The etiology of varicocele depends largely an anatomic conditions. The veins of the spermatic cord are relatively long and take a vertical course, supported only by loose tissue. Their combined lumen is large as compared with that of the artery, so that the vis \l=a'\ tergo is reduced to a minimum (Treves). They are tortuous, have frequent anastomoses, and are imperfectly supplied with valves. These factors, taken with the pressure exerted on the vessels as they pass through the inguinal canal,

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... must favor stagnation of the blood current and cause dilatation and lengthening of the veins, thickening of their walls, and lengthening and relaxation of the scrotum. The last result is given but slight notice in the writings of northern authors, but in warm climates it is an almost invariable accompaniment of varicocele. Varicocele is a common condition, being found in 10 per cent, of all men between the ages of 15 and 30. Unsatisfied sexual desire and excessive intercourse have been ascribed as causes. The former must influence the trouble, since it sometimes disappears in young men after marriage. No doubt a predisposition may be inherited. Occupation plays a part in the causation, since varicocele is common among men who stand a great deal, such as clerks, bookkeepers, etc. More than 90 per cent, of cases occur on the left . side, the explanation of which is also on anatomic grounds. The veins in the left cord are larger, the testicle hangs lower, and the left vein empties into the renal vein at a right angle, while the right vein empties into the vena cava at an acute angle. Again, the left spermatic vein,as it runs behind the sigmoid flexure, is constantly subjected to pressure from the accumulation of feces in the bowel. It is said that the modern habit of "dressing" on the left side tends to increase varicocele on that side, and that mild eases sometimes are improved by changing to the right side. A very large varicocele may produce no symptoms, while a small one often gives rise to pronounced symptoms, depending largely on the effect on the patient's mind. In a large number of cases the mental effect is the main feature of the disease and requires an operation for its relief. This is particularly true when the condition is associated with masturbation, the patient then being fearful of impotence. There is no proof that masturbation is connected with the cause of varicocele. The usual complaint is a sensation of weight and dragging in the scrotum, accompanied at times by an aching pain which extends to the back and groins. The veins may become tender or inflamed and spasm of the eremaster muscle may produce an acute cramp. Occasionally the suffering is so marked as to force the patient to lie down before obtaining relief. In the beginning the testicle becomes slightly enlarged from impediment to the return circulation, but ultimately is apt to diminish in size, whether from true atrophy or not is uncertain. Varicocele without symptoms requires no treatment, though it is sometimes necessary to operate to permit a candidate to pass a physical examination. Some cases are helped by palliative measures. The scrotum is douched daily with cold water, the bowels are kept regulated, and a comfortably fitting suspensory is worn. A suspensory causes much discomfort in hot weather, however, and the sweating and irritation it provokes almost counterbalance the benefit of the support it furnishes. Operative treatment is best and can be carried out under local anesthesia, but a general anesthetic is more satisfactory. The text-books recommend ablation of part of the scrotum as being occasionally indicated, but in the south, where the pendulous scrotum is so common, it is generally indicated. Cures by this procedure alone have been reported. Certainly it is one of the most important steps in the operation. The shortened scrotum affords a natural and permanent support for the cord and testicle. If the scrotum be not partially excised, the incision over the veins should be made just'below the external abdominal ring, as advised by Dr. Bloodgood. Here the veins are fewer in number and the wound heals more readily than in the scrotum. In any operation the genital branch of the genitocrural nerve must not be injured, since it supplies the eremaster muscle and the scrotum, which, if deprived of their nerve supply, would tend to become lax and favor a return of the varicocele. The nerve runs down on the inner side of the cord and below it. Some surgeons excise one or two inches of the veins at the thickest part' of the mass by making a longitudinal incision through the scrotum, and then ablate a portion by using King's clamp. This clamp is applied close up to the testicles tight enough to prevent any tissue retracting when the scrotum is cut. After severing the scrotum with knife or scissors, silkworm-gut sutures are taken through the needle holes of the clamp and are tied in the slits without removing the clamp until all the sutures are taken and tied. The skin edges are then better approximated by a running suture of fine catgut, and thus a completely closed and bloodless operation is effected. The advantages claimed for this method are rapidity and freedom from secondary hemorrhage, since the cut ends of all vessels are supposed to be caught in the sutures. The operation undoubtedly is rapid, but is it following good surgical principles to allow a clamp to compress tissues as tightly and for as long a time as this requires? It does not seem reasonable that the sutures will hold the ends of all the vessels, since these sutures are parallel to most of the vessels. Secondary hemorrhage has followed the plan. It will also follow the open method of operating if sufficient time and care be not given to securing and tying all bleeding points. By the open method two incisions are avoided, as the veins may be removed through the same opening. Inspection of the testicle and tunica vaginalis is afforded, which in a large proportion of cases will reveal a hydrocele. It is well to give attention to small details in the operation, because so often it is performed on neurotic patients in whom the neglect of such details will have considerable mental effect. For instance, in ablating the scrotum a curved clamp should be used, or the ends of a straight incision rounded off in order not to leave any little elevations of tissue. These would absorb in a short time, but their presence will annoy some neurasthenic individuals while they remain. A curved scrotal clamp or two curved long-jawed forceps are employed to hold the scrotum while the redundant portion is being removed. The clamp is pressed Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 05/26/2015