Varicocele in the Female : 
What is its Influence 
upon the Ovary? 
BT 
A. PALMER DUDLEY, M.D., 
SURGEON IN CHARGE, ST. ELIZABETH'S 
HOSPITAL. 
BEPBrNTBD FROM 
®t)e Neto ¥orft ftJetocal 
for August 11 and 18, 1888. Reprinted from the New York Medical Journal 
for August 11 and 18, 1888. 
VARICOCELE IN THE FEMALE: 
WHAT IS ITS INFLUENCE UPON THE OVARY?* 
By A. PALMER DUDLEY, M. D., 
SUBGEON IN CHABGE, ST. ELIZABETH'S HOSPITAL. 
From a valuable paper read before this association at its 
first meeting, by Dr. H. C. Coe, entitled the " Exaggerated 
Importance of Minor Pelvic Inflammations," I make the 
following quotations: These " thickenings, increased ten- 
sion, or whatever it is, which we find at the examining 
table and promptly enter in our case-books as cellulitis," 
frequently vanish after death, when the natural tension of 
the tissues has disappeared." That remark impressed me 
very much, and was parent to the thought, What pathologi- 
cal condition can exist in the broad ligament during life, 
giving rise to pain and symptoms simulating cellulitis, and 
still be found absent post mortem ? It was certainly an in- 
teresting question, one I deemed well worthy patient search 
for an answer, and if I can be in any way instrumental in 
arriving at a correct solution by bringing the subject before 
this society for discussion, I shall feel that I have been am- 
ply rewarded for my efforts. After a careful study of the 
anatomy of the broad ligament, together with the experience 
* Read before the Alumni Association of the Woman's Hospital at 
its third meeting. 2 
VARICOCELE IN THE FEMALE. 
I received from my service in the Woman's Hospital, and 
the results of such investigations as those set forth hy Dr. 
Coe, it seemed to me that the condition must be one due to 
disturbances of the normal pelvic circulation, and I began 
to look the subject up. Hence the title of my paper. 
Some doubts may arise in the minds of my hearers as 
to just why I should use the title " varicocele in the female " 
when the location of the condition I propose to consider is 
in the broad ligament. The only explanation I shall offer 
is the following: That the terms varix and varicocele are 
used synonymously is granted, but while the term varix is 
used to denote the existence of a dilated and knotted or 
tortuous vein in any part of the body, the term varico- 
cele signifies a blood tumor, and is applied to a dilated con- 
dition of the spermatic veins. 
Now, as all writers upon anatomy whom I have been 
able to consult declare the ovarian veins in the female to 
be the analogue of the spermatic veins in the male (some 
authorities even using the term spermatic for both sexes), 
and accredit them with performing analogous functions- 
that of returning the venous blood from the testicle and 
ovary toward the heart, by emptying it on the right side of 
the body into the inferior vena cava, and on the left side 
into the left renal vein-I feel quite sure the term is not 
misapplied when referring to a dilated and tortuous condi- 
tion of the veins in the broad ligament. 
To properly understand any pathological condition in 
the human system, one must first have a correct knowledge 
of the normal anatomical condition of the parts involved. 
This is a difficult matter to do with respect to the broad 
ligament in the female, owing to the various changes which 
it is subject to during the child-bearing period, which, 
though not pathological, but rather physiological, are still 
changes that modify the anatomical structure and relation VARICOCELE IN THE FEMALE. 
3 
of the parts " for the time being" to a marked degree. If 
we pause for a moment and consider the anatomical relation 
and structure of the broad ligament while the uterus is in 
a state of rest, and then consider the changes which must 
certainly take place in the ligament and its vessels during 
the growth of a foetus, the expulsion of the latter, and the 
period of time required for the proper involution of the 
pelvic organs, bearing in mind the accidents which are so 
liable to and do so frequently happen during this process, we 
certainly shall be led to the conclusion that varicocele in the 
broad ligament of the female can not be a rare condition. 
