SO-CALLED "VARICOCELE" M 
BY 
HENRY C. COE, M.D, M.R.C.S., 
PATHOLOGIST TO THE WOMAN'S HOSPITAL; ASSISTANT SURGEON TO THE NEW YORK CANCER 
HOSPITAL; OBSTETRIC SURGEON TO MATERNITY HOSPITAL. 
[Reprinted from the American Journal of Obstetrics and Diseases of 
Women and Children, Vol. XXII., No. 5, 1889.] 
NEW YORK: 
WILLIAM WOOD & COMPANY, PUBLISHERS, 
56 & 58 Lafayette Place. 
1889 SO-CALLED "VARICOCELE'UN THE FEMALE. 
BY 
HENRY C. COE, M.D., M.R.C.S., 
PATHOLOGIST TO THE WOMAN'S HOSPITAL; ASSISTANT SURGEON TO THE NEW YORK CANCER 
hospital; OBSTETRIC SURGEON to maternity hospital. 
[Reprinted from the American Journal of Obstetrics and Diseases of 
Women and Children, Vol. XXII., No. 5, 1889.] 
NEW YORK: 
WILLIAM WOOD & COMPANY, PUBLISHERS, 
56 & 58 Lafayette Place. 
1889. SO-CALLED "VARICOCELE" IN THE FEMALE. 
At the third annual meeting of the Alumni Association of the 
Woman's Hospital Dr. A. P. Dudley read a paper entitled 
"Varicocele in the Female: What is its Influence upon the 
Ovary ? " In reviewing the discussion of this paper (at which I 
was not present), I was surprised to find that the writer's ideas 
apparently met with the entire approval of the assembled gyne- 
cologists. In the brief limits assigned to the present communica- 
tion, I can only give a very condensed statement of my objec- 
tions to the views advanced and ingeniously supported by Dr. 
Dudley, whom I regard as a careful clinical observer; but I hope 
that I shall be able to enlarge upon it in future, when I have more 
data at my command. I may be allowed to preface my remarks 
with the caution that clinical observations in general are less trust- 
worthy in support of a pathological theory than anatomical, the 
former being more influenced by the " personal equation " of the 
observer. The history of pelvic pathology will bear me out in 
this statement. 
The position taken by Dr. Dudley is briefly as follows: Varico- 
cele in the female is a condition closely analogous to varicocele in 
the male, giving rise to certain definite subjective symptoms in 
the former as in the latter. Objectively it is often mistaken for 
cellulitis or salpingitis, but may be clearly recognized by exami- 
nation per rectum. Atrophy or cystic degeneration of the ovary, 
with consequent sterility, are a direct result of this condition. 
Permanent dilatation of the pampiniform plexus is not remediable 
by palliative treatment, but requires a radical operation, i. e., liga- 
tion and excision of the portion of the broad ligament containing 
the dilated veins. 
In studying this subject we naturally consider its anatomical 
and clinical aspects. 
I. Anatomy.-Richet was the first to describe this condition 
under the name, " varicocele ovarien, " and this termappears in 
various French and German works on pathological anatomy, 
though less often than the more correct expressions "varicosities " 
and "varicose dilatations " of the veins of the broad ligaments. I 
have not noted the paucity of references to this condition, of 
which Dr. Dudley speaks; in fact most of the authors, whom I 
forbeai' to quote, mention it as rather a common accompaniment 4 
of pelvic affections. In few extended articles on pelvic hemato- 
cele is there wanting a reference to the presence of dilatation of 
the ovarian and uterine plexuses during menstruation and preg- 
nancy as an element to be taken into consideration in tracing the 
origin of sudden internal hemorrhage. I think that we are all 
prepared to subscribe to Cfraily Hewitt's statement: "It is ra- 
tional to infer in many cases the existence of a chronic varicose 
condition of the uterine and ovarian plexus of veins." 
We are next led to ask these questions: How shall we distin- 
guish between temporary and permanent dilatation of these veins, 
and what is the relative frequency of the two conditions ? Is so- 
called varicocele in the female comparable anatomically with 
varicocele in the male? Is this condition a cause or a result 
of accompanying disease of the pelvic organs, i. e., has it in 
itself any special pathological significance ? 
