ON 
Inguinal Testicle, 
AND ITS OPERATIVE TREATMENT BY 
TRANSPLANTATION 
INTO THE 
SCROTUM. 
BV 
PROFESSOR DR. MAX SCHULLER, 
OF OtimWAtD, OK^RlMVi 
REPRINT. 
BROOKLYN, N. Y. : 
Annals or Anatomy and Surgkryi 
28 Madison Street. 
1881. ON INGUINAL TESTICLE, AND ITS OPERATIVE 
TREATMENT BY TRANSPLANTATION 
INTO THE SCROTUM. 
By PROFESSOR DR. MAX SCHULLER,' 
OF GREIFSW ALD, GERMANY, ' 
DOCENT DER CHIRURGIE IN THE UNIVERSITY OF GREIFSWALD. 
AS we know from embryological investigations, the 
testicle is found originally in the abdominal cavity 
below the kidney. It descends gradually, however, during 
the foetal development, apparently in consequence mainly 
of the traction of the so-called Hunter’s guiding ligament 
(Gubernaculum Huntcri). This latter is a muscular elastic 
string arising from the lower posterior surface of the testicle 
and the epididymis, and branching off into three ends, one 
of which inserts itself at Poupart’s ligament, the other on 
the anterior surface of the pubic arch, and the third, the 
longest, passes through the inguinal canal and takes root at 
the bottom of the scrotum. Under the influence of this 
striped muscle the 11 descensus tcsticuli" takes place within 
the foetal period. During the seventh month the testicle is 
situated behind the inguinal ring; during the eighth month 
the testicle commences to pass through the inguinal canal; 
with the ninth month the external inguinal ring has been 
passed, and after birth the testicle is found in the scrotum. 
This normal descensus tcsticuli may become interrupted or 
retarded by several influences, some of which are not yet 
known, and then the anatomical relations of the testicle to 
the peritoneum and to the sheaths which form around the 
fcf- 
Reprinted from the Amt*k Anal*m‘ W Surge*Vol. iv., No. 3, 
September, 1881. vw $ &C 1 2 
MAX SCHULLER. 
testicle itself and around the spermatic cord must necessarily 
differ from the normal. If the testicle has remained high 
up in the abdominal cavity (abdominal testicle), we find it 
behind the peritoneum, enveloped by this membrane like 
the kidney, often so extensively that a mesorchium, which 
in some respects may be compared with the mesenterium, 
presents itself. The inguinal canal is empty, the corres- 
ponding half of the scrotum imperfectly developed. Such 
a condition generally is not lasting; usually at a later 
period the testicle descends further; this retarded descent, 
however, is seldom a complete one. As a rule, the retained 
testicle descends somewhat at the age of puberty, in some 
exceptional cases even later. The abdominal testicle is not 
seldom preceded by a peritoneal pouch reaching down into 
the inguinal canal. This pouch, to all appearances, consists 
in an independent development of the so-called Seiler’s 
ccecum—that is, the extreme lower end of the proccssiis 
vaginalis peritonei. This peritoneal pouch may facilitate 
the entrance of the testicle, and at the same time may 
be followed by formation of hernia. The testicle when 
located in the inguinal canal at birth (inguinal testicle), 
and remaining there, may give rise to symptoms at a rather 
early period. It temporarily swells, especially at the period of 
puberty, becomes painful, or descends further in the in- 
guinal canal, leaving this canal at times and returning again 
at other times. In such cases we always find alongside of 
the testicle a more or less deep sac-shaped peritoneal 
pouch, the tunica vaginalis, into the branch of which the 
testicle and the epididymis are entered; the spermatic cord, 
remaining outside of this sac, is attached to the outer sur- 
face of the tunica-vaginalis-canal. Around this and the 
spermatic cord is further drawn a fibrous and a muscular 
layer. While the fibrous layer is given off exclusively from 
the walls of the inguinal canal, it appears that the muscular ON INGUINAL TESTICLE. 
