into the approximation, owing to the thickness and resistance of its muscular coat. Union takes place perfectly without scarifying the serous surfaces. I have done this anastomosis in five minutes when I was not doing much talking. The intestine is now ready to be cleaned

and dropped back into the abdomen and the omentum drawn down to its normal position and rents closed if needed. It is unnecessary to give the details of abdominal asepticism that I carry out in experimental work. Suffice it to say that I think asepsis is absolutely essential to give the work any value. We now extend the median incision downward to determine the result of the end to end approximation fourteen days ago I find the

place without difficulty, but there is no button there, or in fact in the intestines, as it wa passed on the fifth day, and the dog has been perfectly well to all appearance for more than one week, and has not refused food at any time I now cut out and slit open six inches of the ileum including the old approximation. You see the inner side of the gut is perfectly normal with the exception of a small linear scar encircling the gut, and not a particle of contraction in the lumen of the intestine.

This cut does not accurately represent the condition, as the scar tissue is not half as wide as the cut shows it to be.

You notice in this case a small yet unusual amount of adhesion of omentum to the

serous surface.

The line of union is apparently as strong as any other part of the gut, and no foreign body remains in the gut or abdominal cavity. The opening is as large as the button The size of the button to be used in any case depends on the size of the intestines operated upon and the size of the opening desired. Of course it is not necessary to use a large button to make an anastomosis between the gall bladder and the duodenum. I have done gastro-duodenostomy, colecysto-enterostomy, lateral, and end to end approximations, specimens from all of which I now show you, and in no case did I fail to get firm union, without a fistula or particle of focal or gaseous extravasation. The animals were killed in from five to twenty-four days.

I wish to call especial attention to the specimen in which an approximation was made between the duodenum and gall bladder. You see that what was a gall bladder has ceased to exist as such in twenty-four days and nothing remains of it but a duct. Its contraction has narrowed the opening which delivered a %-inch button until it is the size of a slate pencil and shows well marked folds of mucous membrane at its margins that must act as a valve to prevent the passage of intestinal contents into the gall bladder. (See cut No. 13.)

This not only simplifies but gives an element of certainty in this formerly impracticable operation that is scarcely believed until it is seen. Its importance can scarcely be overestimated. The operation has been done on eight persons with uniform success. You will notice that no such contraction occurred in the other specimens as that between the gall bladder and duodenum; in fact none whatever.

Dr. F. Andrews says that it is the means par excellence for establishing a gastric or focal fistula. By having a string attached as soon as pressure atrophy has released the button it is at once drawn outside of the wound without being allowed to pass through the intestinal tract."

It is an important addition to our armamentarium in the treatment of gangrenous herniated gut by making the ideal end to end approximation of healthy tissue after excision of the gangrenous portion whether it be inguinal, femoral, or umbilical. In the femoral

variety the ring should be enlarged if need be by cutting directly upward through Poupart's ligament until sufficient space is procured to effect reduction.

Dr. Jos. B. Bacon, of Chicago, uses the button to cure rectal stricture by inserting one segment into the rectum and making an anastomosis by laparotomy between healthy gut above and below the stricture. After the button has passed, in from five to fourteen days, he introduces a forceps into the rectum passing one blade through the stricture and the other through the opening the button has left and clamps the contiguous sides of the entire loop, and when the forceps come away the patient has a short but amply capacious rectum with perfect focal continence, a desideratum that all cases of focal incontinence from any cause can fully appreciate.

VARICOCELE *

BY ELMER F. CLAPP, M. D., IOWA CITY, IA.

Varicocele or circocele is a term used to designate a varicose condition of the veius of the spermatic cord and its extension. And, although this is not strictly true or rather is not all that is meant by the term, it will answer our purpose.

