CHAPTER III.

THE MALE GENERATIVE ORGANS.

Section I. OF THE PENIS.

[=Notice=: Malformations; size; condition of prepuce and glans; chancres, warts, etc. Split open urethra and notice ulcers, strictures, etc.]

=Congenital Anomalies.= The penis may be very imperfectly developed, even with a normal development of the other organs of generation, although it more frequently occurs when the latter are themselves imperfect.

It occasionally happens that, from an arrest of union in the median line of the penis, a slit or fissure is left communicating with the urethra. This commonly occurs in the under surface, constituting _Hypospadias_; less frequently on the upper surface, (_Epispadias_,) and only in cases of extroversion of the bladder.

The prepuce may be wanting.

Congenital phymosis occasionally occurs, usually associated with atrophy of the penis. It is supposed by some, to be a predisposing cause of cancer of the penis.

=Hypertrophy and Atrophy.= In consequence of long-continued onanism, the penis may become hypertrophied, or as the result of chronic irritation and disease, we may have an hypertrophy of the prepuce and of the body of the penis, sometimes attaining an enormous size. Vidal has related and figured a case where the organ reached to below the knees, and was as large as a thigh. Atrophy of the penis, accompanied with obliteration of the cavernous textures, occurs with atrophy of the testicles.

=Fracture of the Penis= has occurred from the giving way of the erectile tissue during coition, in consequence of the state of hyperæmia of the penis. The organ appears broken, and cannot assume the erect condition beyond the part injured.

=Paraphymosis=, by the strangulation of the glans in front of a tight prepuce, may, if not relieved, lead to inflammation, and even gangrene.

=Balanitis= commonly occurs as the result of local irritation, not unfrequently set up by a gonorrhœa. The prepuce is much swollen, infiltrated and reddened. The inflammation is generally complicated with inflammation of the internal lamina of the foreskin, and the mucous membrane of the glans (posthitis), giving rise to excoriation, exudation of coagulable lymph, adhesion of the prepuce to the glans, suppuration and ulceration. “When chronic, it induces exuberant formation of epidermis; and if the deeper parts of the parenchyma of the glans are involved, obliteration, cartilaginous induration and atrophy follow.”

=Herpes of the Glans and Prepuce=, is characterized by the formation of small vesicles or excoriated points upon the mucous membrane of this region, chiefly occurring in persons of a gouty habit of body, with an irritable mucous membrane.

_Psoriasis_ of the prepuce, produces a red, thickened, and fissured condition of the part. Phymosis is apt to occur as a consequence.

=Chancres.= These specific ulcerations form usually upon the glans, although they may be found in the internal surface of the prepuce, the frænum, and near the meatus within the urethra.

The _Hunterian_ or _hard chancre_, is nearly circular, deep and excavated; base and edges are as hard as cartilage, but the hardness is circumscribed; its color is livid or tawny. It may occur upon the integument, the glans, or the body of the penis.

The _non-indurated_ or _soft chancre_ is more frequently found on the inner surface of the prepuce. It appears as a foul, yellowish, or tawny sore. Indolent fungous granulations are subsequently thrown out, unless it be situated upon the glans.

_Phagedenic chancres_ are of irregular shape, their edges ragged or undermined, their surface yellow and dotted with red streaks. The surrounding margin of skin usually looks pulpy and œdematous; but is sometimes firm and of a vivid red.

The cicatrices left by chancres which have healed, are whitish, more or less hard, striated and depressed.

Morbid Growths.

_Warts_, belonging to the class of epithelial tumors, sometimes form on the glans, or on the inside of the prepuce. They are commonly the result of repeated inflammations.

_Cancer_ of the penis is of two distinct kinds, occurring as scirrhus or as epithelioma. According to Dr. Walshe, the disease may originate as a warty excrescence, or as a pimple, which discharges an excoriating fluid, scabs, and breaks out afresh, while induration, followed by ulceration, advances at its base. Or it may infiltrate the glans, so as to convert that part into an indurated mass; or venereal ulcers may take on cancerous action.

