CLASSIFICATION OF THE METHODS -- THREE CLASSES -- FIRST, IMMEDIATE
AMPUTATION -- SECOND, AMPUTATION AFTER APPLICATION OF HEMOSTATIC MEANS
UPON THE CORD -- THIRD, WITHOUT AMPUTATION, BUT DESTRUCTION OF
SECRETING POWER OF THE ORGAN -- SIMPLE EXCISION -- SCRAPING -- TEARING
AND TORSION -- TORSION -- FREE AND LIMITED -- ABOVE OR BELOW THE
EPIDIDYMIS -- LINEAR CRUSHING -- FIRING.
The methods of performing the operation of castration may be variously
classified, though in each class a varying number of modes will come
under our notice.
The first class will include the operations by which, the envelopes
having been cut through, the vaginal sac opened and the testicle
exposed, the organ is separated by an immediate section of the cord. A
number of different processes are included under this head, among which
are those of _scraping_, of _tearing_, of _torsion_, of _linear
crushing_, or by the _ecraseur_, and of _firing_, or the actual
cautery.
The second class has also for its first or preliminary step, that of the
first, viz., the incision of the bags, the opening of the vaginal sac,
and the exposure of the testicle. But instead of removing the organ by
the division of the cord, we proceed as a second step, to the
application of an apparatus designed to operate by producing compression
along the length of the cord, and in this are included but two modes of
operating, that by the _ligature_ and that by the _clamps_.
The third class, according to our category, presents to our view two
further operations, both of which are essentially bloodless and dispense
with the incision of the bags, consisting of certain peculiar
manipulations which insure the destruction of the testicular structure,
and consequently of its secreting power. They comprehend the process of
the _crushing of the spermatic cord_, and that of _subcutaneous double
twisting_--the _bistournage_ of the French.
We now enter upon the consideration of each of the separate modes we
have thus enumerated.
SIMPLE EXCISION.
This is claimed to be one of the oldest modes of operating, and though
to a great extent discarded by practitioners of the present day, still
finds its application in the treatment of the smaller animals. With
larger patients, however, though still strongly recommended by some
practitioners, it is not generally employed on account of the profuse
hemorrhage which necessarily follows the amputation of the cord. Still
it is conceded that this hemorrhage, as in many cases of the clean,
transverse section of arterial blood vessels, will cease spontaneously
by the contraction of the vessels on themselves, and the formation of a
clot at the divided end, as well as in the surrounding cellular tissue.
However, there is a possibility of the continuance of the hemorrhage for
some length of time, and the bad effects of excessive depletion are not
to be overlooked, especially in an animal whose general constitution has
from any cause suffered impairment. If there is any one of the various
modes of operating in which the standing position is allowable, this, in
our opinion, is the one, the steps of the process being so few and so
short, and admitting such simplicity and rapidity. These consist in
making a free opening in the bag, reaching with a single stroke of the
knife into the vaginal cavity; grasping the testicle and pulling it
gently downwards; and cutting the cord right across, from the front
backwards, above the epididymis, the cord returning of itself into the
vaginal sac--the division being made, of course, on both sides. The
animal is then kept quiet in his stall and left alone until the
hemorrhage subsides.
SCRAPING.
This operation, which is said to have originated in India, is but a
modification of the preceding. Instead, however, of using a sharp edged
instrument to divide the cord, the surgeon, on the contrary, employs a
dull knife, with which the coats of the artery and portions of the cord
are scraped until the separation takes place. They are thus placed in
good condition for their temporary closure. This method is probably
attended with a diminished amount of hemorrhage, and if carefully
performed, it may be entirely absent, the clot closing the artery, and
the condition of the lacerated threads of the vessel acting favorably,
as well, in preventing it. The manipulations are similar to those
accompanying the simple excision, though it is better and more safely
effected when the animal is on his back. The testicles being exposed by
the incision through the envelopes, the posterior septum of the cord is
cut through by a transverse section, and the scraping of the anterior
fasciculus of the cord then performed, by a slow movement from above
downwards, along a certain extent, in order to effect a solution of
continuity by a sort of wearing through the tissues. This operation is
slow and requires a careful hand for its execution. But as it may in
some cases be followed by severe hemorrhage, it cannot, for that reason,
be recommended for large animals, for solipeds especially.
TEARING AND TORSION.
