mm L9SJ^ NL11 0510^17 1 NATIONAL LIBRARY OF MEDICINE u &?Sf 2? 5: ••* •'••••• :'■• i* 27 2* 2* 2*2* 2- *?• is* 2* 2* •:- •:• -;• 3* 2?"2* 2* 2r •:• >f SURGEON GENERAL'S OFFICE LIBRARY aausi [*••' Section, . JVb. 7 •2*2* NLM051096179 JS i£ i: "9£ *y 'S^ h VARICOCELE AND ITS TREATMENT G. FRANK BY LYDSTON, M.D. vrr PEOFESSOE OF THE SUEGICAL DISEASES OF THE GENITO-UBINABY OEGANS AND VENEEEAL DISEASES IN THE CHICAGO COLLEGE OF PHYSICIANS AND SUEGEONS; SUEGEON-IN-CHIEF OF THE GENITO-UEINAET AND VENEEEAL DEPAETMENT OF THE WEST SIDE DISPEN- SABY* FELLOW OF THE CHICAGO ACADEMY OF MEDICINE AND OF THE SOUTH- EEN SUEGICAL AND GYNE- COLOGICAL ASSO- CIATION, ETC. WITH ILLUSTRATIONS CHICAGO W. T. KEENER 96 Washington St. 1892 '/V COPYBIGHT, 1892, BY W. T. Keeneb. TO THE ©fKccrs ano /ifcembcre of Gbe Soutbcrn Surgical ano ©^narcological Bssociatlon IN TESTIMONY of Appeeciation of the High Scientific Ability and Kindly Fbateb- NAL COUBTESY OF THE RePEESENTATIYES OF THE MEDICAL "NEW South," and as an Assubanoe of the Wabm Regaed of a Noethebn Dootob, this Monogeaph is Respectfully Insobibed by the authoe. / PREFACE. In this Monograph an attempt has been made to present in a concise and at the same time in a comprehensive man- ner a review of the subject of varicocele and its treatment. Aside from the excellent little work of Mr. W. H. Bennett there is no comprehensive treatise upon the subject. Mr. Bennett's work is practically a presentation of his own views and method of operation alone, and by no means professes to present a complete survey of the field. In the present monograph no attempt has been made to consume paper by verbose padding, the salient points being kept in view. The chapter upon Operative Methods comprises in substance a paper presented to the Southern Surgical and Gynae- cological Association and published in its Transactions for the year 1890. It is to be regretted that the excellent dis- cussion which the paper brought- out cannot be introduced into this Monograph. Opera House Block, Chicago, May 1st, 1892. - / TABLE OF CONTENTS. CHAPTER I. Page Definition and Geneeal Consideeations of Vaeicocele - - 1 Fbequenoy of Vaeicocele ------ 3 CHAPTER II. Anatomical Chabaotees of Vaeicocele Vaeicocele in its Relations to the Public Sebyice Relative Fbequenoy of Vaeicocele on the Right and CHAPTER III. Causes of Vaeicocele - Relation of Vaeicocele to Sexual Distubbanoes Constitutional Obigin of Vaeicocele Mechanical Causes of Vaeicocele CHAPTER IV. Pebiod of Development of Vaeicocele Mobbid Anatomy of Vaeicocele CHAPTER V. Symptoms of Vaeicocele Complications of Vaeicocele CHAPTER VI. Teeatment of Vaeicocele - - 55 Genebal and Palliative Teeatment 55 Teeatment by Coagulation, Electbolysis and Caustics - - 61 CHAPTER VII. Radical Opebative Teeatment ----- 65 Indications foe Opebation - - - - - - 66 Methods of Opebation - ----- 67 CHAPTER VIII. Methods of Opebation Specially Consideeed - - - 85 BlBLIOGBAPHY - - - - - - 111 Index - - ------ 119 9 - 15 Left Sides 16 - 19 20 - 23 28 - 35 36 43 51 Vll. LIST OF ILLUSTRATIONS. Fig. Page: 1. Dissection of Varicocele (Moullin) - - - - 38 3. Carroll's modification of Morgan's Varicocele Compressor - 58 3. Miliano's Varicocele Compressor - - - 59 4. Keyes' Improved Varicocele Needle - 71 5. Keyes' Plain Varicocele Needle - - - - 71 6. Whitehead's Varicocele Needle - - 71 7. Reverdin's Needle ------- 71 8. Case of Extreme Elongation of Scrotum before Operation (Hor- teloup) -------- 74 9. Case shown in Fig. 8 after Operation (Horteloup) - - 75 10. Andrews' Retention Clamp for Varicocele - - 76 11. Hortelonp's Scrotal Clamp ----- 78 12. Case of Varicocele Seven Years after Scrotal Resection - 80 13. Bennett's Method of Approximation of Stumps of Spermatic Veins after Resection ------ 81 14. Lewis' Scrotal Clamp ------ 90 15. Wickham's Method of Scrotal Resection - - 93 16. Wickham's Operation Completed - - 94 17. King's Scrotal Clamp - - 96 18. Application of King's Clamp - - 100* VARICOCELE AND ITS TREATMENT. CHAPTER I. Definition and General Considerations. Varicocele, in a general way, may be said to be one of the most frequent surgical diseases of the male genito- urinary apparatus. If, however, we take into consideration only those instances in which the disease is sufficiently marked to demand the attention of the surgeon, the number of cases is greatly reduced. Varicocele is not an intrinsically serious affection, but from certain circumstances peculiar to its location and the importance of the function of the involved part, there is nevertheless a fair proportion of cases in which the patient sooner or later consults the surgeon. There are few dis- eases of so mild a character per se that are capable of caus- ing so much annoyance to the patient as is varicocele. To be sure the annoyance is more often of a mental than physi- cal character, but to my mind this very fact is a warrant for more careful consideration than is usually accorded it. It is not every patient whom we can convince that the condition is a very trifling matter. In some cases there are urgent physical reasons for most careful consideration of the disease. Varicocele consists of a dilatation of, with accompanying structural changes in, the walls of the plexus of veins sur- rounding the spermatic cord. These changes are the same as those which occur in varix in other situations; the causes 2 VARICOCELE AND ITS TREATMENT. being also essentially the same if we exclude masturbation and sexual excesses. After a time the veins become distorted and bent upon themselves here and there. This, with a notable increase in their diameter, results in the formation of knots or varicosi- ties, true blood sacs more or less extensive which remain in communication with the main vessel, bearing the same relation to the vein that some aneurisms do to the vessel from which they are derived. Beginning at the testicle. the superior border of which they conceal to a greater or less extent, the tortuous veins ascend along the cord, enter the inguinal canal and finally enter the left renal vein or vena cava, according to the side affected. Quite frequently, the veins which accompany the vas deferens become elongated and descend below the upper border of the testi- cle, forming a soft mass in front of this organ. The term varicocele is not very definite, inasmuch as it literally implies a varicose enlargement of the veins in any situation. Etymologicallv, the inaccuracy of the nomen- clature of the special form of varicocity under consideration, is quite evident. The word varicocele (fr. varix=a dilated vein+.r»/m= a tumor) is an awkward but convenient hybrid. Cirsocele (incorrectly circocele .rip Frequency of Varicocele. The frequency of varicocele is a matter of some doubt, statistics varying greatly. The wide variation in estimates is doubtless due to the varying interpretation of the term raricoccJc by different observers, and to the varying classes among whom the observations are made. Landouzy, an old French writer, put the proportion of cases at sixty per cent. of adult males.2 This is undoubtedly an exaggeration due to the classifi- cation of the slighter forms of dilatation of the spermatic veins as varicocele. Henry found but forty-one cases in nearly two thousand men examined for the New York police force.3 This record is, however, not an accurate criterion of the frequency of varicocele, as applicants for the metropolitan police force are exceptionally vigorous, and by no means the class pre- disposed to the disease. My own observations, comprising a large number of life insurance examinations, as well as a large number of patients seen in private and dispensary practice, show that not to exceed five per cent, of male adults have varicocele, of even moderate dimensions. The propor- tion of cases Avhich are marked enough to cause definite symptoms is even smaller. Varicocele tends to diminish in frequency with advanc- ing age. M. Horteloup, surgeon to the Bicetre,4 found 42 subjects Avith varicocele among 1,600 individuals, and of these, 10 had developed before the age of twenty-five. Of the total number of cases 14 increased, 19 remained sta- tionary, 8 diminished and 1 entirely disappeared at the age of 45. Of the cases which appeared before the age of 25, 11 increased or remained stationary, 4 diminished and 1 disappeared. These figures show that while varicocele does not necessarily progress, an increase is to be anticipated in 2 "Du varicocele et en particulier de la cure radicale de cette affection."' 3 "The treatment of varicocele," 1889. 4 Memoire a l'Acad. inedit. 4 VARICOCELE AND ITS TREATMENT. a fair proportion of cases. The prognosis is rendered more favorable, however, if we consider the class of patients on whom these observations were made. The occupants and out-patients of the Bicetre are nearly all engaged in hard manual labor. As Horteloup remarks in connection with the indications for treatment, the surgeon must be guided in his practice by the social status of the patient. Pallia- tion may effectually prevent increase of the varicocele in the wealthier class of patients, yet prove ineffectual among laborers and those subjected to prolonged standing. Tidal has laid especial stress upon this point: Bennett has formulated his conclusions as to the fre- quency of varicocele as follows: "Taking into consideration all classes of subjects, it may safely be said that not more than five or six per cent, have sufficient enlargement of the spermatic veins to justify the term varicocele. "This percentage is less than that noted by some pre- vious observers, the difference being apparently due to the fact, already mentioned, that I confine the term to well- marked cases. "The percentage of subjects presenting slight, temporary or permanent fullness or tortuosity is much greater. A\ ith reference to this point, it is especially important to remember that the fact of the veins on the left side being merely larger than those on the right, although the difference mav be considerable, does not necessarily indicate the existence of varicocele, since the veins on the two sides are so fre- quently unequal in size. "Of subjects affected with varicocele, properly so-called, nearly fifty per cent, are unaware of its existence until it has been pointed out to them or has been discovered acci- dentally. " Only twenty per cent, of the gross number of varicoceles give rise to any noticeable symptoms, and of the cases known to the patients treatment is sought in twenty-five per cent., FREQUENCY OF VARICOCELE. 5 approximately. This last percentage may be raised to some- thing like forty-five by persons applying for operation, in consequence of rejection or prospect of rejection for the public service. • The number of cases coming under observation in feeble and lymphatic subjects is much greater than in the strong and robust (excluding those who apply for advice from curiosity, or in connection with the requirements of the pub- lic services), although the tendency to the affection, as shown by slight abnormal fullness of the veins, appears to be about equal in the two classes. "The actual excess of these cases in the feeble and lymphatic is forty-five per cent, or thereabouts, but it is necessary to note that the feeble and nervous class of sub- jects seek treatment for much slighter reasons than the robust. Hence the mere excess in the number of cases causing symptoms in this class is really no evidence of the actual existence of a greater number of varicoceles, as such, in men of this kind." With a view to ascertaining, as accurately as was practicable, the exact proportion of varicoceles occurring in the two classes of subjects referred to, Bennett examined, 1. A series of three hundred robust patients admitted into St. George's Hospital for injuries or unimportant surgical dis- eases ; c. g. fractures, innocent tumors, etc.; and 2. A series of three hundred patients who were feeble, or naturally lymphatic, admitted for reasons similar to those just men- tioned, and not exhausted by organic disease or long-con- tinued illness. The result will be seen in the following table which does not include any patient admitted for varicocele or other affection of the genito-urinary system. The author states that the small excess in the number of cases of slightly abnormal fullness of the veins found in the feeble and lymphatic subjects is probably accounted for by the fact that in them the flabbiness of the scrotum allowed the vessels to be more easily felt, and does not, therefore, 6 VARICOCELE AND ITS TREATMENT. necessarily indicate any actual preponderance of full veins in this class of subjects. TABLE Showing the Numbeb of Cases of Varicocele Found in a Sebies of Six Hundbed Healthy Subjects Examined: a, Robust; b, Feeble ob Lymphatic 300 300 36 40 15 28 5 is ') b Lymphatic or Feeble .... s Total cases in the two classes 600 76 43 23 10 The comparative infrequency of right-sided varicocele is demonstrated quite forcibly by Bennett's examination of a large number of cases. He found that in 100 consecutive cases examined, the varicocele involved the left side only in SO, the right side only in 1, and both sides in the remaining 10. He concludes, therefore, that instance* in which the right side is alone affected are so rare as to be hardly worthy our attention, excepting as curiosities. He has seen two other cases limited to the right side, but his experience in this respect appears to be exceptional so far as recorded cases are concerned. Breschet. who in the early part of the present century probably had as large an expe- rience of varicocele as any surgeon of his own day or even later, stated that he never saw an example in which the right side alone was affected. Furthermore, while in the more FREQUENCY OF VARICOCELE. 7 modern literature of the subject mention is made of possible limitation of varicocele to the right side, no authentic cases actually observed are reported. CHAPTER II. Anatomical Characters of Varicocele. Taricocele is more frequent than varices elsewhere from the fact that there exists not only general but also special causes of venous dilatation due to local anatomical conditions. The veins forming the pampiniform plexus are relatively large, and follow a devious course along the sperm- atic cord, and surrounding this structure; the vessels of this plexus frequently anastomose, The valves of these vessels are few in number, very defective and yield to the downward pressure of injected fluid very readily. As compared with the veins in other locations those of the pampiniform plexus are poorly supported by connective tissue, which is in this situation sparse, loose and inelastic. The spermatic veins are very long, and independently of defective valves there is a marked tendency to yielding of the illy-supported venous walls to the weight of the long column of blood which flows so nearly perpendicularly upward. Pressure upon the veins as they traverse the inguinal canal tends to enhance the prospect of varicocele. Strains of the abdominal wall and especially those involved in difficult defecation are likely to bring this about. The anatomy of the parts involved in varicocele is a very important consideration and one which is ignored by most anatomical writers. Quain's description is probably the best of any in the ordinary text-books and I will there- fore reproduce it.1 1 Quain's Anatomy. 9 10 VARICOCELE AND ITS TREATMENT. The spermatic veins proceed upwards from the testicle and epididymis, and form in the spermatic cord a thick plexus of convoluted vessels, known as the spermatic, or pampiniform plexus. Passing through the inguinal canal in the abdomen, in company with the spermatic artery, the branches from this plexus join in two or three veins, and these again unite into a single vessel which ascends beneath the peritoneum on the surface of the psoas muscle, and opens on the right side into the vena cava, and on the left into the renal vein. The spermatic veins sometimes bifurcate before their termination, and, in this case, one branch may enter the vena cava, and the other the renal vein. Mr. Bennettl calls attention to a number of other details regarding this plexus as follows: " a. The left vein is always longer and larger than the right; moreover, it receives one or more (generally two) branches from the descending colon. These colico-sperm- atic branches which communicate with the radicles of the portal system, vary greatly in size in different individuals, being in some cases very small, and in others so large that their combined calibre exceeds considerably that of the spermatic vein itself. These branches are normally entirely confined to the left side, the right vein being without tribu- taries, excepting a branch from the ureter which is found on both sides. "b. The junction of the two, three, or more branches proceeding from the pampiniform plexus to form the sperm- atic vein may take place at any point between the level of the external abdominal ring below and the middle of the iliac crest above, the commonest situation being either just below the upper end of the inguinal canal, or immediately inside the abdomen above the internal abdominal ring. "c. The pampiniform plexus is for practical purposes divided into two distinct portions, an upper and a lower, by a central complicated plexiform arrangement; above and 2 Op cit. ANATOMICAL CHARACTERS OF VARICOCELE. 