3 
layer (cremaster) originates partly from the muscular gubcr- 
naculum Hunteri. It is at least not unlikely that with the 
descent of the testicle both lateral ends, or bellies, of the 
gubernaculum, which insert themselves at Poupart’s liga- 
ment and at the pubic arch respectively, attach themselves 
loop-like to the sides of the testicle and the spermatic cord, 
and, together with the muscular fibres originating from the 
oblique and transverse muscles of the abdomen, enter into 
the formation of the muscular hollow cylinder, the cremaster, 
which surrounds the testicle and spermatic cord. According 
to others, these ends, or bellies (the lateral ones), do not 
really belong to the gubernaculum, but are derived from the 
internal oblique and transverse muscles of the abdomen. 
At former anatomical examinations of foetuses of dif- 
ferent ages, however, I had opportunity to convince 
myself that they really belong to the gubernaculum. 
As we know from experience, the inguinal testicle possesses 
great mobility, it protrudes easily from the inguinal canal 
under the integument in front of the external abdominal 
ring, and likewise returns easily, not only into the inguinal 
canal, but also into the abdominal cavity. I am inclined to 
suppose that it is just the muscular layer spoken of which, 
by occasionally contracting, causes the frequent return into 
the abdominal cavity. This may, perhaps, be favored also by 
complete absence of the middle end of the gubernaculum. 
If this end is altogether unattached, the testicle necessarily 
not only does not enter the scrotum, but at the same time 
its return into the abdominal cavity must be facilitated. 
Under such circumstances it may sometimes be the case 
that the tunica-vaginalis-canal, together with the testicle, 
has been drawn upward, and at the same time has become 
inverted like the finger of a glove. But I believe that, as 
a rule, it, together with the testicle, is drawn back into a 
pocket of cellular tissue, formed before the internal aperture 4 
MAX SCHULLER. 
of the inguinal canal by downward pressure of the peritone- 
um of the pelvic abdominal wall. So at least I found it in 
a case which I shall describe further down. Then the tuni- 
ca-vaginalis-canal, drawn back together with the testicle, 
forms a sac situated in front of the peritoneum, into which 
—on account of its permanent communication with the 
abdominal cavity—occasionally a hernia may enter. It is 
possible that the testicle may return without the entire 
tunica-vaginalis-canal following, namely in those cases in 
which a sac-shapcd pouch of the latter, below the testicle 
situated in the inguinal canal, reaches down into the scrotum. 
Under such conditions the testicle may return into the 
inguinal canal, not only when hanging within a mesorchium 
in the tunica-vaginalis-canal, and therefore possessed with 
more than normal mobility, but also when drawn back to- 
gether with the nearest part of the tunica vaginalis only. 
There remains then in the scrotum below the inguinal ring 
a sac-like pouch of the tunica vaginalis, even when the 
testicle has completely returned into the inguinal canal; 
within this pouch, alongside of the testicle placed somewhat 
higher, we may find sometimes the spermatic cord hang- 
ing down in the shape of a downward directed loop. Only 
recently I had an opportunity to observe this state of things 
in a patient after reposition of an inguinal testicle into the 
abdominal cavity. In such cases sometimes we find also 
a portion of intestine or omentum in the open tunica-vagin- 
alis-canal. This may, passing the testicle, enter into that 
part of the tunica-vaginalis-sac which extends lower down, 
and located there, it appears that it may prevent the descent 
of the testicle further down into the scrotum. More fre- 
quently then in this form we observe hernia behind the tes- 
ticle, intestine or omentum having entered behind the testi- 
cle into the open tunica-vaginalis-canal. 
These frequent complications of the inguinal testicle with ON INGUINAL TESTICLE. 
