1892 Journal of the American Medical Association (JAMA)  
I wish in this paper to make a short mention of certain observations and theories which I am not yet prepared to publish in full. The accepted theories in regard to the causation and pathology of varicocele have never been entirely satisfactory to the profession. While it may be ad¬ mitted that certain anatomical relations, more espe¬ cially of veins on the left side of the body, may pre¬ dispose to the disease, and while there can be no doubt of the occasional agency of injuries and vene¬ real
more » ... excesses in producing it, we may nevertheless ac¬ knowledge our ignorance of the exact pathological processes which lead to its development. We cannot explain why of two men of apparently similar con¬ stitution and habits of life one should suffer from the disease and the other escape. We may accept as the truth, the statement that the size, winding course and numerous anastomoses of the veins near the testis, their lack of support by the loose and inelas¬ tic tissues which surround them ; the length and small size of their efferent trunks, the perpendicular course of the left spermatic vein, its right angled junction with the renal and its position under the sigmoid flexure render these veins especially liable to over distention and resulting disease. We may also agree that general debility, sprains, violent muscular exertion and excess of venereal excitement,conduce to the production of variococele, and yet we have still to account for the fact that multitudes of men whose anatomical formation is precisely similar and who are subjected to the influence of all of these so-called causes, go through life nevertheless untouched by the disease. In other words, the alleged causes of vari¬ cocele do not in most people produce varicocele, and unless we are willing to rest satisfied with the vague and unmeaning word "predisposition," we must confess that the essential factor has, as yet, es¬ caped recognition. While we may admit that the particular conditions enumerated above, may influ¬ ence though not in themselves determine the produc¬ tion of varicocele, there are other alleged causes which must be denied as not proven. Thus the often quoted absence of valves in the spermatic veins is said by Curling, never to occur. He invariably found the valves to be present even though useless from over-distention and enlargement of the veins. Whether the spermatic veins could be rendered vari¬ cose through the agency of muscular contraction or by the presence of hernia, tumors, trusses, abdominal belts, and the like must be regarded as more than doubtful. It has seemed to me that certain physiological influ¬ ences which affect the circulation of the blood through the spermatic veins have been too little studied in this connection. If we examine the theories which have been promulgated in respect to this disorder, it will be found that certain factors in the local circu¬ lation have apparently been altogether overlooked, although they have a most important bearing on the :subject. If we omit all considerations of those fac¬ tors of the circulation of the venous blood, which are common to the whole system, such as the action of the heart and diaphragm, atmospheric pressure and the like, we may say that the local venous circulation is furthered by three agencies : 1. The contraction of the venous walls. 2. The action of the nervous sys¬ tem, and 3 : The intermitting pressure exerted on the spermatic vein by the contraction of the muscles which surround them, or are in their immediate vi¬ cinity. In the walls of veins, like those of arteries, there are both longitudinal and circular muscular fibres and elastic tissues. These permit the veins to dilate under the pressure of the column of blood and to contract again, forcing the blood onwards. As long as the venous walls retain their tonicity their con¬ traction will form a most important element in the propulsion of the contained blood. On the other hand, any inherent or acquired defect in their mechanism, would of necessity, seriously impair the local circulation and lead, in itself, to the permanent and incurable distension of the venous Avails. There can, in my opinion, be no doubt that many cases of varicocele are due to this cause. Local injuries, such as contusions and sprains may be presumed to act in this way by rendering the veins themselves in¬ capable of performing their duty in forcing their contents on toward the heart, These are the cases
doi:10.1001/jama.1892.02411290008002b fatcat:q6xscuqvkfddhkn66bttglmpg4