Let us consider for a moment the anatomical make-up of 
the broad ligament in a woman whose uterus has never been 
impregnated. Here we find it a thin double layer of serous 
membrane, stretching across from each side of the body of 
the uterus to the inner surface of the pelvis, thereby dividing 
the upper portion of the pelvic cavity into two parts, an an- 
terior and a posterior. Along its superior or free border runs 
the Falloppian tube, and to its posterior and superior sur- 
face is attached the ovary. Beneath the tube and ovary, 
between these two layers of thin serous membrane, which 
is their only support, lie the blood-vessels and nerves that 
supply and nourish the uterus in its normal state and main- 
tain the life of the foetus during the term of utero-gesta- 
tion. A correct idea of the length, breadth, and thickness 
of these ligaments can readily be ascertained if we first 
consider the size and position of the uterus. The latter, 
pear-shaped, with an average transverse diameter of two 
inches, if in its normal position, occupies the central axis of 
the pelvis, the average transverse diameter of which is about 
five inches at its superior strait. Now, should we measure 
transversely across the fundus of the uterus, when in its 
normal position of slight anteversion, to the brim of the 
pelvis, such a measurement would only allow of an inch and 4 
VARICOCELE IN THE FEMALE. 
a half space to be occupied by the broad ligament; but such 
I feel quite sure would not be a correct anatomical measure- 
ment of the ligament, for the latter, being attached to the 
pelvic wall on a line much posterior to its attachment to the 
uterus, allows of greater length of ligament; and laparoto- 
mists, who have frequent occasion to examine the broad liga- 
ment in the normal and abnormal condition, will bear me 
out in the statement that the average length of it is from 
two inches to two inches and a half, while its depth is depend- 
ent upon the size and position of the uterus. Its thickness 
when in the normal condition is, as I have already stated, 
but trifling. It stands up as a thin partition-wall between 
the rectum and ovary and bladder. From this description 
it will be seen that the blood-vessels which course through 
it to supply the uterus have but very little support (espe- 
cially the ovarian) from the time they leave the pelvic wall 
until they reach their destination, and vice versa with 
the veins on their return, while the latter are put at a dis- 
advantage by gravity and lack of propelling force. Hence 
we can readily see how any undue pressure, from any cause, 
mechanical or otherwise, would tend to influence the blood- 
current through these vessels. 
With this outline of the structure and relations of the 
broad ligament in the virgin, let us pass to consider some 
of the changes which necessarily take place should the 
uterus become impregnated. To accommodate the growth 
of the foetus, the uterus undergoes its gradual increase in 
size, which is accomplished during the first three months 
with the uterus still occupying the pelvis. Its increase is 
nearly or quite symmetrical, and, while pressing the bladder 
and rectum to a certain extent, it must at the same time en- 
croach upon the broad ligament. Then the relations and 
structure of the latter are soon changed. Its opposing sur- 
faces are separated by the growing uterus. The blood-ves- VARICOCELE IN THE FEMALE. 
5 
seis which it holds, receiving the stimulus and being called 
upon to do additional duty, increase in size also, at the same 
time changing their shape and position. And so the pro- 
cess goes on, until the broad ligament, from being a thin, 
quite transparent structure made up of two opposing layers 
of serous membrane, holding between them the small blood- 
vessels and nerves that supply the uterus, together with a 
small amount of cellular tissue and a few muscular fibers 
from the outer layers of the uterus, becomes a mass of 
blood sinuses, its superior border containing the Falloppian 
tube, lying perpendicular to the side of the uterus, and its 
two serous surfaces spread out over the sides of the organ. 
This certainly is not a falsely drawn picture of the condi- 
tion of the broad ligament at or near the time of parturition. 
When the latter is accomplished and the uterus is delivered 
of its contents, a retrograde process commences, and Nature 
makes an effort to return these broad ligaments, together 
with the uterus, to their normal condition, as before impreg- 
nation. Does she always succeed ? No. Innumerable cases 
on record are evidence to the contrary. Some accident ac- 
companies or follows delivery (laceration or cellulitis), and 
involution is arrested. The uterus remains large, and con- 
tains an abnormal amount of blood, the vessels being gorged 
and tortuous, while the overweighted uterus drags upon the 
ligaments, and in time displacement occurs, which still fur- 
ther complicates the difficulty. Is it unreasonable to believe 
that from such a condition the vessels of the broad liga- 
ments, which have no lateral support for a distance of three 
inches along their course, should become permanently di- 
lated and tortuous-in fact, varicose ? I hope the discussion 
will answer this question. 