Dr. Dudley is careful to make a distinction between temporary 
and permanent dilatation-that in the latter cross-sections of 
the dilated veins show that their walls have undergone well-marked 
hypertrophy-but he does not lay sufficient stress upon the in- 
herent power of the pelvic veins to resist the strain of repeated 
and long-continued congestion. We must not compare the pelvic 
plexuses with those adjacent to other organs (the spleen, perhaps, 
excepted), because of the great engorgement to which the former 
are physiologically subjected. Sexual excitement, menstruation, 
pregnancy-each of these Conditions entails a more oi' less contin- 
uous strain upon the walls of the vessels, which they are able to 
resist not so much by reason of their inherent tone, as from the 
continuity of the entire venous system of the pelvis, whereby 
one plexus acts as a safety valve to another when the latter is 
suddenly overcharged with blood, just as the force of a rapid 
river is expended when it pours its waters through a hundred tiny 
branches into a wide delta. In other words, pelvic congestion is 
general, and does not affect any single plexus. Doubtless a plexus 
such as the pampiniform, from its position at the upper portion 
of the broad ligament, must bear more of the brunt, but it does 
not bear it alone. I have often been struck with the degree of di- 
latation which exists in the veins of the broad ligaments in con- 
nection with large uterine fibroids, without anatomical evidence 
of chronic changes in the vessel-walls. That subinvolution and 
displacement of the uterus are a frequent cause of pelvic congestion 
cannot be denied, but, so far as my post-mortem observations 
have shown, I have not found that the vascular dilatation is neces- 
sarily permanent. Certainly the passage in Winckel's work, quoted 
by Dr. Dudley, does not justify the conclusion that he regards true 
varicocele as a very frequent or important complication of retro- 
displacement. Phleboliths are indeed sometimes found in the veins 
of the broad ligaments, but no more frequently than in the vesical 
and urethral plexuses; and, moreover, my reading and observa- 5 
tion would seem to teach me that these bodies are found more 
often in the lower rather than in the uppei' half of the broad liga- 
ment (compare Winckel's most striking case), i. e., not in the pam- 
piniform plexus. Now, it is unscientific to infer that the presence 
of these bodies is proof positive of the presence of varicose enlarge- 
ment of the veins and obstruction to the circulation. Excluding 
the so-called marantic thrombi, found in the female as in the male 
and due to the same cause, I believe that in the majority of cases 
phleboliths are the direct result of thrombo-phlebitis extending 
from the uterus-in short, puerperal infection, rather than subin- 
volution, is the true cause of permanent changes in the vessel- 
walls. If this is true, it is impossible to institute a close compari- 
son between the formation of phleboliths in a varicocele in the 
male and their appearance in the veins of the broad ligaments. 
"Varicocele," to use a convenient definition by Keyes, "is con- 
stituted by a varicose enlargement of the pampiniform plexus and 
veins of the cord." Granting that the ovarian plexus is the 
analogue of the pampiniform in the male, in order to have a con- 
dition in the female actually corresponding with varicocele, 
enlargement should be strictly confined to the ovarian plexus; 
whereas Dr. Dudley thinks that "the term is not misapplied 
when referring to a dilated and tortuous condition of the veins 
in the broad ligament;" in other words, he would describe vari- 
cocele in the female as a general dilatation of all the plexuses in 
the broad ligament. It is a fact that when the veins of the ovarian 
plexus become dilated, those of the uterine and vaginal plexuses 
share in the dilatation; but can this be called "varicocele," as we 
understand it in the male? As well say that varicocele in the 
male includes enlargement of the dorsal vein of the penis and the 
rectal and vesical plexuses. 
Again, the veins in the broad ligaments run generally at right 
angles to the axis of the body, and are far less subject to the 
influence of gravity or change of posture than are the spermatic 
plexuses in the male. On the other hand, as already stated, the 
veins in the female are subject to frequent periodical and irregu- 
lar engorgements to which they become accustomed, as it were; 
far less local congestion in the male leads to abnormal turgescence 
and dilatation of the corresponding veins. Moreover, any attempt 
to draw a close comparison between the ovary and testicle, either 
anatomically or physiologically, is unwise, since the former organ 
is subject normally to congestion which, in the latter, would be 
abnormal, which also applies to their efferent veins. The argu- 
ments with regard to the course of the left spermatic vein and the 
proximity of-the sigmoid flexure hold good in both sexes, yet the 
infrequency of so-called varicocele in females, as compared with 
that in males (ten per cent in the latter, as estimated by Keyes), 
shows that there is an essential difference in the two cases. This 
difference, I believe, lies in the greater resisting power of the veins 6 
of the broad ligaments, and in what I have called the "safety- 
valve " action of contiguous plexuses. 
I think that the pathological significance of dilatation of the 
veins of the broad ligaments can be dismissed in a few words. 
