for years, giving rise to very little inconvenience. On examining the organ in this state, the yellow adventitious deposit is found to possess con siderable firmness and consistency ; the tunica albuginea is thickened, and in some places as dense and indurated as cartilage ; and the surfaces of the tunica vaginalis are closely connected by old adhesions. The glandular structure is partly displaced and atrophied by the pressure of the yellow matter ; and it often happens after some time, that both undergo a slow process of wasting, so that an enlarged and indurated gland is progressively reduced, until scarcely any thing remains beyond a mere nodule of the size of a nut at which the spermatic cord terminates. I found, on examination of the body of a man who some few years previously had suffered from chronic inflammation of the testicles, both glands much indurated, but about the natural size. In both, the tubular structure was very deficient, its place being supplied by a dense fibrous tissue. At the upper part of the right testicle there was a yellowish de posit almost as dense as cartilage, and ex hibiting very little trace of vascularity. In these indurated testicles the epididymis often escapes the morbid alteration affecting the body of the gland ; in other cases, however, the epididymis is also found nodose, irregular, and hard. It will be perceived, from the pre ceding observations, that the tendency of this chronic disease is gradually to destroy the integrity of the testicle. If the inflamma tion he checked in an early stage, the gland is left unimpaired ; if its course be not arrested until a later period, the secreting structure is partly disorganised and reduced in size ; but if the disease be allowed to continue un checked by treatment, the organ is totally destroyed, either by ulceration of its tunics and the escape of the glandular structure in the shape of a fungous growth, or by the slower process of wasting and absorption.