When of the _scirrhus_ form, it usually springs from the ulcers behind the glans, and may thence invade the neighboring parts of the organ.

_Epithelioma_, commencing as a tubercle in the prepuce, may after a time give rise to a large, irregular, and sprouting mass, having a granular fungous appearance. In other cases, it commences as a hard scirrhus mass, of a pale, reddish-white color, situated on the glans, or between the prepuce and the glans. This increases in size, cracks, and allows the exudation of a serous fetid discharge. Ulceration then rapidly takes place.

Secondary cancers, except in the adjacent glands, are not a common occurrence. Phymosis and the irritation caused by the retained secretion, seem to act as an exciting, and advancing age as a predisposing cause of cancer.

_Encysted tumors_, _nævus_ and _fibro-plastic_ tumors, situated about the prepuce, may also occur.

Section II. OF THE SCROTUM.

[=Notice=: General condition; relaxed or contracted; œdema; cancer; tumors, etc.]

=Hypertrophy.= _Common hypertrophy_ of the integument of the corium sometimes occurs; in this there is no alteration of the subcutaneous tissue.

In _Elephantiasis_ of the scrotum, however, the epidermis, the corium, and the subcutaneous areolar tissue, are all, especially the latter, greatly hypertrophied. The areolar tissue is converted into a large mass of fibrous material, infiltrated with an albuminous and fibrinous fluid. “When the disease is confined to the scrotum, and the enlargement becomes great, the penis becomes drawn in and ultimately disappears, while the elongated prepuce is continuous at a navel-like opening in the skin of the surface of the tumor.” The enlargement sometimes is enormous, such a mass having been known to weigh two hundred pounds, more than the weight of the rest of the body.

=Inflammatory Œdema= of the scrotum is an erysipelatous inflammation of this region, giving rise to great effusion into and swelling of the areolar tissue, with a tendency to the rapid formation of a slough, by which the integument may become so affected as to leave the testes and cords entirely denuded. A peculiar form of this disease occurs as a sequence of small-pox and scarlet fever. Here there is a tendency to speedy gangrenous disorganization of the areolar tissue, and of the covering of the generative organs.

Morbid Growths.

_Cancer._ _Epithelial cancer_ is the common form under which it attacks the scrotum. This disease has appropriately been called _chimney-sweeper’s cancer_, as it appears to arise from the irritation of the soot lodging in the folds of the scrotum. It commonly commences as a tubercle or wart, which, after a time, cracks or ulcerates. It spreads rapidly, involving at last the greater part of the scrotum, and sometimes invading the testes, even extending to the groin and thigh, destroying life by perforating the coats of some of the large vessels. The glands of the groin are not always affected.

_Melanotic_ cancer of the scrotum has been observed.

_Fibrous tumors_ are sometimes developed in this part, and may form a large mass when several are grouped together.

Section III. OF THE TESTICLES.

[=Notice=: Malformations; position, in scrotum, inguinal canals, or abdomen. Size; consistence; condition of coats. _Tunica vaginalis_—contents; serum, blood; adhesions. Abscesses; cysts; tumors; cancer; tubercle, etc.]

=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.

Section IV. THE SEMINAL VESICLES AND PROSTATE.

[=Notice=: 1. _Seminal vesicles_—present or absent; size; distended or empty; contents. Condition of mucous lining; inflamed, thickened, ulcerated, perforated; tubercular deposits, etc. 2. _Prostate gland_—abnormalities; size; density; enlargement of middle or lateral lobes; color of section; appearance of inflammation; abscess; tumors; cancer; tubercle. _Contents of ducts_—calculi: their position, size, etc.]

=Congenital Anomalies.= The vesiculæ seminales participate in the defective development of the testes, being absent or imperfect when their related glands are so.

=Inflammation.= It is not uncommon for these bodies to be attacked with chronic catarrhal inflammation, which causes a swelling of their mucous membrane, the secretion of unhealthy mucus, dilatation of the cavity, and thickening of its walls. Ulceration, perforation, and the formation of abscess in adjacent parts, may result.