11 below this, although the veins communicate with each other, the arrangement is in many cases hardly sufficiently intricate to justify the use of the term plexus. "cZ. The valves in the plexus and veins are uncertain in number and situation. They may be absent altogether, or may be very numerous. They may exist in great numbers in the plexus, and be absent in the spermatic veins, or rice versa. Under all ordinary circumstances they are more constant in occurrence and more numerous in the central plexiform arrangement, to which reference has been made. In the spermatic veins there is usually a valve at the junction with the renal. This valve is more frequently absent on the left side than on the right; its absence on the left may or may not be associated with a more or less com- plete valve in the renal vein. "However numerous and competent the valves may be, they tend to become incompetent, as a rule, in subjects over- sixty years of age. The defect thus arising is followed by slight enlargment of the veins below the level of the insuffi- cient valves. The tendency to insufficiency in the vein valves of elderly people is not, of course, peculiar to this region, but occurs in the majority of long veins, notably the internal saphena. "Abnormalities are rare on the right side, but compara- tively common on the left. Setting aside the variation in the level of junction of the efferents of the pampiniform plexus, which hardly comes under the head of abnormality, the left vein was found in two hundred cases examined to present some distinct abnormality in nearly twenty-five per cent.; whilst on the right side the percentage was not more than five. Again, on the right side the abnormalities were trivial, con- sisting, with two exceptions, of bifurcation of the vein high up, both branches then running into the vena cava. The ex- ceptions were: (1) a case in which there passed from the spermatic vein about its middle to join the renal a thin fibrous cord, small and not perceptibly pervious; in the renal vein 12 VARICOCELE AND ITS TREATMENT. was a fairly formed valve; and it is interesting to note that in two of the other instances of bifurcation there was evidence of the existence of an imperfect valve in the renal vein. (2) A case in which the right spermatic vein opened into the renal, and wras considerably more than double the size of the left, having also opening into it large colico-spermatic branches, which were entirely absent on the left side. The veins of the pampiniform plexus were altogether larger throughout than on the opposite side. The ureter was double on the right side, but natural on the left. I have recently met with another case showing the same abnormal arrangement, which amounts in fact to a transposition, of the right and left spermatic veins. Here, again, the ureter was double on the right side, a point which seems to indicate, as it were, some excess of developmental eccentricitv in the production of this abnormality. "The abnormalities on the left side were roughly a* follows: "(a) Bifurcation of the spermatic vein before its ter- mination. In most cases one branch opened into the renal, and the other into the vena cava, but in some the two divis- ions opened into the renal, and in one both ended in the vena cava. "(6) Divisions into three branches (only two examples of this arrangement were seen). In one instance, two of the branches terminated in the vena cava, the second opened into the renal, and the third, very large, joined a vein of consider- able size on the back of the colon; in this case the whole spermatic vein was much larger than usual, and there existed an extensive varicocele, the upper end of which extended quite an inch above the internal abdominal rino-. "{c) Double vein; both vessels opening into the renal by separate orifices, or joining only at the point of junction with the recipient vein. In a subject recently dissected, the vein being double, one portion went to the vena cava, and the other to the renal, having received just before its ter- ANATOMICAL CHARACTERS OF VARICOCELE. VS mination a large vein coming down from the region of the- spleen. "((/) Tein double about the central portion, single above and below. "In varicocele the veins are not only larger and more tortuous than normal, but in many cases much more numer- ous. The relative number of the veins differs greatly in different examples, but, as a rule, varicoceles with very large and manifestly over-tortuous veins have fewer vessels than those in which the swelling is smoother and more compact. The arrangement of the veins differs so much that four distinct varieties of varicocele are recognizable: "(«.) The tortuosity and dilatation involves the whole of the pampiniform plexus and its efferents (Tumor, Class I.), and may, therefore, when the junction of the efferents in forming the spermatic veins takes place at a high level, extend inside the abdomen. This latter statement is directly opposed to the belief of some observers who deny, or have great doubts about, the existence of intra-abdominal vari- coceles. "(6.) The varicose conditions may be more particularly limited to the portion of the plexus below the central plexi- form arrangement to which I have alluded. In this variety,. which is seen clinically in tumors, Class II., the veins in the upper part of the cord, beyond being rather larger than usual, are not abnormal, and this increase of size in some cases is so slight as to escape notice altogether. "(c.) The varicosity may involve more especially the part of the plexus above the central plexiform arrangement extending up to the point of formation of the spermatic vein (Tumor, Class III.), the veins below being full, perhaps more numerous, but not generally much larger than normal. In this variety, the valves in the central plexus are numerous and strong. "In speaking of the clinical aspects of Tumor III., I have referred to its tendency at later periods of life to 14 VARICOCELE AND ITS TREATMENT. assume the general characteristics of Tumor I., in conse- quence of the whole pampiniform plexus becoming involved. "It is not, I think, unfair to assume that the change has some relation to the incompetency which is prone to occur in the valves in the central plexus, in common with those in many other veins, as age advances. "(d) The whole pampiniform plexus and spermatic vein may be much larger, more tortuous, and altogether more important than normal. I have dissected two examples of this variety. In each of these the varicose condition was uniform throughout the spermatic venous apparatus. The valves were proportionately large and strong and the vein walls very thick. The vessels themselves were not more numerous than on the opposite side. The subjects were robust men who had died from acute disease, and no trouble had obviously been caused by the abnormal veins. These cases may be regarded, I believe, as examples merely of congenital exaggeration in size of the veins, a view which is strongly supported by the facts that the testicle, in spite of the large size of the lower part of the varicocele, was in each case perfectly natural, and the spermatic artery considerably larger than that on the unaffected side. Similar cases occur in the lower extremities and in other situations, varying in degree from slight exaggerations in size only, to the condi- tion sometimes called diffused venous nsevus which may involve a whole limb. As already stated, the veins in vari- cocele are not only changed in character, but in many cases (probably the majority) increased in number. This increase is most marked in the second of the varieties just described, and is frequently present in the third kind; in the first it is comparatively rarely found, and in the fourth the veins are not more numerous than normal. In all cases the vein walls are thicker than those of normal veins, the thickness bearing a direct proportion to the size of the vessel, a condition which leads to the open-mouth appearance shown by these vessels on section. This unnatural thickness of the vein VARICOCELE IN ITS RELATIONS TO PUBLIC SERVICE. 15 wall has been almost universally ascribed to the result of chronic inflammation upon, so far as I can judge, no evidence of any kind. It is much more likely indeed, in my opinion it is certain, that with very few exceptions in which thrombi, etc., have occurred, the thickness is merely the outcome of the same tendency to abnormality which produces the in- creased size and tortuosity; for it will be found that, however young the subject may be, the veins on the affected side are distinctly not only larger but thicker in structure than natural." Varicocele in its Relations to Public Service. Taricocele has been a subject of some importance to military surgeons, especially as regards examinations for enlistment. Landouzy states that of 166,317 men examined in England and Ireland during a series of years, 7.5 per cent, were exempted from service on account of varicocele. The Army Medical Reports of Great Britain are quoted as stating that during the years from 1869 to 1873, of 331,568 men examined, 5,312 were rejected for varicocele. Sistach, in 1863, asserted that in France eleven per thousand of candidates for enlistment were rejected for vari- cocele. From 1879 to 1883 the proportion had been reduced to three per thousand. It is claimed that this reduction was due to improved methods of treatment, but this is probably an exaggerated estimate of surgical progress. Horteloup relates a case that was rejected on account of varicocele, in which the candidate was accepted without comment after a successful operation. Not only in relation to military service is the question of varicocele of importance, but the examination of applicants for positions in the fire and police departments of the municipal service are very rigorous in this regard. I have several times been called upon to operate a varicocele which 16 VARICOCELE AND ITS TREATMENT. has been the cause of rejection of a candidate for public service in these departments. The following table shows the proportion per thousand of recruits that were rejected for varicocele in the British service in the years from 1878 to 1887.3 1878 1879 1880 1881 1882 1883 1884 1885 1886 1887 PRIMARY INSPECTION. SECONDARY INSPECTION. Examined by Army Medical Officers. Ratio per 1,000 Rejected. Varico- cele. 12.01 12.92 13.70 16.23 16.93 16.97 13.26 15.67 15.93 13.28 Varix. 17.30 18.10 15.40 16.28 16.43 14.89 16.63 16.62 Examined by Civil Practitioners. Ratio per 1,000 Rejected. Varico- cele. Varix. 12.54 16.32 22.54 14.40 10.56 18.45 20.81 15.68 18.00 20.35 12.80 17.27 15.57 15.06 12.60 13.24 12.83 12.68 12.41 Examined by ' Ratio per 1,000 of Army " Rejections in Total Medical Number of Recruits Officers. Examined, ^Excluding a Small -------------Number Rejected as! Ratio per 1,000 ! ^X^"?1™? Rejected. \ Three Months of Service. Varico- cele. Varix. 17.79 22.76 14.31 5.60 6.62 7.40 6.98 7.71 9.60 5.92 5.64 5.27 5.84 4.62 5.50 Varico-cele. Varix. 13.08 17.96 43.887 14.77 19.22 42.668 16.09 16.14 46.108 16.86 17.20 47.444 16.82 16.97 45.42:-; 18.27 15.80 59.436 15.85 17.69 66.882 16.91 17.03 72.241' 17.74 18.14 74,991 15.39 18.11 60.976 With reference to the question of life-insurance, vari- cocele per se is of no importance. Relative Frequency of Varicocele upon the Right and Left Sides. Taricocele is most frequent upon the left side, the reasons advanced therefor being: 1. The relatively lower position of the left testis. 2. The relative acuteness of the 3 Bennett Op. cit. RELATIVE FREQUENCY OF VARICOCELE. l'< angle formed by the junction of the left spermatic with the renal vein.4 3. The close proximity of the left spermatic vein to the sigmoid flexure of the colon and its consequent exposure to pressure in constipation. 4. The absence of a valve in the left spermatic vein at its junction with the renal. 5. The tendency of men to stand upon the left foot. It would appear that the relatively greater length of the cord and its attendant vascular structures, with the conse- quent greater weight of the contained column of blood upon the left as compared with the right side, is an all-sufficient explanation. Landouzy lays great stress upon the relative frequency of left-sided varicocele. Breschet, in one hundred and twenty varicocele operations found but a single case of right- sided varicocele. Curling records that of 166,317 young men examined for service in England and Ireland within ten years, 3,911 were refused on account of varicocele — a proportion of seventy per thousand;—of these, 282 Avere on the right, 3,360 on the left, and 269 on both sides. Petit is of the opinion that the pressure of fecal matter upon the left spermatic veins is the chief determining factor in left-sided varicocele. Osborn is a champion of this idea. The latter, however, attributes great importance to the relatively greater length of the left spermatic veins. When varicocele is present on the right side, there is almost invariably involvement of the left side also;—indeed, I do not recall a case in which the right side alone was involved. Traumatic causes may, however, give rise to such a condition. The relatively greater frequency of varicocele on the left side was expatiated upon by Celsus: hence there has been plenty of time for an abundant crop of explanations to develop. * Morgagni and Cooper. o CHAPTER III. Causes of Varicocele. The causes of varicocele are several: First and most im- portant is a constitutional lack of tone;—this cause is rarely accorded sufficient importance, the tendency being to seek for exclusively local causes. What is termed congenital or hereditary predisposition to varix in general, consists of an inherent lack of muscular and vascular tonicity. The venous walls are especially weak and flabby, and the circulation sluggish. The same causes that produce laxity of the venous walls produce feeble heart action; there is a deficiency in the ris a tergo which is so important in propelling the blood through the veins, and also a deficiency in the aspirating power of the heart and lungs. The association of these con- ditions with varices of the extremities will on reflection be found to be very familiar. These same patients present a special tendency to hemorrhages on account of vaso-motor deficiency, and I have noticed in a general way that the existence of varices of the extremities in patients about to be operated upon is a note of warning as regards possible annoyance from hemorrhage. Persons who suffer from such diseases as purpura and scurvy are peculiarly liable to relaxed and dilated conditions of the veins. Strumous individuals also present a tendency to varices. Tarices are apt to occur in persons of indolent habits, because of defective circulation as well as a general lack of tone with resulting vascular flabbiness incidental to insuffi- cient exercise. Such persons, who are compelled to stand at ' 19 20 VARICOCELE AND ITS TREATMENT. their work for prolonged periods, are peculiarly subject to varicose veins. Certain diseases of the heart, liver, lungs, and peritoneal cavity, which produce by pressure retardation of the return flow through the inferior vena cava and iliac veins, favor the development of varix. Long-standing portal obstruction is liable to produce varicocele in conjunction with hemorrhoids. Relative to varicocele from intra-abdominal pressure, Guyon has observed some curious cases in which the disease was due to the pressure of a renal tumor. He has encount- ered this condition of uvaricocele symtomatique'''' three times on the left and three times on the right side.1 Relation of Varicocele to Sexual Disturbances. Masturbation, sexual excesses and prolonged venereal excitement without gratification are undoubtedly responsible for varicocele in many instances. I regard it as highly im- probable, however, that these causes, if brought to play for the first time in a healthy adult, would cause varicocele, but occurring as they usually do when tissue development is really in excess as compared with the inherent resisting power of the various structures, they operate very powerfully in producing congestion and finally dilatation of the sperm- atic plexus. Mr. Bennett is still more skeptical regarding the causal influence of sexual aberrations, as the following will show: "The relation of varicocele to sexual irritation, depraved inclinations and practices, does not, so far as I am able to judge from the literature of the subject, appear either to be properly understood, or to have received the attention it merits. "All the ordinary works dealing with the affection, whether in the form of special treatises or as parts of general 1 Guyon, Lee. Clin, sur lesmat. des voies urin. Paris, 1881. CAUSES OF VARICOCELE. 