After quite an extensive search for literature upon this 
subject, I have been able to find only one article published 
in this country-that by Dr. Dwight, of Boston (" Boston 6 
VARICOCELE IN THE FEMALE. 
Medical and Surgical Journal," February 15,1877), in which 
he reports the accidental discovery of a large varicocele in 
the left broad ligament of a subject he had prepared for 
demonstration before his class. The case is one of interest, 
and I shall have occasion to refer to it further on. Winckel, 
in his work translated by Parvin, makes mention of the sub- 
ject, and emphasizes the fact that the condition is one of 
great importance with respect to certain forms of uterine 
disease. Klob makes the statement that in no other part 
of the body are phleboliths so frequently formed, caused, he 
thinks, by absence of valves in the veins. Brandt has often 
seen stones in the veins of the broad ligament of the size of 
peas. Barnes thinks these stones the cause of early atrophy 
of the uterus. 
Causes.-The causes of varicocele in the broad ligament 
are manifold-some constitutional, others mechanical. 
Among the former may be enumerated : 1. Arrest of invo- 
lution of the uterine and ovarian vessels, keeping up pelvic 
engorgement long after confinement. 2. A relaxed condi- 
tion of the tissues from a low state of general health. 3. 
An unhealthy condition of the vessel wall; an absence of 
valves in the veins, allowing of blood-pressure from gravity. 
Chief among the mechanical causes of this condition are 
the anatomical relations of the veins themselves. It is a 
noted fact that varicocele appears much the most frequently 
upon the left side of the body in both sexes, and this has 
been demonstrated to be due to the emptying of the venous 
blood from the left broad ligament into the left renal vein 
at right angles to the blood-current from the kidney, there- 
by obstructing the free flow of the blood from the ligament 
into the general venous circulation. The spermatic and ova- 
rian vessels being of such great length, the weight of such a 
column of blood also has a tendency to weaken the vessels, 
while still another prominent mechanical cause of this con- VARICOCELE IN THE FEMALE. 
7 
dition is the habitual constipation to which so many women 
are subject, and this is accounted for by the passage of the 
veins behind the sigmoid flexure of the colon. The latter, 
being distended with faeces, makes direct pressure upon the 
veins. The veins upon the right side are less liable to this 
affection from not being subject to any direct pressure, and, 
emptying as they do into the inferior vena cava at an 
angle, they are provided with a valve, and thereby escape 
backward pressure. Displacements are a fruitful cause of 
this condition. Winckel emphasizes the fact in the follow- 
ing words : " Associated with uterine displacement is a ten- 
sion of the broad ligaments, which become rotated about 
their transverse axes. Their outer extremities passing to 
the pelvic wall on either side, the infundibulo-pelvic liga- 
ment is even more distorted, and when we consider the great 
frequency of retropositions of the uterus it is not surprising 
to find that they are associated with a variety of complica- 
tions," which he illustrated by the results of twenty-four 
post-mortems, in which he found one double parovarian 
cyst, four myomata, four ovarian cysts, one senile haemato- 
metra, and, he says, of greater significance, three varicoceles 
in one or the other broad ligament. 
From the scanty literature upon this subject, it is im- 
possible to arrive at any correct conclusions as to the fre- 
quency of this condition, but that it exists much more fre- 
quently than has been supposed, I think careful observa- 
tion in the future will demonstrate. Winckel found it ten 
times in three hundred autopsies, but he does not mention 
having made a diagnosis of it in the living subject. 
Symptoms and Diagnosis.-In attempting to bring to 
your notice the symptoms which point to the existence of 
varicocele in the broad ligament, and by which I have been 
able to make a diagnosis of that condition, I am obliged to 
confine myself to my own experience and a short narration of VARICOCELE IN THE FEMALE. 