As Dr. Dudley admits, and as will be inferred from reading vari- 
ous descriptions of the condition under discussion, it is a common 
consequence of obstruction to the circulation, either local (from 
indurations or cicatrices in the broad ligaments) or general (from 
displacement of the uterus or ovaries), or both. I have already 
alluded to the changes in and around the veins resulting from 
phlebitis. 
As to the influence of this venous dilatation upon the ovary, 
we certainly would not expect to find atrophy of the gland as a 
result. No more striking example of general and excessive 
dilatation of all the venous plexuses in both broad ligaments can 
be observed than that seen in connection with uterine fibroids, 
yet here the condition is almost invariably hyper-nutrition of the 
ovaries-hypertrophy rather than atrophy. On the other hand, 
the most typical examples of atrophy are seen in ovaries which are 
buried in adhesions, and thus have their circulation greatly re- 
duced. I cannot accept the view that the varicose enlargement 
precedes the degenerative changes in the ovary-that it stands 
in a direct causal relation to them. Cystic degeneration of 
the ovary is so very common that its presence in connection 
with venous dilatation would prove nothing. Since three of Dr. 
Dudley's four patients had passed the menopause, the atrophy 
could hardly be regarded as pathological; this opinion is not 
modified after a perusal of the description of the microscopical 
appearances presented by one of the ovaries removed. We might 
pertinently ask: Why were not these cases of senile loss of tone in 
the dilated vessels, with ordinary post-climacteric atrophy of the 
ovaries? I am open to conviction of error in this inference, but I 
regard the fact that in all but one of these test cases the patient 
had reached the menopause as the strongest argument against 
his pathological theory. 
II. Symptomatology. - "The most prominent symptom," to 
quote from Dr. Dudley's paper, "is pain of a peculiar dull, aching 
character, extending up the side to the region of the kidney; . . . 
also the fact that this pain will disappear after the patient has 
occupied the prone position for a time, and reappear after taking 
the erect position. The pain is quite similar in character to that 
experienced by the male who suffers from varicocele, while several 
of the general symptoms are analogous in character, such as 
lassitude, a vague sense of unrest, and mental depression." It is 
to be remarked that none of the patients operated upon were in the 
hospital under careful observation for three weeks (!) between 
the time of the first examination and the operation, too short a 
period to justify a positive statement regarding the exact origin 7 
of the symptoms in such complicated cases. I confess that I can 
find nothing characteristic about these symptoms, which do not 
differ from those which we observe in connection with the more 
common pelvic disorders. As for any comparison between pelvic 
pains in the female and those which accompany varicocele in the 
male, a mere reference to the intricate system of nerve-plexuses 
in and around the uterus and ovaries and between the folds of the 
broad ligaments will be enough to indicate how different are the 
conditions in the two cases. I shall not dwell upon this subject, 
but shall refer you to a paper which I read before the Neurological 
Society in 1887, on " The Significance and Localization of Pelvic 
Pain," in which I aimed to show the difficulty of attributing any 
special form of pain to a simple localized lesion. As for the 
"general symptoms" referred to-how do they differ from those 
which may be obtained from questioning nine out of ten gyneco- 
logical patients, especially those who are somewhat advanced in 
years? From a mechanical standpoint alone, I do not see how so 
much stress can be laid upon the posture of the patient, since, as 
I before remarked, the veins of the broad ligaments are less 
influenced by gravity than are the spermatic plexuses in the male. 
III. Physical Examination.-Dr. Dudley lays especial stress 
upon the necessity of examining per rectum, " after the patient 
has been allowed to stand for a short time." "Bimanual pressure 
of the ligament," he adds, " will then readily reveal the knotted, 
angle-worm appearance (feel?) of the vessels." He says nothing 
about drawing down the uterus in order to render the upper 
portion of the ligament more accessible. Unless this is done, it 
must be very difficult to reach the site of the pampiniform plexus 
with the examining finger. I am inclined to believe that without 
such aid few men have fingers sufficiently long for the purpose, 
even if the patient was a most favorable case for examination. 
