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Autolysis of the Testicle
AUTOLYSIS OF THE TESTICLE EDMUND ANDREWS
AND
ROBERT OSLUND
F'rorri the Department of Surgery and Physiology, University of Illinois, Illinois
Received for publication January 4, 1927
The following case represents a pathological syndrome which I have never seen described in the literature. The patient, J. male, aged twenty-one years, entered the hospital, April 30, 1926, complaining of bleeding hemorrhoids and absence of both testicles from the scrotum. The hemorrhoids were of about a. year's duration and he had had numerous attacks of thrombosis, and whenever he was constipated had marked pain and bleeding. The testicles had been absent from the scrotum since childhood. Patient states he bas erection at times but it is impossible for him to have any ejaculation. States he has no desire for women. History otherwise negative. The physical examinati.on revealed a well-nourished, white, adult male, who appears to be about eighteen years of age but who is actually twenty-one years. He is of average intelligence, having completed a three years course in high school at the age of seventeen years. He ap .. pears to have excess adipose tissue on his abdomen, gluteal region and thighs. The hair on the scalp is of very fine texture. There is no growth of hair on the bearded region of the face and he states that he has never shaved. The chest is somewhat obese with slight symmetrical adipose enlargement in the mammary region, but there is no overgrowth of glandular tissue and the areolae show no abnormalities. The abdomen shows an excessive adipose tissue and the public region is rather full with a female distribution of hair, the base of the triangle being upward. The genitalia are small, the scrotum is present and appears to be normally developed but no testicles are palpable in the scrotum, and no cord can be felt emerging from the inguinal canal. The extremities show a very poor muscular development, but a rather thick of fat for one of such a slight bony frame. 121
122
EDMUND ANDREWS AND ROBERT OSLUND
The rectal examination revealed a small hard nodular prostate. Diagnosis: Cryptorchidism; Froehlich's syndrome; hemorrhoids. Careful examination of the inguinal region failed to reveal the presence of any testes, even small ones, in the canals, nor was there any sign of herniation. The external ring was small and would not admit the tip of the little finger. No pulsation on coughing. In spite of this it was thought that we were dealing with a case of undescended testes and as there was an indication for surgery in the presence of the hemorrhoids it was thought to be justifiable to open the canal and bring the testicles, which probably lay in a high position, into the scrotum if possible so as to give them opportunity to develop. The inguinal canal was opened on the right side in the usual manner and as soon as the external oblique was split it was evident at once that our diagnosis had been wrong. The canal appeared most surprisingly empty. There was practically no cremaster muscle and the veins and arteries of the cord were missing. The only cord element which remained was the vas, appearing very nearly of normal size and lying along in the usual location of the cord. This vas stretched the entire length of the canal and disappeared into the scrotum. Traction on the vas brought up the testicle out of the scrotum and a very unusual pathological picture was presented. There was no tunica vaginalis whatsoever and the epididymis was quite small, about the size of a four- to six-year-old child. The tunica albuginea was fully developed, shiny, of normal thickness and consistency. It was, however, completely empty and appeared to contain a few drops of fluid but could be flattened out very much the size and shape of a nickel. Thus it appears that the tunica was about large enough to contain the testicular substance of a four- to five-year-old child, but the entire contents had disappeared, leaving an empty sac (fig. 1). Examination of the floor of the inguinal canal revealed no hernia and there was nothing which we were able to do to alleviate the condition so the testicle was replaced in the scrotum and the wound closed.
A careful search of the literature has failed to reveal any mention of such a pathological picture, and whether the condition was acquired or congenital it is impossible to say. If there ever was orchic parenchyma present it must have disappeared at a very early date to bring about the marked lack of male sex characteristics. Nevertheless one cannot help but incline to a theory that it was post-natal for several reasons. First, the vas
123
AUTOLYSIS OF TESTICLE
Fro, 2
FIG, 1
Fro, 3 FIG,
L
Fm, 4 No1nLH. TESTIS, SPERMATOGENESIS TAKING PLACJ,J aparL of tubuics is an artefact due to fixation)
CONTROL,
FIG, 2. Two \V,JEKS. NomiIAL, FIG,
3,
SoMIU TUBULE', UNDERGOING DEGENERATION,
OTHERS
SPER:VIATOGENESIS STILL TAKING PLACE IN TH,JSE LATTER
°EIGHT \VJ£EKS.