8 
the results obtained from it, for, as I have previously stated, 
I have been able to find nothing written upon the subject 
except the results obtained from post-mortem investigations, 
although medical literature is teeming with narrations of cases 
and methods of treatment for the various forms of varix in 
the male. Therefore I hope that this explanation will be 
sufficient apology for my lack of more positive symptoms. 
That which I consider the most prominent symptom (aside 
from those furnished by physical examination) is pain of a 
peculiar dull, aching character, extending up the side to the 
region of the kidney (and when the patient is in the erect 
position for some time), having its greatest intensity about 
that organ. Also the fact that this pain will disappear after 
the patient has occupied the prone position for a time, 
and reappear after taking the erect position. Of course 
there are numerous pathological conditions which may exist 
in the female and give rise to pain resembling this, but a 
careful examination and history of the case will usually ex- 
clude them. The pain is quite similar in character to that 
experienced by the male who suffers from varicocele, while 
several of the general symptoms are analogous in character, 
such as lassitude, a vague sense of unrest, and mental de- 
pression. These symptoms are accompanied by a history 
of injury at childbirth, followed by inflammatory conditions 
which have arrested the proper involution of the pelvic 
organs. Chief among the physical signs elicited by digital 
examination will be a thickened ligament, flexible, but 
tender under pressure, and transmitting a doughy sensation 
to the touch. Examined with the patient in the erect posi- 
tion, the ligament is thicker than appears by examination in 
the prone position, but positive evidence of the varicose 
condition of the vessels of the ligament can be obtained 
only by careful digital examination per rectum, after the 
patient has been allowed to stand for a short time. Bi- VARICOCELE IN THE FEMALE. 
9 
manual pressure of the ligament will then readily reveal the 
knotted, angle-worm appearance of the vessels. Such was 
the method employed in the diagnosis of my cases. My ex- 
perience is yet too limited to allow me to express an opin- 
ion as to the ultimate result of the procedure I am advocat- 
ing, but I beg your indulgence while I lay before you the 
results so far obtained in the treatment of four cases of 
varicocele in the broad ligament: 
Case I.-Mrs. P., aged forty, married twelve years. One la- 
bor (instrumental); three abortions (produced). No history of 
menorrhagia or metrorrhagia. Some leucorrhoea. No vesical 
symptoms. Bowels very constipated. For the preceding ten 
years she had suffered from pain in the left side, increased by 
standing or walking. This pain was also felt in the back near the 
kidney. She had been treated by various physicians for spinal 
irritation, nervous prostration, etc., and in 1881 underwent an 
operation for lacerated cervix by Dr. Mann, of Buffalo (then of 
Hartford). For twenty months previous to my seeing her she 
had been able to sit up only about three hours each day, and to 
take a few steps across the room with assistance. She was 
brought to St. Elizabeth's Hospital on May 4, 1887, when I made 
my first examination of her. Digital touch showed the perinaeum 
in good condition, the vagina about normal, the uterus in proper 
position, the cervix small and showing evidence of having been 
sutured. The endometrium appeared to be healthy. The broad 
ligaments were thickened and tender, while the ovary lay some- 
what prolapsed behind the left one. Not being satisfied with 
an examination per vaginam, I made a careful rectal examina- 
tion of the ligaments, and then discovered that, besides the pro- 
lapsed ovary on the left side, both ligaments contained a large 
cluster of dilated tortuous veins, giving just the same feel to 
the finger as that given by a varix in the scrotum. I advised 
laparotomy for her relief, believing I could tie the veins off and 
cure her, and I put her upon preparatory treatment for one 
week. On May 10, 1887, I did abdominal section and re- 
moved the ovaries and tubes, together with a large varix in 10 
VARICOCELE IN THE FEMALE. 
each ligament, the left one the largest, the veins being nearly 
as large as my little finger. The tubes were not diseased, but 
both ovaries were atrophied and dotted with small cysts. The 
patient made a good recovery, her pain was relieved from the 
time of the operation, and four weeks later she left the hospital 
to return to her home. Fourteen months after the operation 
she writes that she is perfectly well and free from pain. 
