The introduction of the probang should be cautiously made and repeated daily, the size being gradually increased until a full sized one is reached, and its use should be continued until the stricture is cured, and no tendency to return is manifest.

If the stricture be so tight that we cannot pass the smallest sized catheter, we may try what electrolysis will do. Using a long, well insulated stemmed electrode, with a naked bulbous tip, we pass it down to the stricture, then connecting it with the negative pole of the battery, we press it against the stricture. The circuit is formed by placing on the pit of the stomach a large sponge rheophore wet with salt water, and connected with the positive pole of the battery. In a few minutes the instrument will make its way through the obstruction.

This method has succeeded not only in overcoming its impervious condition, but by continuing the operation at suitable intervals with larger electrodes, cures have been effected.

The points to be regarded in this operation are, that the stem of the electrode be well insulated, the tip bulbous, and not of too large a size, that it is connected with the negative pole of the battery, and that no force be used, the tip being simply pressed against the obstruction; that the current be not strong enough to produce pain, and as soon as the patient feels the current, its intensity is sufficient, and should not be increased beyond this.

If from any cause we have failed to overcome the contraction and gain an entrance into the stomach, and though we have been supporting our patient with nourishing enemata, and yet death is evidently not far off, we have still left the operation of gastrotomy, which although always a doubtful operation, nevertheless the patient should be given the chance which it offers, for if successful we will not only save our patient from immediate death from starvation, but will also gain the time, which may be the only additional thing necessary, to enable us to 'crown our efforts with success.

There are several remedies which from their well known pathogenesis are of great value in the management of stricture.

The

most prominent of these are, Belladonna, Conium, Ignatia, Mercurius, Pulsatilla and Silicia.

In the treatment of malignant stricture, little or no good and possibly much harm will result from dilating instruments; still we may be required to pass a probang, and follow it with the flexible catheter, through which food may be injected into the stomach to nourish our patient.

We must rely mainly upon internal remedies. The principal ones, doubtless there are many others, from which we may expect to derive benefit, are Arsenicum, Apis, Carbo veg., Conium, Galium aparinum, Hydrastis, Lachesis and Phytolacca.

VARICOCELE.

BY J. G. GILCHRIST, M.D.

The term varicocele is applied to a varicosed condition of the veins of the scrotum and spermatic cord, or the pudendal veins of the female. There are few surgical conditions about which authors differ more widely in their estimation of its importance and significance; one will regard it as worthy of claiming persistent attempts at cure; another as a trifling ailment that is so common as almost to be a normal condition. Within the past year the writer has had his attention particularly directed to the subject, and must take a position somewhat between the two extremes above noted, and differ, in some particulars, from the popular ideas of etiology.

Semiology. Those who have taken the trouble to investigate the subject, assure us that about one person in ten suffers from varicocele, to a greater or less extent. I am unable to actually verify this, but on examination find that a very large number are subjects of the malady. Whilst many, perhaps a very large majority have varicocele without any inconvenience from it whatever, in fact often without knowledge of the fact, there are many cases in which the consequences are serious; cases in which the testes become atrophied; hæmatocele produced by rupture of the veins, or even hernia, or hydrocele induced by the traction on and irritation of the cord, or the effect of the persistent distension of the inguinal rings.

The usual symptoms are enlargement of one side of the scrotum, or vulva, usually the left; some feeling of weight in the parts; occasionally coldness, and nearly always perspiration, with slight excoriation of the smaller parts and the inside of the thigh. The scrotum is generally very pendulous, and not seldom the genitals generally seem to be relaxed. On tactile examination the veins of the scrotum and cord are found to be enlarged and tortuous, feeling, as all the text-books classically assert, "like a bundle of angle worms." They may be readily emptied by steady pressure, and are not painful on handling. Joined to these local symptoms are

others of a constitutional character, about which there is much diversity of opinion. There is occasionally pain in the back and loins, constipation, loss or lessening of sexual desire and power, with a sense of exhaustion and fatigue after coition; some disturbance of the digestion, and occasionally more or less mental prostration. Whilst these symptoms are frequently observed in exaggerated cases, the question arises, are they causes or effects of the varicocele, or simply concomitants without special relation? In a future paragraph this will be discussed, but at present it may be asserted that they are oftener causes and concomitants, rarely, if ever, being effects of the varicocele. The above symptoms exist in all degrees of severity; those of a more purely subjective character oftener being so trifling and unobtrusive that attention is rarely directed to them.

As to the pathology of the affection, I mean the pathological anatomy, there also seems to be some difference of opinion, which is the more singular as opportunity is frequently afforded for actual inspection. Most authors can see no difference between varix in the scrotum, and the same conditions elsewhere. If we adopt the classification of Andrall ( Path. Anat. Soc. Leaves, [Eng.] 1831, II, p. 4), as to varix in general, we will find the process may be either pathological or physiological. Thus there are six forms or degrees of the affection, classified as follows:

1st. A simple dilatation of the veins, without any change in the walls or structures, unless it may be a consequent separation of the valves. This may be purely physiological in the sense that unusual functional activity demands corresponding augmentation of the outlets for the unusual amount of blood called to the part. This undoubtedly occurs in the case of excessive and unusual indulgence, and a mild form of varicocele be the result, being to some extent physiological. There is no tortuosity in this form, and an essential feature of varix is thus lacking. The continuance of the condition may lead to further changes.

2d. The enlargement of the veins is in all directions, in length as well as calibre. There may still be no thickening of the walls, or thinning, or any other change; the condition, in spite of the tortuosity, is still often physiological.

3d. The previous conditions exist, with thinning of the walls, often due to rapid dilatation, from sudden and continued intravenous tension. This is purely pathological.

4th. The same abnormalities, with thickening of the walls. This is usually the result of slow and long continued dilatation, and notably pathological.

5th. The enlargement may be at the valves solely, without or with dilatation or tortuosity, and is also pathological.

6th. Finally, when the condition is of long continuance, the pouches in the veins may become perforated with small apertures, and the blood be extravasated into the surrounding tissues.

It would seem to be a matter of some importance to determine the actual condition of the parts affected in all cases, methods of treatment being thereby indicated. Simple correction of injurious habits or practices might avail in one case, and more radical measures be demanded in another.

The causes are variously stated by different authors, as pressure of fæces in the sigmoid flexure of the colon, in those of a constipated habit; the pendulous character of the veins, being supported imperfectly and feebly by the loose tissue in which they are contained; the length of the veins, and a dozen other constant or accidental contingencies. Sir Astley Cooper, in his classic work on the Testes (Call. Works, vol. I, p. 230) uses the following language: "That it occurs more frequently upon the left than upon the right side, must have struck every observer; and the reason for it results from the termination of the spermatic vein on the left side, differing with that on the right, as on the right side it enters the venacava inferior, nearly in the course of the blood towards the heart; whilst in the left side it terminates in the left emulgent vein, nearly at right angles with the stream of blood from the kidney, and therefore some resistance is offered to the return of blood from the left spermatic vein, and moreover the sigmoid flexure of the colon, when distended, presses upon the spermatic vessels on the left side."

Gross (Syst. of Surg. II, p. 866) adduces a similar theory, "for the reason, as Dr. Jno. Brinton, of this city, has shown, that the left spermatic vein, at its entrance into the emulgent, is unprovided with a valve, whereas such an arrangement exists distinctly on the