SPERMATOCELE.

Spermatocele implies a cystic tumor in whose contained fluid, no matter what its source, are found spermatozoa, which may be seen alive under the microscope if examined immediately after removal. Spermatoceles are usually found at the lower end of the cord and in close connection with the testicle. Their occurrence is not uncommon, but somewhat difficult to explain, for it implies connection, at least at some time, between the structures of the cord and a more or less displaced seminiferous tubule. Spermatoceles are rarely diagnosticated as such until aspiration or evacuation and examination of their fluid contents, which usually are of a milky appearance. In general they are to be treated like any other cysts, and by the same methods.

VARICOCELE.

This exceedingly prevalent affection is the result of a varicose condition of the pampiniform plexuses and of the spermatic veins. It occurs in perhaps 10 or 12 per cent. of adult males, rarely before puberty, and almost invariably upon the left side, varicocele upon the right side being as rare as 1 in 500 cases. Its confinement to the left side is explained partly by compression of the left spermatic veins beneath an overloaded and distended sigmoid, and by the disadvantage at which the blood current from the left spermatic vein empties into the vena cava, this being on the left side at a right angle, while on the right the angle is oblique. It has occasionally to do with accident or injury, as well as with occupation or habit. It occurs more frequently in those who are long in the saddle and in those who ride the bicycle to excess. (See Fig. 674.)

Varicocele is usually of slow development, and discovered finally by accident or by attention being drawn to these parts through quack advertisements or misleading statements. The effect is to produce an elongated mass of varicose veins, often described as feeling like a “bag of angle worms,” occupying the lower portion of the cord and extending down upon the back of the testicle. In the more advanced cases the condition can be traced almost to the external ring, but is always more marked low down than higher up. Sometimes it is so extreme that the entire group of veins corresponds in bulk to a hen’s egg; ordinarily it is but a fraction of this size. The consequence is increase of weight and production of dragging sensation upon the cord, often referred to the back, and displacement downward of the testicle, with consequent elongation of the scrotum, which may so greatly relax that it appears to be twice its normal length and contains this varicose mass at its lower extremity. Such a condition will naturally produce a certain degree of discomfort and annoyance, but beyond this it is innocent, save that it is made to cause much mental anxiety, mainly through ignorance, and has led thousands of victims to quacks, for treatment for conditions dishonestly represented and treated as both distressing and extreme. It is true that a large mass of enlarged veins may in time produce some atrophy of the testicle; it is likewise true, also, that virility or masculine potency may be to a trifling extent limited in this way. It is not true, however, that impotence can be so produced, because the affection is limited to but one organ, so that the impotency of which many men complain is mainly of psychical origin. Such individuals need explanations and advice as much as treatment, although it is difficult to elevate many of them from the condition of sexual hypochondria into which they gradually fall.

Treatment.

—Treatment of varicocele may be palliative, i. e., it may consist of suspension of the overloaded testicle and somewhat relaxed scrotum within a well-fitting suspensory bandage, and this suffices for most mild cases in normally minded individuals. When, however, the condition preys deeply upon the mind or upon the body, or when it is actually and anatomically advanced, then radical operation is legitimate and humane. Of the many operations recommended in time past only two will be described here, for it seems to me that all subcutaneous and blind methods are bad in theory as in practise.

Excision of the varicose veins is easily performed under local cocaine anesthesia. It is done by incision below the external ring, over the course of the cord, the cord itself being exposed for two to three inches. Here the enlarged veins appear usually in a group (the pampiniform plexus), and as such can be isolated and separated from the balance of the cord, it being essential to carefully exclude the vas, as injury to or division of this canal would naturally be followed by impotence of that testicle. The veins involved being isolated to an extent of two inches, are ligated above and below, the intervening portion being then exsected, after which it is my custom to utilize the catgut with which this ligation is effected, threading it on each side into a needle, using each as a suture, thus providing two sutures, by which the divided ends are approximated and tied together, the effect being to bring the testicle up and make a more effective suspensory of the cord itself.

Shortening of the Scrotum.