Case II.-Mrs. B., aged fifty-one, married thirty-three years. 
Had borne four children. No miscarriages. Last child born 
ten years and a half ago; labor rapid. She had never been well 
since, suffering all the time from pain in the left side. Never 
had had metrorrhagia, but had suffered from menorrhagia during 
the last two years of menstrual life. Menopause two years ago. 
Leucorrhoea to some extent. No vesical symptoms. Bowels much 
constipated. She had received treatment during the previous 
eleven years from sixteen different physicians without benefit, 
many diagnoses being made. She had been in bed most of the 
time for the past eleven years, and for the past three years had 
only got up to use the commode at the bedside. Her principal 
complaint during this time had been of pain at about the lower 
edge of the spleen, from there shooting down into the left groin. 
Careful physical examination of the abdomen by palpation, per- 
cussion, and auscultation showed nothing abnormal, except a 
prominent pulsation of the abdominal aorta (a diagnosis of aneu- 
rysm of the abdominal aorta had been made by one physician). 
Vaginal examination showed the uterus thrown back somewhat 
and fixed in its position, about normal in size, although the 
menses had ceased for nearly two years. There also seemed to 
be an enlargement to the left of the uterus in the broad ligament. 
Careful rectal examination showed the enlargement to be a mass 
of blood-vessels, and beneath it a strong pulsation of the uterine 
artery could be plainly felt. I made a diagnosis of varicocele, 
and advised the patient to come to New York for operation. 
She was brought to the city upon a bed, October 7, 1887. I at 
once put her upon preparatory treatment of milk diet, vaseline 
baths, etc. 
On October 11th, in the presence of Dr. Smith, her family 
physician, and my assistants, I put her under the influence of VARICOCELE IN THE FEMALE. 
11 
an anaesthetic and made an incision, four inches in length, 
through the linea alba, sufficiently large to allow of the intro- 
duction of my hand and wrist. I carefully examined all the 
abdominal organs before touching the pelvic cavity. Nothing 
pathological was found in the region where the pain was com- 
plained of. There were no adhesions about the spleen or intes- 
tines in that region. The spleen was small, the stomach nor- 
mal, the transverse colon low, and the aorta normal, except that 
it bifurcated high up (behind the navel), and at the point of bi- 
furcation the pulsation was prominent. Tracing the descending 
colon down, I found it bound to the left ovary and tube to the 
extent of an inch. The ovary and tube were atrophied, and the 
uterus was somewhat retroverted and adherent. Beneath the 
ovary and tube on the left side was the bunch of knotted vari- 
cose veins that I had previously diagnosticated by rectal touch. 
All adhesions about the parts were broken up, and as much of 
the ligament as could be drawn up, at the same time that gentle 
traction downward was made upon the ovarian vein. (From 
the extreme emaciation of the patient most of the ligament could 
be brought into view.) It was then quilted with the cobbler's 
stitch, commencing at the outer extremity, near the pelvic brim, 
and including all the ovarian vein that I dared to draw down. 
As I neared the uterine extremity of the ligament I passed the 
stitches deeper, quilting close to the pelvic floor, and in the 
last two stitches I included the round ligament so as to be able 
to remove about an inch and a half of it. The ovary and tube, 
together with the varicose veins, were then cut away. On the 
right side the vessels were not so large, but I wished to correct 
the displacement if possible at the same time, so I treated the 
right broad ligament in the same manner. The result of such 
a pronounced shortening of both broad ligaments can be readily 
understood. When I let go of the pedicles the tension upon the 
round ligaments at once sprang the uterus into a position of 
anteversion, where it remained at the time she left the hospital, 
nine weeks later. She never had a day's pain after the opera- 
tion, and her after-treatment was simply with good diet and a 
nerve tonic of dilute phosphoric acid and strychnine in calisaya 
elixir. Her recovery was slow but steady, and when leaving 12 
VARICOCELE IN THE FEMALE. 
the hospital she walked down two flights of stairs and ont to 
the carriage. A letter from her daughter, received July 25, 
1888, says that she is perfectly well, rises at 7 a. m., never thinks 
of lying down during the day, and goes to bed at 10 p. m. to 
sleep well all night. 