A pertinent question, though one not to be considered in this paper, "being another story," but which presents itself to us, is why we never hear anything about the varicocele of the analogue or homologue of the testes? I mean the ovaries. The answer that there is a vas deferens between the sexes does not explain the presence in the one case nor the absence in the other. I am sure that the condition is often present in the female; have seen and recognized it. If we recognize the symptoms we should often find the disease of the veins of the ovaries and adjacent structure present. At another time, however, with your permission, I will discuss the female side of the question.

I will not enter into a lengthy anatomical description of the testes nor its appendages. Those of you interested in the subject can do that at your leisure, to the length of your nclination. I will at this time only call your attention to the blood supply of the testes and cord, in order to explain the cause as well as the cure of the disease.

The cord proper extends from the int. abdominal ring where the structure of which it is composed converges, to the back part of the testicle, and is composed of arteries, veins, ymphatics, nerves and the excretory duct (vas deferens) of the testicle. These structures are held together by a certain amount of loose areolar tissue, all covered by the spermatic fascia which accompanies the cord and testicles in their descent through the inguinal canal and rings to the scrotum. The left cord is longer than the right, hence the left testicle hangs a little lower than the right.

The arteries of the cord are the sperma'ic, from the aorta; the artery of the vas deferens, from the superior vesical; cremasteric from the epigastric; and I wish here to add, branches from the femoral and branches from the int. pudic.

The artery of the vas deferens, a branch of the superior vesical, accompanies the duct when it separates from the main part of the cord. And be it remembered, for reasous hereafter mentioned, in the treatment of varicocele, that this artery enters the globus minor of the epididymis, this being, as it were, the lower part of the testicle, instead of passing into the globus major or body of the epididymis, the upper part of the testicle, with the spermatic artery.

And just at this point let me remind you that the vas deferens descends or rather ascends from the globus minor, at the lower part of the testicle, to the posterior and inner side of the cord, until it nears the int. ring At this position we drop it, not mattering how it reaches the vesicula seminalis, so far as it enters into the consideration of the subject before

us.

The veins of the spermatic cord are divided into two sets. An anterior, running with the spermatic artery and forming the pampiniform plexus; and a posterior, smaller set, accompanying the deferential artery which surrounds the vas deferens.

The veins on the left side are always larger than the veins on the right side both the veins, right and left, are supplied with valves, the valves on the right side being most perfect and more numerous.

Of the three (3) principal arteries, the spermatic is in front of the vas deferens, the deferential artery accompanies the excretory duct, while the cremasteric is more superficial. The plexus of veins created by the anterior set forms the chief mass of the cord, and after reaching the int. ring forms a single trunk, which terminates on the right side in the interior vena cava, at an acute angle; on the left side, in the left renal vein, at a right angle And here, at the expense of being considered tedious, allow me to digress, while I call your attention to the fact that the left vein passes behind the sigmoid flexure of the colon, a portion of the intestine where fecal accumulations and impactions are common, which may be assigned as one reason why the left vein is more liable to varices than the right.

It is that portion of the veins that form the anterior set of vessels, which usually forms this disease-varicocele.

*Read before the Iowa State Medical Society at Burlington, May, 1893.

Some authors writing upon the subject of varicocele, treat the same as a disease of the imagination rather than of the cord, and intimate that "suggestion," "Christian Science," and other placebos form the proper treatment. In this view I am not in sympathy.

While

we, as practitioners, can cite cases of sexual hypochondriacs, when the foregoing course of treatment might or might not be proper, the same is true of almost any other di ease that we are called upon to treat, in connection with persons with a too vivid imagination.

Curling states that of 166,317 recruits inspected in the district of Great Britain and Ireland during ten years ending March, 1853. 53.474 were rejected; of this number 3.911 were rejected on account of varicocele.

And of 2,165,470 recruits examined in France, from 1850 to 1860, 20,553 were exempted for varicocele. A larger per cent. existed in cases examined in our own country during the last war from this cause.

Not a small item and certainly not a trivial ailment, that disables so many from the performance of military duty.