—To the above procedure, when the scrotum is much elongated and relaxed, may be added its shortening by a species of amputation. The entire procedure may be practised as follows: The scrotum being stretched downward is shortened by removing one and a half to three inches from the lower end of the scrotal pouch of skin and the contained connective tissue, including the septum. In this way the tunical sacs and lower ends of the testicle will be immediately exposed. The left testicle can now be drawn down, and the operation, described above, of exsection of a portion of its veins, may then be practised. This being completed the scrotal wound is closed with sutures, with or without catgut drainage. The effect is to not only remove the varicose veins, but to reduce the size of the scrotum, and to make it, as it were, a suspensory of living tissue (Figs. 675 and 676).

THE SEMINAL VESICLES.

The lower ends of the vasa and the seminal vesicles themselves suffer most commonly from the consequences of tuberculous or of gonorrheal infection, travelling in either direction, they being easily invaded from the prostatic urethra along the seminal ducts. The consequence is seminal vesiculitis, which produces a more or less tender swelling, with discomfort referred to the lower end of the rectum, and discoverable by digital examination above the prostate. When the vesicles are distended or infiltrated they may be felt with the finger in the rectum. In addition there may be on pressure more or less discharge of fluid into the prostatic urethra, while the semen when emitted may be more or less mixed with blood.

It is necessary usually to differentiate between prostatitis or prostatic hypertrophy and vesiculitis.

Chronic involvement of the seminal vesicles may be best treated by a species of massage or “milking,” by which retained contents are coaxed along the ducts and into the urethra. Its local treatment is almost impossible. When the conditions resulting from infection of either type have become chronic and intractable we may take advantage of recent advances and decide upon removal of the vesicles by operation. Fuller suggested that this be done by putting the patient in the knee-chest position or a modified Sims position. While it is not difficult to reach the vesicles through the rectum, the method has its disadvantages and the perineal route is much the better. The operation is then effected, much as is prostatectomy, by perineal opening and blunt dissection between the rectum and the prostate, carried upward until the vesicles themselves are reached, after which they may be curetted or extirpated by a process of enucleation.[74]

SPERMATORRHEA.

Accurately defined this term refers to the escape of semen under abnormal and involuntary conditions, an occurrence which is of great rarity. Most cases of so-called spermatorrhea are, in effect, but the escape of excessive or superfluous amounts of prostatic mucus (prostatorrhea), the fluid, whether it appear drop by drop or in considerable quantity, being mistaken by the patient for semen. Thus with the extrusion of a hard fecal mass there may be sufficient pressure upon the prostate to express from it 1 Cc. or more of this fluid. True spermatorrhea, on the other hand, rarely occurs except in connection with disease of the vesicles or prostate, and will then be recognized rather by the detection of spermatozoa in the urine than from any phenomenon noticeable by the patient. All statements, therefore, made by patients to the effect that they suffer from involuntary escape of semen should be taken with the greatest allowance, and will usually be found to be misleading.

All of this might lead up to a considerable discussion of matters included within the domain of sexual physiology and hygiene, topics which, however, cannot be afforded space in the present work; all that can be said being that many patients are in need of accurate information who suffer acutely in mind, and sometimes slightly in body, for lack of it, and who are tempted by motives of delicacy to consult quacks and charlatans rather than their family physician.

CASTRATION.

The only operation of importance upon the external genitals not yet described is that of castration, i. e., removal of the testicle. This is ordinarily a simple procedure, requiring, first, incision of sufficient length. If the disease condition include the slightest infiltration or involvement of the overlying skin a little or the greater portion of it, as required, should be included in an oval incision, in order that it may be totally removed. The testicle and its coverings, being now exposed, are to be loosened from all their surroundings, the organ pulled down, and the cord brought into sight. If there be no reason for following up the spermatic cord it is sufficient to surround it with a ligature (chromic gut), at a convenient height above the testicle, after which the cord is divided below it and the mass removed. In most instances, however, the disease which calls for so much operating will require to be followed up along the cord, and perhaps through the inguinal canal down into the pelvis. This is done by continuing the incision in the proper direction, isolating the cord, ligating bleeding vessels, and finally dividing the cord itself at a point of election decided to be above the disease. Previous generations were hesitant about including the entire cord in a ligature, for fear of tetanus, but we now know that if the technique be carefully carried out there need be no fear on this score. The diseased mass being removed the wound is closed, with or without catgut drainage at one or more points, as may be indicated.