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]
[74] In the treatment of infections of the seminal vesicles, particularly those of gonorrheal origin, Belfield has advised irrigation and drainage of the same through the vas deferens. He brings this up against the skin of the scrotum, where it is easily identified, and then, through a one to two-inch incision, made under local anesthesia, exposes the vas, into which the blunted end of a hypodermic-syringe needle may be introduced, by means of which a solution of any desired agent may be injected. This being thrown in the direction of the seminal current passes up through the vas and into the vesicle. He has even recommended in certain cases to attach the vas to the skin by a fine silkworm suture, and in this way to make a minute fistula, which can be used for the purpose as long as may be necessary. He considers the method invaluable in the treatment of chronic gonorrheal vesiculitis or the chronic infections of the seminal canal in the elderly, which are often mistaken for enlarged prostate, as well as in cases of recurrent epididymitis resulting from repeated invasion from behind. Thus he has seen benefit follow, in tuberculosis of the epididymis, from irrigation with carbolic solution. The amount injected into the vesicle should never exceed 2 Cc.
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.