These two modes of operation may, to a great extent, be considered as
identical. Indeed, the mode of torsion may be said to have arisen
principally as a modification of that of tearing, which is the older. In
tearing, the cord was subjected to a certain amount of torsion _by the
hand_, and then torn apart at a given point in its length; while in the
process of simple torsion, as properly performed, we obtain a division
of the cord by twisting it _with instruments_, which enables the
operator to effect the separation at a definitely determined spot.
Tearing differs, then, from torsion only in the fact that after giving
several twists to the cord in order to gather its fibres into a more
compact mass, and to diminish the resistance of the more superficial
layers, it is divided in its continuity by a violent traction upon its
fibres in the direction of its length.
In this process, especially applied to ruminants, the testicle being
exposed, the operator secures the cord firmly with the thumb and index
finger of one hand, to prevent the traction from taking effect too far
upwards when being made by the other hand, after the cord has been
twisted a few times on itself.
TORSION.
In this method of castration the cord is twisted with sufficient force
to cause it to break of itself at the point of the greatest violence.
Its design is to accomplish the removal of the testicle without dragging
or excessive traction upon the cord, and thus to avoid the hemorrhage
following the torsion of the spermatic artery, as a mode of hemostasis
sufficient to prevent the flow of blood attendant upon the rupture of
the cord. The operation may be performed either above or below the
epididymis, or may consist simply in the torsion of the artery alone. At
first the hands only were called upon to act in the manipulations, and
the operation was from this cause known as _free torsion_, until about
fifty years ago, when instruments were introduced into general practice,
and gave rise to the plan of _limited torsion_.
FREE TORSION.
_Free torsion_, or that in which the hands alone are employed in the
operation, may be performed, as before stated, either above or below the
epididymis.
_Above the Epididymis._--The first is one of the oldest modes of
castration known; one which must have been practiced contemporaneously
with the use of clamps, or in the first age of surgery. The first steps
of the operation required for the exposure of the testicles are the same
as have already been detailed. When this is accomplished the steps of
torsion and rupture are then performed in the following manner: The
operator, grasping the testicle, carefully draws out the spermatic cord,
and with a pointed bistoury makes a transverse incision, above the tail
of the epididymis, through the posterior septum of the cord, involving
what we know as the white muscle of Bouley, the efferent canal, and the
small testicular artery. He then seizes the anterior fasciculus of the
cord between the thumb and index finger of the left hand, squeezing it
as tightly as possible, and having with the other hand secured the cord
at a short distance below the point where the left hand has already been
placed, performs the torsion by a rotatory movement given to the
testicle itself, the motion having for its result the twisting and
tearing of the cord when long enough continued to overcome the tenacity
of its fibres. Fifteen or twenty turns of the organ will usually be
found sufficient to effect the rupture. A considerable degree of
strength in the fingers is required in this movement, and for this
reason the torsion may take effect further up than may be desired, and
beyond the point designed, which may result in an unnecessary amount of
irritation and injury. When the torsion has gone so far that the rupture
of the cord has been effected, the stump is released, and retracts in
the inguinal canal to a certain height limited by the presence of the
posterior septum, which holds it in place, and to a great extent
prevents its return through the superior orifice of the inguinal canal.
_Below the Epididymis._--This, the fourth step of the operation,
consists in the separation of the testicle from the epididymis and the
torsion of one upon the other. The testicle being exposed, the operator,
taking hold of its appendix, the epididymis, with the left hand, and of
the gland with the right, their cellular serous attachment is divided by
the thumbs from the posterior to the anterior extremity, from the tail
to the head of the twisted efferent canal. If this cannot be done with
the hand, the convex bistoury must be called into action. This
accomplished, the head of the epididymis is firmly secured with the
fingers of the left hand, and the right hand, left free, gives to the
testicle the number of rotatory motions necessary to separate it from
its excretory canal--that is, from eight to ten. When the testicle is
thus severed, the stump of the end, with the epididymis, is pushed back
into the vaginal sac, where it is confined by the application of a
suture upon the middle of the edge of the scrotal wound.
LIMITED TORSION.
_Limited Torsion Above the Epididymis._--As we have seen, this is the
operation by which the division of the spermatic cord is effected by
torsion made upon a given point in its length, and limited by the use of
special instruments.
[Illustration: FIG. 3.