I have reported this case somewhat at length owing to 
the fact that the patient had been bedridden for such a long 
time, and after the operation has returned to such perfect 
health. 
Case III.-Mrs. L., aged fifty-three, married twenty-six 
years, entered the hospital January 24tb. Menses first appeared 
at fifteen, regular but scanty, with pain in the sides and back 
She had given birth to three children, the first by instrumental 
delivery. Had one miscarriage, between the first and second 
child; the last child born thirteen years ago. No history of 
metrorrhagia, menorrhagia, orleucorrhcea, but had had frequent 
and painful micturition. Locomotion painful. Bowels much 
constipated. General health poor. She had passed the meno- 
pause a year and a half. Had never had local treatment. Her 
symptoms at the time of entering the hospital were severe 
pain in the back and pain of a sharp, stinging character down 
through the left side and limbs, also pain in the stomach (dys- 
peptic). Her last confinement had been followed by some form 
of inflammation in the pelvis which confined her to bed twelve 
weeks. She gave no evidence of heart, lung, or kidney disease, 
except that the urine showed some phosphates, evidence that 
the kidneys were laboring. She was put upon the use of a 
strictly milk diet for ten days, and the urine then examined 
with a better result, the phosphates having disappeared. Digital 
examination showed the uterus small; also a small, tender 
thickening behind each broad ligament; the broad ligaments 
were thickened, boggy, and very tender to the touch. A rectal 
examination was made with the same result as in the two pre- 
vious cases, except that the ovaries seemed somewhat enlarged. 
On February 9, 1888, I did laparotomy, and quilted both broad 
ligaments and removed all that I could of them; cleansed the VARICOCELE IN THE FEMALE. 
13 
abdominal cavity thoroughly and closed the wound. She made 
a good recovery. There is nothing in the after-treatment of 
her case worthy of mention. She left the hospital five weeks 
after the operation, relieved of the pain through her back and 
hips, but still suffering somewhat from the dyspepsia. 
Note.-July 26, 1888.-To my personal knowledge she is 
now well and doing her own work. 
This was the third case in which I had made a diag- 
nosis of varicocele in the broad ligament, and done lapa- 
rotomy for its removal. It was the most obscure of the 
three, the varix being the smallest, and on that account I 
determined to have a careful microscopical examination of 
the specimen made, to either confirm or invalidate my diag- 
nosis. I gave the specimen for examination to Professor 
Porter, of the Post-graduate School, who had sections of 
it mounted and drawings made from them for me. The 
following is bis report in full: 
Pampinocele.-Upon microscopical examination of the ova- 
ries, tubes, and broad ligaments removed by Dr. Dudley, the 
following conditions were found : 
First, the ovaries were slightly enlarged and the seat of a 
few small cysts, some of which were filled w'ith a clear serum 
and others with a semi-gelatinous substance. The stroma of the 
ovary was composed of ordinary white fibrillated connective- 
tissue substance (Fig. 1, a), smooth muscular fibers, and blood- 
vessels. The walls of the arterioles and small arteries in the 
stroma were generally thickened (Fig. 1, &); in some the lumen 
was diminished, while in others it was expanded. This con- 
dition would naturally disturb the nutritive supply to the gland, 
and tend to produce a capillary engorgement. 
Second, the Falloppian tube presented no special abnor- 
mity. 
Third, the most marked pathological changes were found 
in the substance of the broad ligament, the pampiniform plex- 
uses, and their tributaries. The pampiniform plexus was in a VARICOCELE IN THE FEMALE. 