21 systems of surgery, invariably refer to self-abuse and excess- ive venereal indulgence as causes of varicocele. LkIt is, however, perfectly clear, if a moment's thought be given to the question, that it is quite impossible for either of these so-called causes to originate the affection. Person- ally, I would go further than this, for I have no doubt what- ever that the relation is quite the reverse of the commonly accepted view, as it seems to me certain that in those cases of varicocele in which any excessive perversion of sexual habit or inclination exists, the varicocele is the cause and not the result of the sexual irritation. "It is most difficult to surmise what the reasons could have been which led to the general acceptance of the opposite view, unless the growth of the disease being, as it so often is, coincident with the acquirement of the depraved habit, was misinterpreted as being due to the depraved practices instead of the acquirement of the habit being caused by the irritation of the testicle by the growing vari- cocele, at a period of life (puberty) when the whole genera- tive system is in a condition easily excited by direct or reflex causes. " My view, therefore, in relation to this point is that the effect of the growth of the varicocele in these cases, which are fortunately not very common, is to produce an irritation in the generative organs which leads to exaggerated sensi- tiveness and at times insatiable desire, the rational and only logical treatment of wdiich lies, not in the administration of a multiplicity of drugs or of comprehensive monitions as to the necessity of moral restraint, but in the removal or modi- fication of the source of irritation by the radical treatment of the varicocele by a proper operation; in short, to apply ordinary surgical principles and attempt to remove the cause rather than dally with the result. "I confess there has always appeared to me a singular want of consistence in the practice of those who, in a case of depraved sexual habit, would not hesitate to recommend the •)•) VARICOCELE AND ITS TREATMENT. removal of a redundant prepuce as a possible cause of the irritation, and who would at the same time, under similar circumstances, hardly think of looking for a varicocele at all, and even if aware of its existence w7ould be satisfied with offering advice as to the practice of self-restraint, the possible source of the irritation being left untouched. "The following is an illustrative case. A youth just under twenty years of age came under treatment with a varicocele, which was rather large and sensitive on pressure. The varicocele had increased very considerably when he was about fifteen years of age, having previously given no trouble, although it had existed as long as he could remember. With the increase of the affection, sexual irri- tation developed itself, and when applying for relief the following was his account of the matter. Every morning on rising there occurred uncontrollable sexual excitement, which was sometimes so acute that until a sexual discharge, spon- taneously or otherwise, actual pain was felt. Distressed at his condition he had sought treatment of more than one practitioner, and had received the same advice, which resolved itself in each instance into a recommendation to exercise control. " The radical treatment of the varicocele by operation entirely relieved these symptoms, and the change in the patient's aspect and general condition was most marked. I have ventured to mention this case, in spite of its unpleasant aspect, in brief detail, and have spoken in a general way somewhat plainly on the question of sexual irritation, because I believe unnecessary hardship is occasionally inflicted upon these unfortunate patients by what seems to be a want of knowledge of the proper relation of cause and effect on the part of those from whom advice is sought in some of these cases. "Again, the abnormally frequent nocturnal emissions which are undoubtedly associated with a certain percentage of varicoceles are not infrequently attributed, together with CONSTITUTIONAL ORIGIN OF VARICOCELE. 23 the varicocele itself, to bad practices on the part of the patient. Actually, however, this symptom is commonly the outcome of this same irritation which I am discussing, and if relief is possible, it is not by medicine and good moral advice that is to be obtained, but by operative measures. Here it is necessary to admit that all of these symptoms may be to some extent alleviated by the avoidance of scenes likely to cause the excitement feared, by the total relinquishing of exciting drink and rich food, and by persistent healthy exer- cise and mental occupation. "It is well known that the first anxiety of many men, especially if they happen to be advancing in life, upon the discovery that they are the subjects of varicocele or any affection in the same locality, is with respect to its possible influence on their virility, a fact fully utilized by quacks and charlatans of every description from time immemorial. It is therefore necessary to refer as briefly as possible to those cases of supposed impotence which are occasionally seen in association with varicocele. Of real impotence under these circumstances I have never seen an instance nor do I believe in its occurrence. "Temporary insufficiency of power may arise simply from apprehension, usually prompted by the evil prognosti- cation of quacks or other ignorant or unscrupulous persons, especially in subjects about to marry after having led lives of dissipation. Great exhaustion from mere fatigue may affect also the genital organs in cases where the irritation of which I have been speaking has led to excessive sexual indulgence or oft-repeated involuntary emissions." Constitutional Origin of Varicocele. It will be found that in a large proportion of cases which seem to be attributable to certain special causes there exists a foundation for the disease in the form of an inher- ently defective tone of the vascular walls, akin, perhaps, to 24 VARICOCELE AND ITS TREATMENT. that mysterious condition which exists in hemophilia as far as its hereditary character is concerned. I am very much gratified to note that Mr. Bennett in his recent excellent monograph on Taricocele has expressed similar views of the congenital foundation of the disease.2 The question of priority is of little consequence in this connection, but it may not be oat of place for me to state that the views which I have expressed are the same as those taught my classes at the College of Physicians and Surgeons in 1882. These were presented to the Southern Surgical and Gynecological Association in November, 1890, and appeared in the Medical Times and Register, August 31 and September 0, 1889, and in the Western Medical Reporter for June, 1891. Mr. Bennett, in investigating the question of heredity, found in one hundred cases, a distinct history of heredity in about fifty; in thirty of these the history pointed to varico- cele ; in the remainder to varix of the lower extremities. In a typical case, the patient being one of a family of four boys, two brothers had varicoceles, and one both varicocele and varix, the father who brought the patient having most exag- gerated varix of both lower limbs, as well as a varicocele. According to Mr. Bennett, at least eighty-five per cent. of persons coming under observation with varicocele present evidence of varix in other parts, scars of old nsevi, etc. He further says that it is impossible to avoid being struck by the singular fact that this congenital origin has not received more support than it has done from previous observers, by whom it seems to have been regarded merely as an occasional or rather possible cause only. Dr. Henry Lee, as late as 1870, in a lecture on varicocele, in which the various supposed causes are enumerated,, suggests the possi- bility of "some inherent predisposition in the 'vessels them- selves,'" when speaking of heredity. Mr. Pearce Gould, in 1880, comes nearer the truth in attributing the disease to a 2 W. H. Bennett, Varicocele, London, 1891. CONSTITUTIONAL ORIGIN OF VARICOCELE. 25 '•primary growth of venous tissue." Mr. Bennett states that in no work has he been able to find any sufficiently definite stress laid upon the actual congenital character of the affection. In my personal experience a number of cases have pre- sented themselves in which there was a distinct history of heredity. In a number of instances several members of the same generation were similarly affected by varicocele. In a few instances the aberrant vascular development was repre- sented by varices of the extremities in the parents. In two cases there was a history of troublesome varices of the legs in the mother of the patient, and in one of these I was afterward consulted regarding obstinate ulcers and eczema of the affected limb. I will mention at this point the interesting circumstance that within a week I have been consulted by two patients with decided evidence of a general lack of vascular tone. Both had a pronounced varicocele and varices of the legs. One consulted me regarding the varicocele and the other regarding the dilated veins of the extremities. In one of the cases there was a distinct history of heredity; in the other the history was not clear. In the former case, there was pronounced dilatation not only of the larger veins of the extremities, but also of the superficial veins of the legs, thighs, chest and abdomen. Monod and Terrillon'' remark, that although certain authors have laid stress upon the influence of heredity because of the fact of the occurrence of varicocele in the father or even more remotely in the line of ancestry, this proves nothing as far as the demonstration of the true nature of the malady is concerned. These authors do not accept the theory of venous aberration in general as a foundation for varicocele, principally because of the comparatively infre- quent association of varicocele with varices elsewhere. With them, therefore, varicocele is ab initio a local malady. But ; Maladies du testicule et de ses annexes. Par. Ch. Monod et O. Ter- rillon, Paris, 1889. •in VARICOCELE AND ITS TREATMENT. it is difficult to appreciate the philosophy of this reasoning. Do we reject the theory of local minor resistancy dependent on a general tissue vulnerability to tuberculosis, in pulmonary tuberculosis, simply because there is no development else- where? To be sure there is no microbe in varicocele, but the predisposition—the inherent tissue weakness—existing, the determining factors which have been mentioned in vari- cocele bear the same relation to the subsequent pathological changes as do the- bacilli to the subsequent tubercular deposit. A general tendency to venous dilatation may mani- fest itself at some particular point or never do so at all;— all depends upon the exciting cause. Monod and Terrillon remark in regard to Spencer's theory of the persistence of fcetal veins Avhich ordinarily undergo complete involution in childhood, as a cause of varicocele,4 that "it does not appear to be^supported by posi- tive proof," which assertion is hardly to be questioned. The analogy of haemophilia to the general condition of structural venous instability which I have advanced may seem a trifle far-fetched, more particularly as the pathology of haemophilia is as yet a terra incognita, or at least still remains for the most part a question sub judice. Inasmuch, however, as it is an established fact that haemophilia is of an hereditary character, and moreover, as the manifestations of the disease are probably dependent to a great extent on defective arterial structure and contractility, it is fair to assume that a similarly defective tone of the venous walls may exist. A case has recently come under my observation which illustrates in a forcible manner the association of per- verted vascular tone and blood quality with varicocele. An epileptic was referred to me-by Dr. S. T. Clevenger for con- sultation. This man had a very large varicocele which annoyed him greatly, the chief complaint being that the profuse perspiration which bathed the part was almost con- stantly of a sanguineous character. The patient informed 4 St.* Bartholomew's Hosp. Rep. 1887. CONSTITUTIONAL ORIGIN OF VARICOCELE. 27 me that his seminal ejaculations were always heavily tinged with blood. My friend Dr. F. AT. McRae, of Atlanta, Ga., has described a similar case to me, in which the scrotal haemi- di'osis was quite distinct. These cases are the only examples of this peculiar condition which have come under my observ- ation. As an illustration of the fact that vaso-motor aberra- tion probably existed in my case, I will state that I operated upon the patient for stricture and had a very alarming hemorrhage to deal with, which persisted for many days. In this connection I recall a very interesting case in which haemophilia and venous aberration were apparently associated. The case was that of a lad who was my playmate during my boyhood, whose prominence of venous develop- ment was a matter of comment among the boys with whom he was wont to go in bathing. He was subject to frequent and obstinate epistaxis, and it was noticed that slight cuts tended to bleed inordinately. This hemorrhagic tendency he evidently recovered from. A few years ago I operated upon my former playmate for the largest varicocele I have ever seen. Notwithstanding what has been said, and despite the fact that the relation of varices of the lower extremities to varicocele is very interesting, no very satisfactory statistics are as yet forthcoming. Landouzy was the first to investi- gate this point, but his investigations were hardly complete enough to be regarded as at all conclusive. He found in fifteen cases only one who had at the same time varicosities of the extremities. In twenty others who had varicosities there was no trace of varicocele, hence he did not admit any relation between the two. It is hardly necessary to call attention to the fallaciousness of such a confusion of propter and post. Curling states that he has often seen the veins of the extremities voluminously dilated in subjects affected by varices of the spermatic cord. The question naturally arises whether varicocele may 28 VARICOCELE AND ITS TREATMENT. not be associated with disease of the veins in other situations than the legs; for example, in the hemorrhoidal plexus. Monod and Terrillon remark on this point, "The discrepancy between authors from this point of view may be explained by the fact that the varices of the rectum, spermatic cord, and inferior extremities do not appear simultaneously but suc- cessively. AA7e could cite a patient wdio had first a left-sided varicocele, three years after he had hemorrhoids, and two years later still, appeared varices of the extremities." The occasional association of varicocele and hemorrhoids is in- dubitable and by no means surprising. From what has been said it is evident that varicocele is, in a general way, usually met with in comparatively feeble subjects. Occasionally, from some special cause involving trauma, robust individuals are affected by it, but such cases are exceptions to the rule. It is to be remembered in this connection, that varicocele may develop during a period characterized by debility, but the patient may not present himself for examination or treatment until he has acquired a more robust appearance. A delicate youth may develop a varicocele, yet subsequently become a robust and vigorous man. Mistakes in etiological deductions are doubtless fre- quently made under such circumstances. Mechanical Causes of Varicocele. Aaricocele has been known to occur from heavy lifting and athletic strain of various kinds. I have seen several cases which were probably of this origin. Keyes describes this variety. Years ago, Percival Pott described what he termed "acute varicocele" due to a combination of fatigue, injury to the part and exposure to cold, the condition being followed by complete atrophy of the testis. These cases were probably phlebitis of the spermatic plexus which was followed by complete occlusion of their lumen. Orchitis was possibly an attendant condition. MECHANICAL CAUSES OF VARICOCELE. 