PLETELY STOPPED,
EXTENSIVE DEGENERATION,
SPERMATOGJUNESIS
COM.,
PARENCbYMA OF TUBULES REDUCED TO A SINGLE FLAT
LAYER OF CELLS.
Fm, 4. Foun l\Jo>fTHs,
CONSIDERABLE SHRINKAGE OF TUBULES
COMPLETE
Loss
OF
OPcHIC
PARENCHYJ\/LL
OF EN'I'IRID TuKICA WITH ADIPOSE TrssuE
FILLING
124
EDMUND ANDREWS AND ROBERT OSLUND
was large and well developed and it is well known that in congenital mal-development of the testes the vas is very tiny. One would not expect such a large vas if it had never functioned. Secondly, the tunica albuginea was apparently normal in thickness and about large enough to enclose the testes of a five-year-
Fm. 5
old child. It is difficult to believe that such an intimate part of the testes was developed normally from the complete absence of any testicular substance. More important, however, in this connection is the condition frequently observed by one of us (Oslund (1)) in experimental work on the testes of animals. In a large group of observations
AUTOLYSIS OF TESTICLE
it has been shown that the testes of young rats and guinea pigs, if traumatized will undergo complete autolysis. A wedge-shaped of tissue being excised and a tunica sewed together, in the course of a few months complete loss of all gland tissue regularly fot. lows. there appears areas of degeneration of the sperm cells which rapidly become reduced to a single flat layer and this process soon extends to the entire testis. The interstitial cells disappear and finally the fibrous intralobular trabeculae. All undergo autolysis, leaving only a liquid matrix, and in some cases as shown in the case of the series of microphotographs the space has been filled with faL Jaffe (2) has noted a very similar train of changes to follow the injection in the testes of bacillus melitensis. be interesting to mention the method that was Finally, it pursued in ancient and medieval times to produce eunuchs. It was well understood that there were two varieties. If castration was performed about the time of puberty little general bodily change resulted. Such eunuchs were very often a fine of man and held positions of responsibility, However, if castration was performed very early marked feminism resulted and such men were in demand for church choirs during the middle ages. However, the mortality of castration was said to have been 50 per cent, shock, sepsis and hemorrhage taking a terrible toll and a common method was the traumatic destruction of the testes closed procedures. I quote from Paulus Agineta, Book 6, 68: There are two methods of performing it (castration/, one by compression, the other by excision. That by compression is thus performed; children still of a tender age are placed in a vessel of hot water and then when the parts are softened in the bath, the testicles are to be squeezed the finger until they disappear and being destroyed can no longer be felt.
A similar operation is described by Celsus, Fabricious, and numerous other ancient and medieval authors. The effect of the hot water is interesting in view of the very important relation of heat to spermatical genesis as previously demonstrated by Oslund (3), (4).
126
EDMUND AKDREWS AND ROBERT OSLUND
One cannot help but suspect that in the case reported a somewhat similar syndrome might have taken place, and the dangers of trauma to the testes of young individuals should be kept in mind. SUMMARY
A case of complete autolysis of the testicle is reported. Such autolysis can be demonstrated to occur from trauma to the testes in young animals. REFERENCES (1) OSLUND, R. M .. Interstitial cell hypertrophy. Amer. Jour. Physiol., lxix, 589-598. (2) JAFFE, R. H.: Ueber die experimentelle lnfektion des Meerschweinchens mit dem Bacillus Melitensis und mit dem Bacillus Abortus. Veichow's Archiv, ccxxxviii, 219-235. (3) OSLUND, R. M.: A study of vasectomy on rats and guinea pigs. Amer. Jour. Physiol., lxvii, 422-443. (4) MooRE, C.H., AND OSLUND, R. M.: Experiments on sheep testis; cryptorchidism, vasectomy and scrotal insulation. Amer. Jour. Physiol., lxvii, 595-607.