14 
state of marked congestion, the walls of the vessels were thick- 
ened, and their course was unusually tortuous. That this en- 
Fig. l.-a, ovarian tissue ; b, b, blood-vessels ; c, an arteriole. 
gorgement was of long duration is sustained by the condition 
of the capillaries, which were found, upon microscopical exam- 
ination, to be enormously distended and filled with blood in a 
state of partial pigmentary degeneration (Fig. 2, 5), indicating 
considerable duration of the stasis. Under ordinary circum- 
stances the capillaries collapse and can not be distinguished from 
the fibrillated connective tissue in which they are imbedded, 
unless an artificial injection is made, or they are distended by 
blood as the result of an acute or chronic congestion. Had the 
congestion been acute in character the capillaries would have 
been distended with red and white corpuscles, which could be 
readily recognized as such. But in this case it was difficult to 
make out the corpuscles, but the vessels were very much dis- 
tended by the blood-pigment matter, showing clearly that the 
engorgement was of long duration or chronic in nature. VARICOCELE IN THE FEMALE. 
15 
The walls of all the veins were thickened and their course was 
quite tortuous, as we commonly see in varicose conditions (Fig. 
2, d). The walls of the arteries were very much thickened ; in 
some the lumen was contracted (Fig. 2, e), in others it was 
expanded (Fig. 3, J). This condition would naturally cause an 
irregular pressure to be maintained in the capillaries, and act 
as an element in producing the capillary engorgement (Fig. 
Fig. 2. -a, fibrous tissue of the broad ligament; b, dilated blood-vessel filled 
with blood-cells ; d, convoluted blood-vessel; e, an arteriole. 
GVS 
3, c), which, together with the chronic congestion of the veins, 
explains the stagnation and pigmentary degeneration in the 
capillaries. The sections were made by Dr. Crowell, and the 
drawings made from them by Dr. George G. Van Schaick rep- 
resent very accurately the great capillary congestion and thick- 
ening of the blood-vessels. 
[Signed] William II. Porter, M. D. 
Case IV.-Mrs. D., aged fifty, married thirty-two years, 
four children, one miscarriage. Matured at fifteen; regular, 16 
VARICOCELE IN THE FEMALE. 
flow normal. All labors normal. Had suffered from profuse 
leucorrhoea and obstinate constipation. Locomotion painful. 
Fig. 3.-a, fibrous tissue; b, ligament, longitudinal cut; c, convoluted blood- 
vessel ; d, fibrous tissue cut transversely to the axes of the fibers. 
(?VS 
Menopause one year previous to my seeing her. Had been 
under the care of three different physicians for local treatment 
during the past two years. Complained of constant pain in the 
left side and back and across the abdomen. AV hen she lay in 
bed this pain would at once disappear; half an hour after her 
taking the erect position it would reappear in the same spot. 
She had suffered so much that she was ready to do anything for 
its relief. I saw her first at my office, April 5, 1888. Exami- 
nation showed thickening and tenderness on the left side only. 
The urinary analysis revealed some pus cells, but no albumin or VARICOCELE IN THE FEMALE. 
17 
casts. She was put upon the use of a strictly milk diet, with 
directions to drink freely of distilled water as well. These 
directions she faithfully carried out. She entered the hospital 
April 15th, when the urine was again examined, with negative 
results, with respect to albumin and casts, but there were still 
some pus cells. No evidence of cystitis existed, and the small 
number of pus cells was accounted for by the presence of some 
large crystals of oxalate of lime. I hesitated about giving her 
an anaesthetic under such circumstances, but afterward decided 
to do so, and on April 20th did the operation and removed the 
varix from the left broad ligament. Digital touch along the 
ureter to the kidney did not reveal any abnormity, still, on the 
fourth day after the operation, the pus cells in the urine began 
to increase until quite a number were present, and yet no pain 
or irritation about the bladder attended their presence; neither 
was there elevation of temperature or pulse, both having become 
normal, on the second day after the operation. The wound 
healed kindly and she returned to her home in sixteen days, 
with directions to watch the condition of her kidneys. 
Note.-A letter from her, dated July 27, 1888, states that 
she has gained flesh, and has no pain through the back, but that 
the urine still contains some pus. 