29 That physical effort of a prolonged and violent character is not only capable of favoring the development of varicocele in the early stages, but of increasing a varicocele already existing, is hardly open to question. M. Gaujot has shown that in young soldiers violent exercise and the fatigue of long marches not only cause a rapid increase in size of varicocele, but are apt to produce considerable pain and tenderness, and perhaps actual inflammation of the varicocele—an occasional blow from the pommel of the saddle being a secondary but by no means unimportant consideration. ATaricocele from this cause is especially apt to be associated with hemor- rhoids. The records of the pension office are very interesting in this connection. Chronic constipation is regarded by many surgeons as a very fertile source of varicocele: this I accept, providing the constitutional defect already described be associated with it. Constipation alone, I believe to be insufficient to produce varicocele. The pressure of accumulated faeces upon the left spermatic vein tends to retard the return circulation, and if the venous walls be naturally defective, varicocele may result. Bennett is still more inclined to question the potency of constipation as a causal factor of varicocele, as will be observed in my quotation of his views on the causes of the disease. The pressure of a truss sometimes produces varicocele in conjunction with a hernia; indeed, the pressure of a hernia itself has been alleged to cause varicocele. This is worthy of note, inasmuch as the application of a truss for the cure of varicocele is recommended by several excellent authorities, as will be seen later. It is to be remembered in connection with the etiology of varicocele that constitutional debility may bear the relation to the disease of both cause and effect. Air. Bennett has discoursed upon the causes of vari- cocele quite exhaustively, and with an ingenious originality 30 VARICOCELE AND ITS TREATMENT. which commands admiration. The folloAving is a resume" of his views. " Theoretically, it may be conceded that any condition in which the support natural to the veins has been removed or modified, would contribute to their distention and possible over-dilatation. Practically, this factor is very unimportant, as there is nothing to support the view that the withdrawal of the natural support which is supposed by some to be afforded by the scrotum has any relation to the true increase of the disease, as I shall attempt to show. The state of the cremaster muscle has, however, I think, a certain relation to the amount of distention possible in a well-marked varicocele. " It can hardly be said that, setting aside the actual obstruction of the blood stream by the pressure of tumors, there is any evidence whatever of either of these so-called causes being even contributary. Certainly neither of them deserve serious consideration in this respect, excepting residence in hot climates, and perhaps constipation, which although it does not actually influence the growth in the sense it is often understood and described to do, bears an incidental relation to the disease which is at least interesting. Accepting the view which seems fair, viz., that the factor which leads to the growth at the later periods is increased intravenous pressure, the explanation which appears to me the most reasonable is afforded by the direct connection of the spermatic vein with the portal system by means of the colico-spermatic branches, which I have described, for it is clear that although these vessels vary greatly in size in different subjects, they are large enough in some to allow any engorgment or obstruction of the portal circulation to throw increased pressure upon the spermatic vein, especially if by chance, as in one instance, any immediate communica- tion existed with the trunk of the mesenteric vein. " The pressure thus arising would of necessity bear a direct ratio to that in the portal system, but for practical MECHANICAL CAUSES OF VARICOCELE. 31 purposes it would depend in degree upon the size of the colico-spermatic veins, which are sometimes so small that the amount of backward pressure transmitted through them could hardly affect the tension in the spermatic circulation to any appreciable extent. "If the grounds upon which this view is based are at all sound, it follows that the liability of varicocele to increase at periods subsequent to puberty must depend, to a great extent at all events, upon the existence of a sufficiently free com- munication between the portal system and spermatic veins, by means either of large colico-spermatic branches, or possi- bly in some cases by more direct connection with the large branches of the portal vein. "To produce actual proof of this is impossible, since it could only be provided by dissection of a large number of subjects known to have had varicocele which had increased at the time noAv being discussed. Circumstantial evidence of considerable weight is nevertheless forthcoming on the fol- lowing points: " 1. It is, I presume, generally known that the growth of varicocele at these later periods is not unfrequently associated with the development of piles, and that remedies which remove the feeling of weight and discomfort about the rectum in such cases have an equally good effect upon any feeling of-distention about the varicocele; these remedies being, for the most part, drugs which directly excite the secretion of the liver, and so relieve the tension in the portal system. "2. Residence in hot climates, especially in India, is admitted to be a cause of this kind of increase; it is also an admitted cause for the development of piles. Now, although the increase of the disease in hot climates is to some extent more frequent than in this country, the difference is very slight, and certainly not more than could be accounted for by the well-known tendency to liver derangements, with result- ing portal engorgement, which is so prevalent in certain 32 VARICOCELE AND ITS TREATMENT. climates. Even then it seems obvious that the increase of the disease must depend upon some peculiarity of the veins, otherwise it should affect a much greater proportion of cases than it actually does. Again, it would affect both sides equally, which it surely does not do. "The cause to which the increase in hot climates is usually ascribed is the general relaxation of parts which is produced by the extreme heat, etc., the result being the loss of the natural support supplied by the relaxed tissues. Although this may give rise to some fullness and discomfort, I have never seen any reason to infer that actual growth could be thus produced, for if it were so, the effect would be altogether more uniform in its distribution over the aggregate number of cases influenced by this supposed cause. "3. A'aricoceles on the right side rarely, if ever, increase except at the time of puberty; those of the left side not uncommonly do so at later periods. I have already said, in cases in which the affection is double, that on the left side may grow, whilst that on the right remains unchanged. Here again it seems clear that this tendency to growth must be associated with some peculiarity in the veins on the two sides, and the only constant difference, excepting in the way of size and length, which could affect the matter at all is the frequent communication with the portal system, which is normally entirely limited to the left side, and is sometimes very free. It is on the whole, therefore, not altogether unreasonable to connect the relative frequency of increase on the left side with the occasional existence of this free communication. "I much doubt whether it is anatomically possible for a loaded colon under any circumstances to exert direct press- ure upon the spermatic vein sufficient to merit consideration. Aloreover, it has been shown again and again that the increase in the affection may, and does, occur quite independ- ently of constipation, whilst on the other hand, constipation of the most exaggerated kind frequently co-exists with vari- cocele without influencing its growth in any way. MECHANICAL CAUSES OF VARICOCELE. 33 " This condition may, therefore, be regarded merely as an incident due possibly to the same cause as the increase of the varicocele, and having no other relation to it, the cause referred to being engorgement of the portal system, which may, however, occur without producing constipation, thus explaining the frequent absence of any relation between this condition and the groAvth of varicocele. In the same way constipation is frequently associated with piles, but it is not actually necessary for their production, and in fact often bears only the incidental relation to that complaint of being due to the same cause. "The following so-called causes may be safely regarded as having no real bearing upon the origin of varicocele. "(a) Great length of the veins on both sides and the manner of termination of the left in the renal vein at a right angle. "(6) Loss of valvular function. The valvular arrange- ments are altogether too uncertain and irregular in the spermatic veins and plexus to have any effect as a cause. Their presence, absence, or insufficiency may, hoAvever, affect the form of the tumor. "(c) Thinness of the vein walls. There is no good reason for supposing that the veins in varicocele are ab initio thicker than normal. Further, there is no reason for assuming that the veins are under normal circumstances too thin to meet the physiological requirements of the part. "(d) Alternating fullness and emptiness in different positions of the body. This is the universal character of the venous circulation in every part of the body, affecting all" individuals in like manner. "(e) Petit's theory of the disadvantage to the circulation in the spermatic veins arising from their pulley-like relation to the pubic bone. Apart from other considerations, this is; disproved by the fact that, although varicocele exists less fre- quently and rarely grows on the right side, the bend in the veins on that side (the right) is quite as acute as on the left. 34 VARICOCELE AND ITS TREATMENT. "(/) Lenoir's theory, that the frequency of occurrence on the left side is due to the pressure exerted upon the veins of that side, as they pass through the abdominal ring, by the constant bending of the body to the right side during the lifting of heavy weights, etc. If this were so, then varicocele in left-handed men should occur only on the right side, which is not the case. " ( g) Inflammation of testicle or scrotum. This condition is much more likely to cause some shrinking of the affection from the veins becoming blocked by thrombus, the result of extension of inflammation to the tissues around the vessels. " ( h ) Pressure of omentum in fat people ( Astley Cooper). Taricoceles are not more common in fat people than in spare subjects." CHAPTER IA'. Period of Development and Morbid Anatomy of Varicocele. Taricocele occurs with the greatest frequency between the ages of fifteen and thirty-five, this being the period when all the faculties of the body are at their maximum and physical growth is most active; or better, this is the period when there is a degree of growth far in excess of the inherent strength of tissue. It is at this period also, that perverted sexual habits and hygiene are apt to enter into the daily life of the patient, either in the form of sexual excess, sexual excitement without gratification, or most frequently, masturbation. It is at this age that men are most likely to overtax their strength; then, too, the effects of exhaustion are most severe, especially near the period of puberty. Taricocele is occasionally met with in young children, and in such cases there is not only a pronounced atonicity of vascular structure in general, but evidences of sexual precocity. In certain rare instances it has been known to occur after middle life, in which event there is a decidedly disproportionate varicocity of the scrotal veins. Landouzy observed in thirty-six cases the following periods of development: 9 at from 9 to 15 years of age. 20 " " 15 " 25 " " " 3 " " 25 " 35 " " " 4 above 35 " " " 35 ' 36 VARICOCELE AND ITS TREATMENT. Curling made an almost similar observation. Thus, in fifty cases there were: 2 at from 10 to 15 years of age. 26 " " 15 " 25 " " " 14 " " 25 " 35 " " " 5 " " 35 " 45 " " " 3 " " 45 " 65 " " " The average in this table is about equivalent to that of Landouzy. Nelaton gives the years from fifteen to twenty- five as the most favorable to the development of varicocele. Helot states that it is most often developed at from ten to thirty-five years. Bennett asserts that there are tAvo periods when the disease is apt to increase, viz: at puberty, and at about the age of thirty-five. He has seen it develop in old men, and has met with it in many children of from five to eight years of age. In one case he found a marked varicocele in a boy of four on the post-mortem table, and on another occasion he found an incipient varicocele in a foetus. These cases are all sufficient proofs of the frequently congenital nature of varicocele. Morbid Anatomy of Varicocele. The morbid anatomy of varicocele comprises few changes of importance. The pathological changes consist mainly in dilatation and tortuosity of the veins Avith a coincident loss of elasticity and contractility. There is usually more or less increase in the thickness of the venous walls. This, how- ever, does not make the vessels proportionately strono-er because of the fact that the vessels are enormously dilated, and their walls are consequently much thinner in proportion to the bulk and weight of the contained blood than is the case with normal vessels. Not only are the elastic and con- tractile elements of the vascular walls absorbed in pronounced varicocele, but they are replaced by a low grade of connective MORBID ANATOMY OF VARICOCELE. 37 or fibro-connective tissue. These conditions enhance the structural weakness. Subacute or chronic inflammatory changes may occur and cause primarily still further thickening, and secondarily a more pronounced degree of degeneration of the vessels. As a consequence of these conditions of innutrition, areas of fatty degeneration may develop. These degenerated areas explain the occasional occurrence of haematocele of the scrotum from slight exciting causes in severe varicocele. Acute phlebitis may attack varicocele and prove a serious matter. Aridal de Cassis reported two cases of this kind, one due to a kick and the other to propagation of inflammation from an acute epididymitis. Pla-,-*' (After Wickham.) is passed a hare-lip pin. Small sections of lead-tubing are passed OArer the ends of the double sutures, and at the com- pletion of the operation are clamped down firmly in a manner similar to that employed with split shot. I append illustrations of AVickham's method, not be- METHODS OF OPERATION SPECIALLY CONSIDERED. 95 cause I recognize its superiority, but because the cuts repre- sent quite accurately the proper method of application of all forms of clamps and the passage of the sutures. As already remarked in connection with the Horteloup clamp, I am inclined to believe that there is likelihood of too much scro- tum being left where this clamp is used for the purpose of outlining the proper amount of tissue for removal. In describing Avhat I believe to be the ideal method for large varicoceles, it is not my intention to advocate it as a routine practice. The surgeon must necessarily at all times use his best judgment and select the operation apparently best suited to the exigencies of the case in hand. I will simply describe the method which I believe to be the safest and nearest approach to a radical cure in the vast majority of cases of pronounced varicocele. I shall not follow the usual custom of claiming the method by Arirtue of some little modifications of technique. As I have already hinted, the raison d' etre of so-called special methods usu- ally exists only in the mind of the operator. I do not know whether this particular combination of the old and new is practiced by others, nor do I consider it material to the sub- ject in hand. If it is so practiced the operator is privileged to label it to suit himself, providing he will permit me to use the label.4 4 Since this portion of this monograph was written I have noted the following by A. B. Barrow: " I have simplified the operation of varicocele slightly, by making the incision over the external abdominal ring only, and not extending it into the scrotal tissues at all, as I found that it was quite easy to pull up the veins into this limited opening and ligature them; and in this situa- tion there is no liability to injure the vas deferens, so I have discontinued the use of the pins I then recommended. But I attach the same im- portance to that point in which I advocated the clearing and ligaturing the veins first at the external abdominal ring, where it is easily done; and, having cut them through, to pick up the distal ends of the veins, and lifting them up to strip off the surrounding tissues of the cord as low as the upper part of the testicle; then apply the lower ligature, cut the veins through again, and allow the testicle, which has been drawn up to the wound, to slip back into the scrotum. In this way I have operated upon a large number of cases, in a few instances removing the veins of both sides at the same operation, and often doing the operation in association with the radical cure of hernia, and I have had unvarying success both 96 VARICOCELE AND ITS TREATMENT. The bowels having been emptied by a saline or castor oil,—the latter being perhaps preferable,—the scrotum, pubes and thighs are thoroughly scrubbed with green soap and bichloride 1-2000 and then bathed with a bichloride solution 1-1000. This completed the patient is anaesthetized, during which process the scrotum is wrapped in a towel wet with the bichloride solution. It is hardly necessary to say that the operator is now supposed to Avash his hands and remove all superfluous subungual organic matter. Everything, includ- ing the operator's conscience, being thus prepared, and all instruments haATing been asepticised by boiling water, an incision one inch or a little more in length is made, beginning just below the external abdominal ring and parallel with the Fig. 17. King's Scrotal Clamp. spermatic cord. This is carried doAvn until the cord and its accompanying veins are exposed. The number of veins varies in my experience; they are here quite straight and Avhen emptied of blood quite small. The cord and veins are hooked with an aueurism needle out of the wound, which is meanwhile occasionally irrigated with bichloride solution; the veins are now separated and several of the larger ones ligated with a single ligature of medium-sized juniperized as regards the rapidity of healing of the wound, the cure of the affection, and the satisfactory condition of the testicle. Several cases have been afterward admitted into the services. " I have not found the testicle diminish in size in any case, but, on the contrary, it usually increases. In some cases I have observed that there is a tendency for the tunica vaginalis to become slightly distended with fluid when the patient first begins to walk about, but this condition disappears during the night when the patient is lying down."