5 
hernia have, perhaps, as often been the cause of error in 
diagnosis between inguinal testicle and hernia, as the loca- 
tion, the mobility and other symptoms of inguinal testicle, 
but the true state can be very easily discovered by careful 
examination of the scrotum and the inguinal region. The 
corresponding half of the scrotum is empty. The scrotum 
surrounds only one testicle, grasping it pretty tightly. The 
inguinal testicle forms in the inguinal region a roundish- 
oval, more soft than hard swelling, with several strings of 
vessels which are continued upward. ,As a rule, it has been 
arrested in its development, is small and of infantile con- 
dition, though it may not always remain in the low state of 
development corresponding with the foetal period at which 
the development was interrupted. The epididymis and the 
the spermatic cord, however, are developed to their normal 
size and these formations appear, in consequence of the 
smallness of the testicle, generally of unusually large and 
massive development. The small inguinal testicle reacts 
upon pressure as lively as a testicle of normal de- 
velopment, indeed, I have not seldom observed a much 
greater tenderness of the same. This tenderness is 
very characteristic, and distinguishes the inguinal testicle 
very well from an omental hernia, which would be the thing 
most liable to be confounded with it. In my opinion, a 
hernia co-existing with the inguinal testicle may render the 
diagnosis somewhat more difficult only in such cases in 
which the hernia, after having passed the inguinal testicle, 
has entered deeper down into the tunica-vaginalis-sac. 
But, after reduction of the hernia, which, on account of the 
relatively great width of the canal of the vaginal process, 
does not generally happen to be difficult, we may soon be 
able to inform ourselves of the real state of affairs. The 
absence of the testicle in the corresponding half of the 
scrotum, the presence of a soft or moderately firm, roundish 6 
MAX SCHUf.LER. 
body, with vascular strings, often coil-like, surrounding it 
and continuing themselves towards the abdominal cavity, 
and the characteristic tenderness of this body at the exter- 
nal inguinal ring, or in the inguinal canal, are pathogno- 
monic. If, as it not seldom happens, the inguinal testicle 
has been pushed out of the inguinal canal by cough or 
pressure, it is apt to be confounded with omental hernia, 
but can also easily be distinguished therefrom by the symp- 
toms enumerated. Besides, omental herniae, do not gener- 
ally possess the lively mobility which is quite characteristic 
of the inguinal testicle. If this mobility is lost in conse- 
quence of inflammatory processes, the distinction, on the 
other hand, is facilitated by the swelling, the enlargement 
and the firmness of the testicle. 
All patients with movable testicle retained in the abdom- 
inal cavity, or in the inguinal canal, sooner or later experi- 
ence varying complaints necessitating our interference. 
Whenever such a testicle, leaving the abdominal cavity, or 
returning again from the scrotum, enters into or passes 
through the inguinal canal, it suffers, as a rule, a more or 
less severe pressure from the firm walls of the inguinal 
canal, which pressure is always accompanied by a character- 
istic sensation of pain. This pain, especially while the 
testicle is pushed through the external or internal aperture, 
is described sometimes as quite similar to that of concussion 
of the testicle. These pains of incarceration are the more 
troublesome, as they repeat themselves most frequently, 
though not always, with equal severity; in some cases with 
every violent movement, with stooping down, pressure, 
running, jumping. As a rule, the sensation of pain soon 
passes away, but it may become so intense that the patients 
vomit, faint, etc. This I observed only recently in a case. It 
is comprehensible that under such circumstances we at first 
suspect incarcerated hernia, and it is necessary to make the ON INGUINAL TESTICLE. 
7 
examination the more carefully, because inguinal testicles 
not seldom are accompanied by herniae. If we do not at 
once attempt reduction, but first examine the parts very 
carefully, we soon will discover the true state. In the case 
of incarcerated testicle the symptoms readily disappear if 
the patient is laid horizontally with relaxed abdominal walls 
and if cold applications are made. Usually, however, there 
remains an extraordinarily increased tenderness of the testi- 
cle in patients with movable inguinal testicle. The slightest 
touch sometimes is painful. 
