VARICOCELE, 
With a Report of Nineteen Radical 
Operations, and the Different Ways 
in which they were done. 
by 
B. MERRILL RICKETTS, MD., 
CINCINNATI, OHIO. 
REPRINTED FROM 
Etc Neto fHebtcal JJournal 
for June 17, 1893. Reprinted from the New York Medical Journal 
for June 17, 1893. 
VARICOCELE, 
WITH A REPORT OF NINETEEN RADICAL OPERATIONS, 
AND THE DIFFERENT WAYS IN WHICH .THEY WERE DONE.* 
By B. MERRILL RICKETTS, M. D., 
CINCINNATI, OHIO. 
Varicosity of the spermatic vein, especially the left 
one, is quite a common occurrence. There are many rea- 
sons assigned as being the cause, but I think the most 
plausible one is its anatomical relation to the rectum and 
the influence of fyecal masses pressing upon it. These 
varicose veins increase both in number and size until they 
become greatly distended and hold great quantities of 
venous blood when their possessor stands erect. There is a 
sensation of weight, producing great discomfort at times 
and occasionally sharp lancinating pains. The scrotum 
becomes redundant and in a few cases extends almost to 
the knee. I myself have seen three that reached to the 
lower third of the thigh. In cases of long standing the 
pressure upon the veins is sufficient to produce atrophy of 
the testicle, thus necessarily destroying its usefulness, so 
that the operation is not always the cause of sterility. 
* Read before the Cincinnati Academy of Medicine. 
Copyright, 1893, by D. Appleton and Company. 2 
VARICOCELE. 
From time immemorial various operations have been 
resorted to for the purpose of destroying these veins and 
preventing their return. One of the first was the subcuta- 
neous operation, which is now performed but by a few 
surgeons. Among this number is Dr. Edward L. Keyes, of 
New York, who seems to be satisfied with the results. He 
believes it the ideal operation, claiming for it less suffer- 
ing, less loss of time, with greater dispatch, and without 
danger to either the testicle or the patient. I think I 
am safe in saying that the principal reason for the opera- 
tion going into disrepute is the great danger of the sper- 
matic artery being destroyed, for surely an operator can not 
follow the point of the needle with his eye. It must 
necessarily be done with the sense of touch. Then the in- 
jections of quercus alba, carbolic acid, tincture of iodine, 
perchloride of iron, and permanganate of potassium have 
all been thoroughly tried and found wanting. They were 
injected into the veins for the purpose of producing an 
acute inflammatory process which would destroy their walls. 
1 do not believe that two per cent, of those operated upon 
ever experienced radical results. These injections are at- 
tended with great risks of abscesses, phlebitis, and consti- 
tutional disturbances of a dangerous nature ; then the re- 
maining ninety-eight per cent, of all the patients operated 
upon experience greater trouble after these injections than 
before. I have recently operated upon four of these sub- 
jects who had been treated with the injections of iodine 
and quercus alba. In each case there were hard masses of 
veins which had not been absorbed and around which the 
smaller ones had become greatly distended, so that I am 
thoroughly convinced of the fallacy of this operation. 
Within the last ten years the radical operation, which 
consists of the removal of these veins in toto, has been 
adopted. To my mind this has been the most rational VARICOCELE. 
3 
means of destroying varicosity of the spermatic veins ; con- 
sequently it was not until this radical operation of ligating 
and cutting en masse was introduced that 1 was willing to 
adopt operative procedures for the relief of varicocele. 
Of the nineteen operations that I have done there has 
been the loss of but one testicle. Here the varicosity was 
extensive and the testicle of not more than one third the size 
of its mate. The operation resorted to was double ligation 
of the mass at points about half an inch distant, its removal, 
and bringing the stumps together with silk. This was done 
under the influence of chloroform and the recovery was un- 
interrupted, except for a slight rise of temperature, which 
lasted for three days. 
I have done the operation in the following ways: 
1. Single ligature without cutting. 
2. Double ligature without cutting. 
3. Double ligature with one incision between. 
4. Double ligature with the removal of the intervening- 
mass. 
5. Ligating the veins separately. 
6. Clamping the veins and applying the cautery. 
7. Median amputation of the scrotum (lower portion). 
8. Lateral amputation of the scrotum. 
So that I feel that I am prepared to choose from these 
operations the one most desirable to do and the one most 
beneficial and with least loss of time to the patient. I have 
used both silk and catgut ligatures, and am now free to 
say that I prefer the latter to the former, although I have 
occasionally observed slight suppuration with the catgut. I 
have not yet been able to do the operation with silk liga- 
tures in such a way that they would not sooner or later 
work their way out; so that 1 would not do the operation 
with silk if the catgut could be had. In three cases I have 
had the temperature go as high as 102° F. and range from VARICOCELE. 
4 
that to 101° for three or four days and then gradually and 
rapidly subside. There have not yet been any unpleasant 
complications arising from the operation, although in three 
or four cases it was three months before the silk ligatures 
escaped. I have thought within the last year that the 
ideal operation would be to clamp and cauterize the vari- 
cosities as is done in haemorrhoids about the anus, and 
upon the suggestion of Dr. F. W. Langdon this has been 
done; but I find after doing the operation that it is thus 
far unsatisfactory. I shall, however, resort to it again and 
see if the fault does not lie in myself more than in the 
means adopted. 
The operation that I have now decided upon and would 
most earnestly advocate is to inject a solution of cocaine in 
the field of incision, cut down upon the veins, apply two 
catgut ligatures half an inch distant, divide with a knife, 
and bring the stumps together with a single catgut suture. 
The parts are then returned and the external wound closed 
by continuous catgut or silk and dressed with boric acid. 
I do not now find it necessary to administer an anaesthetic 
of any kind to produce unconsciousness, having found that 
injections of cocaine will enable a painless operation to be 
done. 
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