—Brit. Med. Jour., March 21, 1891. METHODS OF OPERATION SPECIALLY CONSIDERED. 97 silk; the ligatures are cut short and the veins and cord dropped back in place. If there is any difficulty in reposi- tion of the cord it is readily overcome by traction on the testicle. The wound is now irrigated and thoroughly dried, towels instead of sponges being used for this purpose. Sponges are far inferior to soft dry sterilized towels for checking oozing and for many reasons to be preferred. Several fine stitches of juniperized silk are now inserted, the wound closed and dusted with iodoform. During the remain- der of the operation the wound should be compressed with antiseptic gauze by an attendant. The next step is the appli- cation of the clamp—I have used both Henry's and a modifi- cation of King's clamp,5 but any other good clamp will do. (Fig. 17.) Care should be taken to divide each side of the scrotum equally, and to include sufficient tissue in the clamp. As already obserA7ed, it is Avell-nigh impossible to remove too much. I have operated in cases where I have remoATed the clamp after excision of the scrotum for the purpose of ligat- ing a vessel and have found so little tissue left that I had extreme difficulty in covering in the testes, yet the new scrotum has not only proved sufficient, but I have wondered whether it Avould not have been practicable to remove more tissue. It is an excellent plan to insert a few harelip pins beneath the lower border of the clamp before cutting away the scrotum, as the dartos is very elastic, and is likely to retract so that there is too little room for the sutures. The point of election having been determined upon, the redundant tissue is quickly cut away along the face of the clamp with either scissors or knife. Juniperized silk sutures and harelip pins are to be used and may be inserted either before or after the excision, but always before removing the clamp. There should be as little delay as possible, as the prolonged pressure of the clamp produces more or less bruis- ino- of the loose scrotal tissues which is not conducive to prompt union. Three or four pins are usually enough; these 5 King's clamp is lighter and less bunglesome than Henry's. 7 98 VARICOCELE AND ITS TREATMENT. should be inserted at equally divided intervals and the silk sutures interposed in sufficient number to prevent gaping and maintain accurate apposition. Henry covers the heads of the pins with sealing wax and embeds their points in small corks. A plan which is perhaps better, and one which I occa- sionally practice, is to pass reinforcing sutures of silver wire instead of the pins. A single strand of wire is used and its ends knotted upon small rubber buttons or fixed in split shot. The tension is so extreme that something more than ordinary sutures is required. The secondary blade of the clamp having been removed the* sutures are lightly tied and the main clamp removed. If the sutures be permanently tied before removal of the clamp, the surgeon may have to reopen the wound to tie some spouting vessel. Vessels should be tAvisted where possible, or traversed by a suture. An assistant must now press back the testes, else they will pop out in a truly demoralizing fashion. I well remember my first experience in this re- spect. I wondered where on earth I was going to get skin enough to cover those obstreperous appendages. All hemorrhage having been checked the wound is per- manently closed. Too much care cannot be taken in check- ing hemorrhage, as there is an especial tendency to venous oozing. The formation of a clot beneath the Avound will not only prove a source of septic danger, but will prevent speedy union. There is also the danger of serious hemorrhage of a passive character. To one unfamiliar with operations about these parts the tendency to prolonged oozing is peculiar; I have noticed it for several days after a most careful opera- tion for varicocele. The danger of hemorrhage is in a great measure de- pendent on the constitutional condition of the patient, as shown in one of my cases. The occurrence of concealed hemorrhage and formation of clot can be readily avoided by the insertion of a small METHODS OF OPERATION SPECIALLY CONSIDERED. 99 drainage tube along the line of suture at the lower angle of the wound. I prefer for this purpose decalcified bone, but rubber will of course answer the purpose. Henry uses adhesive plaster as an additional support to the wound, but I have found graduated compresses to be all that is required. Having closed the Avound and made provision for drain- age, the parts are irrigated with the bichloride solution, dried, the edges sprinkled Avith iodoform and a piece of oiled silk or protective laid along the edges to prevent adhesion of the subsequent dressings. A quantity of borated cotton and antiseptic gauze in which a hole has been cut for the penis is now applied and the whole secured by a three-tailed band- age secured at the waist. A light diet should be advised, and no attempt made to move the bowels for four or five days. When a movement does occur, the parts should be carefully supported and a bedpan used. The sutures should not be removed for six or seAren days or gaping will quite likely occur. So extreme is the tension when the operation is properly performed that gaping is quite frequent. The drainage tube should be removed in three or four days. The silver pins, or wire sutures, as the case may be, can be allowed to remain for several days longer if necessary. An excellent plan, where gaping occurs, is the application of stout mole-skin plaster on either side of the wound; through the edges of the plaster holes are punched and the two strips laced together with a stout silk or hempen thread, shoe-string fashion. The strips of plaster should extend well out to the thighs. Although a speedy union is desirable as lessening the liability to inflammatory complications and enabling the patient to get about soon, gaping of the wound has some compensatory advantages. The cases which heal by granulation yield a firmer support to the A'arix from cicatricial contraction and inflammatory thickening. This Avas well illustrated by one of my cases in which erysipelas occurred. 100 VARICOCELE AND ITS TREATMENT. The patient may be allowed to get up in two weeks, if no complications arise. Aly operations for varicocele uoav comprise forty-five cases of all methods, twelve of which have been subcutaneous deligations of the veins, eighteen of simple resection of the scrotum, four of resection of the scrotum with ligation of the veins at several points, one of open deligation with resection of the veins, one of open deligation without resection of veins. Fig. 18. Application of King's Clamp. and nine of ligation of the veins high up Avith resection of the scrotum. A recital of these cases in detail would be monotonous; hence I Avill give only the points of interest deAreloped by their study. I have had no deaths and but few cases in which there was serious reason for alarm. In some few instances, howeA^er, there Avere certain features which caused me considerable uneasiness for a time. The youngest patient operated on was eighteen and the METHODS OF OPERATION SPECIALLY CONSIDERED. 101 oldest forty years of age. Most of the patients were betAveen twenty and thirty. The duration of the affection varied, according to the patients' statements, from one to twenty years. The question of duration, however, is not of impor- tance, nor can it be arbitrarily settled in any case. The duration of varicocele is necessarily a relative matter, and implies the period since the condition was first brought to the patient's attention. Obviously the sexual hypochondriac who proverbially seeks for what he does not wish to find, is likely to discover the tumor earlier than one in whom the sexual functions are not a matter of especial concern. Pa- tients Avith neuralgic manifestations, referable to the cord, testes or penis, are apt to discover their varix at an early period. The causes of varicocele, as suggested by my cases, are also difficult to outline arbitrarily. Masturbation and sexual excesses are the causes which are usually assigned for vari- cocele.. Often, however, sexual excesses do not appear to be sufficient per se to account for varicocele, but no other cause is discoverable. It is certain that only a small percentage of masturbators have varicocele. As, hoAvever, nearly all boys masturbate, it is safe to say that about all subjects of varico- cele have; hence the post hoc ergo propter hoc argument is quite natural. I believe that I am safe in saying that sexual abuse alone never causes varicocele, and that it is an effective cause in direct proportion as it is associated with some con- stitutional fault involving vaso-motor perturbation and laxity of tissue, with especial reference to the venous walls. As illustrative of the important relation of general vas- cular atonicity to varicocele, one of my cases already men- tioned is certainly striking. This case was under the charge of Dr. S. V. Clevenger, one of our leading neurologists, who was treating him for epilepsy. The doctor observed scrotal haemidrosis, and referred the patient to me as a curi- osity. On examination I found a large varicocele, which the patient claimed was causing him great annoyance by its 102 VARICOCELE AND ITS TREATMEMT. weight, and the consequent dragging upon the cord and back-ache. On inquiry I elicited the fact that he was ex- ceedingly hypochondriacal. A peculiar feature of the case was the fact that the seminal emissions, like the sudoriparous secretion of the scrotum, Avas heavily tinged with blood. Urethrametry revealed several strictures in the penile urethra. As the epileptic attacks were infrequent and had devel- oped since the acquirement of the strictures—and the pa- tient claimed since the development of the varicocele—it Avas thought advisable to operate. As I considered the hemor- rhagic secretions to be a fair warning of the danger of hemorrhage, I ligated the varix subcutaneously, and at the same time performed a dilating urethrotomy. As I antici- pated, a terrific hemorrhage from the urethra resulted. The bleeding continued for three days and necessitated the con- stant presence of an attendant who applied pressure by an ice-bag during that time. There was considerable indura- tion of the veins and a sharp orchitis following the ligature. The result, however, has been excellent so far. The epilep- tic attack which was expected at the time of the operation has been postponed for nearly four months. I do not say that this fact is proof of the causal relation of the stricture and the varicocele to the epilepsy. Time may show this, however. Like many operations upon the skull for epilepsy, the result in this case may be due to a temporary revulsive effect upon the nervous mechanism, which has merely post- poned the usual explosion. I will state, however, that the patient's general health is much better, and that he has markedly increased in weight. Several of my cases have apparently folloAved an epi- didymitis or traumatism. In how far these causes were responsible for the varix in these cases, I am unable to say. Very often the only relation betAveen epididymitis or injury and varicocele, is the fact that the latter has been first dis- covered after these accidents. Personally, I think that METHODS OF OPERATION SPECIALLY CONSIDERED. 103 either of these causes may be operative. I haATe had one case of varicocele undoubtedly due to athletic strain. All authors, I believe, admit the possibility of a kick producing varicocele. In several instances I have had patients with small varicoceles avIio happened to be under observation, whose Ararices increased after an attack of epididymitis. Any- thing which will impair the tone of the involved part, or induce circulatory obstruction, should be operative in pro- ducing or at least aggra\*ating varicocele. I have operated on two jockeys, each of whom attributed his ATaricocele to excessive horseback-riding; in one case the patient recalled an injury in springing into the saddle. There is no question in my mind as to the causal influence of excessive horseback-riding in producing varicocele. All old cavalrymen Avill support this opinion. The records of the pension office afford abundant proof. Dr. James A. Lydston, who has been connected Avith the pension bureau for some years, informs me that ATaricocele is one of the most frequent disabilities presented to the attention of the depart- ment, and that it is especially prevalent among those who served in the cavalry. How important the appearance of two jockeys, in this connection, I cannot say; it may have been a coincidence, as I am unable to state that the preA7a- lence of varicocele among jockeys is a matter of comment. Other things being equal, they would be less likely than other riders to injure themselves, as they ride on plain saddles, and they cannot therefore experience the disagreeable effects of a blow with a pommel. Jockeys, as a class, are young, healthy, light-weight subjects Avho are well-kept, and not subject to vascular debility. The symptoms for which the patients upon Avhom I have operated, have sought relief, have varied. In several instances the principal annoyance complained of was the deformity. One of my patients, for example, was annoyed by the frequent comments which were made upon his appearance, his varicocele being so bulky as to be quite 104 VARICOCELE AND ITS TREATMENT. prominent even when his trousers were amply large. There was no other symptom in his case Avhich Avas of any partic- ular moment. In several other cases there was noticeable deformity, but associated with it were sexual hypochondriasis and various reflex disturbances. In some instances mechanical discomfort has been chiefly complained of. In several cases intertrigo, and in one instance severe chronic eczema, con- stituted the chief source of annoyance. Pain in the back, shooting pains along the cord and penis, and neuralgia of the testes have been frequent. In some cases irritability of the bladder has been complained of. In nearly all instances sexual hypochondriasis, with or without spermatorrhoea, has been pronounced. I do not wish to be understood as assert- ing that all of the symptoms for which the patients sought relief were necessarily dependent upon the varicocele. The nocturnal pollutions, spermatorrhoea and prostatorrhcea, might have been due in many of my cases not to the varix per se, but to the same underlying cause as the varix. In several instances the principal symptoms were not removed by the operation. In but one case have I had sufficient hemorrhage to give rise to any particular annoyance. In this case there was a tendency to hemophilia. This, with my failure to use a drainage tube, resulted in a concealed hemorrhage, the formation of a clot, and after removal of the latter, free passage oozing for some days. In this case there was the most extensive ecchymosis that I have ever seen, the tissues from the umbilicus down to the middle of the thighs being as black as extravasated blood could make them. The result, although alarming in appearance, was not a matter of con- cern, but the patient became very much frightened at what was apparently, as he expressed it, a general mortification. A tendency to ecchymosis exists in all cases of operation for varicocele, and this should be remembered, else both surgeon and patient are apt to be demoralized by the consequent METHODS OF OPERATION SPECIALLY CONSIDERED. 