The frequent incarceration of the inguinal testicle, besides 
these troubles, gives rise to oedematous or inflammatory 
swellings of the testicle and the tunica vaginalis, to hydro- 
celes, etc., whereby the complaints are augmented. It is, 
further, easily comprehensible that accompanying herniae 
increase the difficulties of the inguinal testicle by their 
causing a constant pressure on the same. Occasionally 
there also may happen incarceration of hernia. Finally, it 
is a fact established by experience of long standing that 
testicles interrupted in their normal descent, and especially 
the movable inguinal testicle, in relatively a great number of 
cases, become attacked by malignant new formations, by 
sarcomas and cancers, which fact, according to Cohnheim, 
we may well bring in connection with the interruption of 
development and growth of the testicle, which, as stated 
above already, are accompanying symptoms of the inter- 
rupted descent. Cohnheim, as is known, supposes that the 
retained testicle shows a great inclination to formation of 
malignant tumefactions because “ the existing germs of 
growth, on account of the retention, have not attained their 
regular development.”1 
All these difficulties and secondary diseases of the in- 
1 /. Cohnheim, Vorlesungen liber allgemeine Pathologie. Berlin, 1877. 
I. Bd., p. 643. 8 
MAX senUf.LEA'. 
guinal testicle make remedies and help desirable. In the 
case of abdominal testicle we may, as a rule, find no cause 
for interference before it has entered into the inguinal canal 
—that is, before it has become inguinal testicle. As a gen- 
eral thing, first a truss is recommended, either with the 
intention of pushing the movable testicle down into the 
scrotum, or for the purpose of keeping it back in the 
abdominal cavity. In the latter case, after reposition of 
the protruding testicle has been made, the truss is to be 
worn on the external inguinal ring, while in the former we 
have the pad lying above the testicle, which has been 
protruded from the external aperture of the inguinal canal, 
thus to push gradually the testicle downward and to 
prevent its sliding back. For this end, the application of 
trusses with fork-shaped pads is thought especially useful. 
Even if a success has been obtained in some cases by this 
treatment, we must not expect too much from it. In spite 
of the best constructed truss, the testicle occasionally will 
slip back into the inguinal canal, or from this it will glide 
from under the pad, and it is readily understood that under 
such circumstances a truss can be not only of no advantage, 
but must directly do injury by increasing the difficulties of 
incarceration. In general, I do not believe that the oc- 
casional entering of a movable testicle from the abdominal 
cavity into the inner opening of the inguinal canal can ever 
be prevented completely by means of a truss. If a hernia 
protrudes behind or alongside an inguinal testicle, the diffi- 
culties of the treatment by truss become still greater, and 
the results attained by the same very imperfect and unsatis- 
factory. The trusses with hollow pads, which have been 
recommended for this complication, are equally inefficacious 
to prevent the occasional incarcerations of the inguinal tes- 
ticle. In view of this inadequateness of the treatment by 
truss in cases of inguinal testicle, I feel justified in recom- ON INGUINAL TESTICLE. 
9 
mending instead, for proper cases, the bloody transplantation 
of the testicle into the scrotum.1 By this operation, however, 
I do not mean the mere attachment of the testicle in the 
scrotum by means of suture—a method which might be of 
only little reliance. I am of the opinion that, above all 
things, the influence of the cremaster upon the testicle has 
to be annihilated, and the passage of the inguinal canal 
obstructed. As is easily to be seen, a reliable and lasting 
fixation of the testicle in the scrotum, therefore, can only be 
secured when, in addition to the division of the muscular 
envelope of the spermatic cord and the tunica vaginalis— 
after the vessels of the spermatic cord have been isolated— 
the tunica-vaginalis-canal also, at the orifice of the inguinal 
canal, and 'the external opening of the latter itself, have 
been closed by means of the suture. Only then is it to be 
expected that the testicle, attached by means of suture, 
no longer being pulled at, will permanently remain in the 
scrotum ; the sliding back into the inguinal canal is made 
completely impossible. 
After this plan of operation, I have, in a vigorous lad of 
20 years, transplanted, with completely favorable result, a 
movable right inguinal testicle, which was resisting all treat- 
ment by trusses, from the abdominal cavity, whither it had 
/ 
retracted itself at the time, into the corresponding half of 
the scrotum. 
To prepare the patient, a purgative is given the day be- 
fore the operation, or the intestines are washed out by 
means of a rectal tube. In the morning, before the 
operation, the patient should take a warm bath, and the 
whole pelvic region be most thoroughly soaped and 
cleansed. The operation is to be made under strictly anti- 
septic precautions. 