FIXING FORCEPS FOR TORSION.
A.--Renault and Delafond pattern.
B.--Perier.
C.--Reynal.]
We have already called attention to the difficulty of the operation of
free torsion, which requires a great deal of strength, and which,
besides, may be accompanied by a serious inflammatory condition of the
parts, through rough manipulations of the cord. It is for this reason
that this mode of procedure must have been reserved for small animals,
as, if performed upon the larger kinds, it can only be by men whose
muscular force is sufficient to enable them to overcome and bring into
subjection the struggling subjects of their operations.
[Illustration: FIG. 4.
MOVING FORCEPS FOR CASTRATION BY TORSION.
Renault and Delafond pattern. Reynal pattern.]
It was in 1883 that two French veterinarians, Renault and Delafond, of
the Alfort school, introduced the use of instruments in the operation,
as an improvement upon the manual methods and their effects on the
sequelæ, though it is said to have been already practiced in Germany as
far back as the last century. The instruments employed are two forceps
of peculiar construction, and which were more or less modified, one of
which (_fixing_ forceps, Fig. 3,) is to be applied upon a fixed point of
the cord, where it is suffered to remain, and the other (_moving_
forceps, Fig. 4,) is employed to accomplish the rotation of the testicle
and the lower end of the cord. Those of Renault and Delafond or of
Reynal are now in general use. Those of Beaufils (Fig. 5) are, we
believe, too complicated for general use.
[Illustration: FIG. 5.
COMBINED FORCEPS OF M. BEAUFILS.]
_Modus Operandi._--In the first step of the operation, the ordinary
manipulations of the division of the envelopes, the opening of the sac
and exposure of the testicle being accomplished, and the envelopes being
carefully pushed upwards, the torsion and excision of the cord are
effected in the following manner: The entire cord is embraced by the
fixing forceps (see Fig. 6), or only its anterior fasciculus if the
posterior septum has been cut, as in the process by free torsion above
the epididymis. An assistant, seizing it from before backwards between
its open branches and strongly closing them, holds it firmly, without
pulling upon the cord. The operator then grasps the cord with the moving
forceps above the testicle, and a little below the point held by the
assistant, leaving a small space between the instruments, and closing
his own tightly, begins the movement of torsion, which he directs from
left to right. For this he sometimes requires both hands, one of them
keeping the instrument in place, while the other continues the
rotation as described. Ten or fifteen turns of the forceps are usually
sufficient to complete the rupture of the cord, the artery, owing to its
facility of elongation, being the last part to give way. The testicle
then separates, being held in the branches of the moving forceps; the
fixing forceps are removed, and the cord is drawn upwards into the
vaginal sac. It is important in this operation to caution the assistant
against drawing on the cord during the struggles of the animal,
consequent upon the pain caused by the first application of the
instruments, and the pressure upon the parts when held between their
inflexible iron jaws; but on the contrary, to maintain it as closely as
possible against the inguinal region.
[Illustration: FIG. 6.
OPERATION OF LIMITED TORSION.]
This process of castration is one of the most rapid of all the forms of
operating. The only hemorrhage likely to occur is merely that of the
small testicular artery, if it should happen to be divided when the
torsion is confined to the front portion of the cord.
_Below the Epididymis._--This process differs from the preceding only in
the fact that instead of holding the cord between the fingers, it is
held by the fixed forceps, the use of the moving instrument being
rendered unnecessary by the slightness of the adhesion of the seminal
gland to its appendix.
[Illustration: FIG. 7.
VARIOUS KINDS OF ECRASEURS.]
LINEAR CRUSHING.
The originator of the use of that peculiar instrument, the ecraseur
(Fig. 7), so valuable an adjunct in the operation of castration, is Mr.
H. Bouley, who brought it into use at a date as early as the year 1857.
It is not, therefore, an American invention, as has sometimes been
claimed. The function of this instrument is to effect the division of
living parts without hemorrhage. The original ecraseur of Chassaignac
has received many modifications, all of which, however, operate upon the
same principle The essential design of all is to produce a general
constriction of the blood vessels, by which their internal and middle
coats being first divided, may contract within the cavity of the vessel
in such a manner as to close their cavity and form a sort of stopper to
the artery, while the external cellular covering, the last to undergo
division, is so stretched, under the action of the instrument, and so
closely adapts itself by its ends, that insufflation through the free
ends of the vessels fails to remove the closing arrangement of the two
coats first divided.