105 appearance of the parts. In several other instances there has been a tendency to oozing for some days, thus preclud- ing the possibility of primary union. The use of the drainage tube is, in my estimation, one of the most Araluable points in all operations involving resec- tion of the scrotum. Concealed hemorrhage, tension and sepsis are not liable to occur when the tube is used; there is unquestionably danger of these accidents Avithout it. As long as marked oozing persists, the tube should be allowed to remain. Should severe hemorrhage occur after the operation has been completed, the tube facilitates hot water irrigation or the application of styptics, the former being the best haemostatic. The healing of the wound in a fair proportion of my cases of resection of the scrotum has been by first intention; but I have found that there is in many cases a tendency to gaping, even though the sutures be allowed to remain for a week or more. Indeed, I am inclined to believe that when there is no tendency to gaping, hardly enough scrotum has been removed. The gaping is always due to the extreme tension upon the parts incident to a thorough operation. It may be prevented in many cases by allowing the sutures to remain in for some little time. If juniperized silk and silver- wire be used, as I have suggested, the stitches can be allowed to remain in from five to eight days with impunity. In several instances I have had slight sloughing of the scrotum, evidently from extreme tension. In these cases, however, the result has been even better than those in which primary union occurred. No matter how much tissue may slough, the parts become covered in by an excellent scrotum Avith almost marvelous rapidity. Although the fit is decidedly snug at first, the testes soon accommodate them- selves to their neAv investment. I have never seen a more delighted patient than one of mine in whom cellulitis occurred as a consequence of infection after operation. I recall a case of cellulitis of the scrotum, not, how- 106 VARICOCELE AND ITS TREATMENT. ever, following operation, that occurred some years ago in the New York Charity Hospital, in which the testes were bared completely, yet by judicious strapping and occasional stimulation of the granulations a good scrotum was finally secured. I saw several other cases of scrotal cellulitis in the New York State Emigration Hospital during my term of service in that institution. Contrary to the rule" in such cases, none of these died. In all there was extensive slough- ing of the scrotum, but repair once begun was very rapid. Such cases teach us that in resection of the scrotum there should be little fear of excising too much tissue. The more excised the better the result; and while it is always desir- able to obtain primary union where possible, I feel justified in saying that the more gaping, the better the result. Cellu- litis, i. e. erysipelas, is not a source of danger in resection of the scrotum unless direct infection occurs. This was the explanation in one of my hospital cases, which I have already mentioned. The failure of the wound to unite promptly is undoubtedly, in some cases of scrotal resection, due in a measure to the prolonged pressure of the clamp. Sloughing may be partially explained in this manner. As I have already remarked, my faith in resection of the scrotum as a radical cure for varicocele has been somewhat shaken by several of my cases. In one instance already related, I have had an oppor- tunity to watch the gentleman for nine years since the oper- ation, and although I removed all the tissue necessary to an ideal operation in this case, the varix, which was a very large one, has recurred, and is now nearly as large as exer. The symptoms, however, for which he sought relief, haATe not returned. In two other cases there has been a moderate recurrence. The objection may be urged that I have not taken off enough scrotum. My conscience is clear upon this point, however, as I have invariably taken off all I could in reason and still retain a covering for the testes. My operations of subcutaneous deligations haAre been METHODS OF OPERATION SPECIALLY CONSIDERED. 107 successful, but on the average have given me more uneasi- ness and trouble than those in which I performed the open operation. In one case recently examined there has been a moderate recurrence two years after subcutaneous deliga- tion. Induration, pain and orchitis are some of the disagreeable features which I have experienced from this method of operation. I have found that the operation of tying the veins low down is much more objectionable from this standpoint than that involving ligation higher up as in the combined operation which I have recommended. It is obviously safer to ligate the veins at their comparatively straight portion, where the changes in the vascular walls are at a minimum, and there is the least necessity for mauling about the boyestments of the testes and tearing up the planes of areolar tissue. I have already given my reasons for advo- cating the combined operation. In one of my cases of com- bined operation, I ligated the vessels at several points rather low down. This patient did fairly well for two weeks, when he arose against orders, or rather over-exerted himself when allowed to sit up. As a consequence, phlebitis, cellulitis and consequent slight suppuration developed. During con- valescence this patient developed severe la grippe with marked pulmonary symptoms, haemoptysis being profuse, giving me great apprehensions of pyaemia with embolic pneumonia, etc. Although never very strong-lunged, this patient perfectly recovered. In four or five cases stricture existed and urethrotomy was performed simultaneously with the operation for varix. I can see no objection to this procedure, and I have had but one case in which the operation upon the urethra afforded any complication. This instance, already alluded to, was one in which severe urethral hemorrhage resulted. Two cases have come under my observation which sug- gested the possible development of hydrocele as a result of operation for varicocele. In one of these cases, operated on by me several years ago by subcutaneous deligation, I again 108 VARICOCELE AND ITS TREATMENT. t operated, a short time since, for an encysted hydrocele upon the same side. In another instance I operated for hydrocele in a case in which subcutaneous deligation had been previ- ously performed for varicocele of the same side by another practitioner. The patient was complaining of the same symptoms, according to his statement, that had character- ized the original varicocele. My operation for hydrocele, although perfectly successful per se, has not relieved the symptoms from which he was suffering. He is now giving me a great deal of annoyance by his complaints of severe neuralgia of the testicles. The irritation of sunken sutures which had accidentally traversed the tunica vaginalis, or obstructed venous circulation, plus irritation, might account for these cases. In ligating low down the tunica vaginalis is apt to be quite roughly handled, if not actually traversed by the ligature. Acute hydrocele is a very frequent element in the swelling resulting from ligature of the varix. As already remarked, the testis itself may be involved. Injury of the fascial envelopments of the cord high up is not im- portant, and is a necessary factor in the operation which I have suggested. I have never performed an operation for double varico- cele. Indeed, I have met with no case which, to my mind, required such operation. Even though a case of double varicocele should apparently require a double operation, I should hesitate to incur the risk of atrophy of both testes, slight though I believe it to be. In ordinary single opera- tions the risk of atrophy is doubtless overrated. This is probably due to (1) the relative appearance of shrinkage incidental to the subtraction of the swelling of the \7arix per se. (2) Continuation of atrophy, which was steadily pro- gressing prior to operation. (3) Atrophy due to embolism, syphilis, epididymitis, etc. Theoretical considerations, how- ever, do not always mollify the patient where actual atrophy of the testes occurs. It will be remembered that Delpech was assassinated by a man upon whom he had performed a METHODS OF OPERATION SPECIALLY CONSIDERED. 109 double deligation for varicocele some years before. On autopsy the murderer's testes were found to be soft and shrunken, presumably from the operation. I have had no case in which atrophy of the testes has followed an operation, and have had several both of scrotal resection and ligation of the veins, in which the testes became firmer and larger after the operation. Among my cases Avas one of scrotal haematocele, resulting from the injury of a large varicocele. In this case suppuration occurred, and I Avas obliged to lay the part open; as soon as it Avas healthily granulating, I removed the pendulous scrotum with an excellent result. AVhile I have not been able to follow all of my cases for a great length of time, the immediate results have been eminently satisfactory, and in those cases Avhich I have been able to folloAv for a period of seAreral years, I have no occasion to regret the operation. In the majority of instances the relief obtained has been so marked that the patients were greatly delighted. That this has always been a physical result of the operation I do not claim, nor do I think that under the circumstances it is a question of great importance. In general I have found that the combined operation of high ligation of the veins, with resection, has been much better from the standpoint of economy of time, than the sub- cutaneous or ordinary open operations of ligation. Painful induration and swelling of the testes, with consequent dis- ability aud impeded locomotion, are very frequent in my experience, Avhen these operations of deligation have been performed. In nearly all of my cases, there has been a marked improvement in the patient's mental condition. Hypo- chondriasis has been relieved, and sexual vigor improved or restored. Pain has been relieved in most instances. A notable exception is the case already mentioned, in Avhich hydrocele followed an operation for varicocele, and severe pain persisted after cure of the hydrocele. BIBLIOGRAPHY. A7idal (de Cassis).—De la cure radicale du varicocele par l'enroulement des veines du cordon spermatique. 1850. D. Hayes AgneAv.—Surgery, Vol. II., 1881. Curling.—Diseases of the testicle. Sir Astley Cooper.—Guy's Hosp. Rep., 1838. On the structure and diseases of the testes. London, 1841. AI. H. Henry.—American Jour, of Syph. and Dermatology, 1871, p. 220. Trans. Connecticut State Soc, 1883. Treatment of varicocele by excision of redundant scrotum. J. H. Vail & Co., 1881. Additional remarks on resection of the scrotum in varicocele. N. Y. Med Rec, XXII, p. 509. Journal Am. Med. Ass'n, Vol. XL, 1888. Boenning.—Radical cure of varicocele by excision of the veins. Phila. Med. Times, 1882-83; Vol. XIII., p. 720. Nebler.—ATaricocele and its surgical treatment. Breslau, 1880. B. Cooper.—Guy's Hosp. Rep., 1838. Escallier.—Memoires de la societe de chirurgie, 1851, and Vol. II., p. 66. John Ashhurst.—Surgery. Philadelphia. 1889. Heath's Prac. Diet, of Surgery, 1886. Stephen Smith.—Operative Surgery, Philadelphia, 1887. Clark.—Treatment of varicocele. N. Y. Med. Jour., 29, p. 631. Nicaise.—Traitement du varicocele par la ligature et la section antiseptique du veines. Revue de Chirurgie, May, 1884. J. G. Will.—Influence of varicocele on the nutrition of the testicle. Lancet, London, 1880, p. 754. Ill 112 ^ VARICOCELE AND ITS TREATMENT. De Wenter.—Cong. Francais de chirurgie. Paris, 1886-87, p. 400. Ann. de mal. des org. gen. urin. 1887. Dujardin Beaumetz.—Bull. gen. de therap., 110. 1886, p. 554. Leonard AVeber.— M.ed. Rec, N. Y., 1885, Vol. XXVIII. T. W. AATilliams, Chicago Med. Jour, and Ex., 1879, Vol. XXVIII., p. 469. Med. Age, Aug. 1884. L. Picque, Revue de Chirurgie, Paris, 1886, Vol. VI.,p. 289. }\T. H. A. Jacobson.—Operations of Surgery, 1889. AIcKay, Thos. AV, Cleveland Med, Gazette, Dec, 1889. Verneuil.—Gaz. Hebdominaire de Med. et de Chirurgie, Sept. 16, 1889. HoAATe.—Eclectic Med. Jour., Cincinnati, 1879. Spencer.—St. Bartholomeiu's Hosp. Rep., 1887. Guyon.—Ann. des Maladies des org. genito urin., Alay, 1884. Landouzy.—Du varicocele et en particulier de la cure radicale de cette affection, 1838.—Druitts Surg. A7ade Mecum. Ed. by Boyd, London, 1887. Horteloup.—Memoire a l'Academie, inedit. F. Gant.—Surgery, 1886, Vol. II. H. Lee.—London Lancet, Jan\ 15, 1881. Frederick" TreA^es.—Surgery, Vol. III., Philadelphia, 1886. R. J. Levis.—Treatment of A'aricocele by excision of re- dundant scrotum.—Southern Clinic, 1882. S. D. Gross.—Surgery, Arol. II., Philadelphia, 1882. Lydston.—Treatment of varicocele by resection of the scro- tum.—Chicago Medical Journal and Ex., ATol. XLVIL, p. 351. AV H. A. Jacobson.—Operations of Surgery. Philadelphia, 1889. D. Maclean.—Cases of varicocele cured by amputation of redundant scrotum.—Physician and Surgeon, Aug. 1884. T. Bryant.—Surgery, Vol. II., London, 1884. BIBLIOGRAPHY. 113 Perier.—Anatomy and physiology of the spermatic veins. These de Paris, 1864. T. Holmes.—Surgery, 1889, Philadelphia. Alexander Ogston.—Annals of Surgery, A7ol. IV., p. 120, 1886. Segond.—Article on varicocele, diet. Jaccoud. E. L. Keyes.—Trans. N. Y. Med. Soc, 1886, p. 350.— Med. Rec, N. Y., 1886, Vol. XXX., p. 317. Sistach.—Etude statist, sur les varices et le varicocele.— Gazette Med., 1863. C. H. Rodi, Med. Rec, N. Y., 1888, Vol. XXXIV, p. 12. H. AV. Mitchell, N. Y. Med. Rec, 1888, Vol. XXXII., p. 538. Discussion on Varicocele.—Philadelphia Med. Times, 1881- 82, Vol. XII., p. 88. F. King.— Med, Rec, N. Y, Vol. XXX., 1886. A^elpeau.—Gazette des hopiteaux, Aug. 3, 1884. R. F. AVeir.—Med, Rec, N. Y., Vol. XXIX., p. 321, 1886. Barwell.—Lancet, 1869, Vol. I., p. 711. Barwell.— Lancet, 1875, Vol. I., p. 820. A^incent.—Traitement du varicocele, applic de la meth. antiseptique.—These de Paris, 1884. Edmund Andrews, N. Y. Med. Jour., 1884, Vol. XL., p. 591. Robson, Brit. Med. Jour., 1886. AAratkins, New Orleans Med, and Surg. Jour., 1882-83, Vol. X., p. 508. AVm. Mac Cormac, Ibid, p. 493. White, Southern Clinic, 1878-1879, p. 466. Virginia Medical Monthly, 1879-1880, p. 706. Edmond Wickham, These de Paris, 1885. Revue Generale de Clinique, Dec, 1891. L'Union Medicale, Vol. XLIIL, p. 341. L'Union Medicale, Vol. XLIV, p. 337. AV. H. Bennett, London Lancet, Feb. 9, 1891, and March 7, 1891. Monograph on Varicocele, London, 1891. A. AAr. M. Robson, London Lancet, March 21, 1891. 8 114 VARICOCELE AND ITS TREATMENT. A. B. Barrow, London Lancet, March 21, 1891. Helot.—Du varicocele et de sa cure radicale.—Arch. gen. de Med., 1844, Vol. VI. and Vol. VIII. Coulson.—Varicocele and its Radical Cure. London, 1865. A. Amussat.—Varicocele du c6t£ gauche opere" par la galvano-caustique.—Gaz. des Hopitaux, 1866. L. J. M. Montan6.—Du traitement curatif du varicocele et en particulier de son traitement par l'isolement des veines. —These de Strasbourg, 1868. Maissoneuve.—Memoire sur 1'application des injections coagulantes a la cure du varicocele.—L' Union Medicale, 1866. C. Delageneste.—Du varicocele et de son traitement.—Th&se de Paris, 1869. A. AAriart.—Du traitement du varicocele et specialement du procede par les injections de perchlorure de fer.—These de Paris, 1866. West.—Varicocele treated by elastic ligature.—London Lancet, July 4, 1874. Wm. Rose.—The subcutaneous treatment of varicocele.— London Lancet, June 19, 1875. G. W. Copeland.—Varicocele and its radical cure.—Boston Med. and Surg. Jour., Mar. 29, 1877. Onimus.—Traitement du varicocele par l'electricite.—Gaz. des Hop., 1877, No. 127. M. Reichert.—Radical operation for varicocele.—Arch, fiir min. Chir., Vol. XXL, 1871. R. Percepied.—Application l'electricte au traitement du vari- cocele.—These de Paris, 1877. *W. R. Williams.—Treatment of varicocele by elevation, with a new suspensory.—Med. Times and Gazette, Dec. 15, 1877. J. G. Will.—On a case of varicocele treated according to the method of Ricord, with a description of a new operative method by sub-cutaneous ligature.^London Lancet, Feb. 24, 1877. BIBLIOGRAPHY. 115 G. H. B. MacLeod.—Treatment of varicocele.—London Lancet, March 3, 1877. C. Genin.—-Cure radicale du varicocele par la meth6de de l'isolement simple.—These de Paris, 1876. Dubreuil.—Sur une modification de l'operation du varico- cele.— Gaz. des Hdp., 1870, No. 97. Morgan.—Treatment and cure of varicocele by suspension of the testicle.—Dublin Quart. Jour., 1869. John Wood.—Operation for simple varicocele of the sper- matic cord.—London Lancet, July 4, 1868. E. Rochelt.—Varicocele. Exposure and ligature of the plexus of veins.— Wien, med. Presse, 1879, Vol. XX. Th. Trandafiresco.—Le varicocele et de son traitement.— Thdse de Paris, 1867. R. J. Levis.—-Varicocele and its treatment by subcutaneous ligature.—Med. and Surg. Rep., Philadelphia, 1879, Vol. XL. Rep. by N. H. Chapman. Leon Bernard.—Contribution a l'etude du traitement du varicocele par 1'electrolyse.—These de Paris, 1880. P. A7autier.—Traitement hygienique du varicocele au debut. —These de Paris, 1879. A. E. Barker.—A simple method of operating for varicocele. —London Lancet, 1882. F. R. Coffman.—Castration as the best remedy for varico- cele.—Cincinnati Lancet Clinic, 1882, n. s. IX. Reginald Harrison.—Radical cure of varicocele.—London Lancet, 1882. R. G. Bogue.—A new and safe operation for varicocele.— Chicago Med. Jour, and Exam., 1883, A7ol. XLVI. F. G. Roddick.—Remarks on varicocele and its treatment. Hache.—Note sur nouveau procede de traitement du varico- cele.—Ann. des mal. des org. g6nito-urin., 1884. C. C. P. Clark.—Treatment of varicocele.—N. Y. Med, Jour., 1884. H. L. Jenkes.—Radical cure of varicocele.—Am. Jour. Med. Sci., 1883. 116 VARICOCELE AND ITS TREATMENT. R. AVhitman.—A bandage for the treatment of varicocele.— Am. Jour. Med. Sci, 1882. A. H. Goelet.—Amputation of surplus scrotum in varicocele. —North Carolina Med, Jour., 1883. V. Caporali.—Two cases of varicocele. Radical cure accord- ing to the method of Vidal de Cassis.—Gazz. med. ital. lomb., Milano, 1882. T. AV. Williams.—Treatment of varicocele to replace occlu- sion and excision of the veins.—Med. Age, Detroit, 1884. E. Blanc.—De la cure radicale du varicocele par la resection du scrotum.—Therap. Contemp., Paris, 1885. R. Barwell.—One hundred cases of varicocele treated by subcutaneous ligature.—London Lancet, 1885. A. Vincent.—Traitement du varicocele par 1'application de la methode antiseptique.—These de Paris, 1884. D. G. Zesas.—Operation for varicocele.— Wien Med. Woch- enschrift, 1884. Ferron.—Cinq, observations de varicoceles traites par la ligature.