Marshall states that of 30 000 recruits examined by him, no case of well marked varicocele was found to exist upon the right side. And Sir Astley Cooper never saw the disease upon the right side. On the other hand, Mr. Curling states that of 5,639 cases of varicocele examined by him. 344 were affected on the right side, 4,881 upon the left side and 414 upon both the right and left side. Between these statements there is certainly a great discrepancy; the discord can only be reconciled by the qualifying adjective well marked."

I have certainly seen a few cases of varicocele upon the right side, but truth compels me to admit that when it existed upon the right side there was enlargement of the veins of the left cord, slight or otherwise.

That varices are apt to exist in other regions when varicocele is present is disproved by the fact that the former occur after middle life, while the latter is present with greatest frequency from fifteen to thirty-five, or during the period of most active sexual function.

As to cause, many reasons are assigned, and I must admit that none of them, separately or combined, are to me altogether satisfactory. And the same can be said for the reasons g ven for the almost universal frequency of the appearance of the disease upon the left side. Anything that increases the amount of blood to the testicles or impedes the return of the same, or relaxes the tissues, may be considered as an existing cause.

The great length of the spermatic veins, their tortuous course, imperfection or absence of valves, pressure upon veins by other organs, from their position and lack of support, are some of the anatomical reasons, together with the fact that during the progress of evolution from walking upon all fours to the erect position, no additional support was added. Greater length and calibre of lef: vein, and increased amount of muscular fiber in dartos on right side, are the most potent reasons for appearing so often on the left side.

The disease is usually slow in its development, often without pain, and when the same is present bears no relation to the size of the varix. The character of the pain is not pathognomonic, but generally is a dull ache that extends along the cord to the lumbar region. The victim usually experiences a depressing effect mentally, out of proportion to the gravity of the disease.

The diagnosis is not difficult-the eye takes in the elongated rather than distended scrotum, the purple discoloration while the touch encounters that mass of convoluted veins that conveys the impression of a mass of earth worms in the scrotum, not met with in any other disease. It is claimed that varicocele is liable to be confounded with scrotal hernia and congenital hydrocele-a mistake unwarrantable.

Agnew thus sums up the resemblance between varicocele and scrotal hernia: Both produce an enlargement in the scrotum, both commence above and descend. Presuming the hernia to be reducible, both disappear in the recumbent and appear in the erect position, and in both is an impulse given to the hand in coughing, but the crucial test leaves no room for doubt.

Place the subject upon the back, make pressure upon the, enlargement, and in either case it disappears Keep up the pressure at ext. ring while you request the person to stand upon the feet; if hernia, it is retained in position, but the pressure prevents the return blood in the veins and the varicocele appears.

TREATMENT.

No case of varicocele was ever cured by the so-called palliative treatment --such as the use of the suspensory bandage, the truss, the ring, or the application of cold. If a placebo only is required, the above treatment meets the indication. If, however, a cure is desired. an operation is necessary. I cannot enter into a discussion of the merits of the hundred and one operations devised for the radical cure (oft-times a misnomer) for varicocele, time will not admit nor your patience permit such a course.

The old saw that there is nothing new under the sun is exemplified in the treatment of varicocele. All, or nearly all, the methods practiced today were known and practiced by Celsus. The so-called new methods of operating are merely modifications of operations in use for hundreds of years. Of the many operations, I will only mention three-one to condemn, one I shall recommend, while the third is open to criticism.

The operation devised and practiced by Sir Ashley Cooper (it was in use hundreds of years before he was born), the incision of the scrotum, thus shortening the redundant sac and thereby forming a natural suspensory bandage. I have performed this operation-- I shall never perform it again. Aside from the fact that it keeps the victim-I speak advisedly-confined to the bed from three to ten weeks, it is not without danger to life, and the relief is not permanent, the dartos will again become elongated.