1 Kother states that Rosenmerkel and Chelius have already attempted, 
without success however, the bloody transplantation of the inguinal 
testicle. I have not been able to find the description of their method. 10 
MAX SCHULLER. 
The method of operation is as follows: If, as in my case, 
the movable inguinal testicle has slipped back into the 
abdominal cavity, and the anterior aperture of the inguinal 
canal is found completely empty, we divide exactly as in 
incision for hernia, integument and fascia over the external 
inguinal opening, continue the incision down into the empty 
half of the scrotum, divide the loose cellular tissue covering 
the aperture, and pass the fingers through the inguinal canal 
into the preperitoneal space, in the wall of which the re- 
tracted testicle is lying. It is difficult to feel, as it is usually 
small; it is, however, easily recognizable by the strings of 
vessels of the spermatic cord, which generally are strongly 
developed. This mass is hooked with the index finger, 
drawn against and finally passed through the inguinal canal. 
Within this mass the testicle is found. It can now easily 
be felt within its coverings. We next draw a thread-loop 
through the sac-shaped extreme lower end of these cover- 
ings, for the purpose of holding the testicle well outside of 
the inguinal canal. We then divide in a longitudinal direc- 
tion, commencing from the inguinal ring, down to near the 
testicle, the muscular and fibrous coverings in which, as in a 
sac, the spermatic cord and the testicle are lying, and divide 
also the tunica vaginalis. After this, follows the isolation 
and mobilization of the spermatic cord : Carefully avoiding 
the vessels and nerves of the spermatic cord and vas defer- 
ens, we divide, in a horizontal line, somewhat above the 
testicle, the tunica vaginalis, and likewise the muscular and 
fibrous coverings of the spermatic cord, and loosen the 
same a little way, like a ring, from off the spermatic cord ; 
we may even remove a piece of these coverings. As soon as 
this has been done, the testicle and the spermatic cord, without 
the slightest difficulty, can be drawn as low down as is required 
The testicle remains down, and cannot retract itself again. 
Then follows the fixation of the testicle to the bottom of ON INGUINAL TESTICLE. 
11 
the scrotum, by means of suture. We fasten it by the ap- 
plication of some cat-gut sutures passing through its poster- 
ior and lower surface, in such a manner that it rests on a 
base as broad as possible; in addition, we pass some lateral 
sutures from it through the integument of the scrotum, and 
tie the same outside on the tegumentary surface (mattress 
sutures) to secure as firm a fixation as possible, of the 
testicle in its new bed. The next act of the operation is 
that of the occlusion of the tunica-vaginalis-canal and of the 
external inguinal ring. We first pass a finger through the 
open tunica-vaginalis-canal, into the abdominal cavity, and 
push back any part of intestine or omentum that may 
protrude. Then an assistant draws the divided tunica 
vaginalis, just in front of the external inguinal ring, firmly 
asunder, and by means of an aneurism-needle, we apply a 
constricting cat-gut suture in such a manner that, beginning 
at the one cut surface of the tunica vaginalis, we pierce the 
needle at short intervals of c.m. in and out until we 
arrive at the other cut surface and the thread has been 
passed through the whole width of the tunica vaginalis. To 
effect greater security, there may be applied, in the same 
manner, a second suture closely below the former. Natur- 
ally enough, when the needle is passed in and out care 
must be taken that it passes through nothing else but the 
tunica vaginalis, which, however, can be done easily. Now 
follows a renewed examination of that part of the tunica 
vaginalis which is open towards the abdominal cavity, while 
the assistant, by digital pressure from outside upon the in- 
guinal ring, prevents the protrusion of viscera; the thread 
ends of the constricting suture are tied firmly together, 
whereby the tunica vaginalis at the point of constriction is 
drawn together, tobacco-bag like. This suture, which I 
have often applied in the same manner, after herniotomy, 
holds very tightly, and cannot slip off. The parts constitut- 12 
MAX SCHULLER. 