—Arch, de mid. et pharm. mil., Paris, 1885. Turner.—Two cases of varicocele in which the veins were ligated with kangaroo tendon, with remarks.—London Lancet, 1866. L. Picque.—Considerations sur la traitement du varicocele par la cauterization.—Rev. de Chirurg., Paris, 1886. Ernoul.—Nouveau suspensoir pour le varicocele.—Bull. gen. de th&rapeutique, Paris, 1886. L G. Richelot.—Traitement chirurgical du varicocele.— L'Union Medicale, 1885, et Bull. Soc. mid.-prat. de Paris, 1884-85. J. Freixas.—Treatment of varicocele, its history, with cases in practice.—Independ. med., Barcelona, 1885-86, Vol. XVII. Carre.—Essai critique sur l'etiologie du varicocele.—Gaz. Med. de Paris, 1863. BIBLIOGRAPHY. 117 John AVood.—Varicocele and its treatment.—Brit. Med. Jour., Sept. 16, 1871. Rivington.—Cases of varicocele dependent upon masturba- tion and venereal excesses.—Med. Press and Cir., Nov., 1868. Sydney Jones.—Three cases of varicocele.—Brit. Med. Jour., Mar. 18, 1876. Ravoth.—On varicocele.—Deutsch Zeitschr. fur pract. Med., No. 1, 1877. G. Gascoyen.—Varicocele. Trans. Harveyian Soc. London. Brit. Med. Jour., Nov. 20, 1869. Patruban.—Varicocele and its surgical treatment.—Allgem. Wien Med. Zeit. 1870, and Wien Med, Presse, 1870. Negretto—Gaz. Med. Hal. Padone, Vol. XXV, 1882. A. Pearce Gould—Lancet, 1880.—Two cases of varicocele, with arrest of development of the testicle. Remarks on the nature of varicocele. Trans. Clin. Soc, London, 1881, Vol. XIV J. F. Thompson.—Report of a case of varicocele.—Maryland Med, Jour. Vol. XII. Reclus and Forgue.—Art. Varicocele. Diet. Encycl. des sc. med., Paris, 1888. J. H. Tyndale.—Operations for varicocele.—N. Y. Med. Rec, July 15, 1871. Ravoth.—On the treatment of varicocele by means of a hernial bandage.—Berl. klin. Wochensch., 1872, No. 41, and 1874, No. 19. Traite des maladies du testicule et de ses annexes. Paris, 1889.—Ch. Monod et O. Terrillon. INDEX. /ANATOMICAL characters of varicocele - 9 Anatomy of spermatic veins ------ 10 Army medical reports of Great Britain as showing rejections for varicocele --------15 Association of varicocele with varices elsewhere - - 24 " " with nsevi, etc 24 Analogy of venous aberration in varices to hasmophilia - - 26 Acute varicocele ------- 28 Acute phlebitis in varicocele -. - - - 27 Atrophy of the testes in varicocele ----- 39 Absence of pain in varicocele in old persons - 47 Ashurst—modification of Lee's accupressure method - 72 Annandale—operation for varicocele ... - 73 Abbe—operation for varicocele ----- 75 Andrews, E.—Retention clamp for varicocele - 76 Approximation of stumps in resection of veins 81 Atrophy of testis from subcutaneous deligation of veins - 86 Atrophy of testis, relation of ligation of spermatic artery to - 87 DENNETT, W. H.—Frequency of varicocele - 4 Relative frequency in robust and lymphatic subjects - 5 Table of results in examination of 6C0 subjects - - 6 Observations on the comparative frequency of right and left sided varicocele ----- 6 Descriptive anatomy of spermatic veins 10 Relation of varicocele to sexual irritation - - 21 Constitutional origin of varicocele 24 Constipation as a cause of varicocele - 29 General consideration of causes of varicocele - 30 Residence in hot climates—relation to varicocele of - 30 Period of development of varicocele 36 Remarks on atrophy of testis - 40 Accidents and complications from injury of varicocele - 51 Use of the truss in varicocele ... - 60 Contra-indications for operation 66 Operation of resection of cord - 79 Safety of ligation of spermatic artery - 87 119 120 INDEX. Page British service, rejections for varicocele in, - - - 16 Breschet—Frequency of left-sided varicocele - - 17 Bryant—Method of operation for varicocele - - 69 Barker, A. E.—Operation for varicocele - - - 72 Barwell— " " 73 Bogue— " ------ 73 Briggs— " " 74 Bibliography - - 111 ClRSOSELE ------- 2 Causes of varicocele ------- 19 Constitutional origin of varicocele - 23 Cases of association of varicocele with varices of extremities - 25 Curling—On the association of varicocele with varices of limbs and frequency of left-sided varicocele - - - 17 Period of development of varicocele - 36 Death after enroulement of veins 88 On castration for the relief of pain in varicocele - 47 Operation for varicocele ----- 73 Constipation, relations of, to varicocele - 29 Cornil—Ultimate lesion in varicocele 39 Castration for pain in varicocele - - - - - 47 Coitus, aggravation of varicocele by - - - - - 50 Complications of varicocele ..... 51 Coagulation as a remedy for varicocele 61 Caustics in the treatment of varicocele - 61 Congenital predisposition to varicocele 19 Contra-indication for operation - 65 Cold as a remedy for varicocele ----- 57 Cooper, Sir A.—Pressure of omentum as a cause of varicocele - 34 Operation for varicocele 75 Combined ligation of veins and scrotal resection - - 96 Cellulitis following scrotal resection - 106 Definition of varicocele - 2 Descriptive anatomy of parts involved in varicocele - 10 Diseases of the viscera as causes of varicocele - - - 20 Disproportionate frequency of left-sided varicocele, causes of, - 17 Defective vascular walls as a cause of varicocele - - 24 Degeneration of valves of veins ----- 37 Dissection of varicocele --.... 3^ Doumenge—Seat of varicocele ----- 39 Dropsy of tunica vaginalis in varicocele - 39 Double varicocele, inflammation of, - - - - - 41 Depressing character of varicocele - - 45 INDEX. Destruction of elongated scrotum by potential caustics Davat—Operation for varicocele - Drainage tube in scrotal resection Dressing after scrotal resection Decrease of frequency of varicocele with advancing age Etymology of varicocele - 2 Escallier—Fatal spontaneous suppurative inflammation in varicocele 41 Eczema of scrotum in varicocele ----- 50 Electricty as a palliative remedy in varicocele 61 Electrolysis in the treatment of varicocele ... 61 Enroulement, operation by - - 67 Erichsen—Operation for varicocele .... 69 Excision of scrotum in varicocele ----- 75 Epididymitis, relation of, to varicocele - 102 Epilepsy, improvement of, after operation for varicocele - - 102 Ecchymosis following scrotal resection - 105 Erectile tumors in conjunction with varicocele 41 Extreme elongation of scrotum, case of - - - - 79 Frequency of varicocele ... 3 Flagellation of the scrotum in varicocele ... 57 UfROSS, S. D.—Operation for varicocele 70 Great length of left spermatic cord as cause of varicocele 17 Guyon, F.— Varicocele symptomatique 20 Grouping of veins in varicocele ----- 37 Gastralgia from varicocele ----- 50 General treatment of varicocele ----- 55 Gould, P.—Operation for varicocele ----- 70 Primary growth of venous tissue a cause of varicocele - 24 Galvano-cautery in varicocele ------ 70 Globus minor, varicocele of, - - - - 39 Gaujot—Fatigue as an aggravating factor in varicocele - - 29 11 ORTELOUP—Decrease in frequency of varicocele with advancing age ------- 4 Social status of patient as a guide to treatment - 4 Case of candidate rejected for military service, and accepted after operation - 15 Involvement of posterior spermatic plexus in varicocele - 38 Operation for varicocele ----- 76 Scrotal clamp - - - - - 78 Case of extreme elongation of scrotum - - - 75 Henry—Frequency of varicocele in candidates for public service - 3 Operation for varicocele ----- 76 121 Page 64 68 99 99 4 122 INDEX. - Page Haemophilia, association of, with varicocele - - - - 27 Haemorrhoids, association with varicocele - 28 Hasmophilia, relation of, to venous aberration in varices - - 26 Helot—Period of development of varicocele - - 36 Varicocele in a foetus ------ 36 Hypochondriasis from varicocele ----- 46 Hernia, as a possible result of varicocele - - - - 53 Holmes, T.—Operation for varicocele - 70 Howse—Operation for varicocele - - - - 73 Harrison, Reginald—Operation for varicocele ... 75 Hutchinson—Operation for varicocele 76 Howe—Peritonitis after subcutaneous deligation - - 88 Hemorrhagic oozing after scrotal resection - - - - 98 Horseback-riding, relation of, to varicocele ... 103 Haemorrhage, severe case of, after combined operation of varicocele and stricture ------- 102 Haemidrosis of scrotum in varicocele ----- 101 Haemorrhagic emissions in varicocele - 102 Hydrocele, following operation for varicocele - - - 107 Hydrocele, cause of, after operation for varicocele - - 108 INFECTION as a cause of inflammation in varicocele - 41 Indolent habits, as a cause of varicocele - - - - 19 Impotency, as a result of varicocele ----- 23, 48 Inflammation of testis and scrotum as a cause of varicocele - 34 Indifference of physicians to sexual ailments - - 49 Infibulation of the scrotum for the relief of varicocele - - 58 Indications for operation ------ 66 Inherent predisposition as a cause of varicocele - - - 24 U AMIN—Congenital impotence from varicocele - - 50 Jockeys, varicocele in ----- - 103 IVEYES, E. L.—Varicocele from physical strain - - 28 Operation for varicocele ----- 70 Needle for varicocele ------ 71 Kocher—Operation for varicocele - 74 King—Clamp for varicocele ----- 96 King's clamp, application of - - - - 100 LANDOUZY—Frequency of varicocele - - - 3 Relation of varicocele to public service - 15 Frequency of left-sided varicocele 17 Association of varicocele with varices of extremities - 27 Period of development of varicocele - - - 35 INDEX. 123 Page Life insurance, the relation of varicocele to 17 Lack of tone, as a cause of varicocele 19 Lenoir—Pressure on veins from bending of body, as a cause of vari- cocele - - - - - - - - 34 Limitation of varicocele to globus minor ... 39 Lannelongue—Seat of varicocele ----- 39 Le Fort, Leon—Spontaneous disappearance of varicocele - 44 Laxatives in varicocele - - - - - - - 56 Landerer—Pressure by truss as a remedy for varicocele - - 60 Levis, R. J.—Use of rubber tubing in subcutaneous deligation - 70 Lee, H.—Accupressure method for varicocele - - 72 Inherent predisposition as a cause of varicocele - - 24 Open operation for varicocele ... - 72 Ligation of spermatic artery, relation of, to atrophy of the testis - 87 Lewis—Scrotal clamp ------ 90 MASTURBATION as a cause of varicocele - - - 20 Monod and Terillon—Relation of heredity to varicocele - 25 Spontaneous cure of varicocele 44 Fluid in vaginal sac in varicocele - 39 Association of varicocele and haemorrhoids 28 Morbid anatomy of varicocele ----- 35 Moullin, Mansell—Dissection of varicocele 38 Mechanical causes of varicocele ----- 28 Mechanical support in varicocele ----- 57 Morgan—Varicocele compressor ----- 58 Miliano—Compressor for varicocele ... - 59 Markoe—Operation for varicocele ----- 68 McKay—Case of bungling subcutaneous operation for varicocele 86 Malgaigne—Inclusion of spermatic artery in ligation of veins - 87 N.EEDLES for subcutaneous deligation - - - - 71 Naevi, association of varicocele with, ----- 24 Nelaton—Period of development of varicocele - - 36 Neuralgia of testis and cord - - 47 0 SBORN—Cause of left-sided varicocele - - 17 Over-exertion, avoidance of, - - - - - - 55 Old age, varicocele in, ----- 39 Operations for varicocele - - 65 Ashurst's method - - - 72 Annandale's method - ------ 73 Abbe's method - . . - - - 75 Author's method - - - - 96 Bryant's method - - - - 69 Barker's method - - - 72 124 INDEX. Operations for Varicocele—Continued. Barwell's method - Bogue's method - Bennett's method Barrow's method ----- Curling's method - Cooper's method - Davat's method ----- - Erichsen's method ----- Gould's method ----- Gross' method - Holmes' method ------ Harrison's method - - - - Horteloup's method - - Keyes' method - Kocher's method ------ Levis' method - Lee's method ..---. Ogston's method - Ricord's method ------ Treves' method - Wood's method ------ Weir's method - AA'ickham'e method - Vidal's method ..... Ogston, A.—Operation for varicocele Pampiniform plexus - Petit, J.—Determining factor in left-sided varicocele Petit—Theory of the causation of varicocele Portal obstruction as a cause for varicocele Persistence of foetal veins as a cause for varicocele - Pott, P.—Varicocele from physical strain Pressure of truss as a cause of varicocele Pulley theory of varicocele - Period of development of varicocele - - - Plaques of calcific deposits in varicocele Phleboliths in varicocele - Partial involvement of spermatic veins - Perier—Group of veins affected in varicocele Paget, Sir J.—Atrophy of testis in varicocele Pyaemia after subcutaneous deligation Persistence of pain after operation Palliative treatment - Porta's method of injection - Patruban—Operation for varicocele - INDEX. 125 Page Plaster support after scrotal resection - - - - 92 Personal cases, observations on, ----- 100 Phlebitis following over-exertion after ligature of spermatic veins 107 idlDAIN, R.—Anatomy of spermatic veins - - - - 10 lAELATION of varicocele to examinations for police and fire service 15 Relative frequency of right- and left-sided varicoceles - - 17 Renal tumors as a cause of varicocele - 20 Rupture of varicocele from straining at stool 52 Richet—Cauterization of scrotum in varicocele - - - 62 Source of error, in isolating the vas deferens - - 87 Radical treatment of varicocele ----- 65 Ricord—Operation for varicocele ----- 68 Reverdin—Needle for varicocele ----- 71 Retention clamp for varicocele ----- 76 Remote results of scrotal resection, illustration of, - - 80 Richelot—Case of thickened vein mistaken for vas deferens - 87 Robson, A. M. W.—Safety of ligation of spermatic veins and artery 88 Recurrence after scrotal resection, case of, - - - - 92 Results of personal operations for varicocele - - - 100 OlSTACH—Rejectment of candidates with varicocele by the French military service ...--- 15 Scurvy and struma, relation of varices to, - - - - 19 Symptomatic varicocele ------ 20 Sexual disturbances as a cause of varicocele 20 Sexual irritation, relief of, by cure of varicocele - - - 22 Spencer—Cause of varicocele ------ 26 Scrotal haemidrosis ------- 26 Spontaneous inflammation of varicocele 41 Suppuration in varicocele ------ 41 Symptoms of varicocele ------ 43 Spermatic congestion mistaken for varicocele - 44 Spontaneous disappearance of varicocele - - - - 44 Sexual debility in varicocele - 46 Scrotum, eczema of, - - - - - - - 50 Satyriasis from varicocele - - . - - 51 Scrotal haematocele ------- 51 Spontaneous rupture of varicocele - 52 Spermatozoa, absence of, in varicocele with disease of opposite testis 52 Subcutaneous deligation of varicocele - 70 Shortening of spermatic cord in varicocele - - - 79 Special consideration of operative methods ... 85 Subcutaneous operation for varicocele, dangers of, - - - 86 Sloughing of scrotum, result of, after scrotal resection - - 105 126 INDEX. Page 1 ABLE of rejections for varicocele in British service Thinning of scrotum in varicocele Testis, restoration of, after cure of varicocele Treatment of varicocele - - - - Tonics in varicocele - Trusses in the treatment of varicocele Treves, F.—Operation for varicocele - Tetanus from ligation of vas deferens Thievenow—Septicaemia after subcutaneous ligature U RETHROTOMY in conjunction with operation for varicocele 102 V ALLIN—Phlebitis of double varicocele 41 Valves of spermatic veins ------ 9 Varices of extremities as indicating danger of haemorrhage in opera- tions .-------19 Varices and varicocele, association of, in a family of four - 24 Varices of extremities, association of, with varicocele - - 25 Veins, vulnerability of, as a cause of varicocele 26 Venous changes in varicocele ----- 36 Vidal, De Cassis—Acute phlebitis in varicocele 37 Haematocele from injury of varicocele - - - 51 Operation for varicocele ----- 67 Verneuil—Erectile tumors in conjunction with varicocele - 41 Spontaneous inflammation in varicocele - - - 13, 41 Vascular tonics in varicocele ----- 56 WALLS of veins, changes in, - - - - - - 38 Wickham, E.—Aggravation of symptoms of varicocele by coitus 51 Operation for varicocele ----- 7s Method of operation, illustration of, - - 93 Welsh—Satyriasis cured by operation for varicocele - 51 AVillard, A. L.—Treatment of varicocele by Porta's method - 63 Wood—Modification of Ricord's operation 68 AVhitehead—Needle for varicocele - 71 Weir, R. F.