[Illustration: FIG. 8.
HOUSE CLAMPS.]
_Modus Operandi._--The operation is comparatively a very simple one. The
testicle being exposed, as in all the other methods, the chain of the
instrument is so placed around the cord that the pressure takes place
upon the greater mass of tissue, in order that it may continue the
longer; which being done, the lever of the instrument is brought into
action, and the constriction caused by the chain slowly kept up until
the definite division of the tissue is accomplished. The essential
condition of success in the operation, having in view the desired
hemostatic effect, is to _act slowly_. According to Prof. Bouley, an
interval of several seconds should be suffered to elapse after each
rotation of the wheel which moves the chain. If the tissues are divided
too rapidly, the section of the artery is apt to be too clean, and a
hemorrhage is likely to be the result. This objection, however, though
made by one of the highest authorities in veterinary surgery, does not
seem to be justified by the results obtained by American operators, most
of whom both recommend and practice its execution as rapidly as
possible; and according to their own statements, a serious hemorrhage is
seldom encountered. The fact that it has been observed in any case,
however, confirms the wisdom of the recommendation of Prof. Bouley, and
as most of our American _confrères_ prefer the operation with the animal
in the standing posture, the reason of their neglect of the prudent and
more truly surgical process can be readily appreciated. To avoid the
hemorrhage Dr. House invented a clamp which he applied upon the cord
previous to the amputation with the ecraseur (Fig. 8). This mode of
castration is not very extensively practiced by European practitioners.
The reason of this is probably to be looked for in the essential
necessity of safety which so protracts its performance.
FIRING.
This mode of castration consists in the application to the cut end of
the testicular cord--previously divided with the bistoury, or by the
cautery--as a means of hemostasis, of an iron heated to a white
heat--the actual cautery. This is claimed to be one of the oldest modes
of operating, Vegetius and Absyrtus describing it as a common process
of castration. It is much in favor in England, and in some parts of
Germany, though less practiced in some other parts of Europe. The
instruments essentially needed for the operation of castration by firing
are two; the first, a peculiar forceps for holding the cord and securing
it while the application of the cautery is being made; and the second,
the iron or cautery itself.
[Illustration: FIG. 9.
SINGLE FORCEPS FOR CASTRATION BY FIRING.]
[Illustration: DOUBLE FORCEPS FOR CASTRATION BY FIRING.]
These forceps, or nippers, are either single or double (Fig. 9), and may
be made either of wood or of iron, and more or less modified in form,
according to the fancies of the different operators. But they all work
on the same principle, and effect the same object. With the single
forceps but one cord can be treated at a time, but with the double
instrument both cords may be secured at once, and may be divided and
cauterized at one step. In this way the possibility of disturbing the
eschar caused by the cauterization of one cord while manipulating the
second, is quite obviated.
When the testicles, either or both, have been exposed, the mass of the
cord is fixed between the jaws of the forceps, from before backwards, at
about one inch above the tail of the epididymis, and firmly secured.
This may be effected either by tying it tightly with a string wound
about the handles, or by means of a spring crank with which some
instruments are furnished. The testicle is then amputated, either by a
stroke of the bistoury, or with the sharp edge of the cautery carried
across and at a right angle with the direction of the cord. This done,
the operator applies the broad portion of the iron over the entire
surface of the stump of the spermatic cord, and cauterizes (or sears)
the part thoroughly. It must be remembered that to insure the safety of
the cauterization, the iron must be very hot. Otherwise, when it is
removed, if it has cooled off, it may adhere to the carbonized surface,
and the scab formed at the end of the blood vessel may accompany the
instrument. The application of pulverized rosin to the end of the cord,
previous to the cauterization, is recommended by some practitioners.
A very proper precaution, and one on no account to be omitted, is the
protection of the surrounding parts from the radiating heat by covering
them with wet cloths.
When the operation is completed, the forceps should be opened with great
care, in order to ascertain whether all hemorrhage has ceased, and the
cord may be allowed to retract. If any oozing of blood appears at the
point of the operation, the cauterization must be repeated at the point
indicated.
A free application of cold water, in the form of a _douche_, after the
operation, will contribute to the formation of a clot in the cauterized
artery.