Dr. Dudley says that even such a prominent special pathologist as 
Winckel " does not mention having made a diagnosis of it in the 
living subject." The probabilities are that the learned and conser- 
vative gynecologist referred to, having made a study of varicosities 
in the cadaver, has frequently sought to detect this condition at 
the examining-table, but has either failed to satisfy himself that 
he found it, or considered it merely as a complication of disease of 
the pelvic organs, and therefore not sufficiently important to be 
mentioned. Certain it is that Winckel would be the last man to 
verify his diagnosis by opening the abdomen, unless there was a 
more serious condition present than supposed varicose veins. I 
have frequently made careful examinations per rectum, the patient 
being thoroughly anesthetized and all the conditions favorable for 
ascertaining all that was possible by the bimanual. I cannot recall 
a case in which I have felt the " knotted angle-worm" mass which 
has been described. In patients who had no displacement of the 
uterus or ovaries, no pelvic indurations-in short, nothing to dis- 8 
tract the attention from the broad ligaments-I have readily de- 
tected what have been called " the three winglets of the broad 
ligament," i. e., the Fallopian tube, round and ovarian ligaments, 
which branch out from the cornu. Moreover, under favorable 
conditions, the large and tortuous ovarian arteries can be felt 
pulsating between the two latter cords. These might readily be 
mistaken for a bunch of veins. In order that the veins may give 
sufficient resistance to be mapped out through the rectal wall, 
these must be not only enlarged, but their walls must be greatly 
thickened. Frequently, in both the living and dead subject, have 
I grasped the broad ligament between the thumb and finger when 
the veins were enormously dilated, and felt so little resistance that 
they gave the sensation of an ill-defined mass rather than a bun- 
dle of cords. On the contrary, a diseased vein does give a decided 
sense of resistance. In this connection, I would refer to a point 
upon which I laid special stress in my paper on ' ' Minor Pelvic 
Inflammations," viz., the fact that phlebitis and periphlebitis are 
a common cause of thickening of the veins neai' the base of the 
broad ligaments, and that this condition, as found in the cadaver, 
frequently represents the indurations usually attributed to "cel- 
lulitis " when felt in the living subject. I also mentioned lym- 
phangitis and phleboliths as other conditions which could some- 
times be recognized clinically. It did not occur to me that dila- 
tation of an entire venous plexus at the upper portion of the 
broad ligament could be mistaken for old parametric indurations 
in the lower half of the same, although I have several times noted 
that the engorgement persists after death. 
Granting, as we must on the authority of such an experienced 
examiner as Dr. Dudley, that he clearly recognized before opera- 
tion the peculiar knotted mass which he took to be varicose veins, 
and these alone, we note in all his cases the omission of an im- 
portant means of absolutely reconciling the mass felt with the 
mass seen after opening the abdomen. I allude to the examina- 
tion of the pelvis, with an assistant's finger in the vagina (or rec- 
tum) while that of the operator is within the cavity. I have often 
practised this in the cadaver, and Dr. Polk at the operating-table, 
in the course of his most convincing investigations into the 
nature of so-called cellulitis. Dr. Polk, by the way, makes no 
mention of varicocele in any one of his series of operations or au- 
topsies. Since the ovaries, tubes, ovarian ligaments (and in one 
case a portion of the round ligament) were removed with the 
enlarged veins in Dr. Dudley's cases, there must remain some 
doubt as to the exact correspondence between the clinical and 
the anatomical diagnosis. I do not see how there can be much 
danger of confounding dilated veins with "salpingitis"-under- 
standing by the latter term disease of the tube sufficient to cause 
marked enlargement. The symptoms attending the latter con- 
dition are unquestionably far more severe in character, while the 9 
accompanying peritonitis would effectually conceal any venous 
enlargement, even if it did not mask the shape of the large resist- 
ant tube. 
IV. Treatment.-I now pass to a brief consideration of the 
treatment of permanent dilatation of the veins of the broad liga- 
ment. I agree with the writer perfectly in regard to the small, or 
only temporary, benefit obtained by local treatment directed 
through the vagina (hot injections, counter-irritation, tamponing 
or local depletion), for reasons which I have frequently set forth, 
the principal being the free anastomoses of the venous plexuses, 
in consequence of which anemia at one point in the pelvis is ob- 
tained only through corresponding hyperemia at another point. 
Pelvic massage, according to Brandt's method, may possibly 
offer an efficient substitute for the above-mentioned palliative 
treatment. That laparatomy is ever justifiable for the relief of 
this condition alone I cannot allow, for the following reasons: 
The operation of ligating or excising the dilated veins alone, 
as in the corresponding operation in the male, presents excep- 
tional difficulties because of the number and intimate relation of 
the various delicate structures, in the broad ligaments. If the 
operation is not done thoroughly, all the affected veins will not 
be removed, and those which remain will become still further 
dilated, as seen in ordinary cases of extirpation of the tubes and 
ovaries. On the othei' hand, by " quilting " the ligaments " close 
to the pelvic floor," it is difficult to avoid the uterine arteries and 
ureters. If the ovary and tube are removed with the affected 
veins, and an attempt is made to include in the stump as much as 
possible of the broad ligament, the latter may be either torn at its 
base, or may subsequently slip from the grasp of the ligature, both 
of which accidents have occurred in the hands of the best opera- 
tors. I have seen several cases of fatal hemorrhage from this 
cause in easy, uncomplicated operations. 