I do not consider this case an entire success, but the 
points of interest in it are the character of the pain caused 
by standing, the fact that it was entirely relieved by lying 
down, and the rapid increase of pus in the urine after the 
administration of an anaesthetic, its appearance being un- 
attended by elevation of temperature or pulse. 
My paper is already much longer than I intended, and 
the subject too great for me to attempt to touch upon all 
the conditions which may bear relation to it, but before 
summing up there is one point to which I wish to draw 
attention. 
At the reading of this paper I raised the question as to 
what the influence of varicocele might be upon the ovary. 18 
VARICOCELE IN THE FEMALE. 
Then I had not received the report of the result of Professor 
Porter's examination of the specimens, and could only 
reason from analogy, believing that if a varicocele in the 
scrotum would in time produce atrophy and loss of function 
in the testicle (which is a well-known fact), the same con- 
dition of constant increased blood-pressure in the venous 
circulation of the ovary must necessarily produce analo- 
gous changes in that organ, which would cause a train 
of symptoms such as I have endeavored to describe 
and have demonstrated by operative measures to actually 
exist; and the result of the microscopical examination by 
Dr. Porter confirms the opinion I then held, while the 
drawings made from the mounted specimens are positive 
evidence of the changes which had taken place. Hence, 
to sum up- 
1. It is my belief that varicocele in the broad ligament 
is not a rare condition. 
2. That it is produced by long-continued congestion; 
arrest of uterine involution, from whatever cause, and 
chronic constipation being the most important factors in 
its production. 
3. That it may exist and be mistaken for so-called cellu- 
litis or salpingitis unless careful rectal examination of the 
broad ligament is made. 
4. That it will produce changes in the structure and 
function of the ovary similar to those produced in the 
testicle, causing atrophy of its stroma, and interference 
with the proper development of the ova to such an ex- 
tent as to produce cystic degeneration of it and consequent 
sterility. 
5. That when the varicocele has existed for some time, 
or for a sufficient length of time to have caused a permanent 
dilatation of the veins, local treatment by counter-irritation 
(with Churchill's tincture of iodine), cotton tamponing, pes- VARICOCELE IN THE FEMALE. 
19 
sary support, or local depletion will be of no permanent 
benefit. 
6. That the result of a radical operation for its removal 
in the four cases reported, although not sufficient to make 
the operation a justifiable one in all cases, is strong evidence 
in its favor, even though the woman has passed the meno- 
pause. REASONS WHY 
• 
Physicians Should 
Subscribe 
FOR 
The New York Medical Journal, 
Edited by FRANK P. FOSTER, M. D.,' 
Published by D. APPLETON & CO., 1, 3, & 5 Bond St 
1. BECAUSE : It is the LEADING JOURNAL of America, and 
contains more reading-matter than any other journal of its class. 
2. BECAUSE : It is the exponent of the most advanced scientific 
medical thought. 
3. BECAUSE : Its contributors are among the most learned medical 
men of this country. 
4. BECAUSE : Its "Original Articles" are the results of scientific 
observation and research, and are of infinite practical value to the 
general practitioner. 
5. BECAUSE : The "Reports on the Progress of Medicine," which 
are published from time to time, contain the most recent discov- 
eries in the various departments of medicine, and are written by 
practitioners especially qualified for the purpose. 
6. BECAUSE : The column devoted in each number to "Therapeu- 
tical Notes " contains a resume of the practical application of th© 
most recent therapeutic novelties. 
7. BECAUSE : The Society Proceedings, of which each number con- 
tains one or more, are reports of the practical experience of 
prominent physicians who thus give to the profession the results 
of certain modes of treatment in given cases. 
8. BECAUSE : The Editorial Columns are controlled only by the 
desire to promote the welfare, honor, and advancement of the sci- 
ence of medicine, as viewed from a standpoint looking to the best 
interests of the profession. 
9. BECAUSE : Nothing is admitted to its columns that has not some 
bearing on medicine, or is not possessed of some practical value. 
IO. BECAUSE : It is published solely in the interests of medicine, 
and for the upholding of the elevated position occupied by the 
profession of America. 
Subscription Price, $5.00 per Anntun. Volumes begin in January 
and July.