The second operation is the subcutaneous ligation of the veins and leaves little to be desired. This is performed in various ways, many of them open to objections, these I need not describe. The method I would employ is a modification or simplification of that used by Keys, of New York, and is as follows: After taking every precaution to guard against sepsis I do not think it necessary, however, to shave the parts, though well enough to do so-arm a Peasley's needle or the needle devised by Keys, a modified Peasley, with a strong silk ligature, which is better than cat-gut-though chromatized cat-gut will answer-your patient standing in a good light, grasp the scrotum near the mesial line as high as possible, between the thumb and forefinger of the right hand, unless you chance to be ambidextrous, steadying the scrotum with the left, let the thumb and finger slip outwards until you feel the vas deferens slip to the inner side of your grasp. Now pass the needle through the scrotum to the posterior of same, between the vas deferens and spermatic cord, unthread the needle and draw through ligature, retract the needle until anterior to spermatic cord, then push it backwards through the scrotum between the outer side of the spermatic cord and scrotum until it emerges through the same opening posteriorly as before; re-thread the needle with ligature and draw the same through the point of entrance in front. Tie the ligature firmly, cut short and drop knot into scrotum. If the knot does not readily disappear grasp both anterior and posterior wall of same and separate them by pulling asunder, when the knot will disappear into scrotial cavity, and the operation is over. No after treatment is necessary. I usually advise patient to remain quiet one or two days; frequently they disobey the instructions and as yet no evil consequence has followed thereby. I encircle the entire cord in the ligature and no atrophy of testicle follows. The reason is easily found in the fact that you do not enclose the posterior sets of vessels, those corresponding to the vas deferens. The advantage of this operation is its freedom from danger and short duration of confinement, if any, to the bed, slight pain and the freedom from the use of an anæsthetic.

While the use of antiseptics in modern surgery may, to some degree, obviate the danger to the open operation, it does not abolish the necessity of remaining in bed from one to three weeks, not to mention the pain and after treatment and the employment of an anæsthetic. There is one condition, where the result of the open operation is superior to that obtained by subcutaneous ligation of the cord. It is when great elongation of the cord exists. In this condition, after shaving and cleansing the parts, an incision some two or two and one-half inches is made over the prominent part of the varicocele, the veins exposed but not separated from the fascial covering, a cat-gut ligature is passed under the cord at the upper and lower ends of the incision and tied, leaving a long end to each ligature. The intermediate veins excised and the stumps brought together by tying the long ends of the ligatures, thus shortening the cord at the same time you occlude the varix.

Of thirty-six cases that I have operated upon by the subcutaneous ligature, not a case was confined to the bed over forty-eight hours and in every case the operation was satisfactory to both patient and operator.

DISCUSSION.

DR. SCHOOLER: I have listened with a great deal of interest to the paper just read, but have some doubt as to the anatomical causes which produce varicocele. As long as the patient is in a healthy, normal condition, I very seriously doubt any great effect from anatomical peculiarities. I think there is a diseased condition of the blood vessels, and particularly of the veins. It is well-known that dilation of the veins occurs in all structures of the body, even in the bones themselves. I think thorough investigation will reveal a varicose condition of the venous system as well as the urinary region. I always investigate and determine the actual condition of the venous system. I think that has much more to do with the production of varicocele than anatomical peculiarities. While the operation that has been described by the author of the paper is extremely simple, practically without danger and is easily performed without the use of anesthetics, and is reasonably effective in the large majority of cases that are uncomplicated, it cannot be expected to accomplish much, little if anything in fact, where there is a varicose condition of the scrotum.

Various authorities differ very much as regards the most effective treatment. It will be found after a series of years, that no Keys' operation subcutaneous ligature, or making incisions in the abdominal regions, will effect a real and radical cure there will be more or less return of the difficulty after from five to fifteen years. In the majority of cases it will not be so serious as to interfere very materially with the proper functions of the organs in that locality. But where the scrotal veins are involved, there is certainly nothing left to be done but the ablation of a portion of the scrotum. It is necessary to remove as large a portion as possible, to press the intestine up in the canal and you will be surprised at the amount of redundancy.