AND
ROBERT OSLUND
F'rorri the Department of Surgery and Physiology, University of Illinois, Illinois
Received for publication January 4, 1927
The following case represents a pathological syndrome which I have never seen described in the literature. The patient, J. male, aged twenty-one years, entered the hospital, April 30, 1926, complaining of bleeding hemorrhoids and absence of both testicles from the scrotum. The hemorrhoids were of about a. year's duration and he had had numerous attacks of thrombosis, and whenever he was constipated had marked pain and bleeding. The testicles had been absent from the scrotum since childhood. Patient states he bas erection at times but it is impossible for him to have any ejaculation. States he has no desire for women. History otherwise negative. The physical examinati.on revealed a well-nourished, white, adult male, who appears to be about eighteen years of age but who is actually twenty-one years. He is of average intelligence, having completed a three years course in high school at the age of seventeen years. He ap .. pears to have excess adipose tissue on his abdomen, gluteal region and thighs. The hair on the scalp is of very fine texture. There is no growth of hair on the bearded region of the face and he states that he has never shaved. The chest is somewhat obese with slight symmetrical adipose enlargement in the mammary region, but there is no overgrowth of glandular tissue and the areolae show no abnormalities. The abdomen shows an excessive adipose tissue and the public region is rather full with a female distribution of hair, the base of the triangle being upward. The genitalia are small, the scrotum is present and appears to be normally developed but no testicles are palpable in the scrotum, and no cord can be felt emerging from the inguinal canal. The extremities show a very poor muscular development, but a rather thick of fat for one of such a slight bony frame. 121
122
EDMUND ANDREWS AND ROBERT OSLUND
The rectal examination revealed a small hard nodular prostate. Diagnosis: Cryptorchidism; Froehlich's syndrome; hemorrhoids. Careful examination of the inguinal region failed to reveal the presence of any testes, even small ones, in the canals, nor was there any sign of herniation. The external ring was small and would not admit the tip of the little finger. No pulsation on coughing. In spite of this it was thought that we were dealing with a case of undescended testes and as there was an indication for surgery in the presence of the hemorrhoids it was thought to be justifiable to open the canal and bring the testicles, which probably lay in a high position, into the scrotum if possible so as to give them opportunity to develop. The inguinal canal was opened on the right side in the usual manner and as soon as the external oblique was split it was evident at once that our diagnosis had been wrong. The canal appeared most surprisingly empty. There was practically no cremaster muscle and the veins and arteries of the cord were missing. The only cord element which remained was the vas, appearing very nearly of normal size and lying along in the usual location of the cord. This vas stretched the entire length of the canal and disappeared into the scrotum. Traction on the vas brought up the testicle out of the scrotum and a very unusual pathological picture was presented. There was no tunica vaginalis whatsoever and the epididymis was quite small, about the size of a four- to six-year-old child. The tunica albuginea was fully developed, shiny, of normal thickness and consistency. It was, however, completely empty and appeared to contain a few drops of fluid but could be flattened out very much the size and shape of a nickel. Thus it appears that the tunica was about large enough to contain the testicular substance of a four- to five-year-old child, but the entire contents had disappeared, leaving an empty sac (fig. 1). Examination of the floor of the inguinal canal revealed no hernia and there was nothing which we were able to do to alleviate the condition so the testicle was replaced in the scrotum and the wound closed.
A careful search of the literature has failed to reveal any mention of such a pathological picture, and whether the condition was acquired or congenital it is impossible to say. If there ever was orchic parenchyma present it must have disappeared at a very early date to bring about the marked lack of male sex characteristics. Nevertheless one cannot help but incline to a theory that it was post-natal for several reasons. First, the vas
123
AUTOLYSIS OF TESTICLE
Fro, 2
FIG, 1
Fro, 3 FIG,
L
Fm, 4 No1nLH. TESTIS, SPERMATOGENESIS TAKING PLACJ,J aparL of tubuics is an artefact due to fixation)
CONTROL,
FIG, 2. Two \V,JEKS. NomiIAL, FIG,
3,
SoMIU TUBULE', UNDERGOING DEGENERATION,
OTHERS
SPER:VIATOGENESIS STILL TAKING PLACE IN TH,JSE LATTER
°EIGHT \VJ£EKS.