The fact that the patient is relieved of certain symptoms after re- 
moval of the ovary, tube, and varix does not prove that they were 
due to the presence of the varix alone, as that was not the only 
important structure excised. A more satisfactory proof would be 
afforded by the persistence of the symptoms in cases in which the 
varix was left and the ovary and tube were removed. In short, 
laparatomy performed on this indication only is a purely empiri- 
cal measure, as it always is when done for the relief of pelvic 
pain alone. What the profession needs is not a new indication for 
laparatomy, but the reduction of the already long list. 
There is no precedent for the performance of the operation de- 
scribed by Dr. Dudley in the case of women who had passed the 
menopause, since it is acknowledged that the ovaries were atro- 
phied; and from the physiological rest enjoyed by the pelvic or- 
gans, there is reason to believe that the venous congestion would 
have become diminished in nature's way. We would hesitate be- 10 
fore operating upon more serious conditions after the menopause; 
why would not the same rule apply to these cases ? 
I submit the following deductions in opposition to those set 
forth by Dr. Dudley: 
1. True variocele in the female, if this term is applied to 
permanent dilatation of the veins forming the pampiniform 
plexus, with considerable thickening of their coats, is rare; at 
least, it is seldom found at the post-mortem table, which is the 
best test of the absence of chronic changes in the vessels. 
2. Varicose enlargement of the veins of the broad ligament can- 
not be regarded as closely analogous to varicocele in the male, as 
viewed from the standpoint of etiology, anatomy, or symptoma- 
tology. The anatomical conditions in the female are widely dif- 
ferent from those in the male. 
3. In deciding as to the cause of the venous dilatation, regard 
should be had not only for the influence of long-continued conges- 
tion (from displacements or other causes), but for the changes in 
the vessel-walls and the surrounding connective tissue, which 
point to previous phlebitis of uterine origin (puerperal or trau- 
matic) . 
4. In exceptional cases of varicocele in the male, atrophy of the 
testis may result from interference with its circulation. It is ex- 
ceedingly doubtful if atrophy of the ovary can be traced to a 
similar cause. The obstruction to the circulation can usually be 
ascribed to surrounding adhesions, and the conditions of the 
veins is post rather than ante hoc. In other words, the same 
cause may lead to both the ovarian disease and the dilatation of 
the veins. Or, if no adhesions are present, cirrhosis of the ovary 
is more likely to precede, than to follow, venous dilatation. 
5. There is no evidence that varicose enlargement of the veins 
in one or both broad ligaments gives rise to any peculiar symp- 
toms which could not be explained equally well by the presence 
of accompanying disease of the pelvic organs, especially to local- 
ized peritonitis. There can be no just grounds for comparing the 
symptoms due to varicocele in the male with somewhat similar 
pains in the female, even when these are associated with venous 
dilatation, since the anatomical conditions in the latter sex are 
far more complicated. 
6. So-called varicocele ought not to be mistaken for cellulitis, or 
resulting indurations, since the former should occupy the upper 
portion of the broad ligament, while the latter is usually found at 
its base. Well-marked tubal disease should give a different his- 
tory, and enlargement of the tubes sufficient to call for operative 
interference ought to be distinguished from a cluster of dilated 
veins. On the other hand, it must be under exceptional circum- 
stances, and by an examiner possessing in a high degree the tactus 
eruditus, that such veins are clearly detected at the examining 
table, nor does the finding of dilated veins after opening the abdo- 11 
men necessarily prove that they were the objects felt within the 
pelvis before the operation. 
7. Varicose enlargement of the veins of the broad ligament does 
not constitute a sufficient indication for laparatomy, nor is it 
possible to remove all the affected plexuses without ligating or 
excising nearly the whole of the broad ligament-a dangerous pro- 
cedure which has led to most of the fatal cases of secondary 
hemorrhage. Laparatomy is certainly not justifiable after the 
patient has passed the menopause, as the quiescent state of the 
pelvic organs would naturally seem to favor a spontaneous cure.