ing the spermatic cord remain outside of the suture. After 
this, the pillars of the external inguinal ring are brought 
together by means of some interrupted cat-gut sutures, either 
so near, that this opening, which is generally very wide, is 
closed tightly around the spermatic cord, or only so near 
that there is room yet for a narrow drainage tube to be 
placed in the preperitoneal cellular-tissue space. Finally, 
we insert a drainage tube into the lower part of the tunica- 
vaginalis-sac as far downward as to the testicle, and close the 
wound of the integument and the soft parts, by means of 
silk suture as far as to the point where the ends of the 
drainage tubes are passed out. Over this is applied 
Thiersch’s salicylized jute, or Lister’s gauze-bandage, cover- 
ing, besides the sexual organs, the whole pelvis, and leaving 
free only penis and anal opening. For the purpose of 
preventing soiling of the dressing and to be able to leave 
the first bandage undisturbed as long as possible, the urine, 
during the first days, is taken away by means of a soft 
Nelatoris catheter, and an opiate is administered to the 
patient. 
In my case there happened, while there was absolute ab- 
sence of fever, union by first intention, except at that point 
at which the drainage tubes were located. A firm cicatrix 
formed itself. The testicle remained in the scrotum, and, 
which is most remarkable, resinned its growth, which for so 
long a time had been retarded. At the time the patient was 
dismissed (four weeks after the operation), it had the size of 
a large walnut, and was completely painless. 
If the testicle is located within the inguinal canal, the 
method of operation needs no essential modification. If 
the testicle is located closely before the external inguinal 
ring, the above described searching for the testicle, it is un- 
necessary to say, is done away with. We proceed directly 
to the testicle ; otherwise, we operate in the manner described. ON INGUINAL TESTICLE. 
13 
This method of operation is equally adaptable to those 
cases in which the inguinal testicle is accompanied by a 
hernia. In such cases we shall have to divide first the 
hernial sac, reduce the contents of the hernia, and then 
isolate the spermatic cord, transplant the testicle into the 
scrotum, and further finish the operation in the above 
described succession. 
This operation, in cases complicated by hernia, as well as 
in those where only difficulties of incarceration of movable 
inguinal testicle exist, is certainly to be preferred to that of 
extirpation of the testicle, which latter operation has long 
been proposed for cases resisting treatment by truss, and 
which, too, has been performed several times. Our opera- 
tion preserves the organ, transplants it to that very place 
which it occupies under normal conditions, prevents the 
retraction of the testicle, protects it against incarceration 
and against the diseases caused thereby, and enables us at 
the same time to keep back accompanying herniae reliably 
and permanently. 
If it becomes confirmed, by future operations, that the 
testicle, having been arrested in its development, grows and 
attains its normal size after its transplantation into the 
scrotum, as in our case, this fact, as is readily comprehen- 
sible, would not only be of theoretical interest, but certainly 
of practical value also, since, to all appearances, this increase 
in size depends on the growth of the parenchyma of the 
testicle. I draw this conclusion from the absolutely normal 
condition of the testicle of the patient operated on by me. 
We may, therefore, be allowed to expect that the inguinal 
testicle by its transplantation may regain, together with its 
normal size also, its ability of function. If such, however, is 
the case, it follows by itself that, as long as the inguinal testicle 
is healthy, castration must not be performed, but transplan- 
tation into the scrotum should be resorted to in preference. 14 
MAX SCHULLER. 
Simple inflammatory processes of the inguinal testicle 
offer no contrary indication to the operation. It may well 
be performed after the inflammation has subsided. 
Perhaps the inclination of retained testicles to the devel- 
opment of malignant new formations is lessened with the 
resumption of normal growth after the transplantation of 
such testicles into the scrotum. According to Cohnheim’s 
views, with whom we concur, such, indeed, should be ex- 
pected ; for, after the transplantation, as our case shows, 
“ the existing germs of growth of the testicle may assume 
regular development.” Even if we may not have to allow 
ourselves illusions in this regard, we may, nevertheless, find 
in these ideas a further inducement to perform the operation. 
Grcifsivald, July, 1881.