PLETELY STOPPED,
EXTENSIVE DEGENERATION,
SPERMATOGJUNESIS
COM.,
PARENCbYMA OF TUBULES REDUCED TO A SINGLE FLAT
LAYER OF CELLS.
Fm, 4. Foun l\Jo>fTHs,
CONSIDERABLE SHRINKAGE OF TUBULES
COMPLETE
Loss
OF
OPcHIC
PARENCHYJ\/LL
OF EN'I'IRID TuKICA WITH ADIPOSE TrssuE
FILLING
124
EDMUND ANDREWS AND ROBERT OSLUND
was large and well developed and it is well known that in congenital mal-development of the testes the vas is very tiny. One would not expect such a large vas if it had never functioned. Secondly, the tunica albuginea was apparently normal in thickness and about large enough to enclose the testes of a five-year-
Fm. 5
old child. It is difficult to believe that such an intimate part of the testes was developed normally from the complete absence of any testicular substance. More important, however, in this connection is the condition frequently observed by one of us (Oslund (1)) in experimental work on the testes of animals. In a large group of observations
AUTOLYSIS OF TESTICLE
it has been shown that the testes of young rats and guinea pigs, if traumatized will undergo complete autolysis. A wedge-shaped of tissue being excised and a tunica sewed together, in the course of a few months complete loss of all gland tissue regularly fot. lows. there appears areas of degeneration of the sperm cells which rapidly become reduced to a single flat layer and this process soon extends to the entire testis. The interstitial cells disappear and finally the fibrous intralobular trabeculae. All undergo autolysis, leaving only a liquid matrix, and in some cases as shown in the case of the series of microphotographs the space has been filled with faL Jaffe (2) has noted a very similar train of changes to follow the injection in the testes of bacillus melitensis. be interesting to mention the method that was Finally, it pursued in ancient and medieval times to produce eunuchs. It was well understood that there were two varieties. If castration was performed about the time of puberty little general bodily change resulted. Such eunuchs were very often a fine of man and held positions of responsibility, However, if castration was performed very early marked feminism resulted and such men were in demand for church choirs during the middle ages. However, the mortality of castration was said to have been 50 per cent, shock, sepsis and hemorrhage taking a terrible toll and a common method was the traumatic destruction of the testes closed procedures. I quote from Paulus Agineta, Book 6, 68: There are two methods of performing it (castration/, one by compression, the other by excision. That by compression is thus performed; children still of a tender age are placed in a vessel of hot water and then when the parts are softened in the bath, the testicles are to be squeezed the finger until they disappear and being destroyed can no longer be felt.
A similar operation is described by Celsus, Fabricious, and numerous other ancient and medieval authors. The effect of the hot water is interesting in view of the very important relation of heat to spermatical genesis as previously demonstrated by Oslund (3), (4).
126
EDMUND AKDREWS AND ROBERT OSLUND
One cannot help but suspect that in the case reported a somewhat similar syndrome might have taken place, and the dangers of trauma to the testes of young individuals should be kept in mind. SUMMARY
A case of complete autolysis of the testicle is reported. Such autolysis can be demonstrated to occur from trauma to the testes in young animals. REFERENCES (1) OSLUND, R. M .. Interstitial cell hypertrophy. Amer. Jour. Physiol., lxix, 589-598. (2) JAFFE, R. H.: Ueber die experimentelle lnfektion des Meerschweinchens mit dem Bacillus Melitensis und mit dem Bacillus Abortus. Veichow's Archiv, ccxxxviii, 219-235. (3) OSLUND, R. M.: A study of vasectomy on rats and guinea pigs. Amer. Jour. Physiol., lxvii, 422-443. (4) MooRE, C.H., AND OSLUND, R. M.: Experiments on sheep testis; cryptorchidism, vasectomy and scrotal insulation. Amer. Jour. Physiol., lxvii, 595-607.