=Tubercular Deposits= are occasionally met with, chiefly in cases of extensive tuberculosis. “It appears as a thick, yellow, cheesy, lardaceous, fissured, purulent layer, replacing the mucous membrane.” It never occurs before puberty.

The Prostate Gland.

=Congenital Anomalies.= When the organs of generation are imperfectly developed, the prostate gland is generally found to be so too.

=Hypertrophy and Atrophy.= _Hypertrophy_ is of frequent occurrence, especially in connection with old age. All the lobes may be enlarged equally, or nearly so, or one or the other of the lateral lobes alone, or the middle lobe, without any corresponding hypertrophy of the lateral. Hypertrophy of the middle lobe, when considerable, throws the neck of the bladder forward, and increases the depth of its lower region, so that calculi may lodge behind and below the prostate in its cavity. The canal of the urethra becomes lengthened in its prostatic portion, and may be narrowed by compression, or considerably dilated, so that the prostatic sinus may contain two or three ounces of urine. The retained urine decomposing, may cause irritation and inflammation of the bladder.

The texture of the enlarged gland is generally indurated, though sometimes it is found to be looser and softer than natural. On section, the cut surface bulges above the level, and the shades of color are more strongly marked than in health. Frequently single gland-lobules are found hypertrophied. Small cavities, dilatations of the gland-follicles, are occasionally met with, sometimes empty and sometimes containing a yellow, pus-like fluid, the prostatic secretion in a thickened state.

_Atrophy_, with consolidated texture, is found with atrophy of the testes.

“_Eccentric atrophy_ is occasionally met with; the cavities are dilated and the walls thinned, in consequence of the increase in size of calculous concretions in its follicles. Cases sometimes occur, in which the whole of one lobe, or even the entire organ, is converted into a thin fibrous capsule, the proper substance of the gland being almost wasted.”

=Inflammation.= As a result of suppressed gonorrhœal discharge, the prostate may be attacked with acute inflammation, followed by suppuration, or chronic enlargement, or an irritable state of the gland, with increased secretion.

_Abscesses_, single or multiple, may occur, and open into the bladder, into the prostatic sinus of the urethra, into the rectum, or, externally through the perineum.

Ulceration rarely occurs.

Morbid Growths.

_Cancer_ of the prostate is rare; encephaloid is almost the only form that occurs. The gland is enlarged and the growth may perforate the mucous membrane of the bladder, and vegetate in its cavity.

_Tubercles_ occasionally occur. Their softening and disintegration give rise to abscesses, which pursue the same course as inflammatory abscesses.

_Fibrous tumors_, varying in size from that of a pea to a nut, are of frequent occurrence; sometimes but loosely attached to the hypertrophied gland.

_Cysts_ are of extremely rare occurrence, commonly resulting from closure and dilatation of the gland-follicles.

_Concretions._ “In greater or less numbers, they are of almost constant occurrence in the prostatic cavities; they may often be seen on making a section of the gland, as reddish-yellow grains. Their form varies very much; in the smaller it approaches the oval or circular; in the larger it is more polygonal or triangular. They are not unfrequently pale or colorless. The contents of these semiorganized formations appear to be earthy matter (phosphate, with a little carbonate of lime), tinged by the ordinary yellow pigment which is so often derived from the blood.

It is most probable that, in ordinary healthy states, these concretions undergo solution at an early period of their existence, yielding up their contents to form part of the secretion of the gland. But, if this does not occur, and they go on increasing in size, they become the nuclei, or are developed into _prostatic calculi_. These are not unfrequently very numerous; as many as fifty or sixty have been found in an atrophied, dilated prostate. The calculi sometimes cohere, and form a large mass, projecting into the membranous portion of the urethra, which becomes in consequence much dilated. The smaller calculi often escape into the bladder through the dilated prostatic ducts; if they remain there, they excite irritation of the mucous membrane and deposition of phosphates upon their own surface.”