—Operation for varicocele 74 16 40 40 55 56 58 73 87 88 GHICAGO MEDICAL RECORDER A Journal of Medicine and Surgery. ARCHIBALD CHURCH, M.D., Editor. Published on the Fifteenth of each month. Subscription price $2.00 a year. THE CHICAGO MEDICAL RECORDER began its third volume with the number for March, 1892. Its cordial reception and the hearty co-operation ac- corded to it by the Medical Profession, justify its claim to be the leading Journal of Scientific Medicine in the North-west. - EACH NUMBER CONTAINS - Original Articles. A Department Showing the Current Advances in the various branches of Medicine and Surgery. Society Proceedings. Reviews of Books, etc. Medical News. Meteorological and Health Re- ports and other matters of interest to the Profession. Vols. I. and II. of The Chicago Medical Recorder, March to August, 1891; September, 1891, to February, 1892. Handsomely Bound in Green Cloth. Price $2.00 each, Postpaid. -------------------■» •»------------------ PUBLISHER, 96 Washington Street, Chicago. THIRD EDITION. (SIXTH THOUSAND) Now Ready. Rectal and Anal Surgery. With Description of the Secret Methods of the Itinerant Specialists. By Edmund Andrews, M.D., LL. D., Edwakd Wyllys Andrews, A.M., M.D., Professor of Clinical Surgery, Chicago Medical Professor of Clinical Surgery, Chicago Medical College; Surgeon to Mercy Hospital, etc. College; Surgeon to Mercy Hospital, etc. Third Edition, Revised and Enlarged. One Volume, 8vo. Cloth, $ 1.50, net. With Illustrations and Formulary, Profusely Illustrated. The rapid sale of the first and second editions of this manual has compelled the preparation of the third much sooner than was anticipated. Advantage has been taken of the opportunity thus given to re-write and enlarge almost every part of the work, and to introduce several new chapters and an Appendix. A few cuts have also been added. A chapter has been added upon the Neuroses of the Rectum and Anus. Rectal Neuropathy now receives that separate consideration which it deserves, a new feature in this Edition. Further to make this book a vade mecum in the hands of those who must hurriedly turn many books in the intervals of active practice, a compact formulary has been pre- pared, which contains in classified form every prescription in the body of the work and a considerable number of others. These are all tried remedies and many of them have the authors' names affixed. With this Formulary for reference, the practitioner who has once read the book can by almost instantaneous reference secure the necessary details for the treatment of any given case which is before him. These formulas have been collected from a very large number of works in various languages. Over fifty are given, and these are nearly all that can be found in a score or more of the best modern treatises, those being omitted, of course, which are practical repetitions of each other. A chapter has also been given to the sacculi Horneri and columns of Morgagni, in order more clearly to expose the ridiculous pathology which some have sought to connect with these innocent structures. From The Post-Graduate, N. Y. "Originally this book of Professor Andrews and his son derived its chief value from the thorough exposition of the ways of the travelling quacks who flourished with their hypodermic syringes throughout the West. The authors devoted more time to these gentlemen than they deserved, with the result of rendering the profession fairly conversant with their secrets and methods. By stating plainly and concisely what was true in the surgery of the rectum, and comparing it with what was false and fraudulent, the book was first written, and from this beginning has now reached its third edition. It has grown in scientific value with age. It makes no claim to completeness in pathology or research on doubtful points—its size, indeed, precludes that—but it claims to be a correct working hand-book, embodying much useful practical information; and such it is. "In this, the last edition, however, a chapter has been added which, as far as it goes, raises the status of the work to a much higher plane. We refer to the attempt, and successful attempt, here made for the first time at something like a complete, scientific classification of the neuroses of the rectum, and we congratulate the authors on the result. This chapter alone gives the work an indisputable place in the library of every student of diseases of the rectum." C. B. K. W". T. KEENER, 96 Washington Street, CHICAGO, IL.L.. NOW READY! Indigestion and Biliousness. ----BY---- J. MILNER FOTHERGILL, M.D., Member of the Royal College of Physicians of London; Senior Assistant Physician to the City of London Hospital for Diseases of the Chest (Victoria Park); late Assistant Physician to the West London Hospital; Associate Fellow of the College of Physicians of Philadelphia. " Dr. Fothergill's writings always command attention; they are sprightly and full of instructive facts, drawn mostly from his own large experience. This volume is written from a physiological standpoint, and begins with an account of natural digestion, by way of introduction or antithesis to the main topic of the book. As the liver is the great storehouse of supplies for the use of the system, four chapters are devoted to its functions and their disturbances. 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Altogether, the work is a remarkably comprehensive study of a subject whi^h is too little understood by the majority of medical men." —New York Medical Record. One Volume, 12mo., Cloth, $2.25. Mailed postpaid on receipt of price. W. T. KEENER, PUBLISHER, 96 Washington Street, CHICAGO. A TEXT-BOOK —OF THE— PRACTICE OF MEDICINE BY R. C. M. PAGE, JI.D., Author of "A Handbook of Physical Diagnosis"; Professor of General Medicine and Diseases of the Chest in the New York Policlinic, etc., etc. To facilitate clinical instruction, and enable both physician and student to obtain in brief the most practical as well as scientific views of the various subjects treated of in a work on medicine, are the chief objects in preparing this volume. Students in our medical colleges and those who visit New York and other medical centers for the purpose of taking a supplementary course in clinical medicine, as well as the busy practitioner, often find that they have not time sufficient at their command to sift out desired information on any given subject from extensive treatises and systems. While, therefore, such books may be regarded generally as invaluable as monuments of research, it is believed that a somewhat shorter work is both called for and will prove to be a valuable aid. Only the chief points in pathological anatomy, for instance, are given. Should further study in this direction be deemed necessary, there are works specially devoted to this subject. On the other hand, the author has thought it better to go rather more into detail regarding treatment than is custom- ary ; not only are drugs mentioned, but in many instances the prescrip- tion and dose are given.—Preface. One Handsome Volume. 8vo. Red Parchment Cloth. 560 pages. Illustrated $4.00. W^. T_ KEENER, Medical Publisher, Importer and Bookseller, iM> Washington Street, CHICAGO. THE WORKS OF NICHOLAS SENN, Ph.D., M.D., Professor of Practice of Surgery and Clinical Surgery in Rush Medical College; Attending Surgeon Presbyterian Hospital. EXPERIMENTAL SURGERY. Contents—Fractures of the Neck of the Femur, with special reference to Bony Union after Intra-Capsular Fracture. II. Experimental Besearches on cicatrization in Blood Vessels after Ligature. III. An experimental and clinical study of Air-Embolism. IV. The surgery of The Pancreas as based upon experiments and clinical researches. V. An experimental contribution to Intestinal Surgery, with special reference to the Treatment of Intestinal Obstruction. VI. Kectal Insufflation of Hydrogen Gas as an Infallible Test in the Diagnosis of Visceral Injury of the Gastro-Intestinal Canal in Penetrating Wounds of the Abdomen. Complete in One Handsome Volume, 8vo. Cloth $5.00; Half Mor. $6.00. The different parts of this volume have been published from time to time in Transactions of The American Surgical Association, and in periodicals not readily accessible to the majority of the Medical Profession. In response to a very general demand they have been revised by the Author and published in a convenient sized volume, carefully indexed. II. INTESTINAL SURGERY. Contents—The Surgical Treatment of Intestinal Obstruction. II. An experimental contribution to Intestinal Surgery with special reference to the Treatment of Intestinal Obstruction. III. Bectal Insufflation of Hydrogen Gas as an Infallible Test in the Diag- nosis of Visceral Injury of the Gastro-Intestinal Canal in Penetrating Wounds of the Abdomen. IV. Beport of cases. One Handsome Volume, 8vo. Cloth $2.50. III. THE PRINCIPLES OF SURGERY. In One Handsome Octavo Volume. Cloth $4.50 net. Leather $5.50 net. From The American Journal of Medical Science. In at work characterized not only by careful arrangement and clear exposition, but also by a paience of research and an originality of conception which promise the author a Listing fame in the annals of surgery, there must necessarily be much to praise; and again, it is a poor book in which there is nothing to criticise. The most striking, the most valuable of Senn's original conceptions or applications are: 1. The uses of gaseous enemeta both for diagnostic and therapeutic purposes. 2. Lateral approximation by decalcified bone plates. 3. The application of omental grafts in abdominal surgery; and, 4. The mechanical irritation of peritoneal surfaces between which it is desired that adhesion should take place. The value of all these methods has been experimentally proven, and they have been suc- cessfully applied by Senn and by other surgeons who have carefully reviewed his work. It is difficult to determine whether the enthusiasm and the confidence with which he writes should be praised or condemned. After completing his book, the surgeon lays it down with the con- viction that at last the difficulties and dangers of abdominal work have been overcome, that the definite rules of operative procedure are established, that this branch of surgical knowl- edge is completed from Alpha to Omega. In the toil and travail of an obscure case there may be a tendency in the mind of the operator to resent this "cock-sure " style which filled his mind with such joyous anticipation, but when one or another of Senn's brilliant expedi- ents has finally brought him to a successful termination, he may be disposed to look more forgivingly on this fault. The greatest value of Senn's work is its suggestiveness. He has set surgeons in all countries to thinking and planning. His methods as such may none of them be permanent, but he has given an impetus to abdominal surgery the outcome of which none can foresee, but which is full of promise. He is in the very van of progress, a leader who is not infallible, but who has earned by hard work and ability the enviable place he holds in the scientific world. The gaseous enemeta which he advocates as an infallible test in the diagnosis of wounds of the gastro-intestinal canal will probably not be found to sustain this claim, yet no one can deny the immense value of this method, nor withhold admiration for the genius which prompted its application. Finally, his book should be read to be duly appreciated, and no higher tribute can be paid to its value than that it stimulates the surgeon to better thought and better work. ____________________ W. T. KEENER, Medical Publisher, Importer and Bookseller, 96 Washington Street, CHICAGO. NOW READY! ft IlTSOMlTIii ft ---AND--- OTHER DISORDERS OF SLEEP. --BY-- HESTRY M. LYMAJf, A.M., M.D. Professor of Physiology and Diseases of the Nerves in Bush Medical College. Prof, of Theory and Practice of Medicine in The Woman's Medical College. Physician to Presbyterian Hospital of Chicago. CONTENTS: I.—Nature and Cause of Sleep. II.—Insomnia or Wake- fulness. III.—Remedies for Insomnia. IV.—Treatment of Insomnia. V.—Dreams. VI.—Somnambulism. VII.—Arti- ficial Somnambulism or Hypnotism. 'Insomnia and Other Disorders of Sleep,' by Dr. Henry M. Lyman, (Chicago: W. T. Keener), is a medical book whose matter and style carry it into the higher grades of literature. It represents thought and knowledge, and to students interested in psychical research the last half of the book should be useful and attractive. The first half is limited in its adapta- bility to practising physicians.—The Nation. It is pleasant to find a book which is clearly the result of a natural literary effort and the author's fondness for his theme—a book not written to "supply a long-felt want" or "to fill an existing gap." Dr. Lyman's is such a one, and shows that the subject of which he writes has been a pleasant study. It is readable and full of interest, and is quite up to the times, which is important, as the last work upon Sleep, a very good one by the way, was written by Dr. Hammond nearly fifteen years ago. Dr. Lyman agrees with Mosso that sleep depends rather upon molecular disturbance than upon fluctuations in the blood-supply, which is the modern and generally accepted theory. His considerations of the pathological states which induce wakefulness are especially full and practical, and his therapeutical suggestions, despite a tendency to polypharmacy and rather heavy dosage, are in the main excellent.—The New Torh Medical Journal. r Those who would like to acquaint themselves with what science has to say on these topics and learn how they are regarded by the wisest students of this age, may turn with profit to the pages of this book. The author is well known, not only as a skilled physician and accomplished teacher, but as one of the most polished writers of the American Medical Press.—Philadelphia Medical and Surgical Reporter. The author has evidently brought to bear upon the subject, extended research, and close observation. Insomuch that there are few medical practitioners who may not find in it much that is both interesting and profitable, that is practical ***** It is the best book on the subject.—The Sanitarian. OXE VOJLUME. 13MO. CL.OTH, - $1.50. W. T. KEENER, Medical Publisher, Importer and Bookseller, 96 Washington St., CHICAGO. NOW READY—SECOND REVISED EDITION. FIRST AMERICAN EDITION EXHAUSTED WITHIN SIX MONTHS. MEDICAlTDIAGNOSIS, BY DR. OSWALD VIERORDT, ___________________________ Professor of Medicine in the University of Heidelberg. Translated, with Additions, from the Second Enlarged Ger- man Edition, with the Author's Permission. BY FRANCIS H. STUART, A.M., M.D., Member of the Medical Society of the County of Kings, N. Y.; Fellow of the New York Academy of Medicine; Member of the British Medical Association, etc. In one handsome royal octavo volume of 700 pages. 178 tine wood-cuts in text, many of which are in colors. Price, Cloth, $4.00 net: Sheep, $5.00 net. 167 Clinton St., Brooklyn, Sept. 30,18yl. My Dear Dr. Stuart :— I have long desired to possess a thorough, syste m atic, and com- prehensive work on medical di- agnosis. All my wants in this direction are now supplied by "Vierordt's Medical Diagnosis." Very truly yours, [Signed] Alex. J. C Skben, Dean of the Long Island College Hospital, and Professor of the Medical and Surgical Diseases of Women. Since its first publication, in 1888, Prof. O. Vierordt's "Diag- nostic der inneren Krank- heiten" has been recognized as a practical work of the hi g best value. Dr. Stuart's translation of the enlarged and improved edition makes it available to those who are not acquainted with the German language, and it may be considered indispen- sable both to students and prac- titioners. [Signed] Dr. F. Minot, Hersey Prof, of Theory and Practice in Harvard Univer. Philadelphia, Aug. 31,1891. Dear Mr. Saunders :— Iain very much obliged to you tor the opportunity of examin- ing the work on Diagnosis which you kindly sent me. It is very well arranged, and very complete, and contains valua- ble features not usually found in the ordinary books. It will give me pleasure to recommend it to my classes. Eespectfully yours, [Signed] J. H. Musser, Assis' t Prof. Clinical Medicine, University of Pennsylvania. SAUNDERS' Pocket Medical Formulary. BY WILLIAM M. POWELL, M.D., Attending Physician to the Children's Seashore House for Invalid Children, and the Mercer House for Invalid Women at Atlantic City, N. J.; Member of the Philad'a Pathological Society. Consisting of some 1750 Formulae selected from Several Hun- dreds of the Best-known Authorities. WITH AN APPENDIX, CONTAINING VERY COMPLETE DOSE TABLE ; POSOLOGICAL TABLE; FORMULAE AND DOSES FOR HYPODERMIC MEDICATION : POISONS AND THEIR ANTIDOTES ; DIAMETERS OF THE FEMALE PELVIS AND POSTAL HEAD ; DIET LIST FOR VARIOUS DISEASES : OBSTETRICAL TABLE : MATERIALS AND DRUGS USED IN ANTISEPTIC SURGERY ; TREATMENT OF ASPHYXIA FROM DROWNING : SURGICAL REMEM- BRANCER ; TABLES OF INCOMPATIliLES ; ERUPTIVE FEVERS; WEIGHTS AND MEASURES, ETC. The whole forming a Handsome and Convenient Pocket Com- panion of about 275 printed pages, with blank leaves for Additions. Flexible Morocco Binding, with side Index, Wallet and Flap. PRICE, $1.75 NET. FOR SALE BY Medical Publisher, Importer and Bookseller, 96 Washington Street, CHICAGO. Genito-Urinary Surgery WITH CYSTOSCOPY. BY WM. T. BELFIELD, M.D., CHICAGO. One Volume, 8vo., with Illustrations, including Colored Plates of Morbid Conditions of the Bladder as seen by means of the Cystoscope. IN PRESS. The great improvement in means of diagnosis of the diseases of the urinary tract in the last ten years, has been followed by a correspondingly greater success in the treatment of the diseases of these organs. It is the purpose of this volume to present in concise form the present status of genito-urinary surgery; it will include the modern means for recognizing and treating the surgical diseases of the urinary and male sexual organs. Special features will be chapters on the very frequent but often un- recognized tuberculosis of the genito-urinary tract; on the operative treatment of the enlarged prostate, and on the use of the cystoscope. This instrument, in its modern improved form, has become a most valuable aid in the accurate diagnosis of urinary affections; in a certain percentage of cases the cause and nature of a cystitis cannot be determined without it. Directions for the use of the instrument and illustrative plates from the author's cases will be included in the work. Medical Publisher, Importer and Bookseller, 96 Washington St., CHICAGO.