METHODS OF THE SECOND CLASS -- CLAMPS -- COVERED AND UNCOVERED
OPERATION -- INSTRUMENTS -- FOUR VARIOUS STEPS -- OBJECTION TO THIS
METHOD -- TIME TO REMOVE THE CLAMPS -- LIGATURE -- OF THE CORD AND ITS
ENVELOPES -- OF THE CORD ONLY -- OF THE SPERMATIC ARTERY -- OF THE
EFFERENT CANAL -- SUBCUTANEOUS OPERATION.
Having completed the consideration of the various methods included in
the first class, we propose next to examine those entering into the
second, which embrace those in which certain means of pressure are
applied and suffered to remain upon the cord previous to the amputation
of the testicle. These are two in number, and consist of the process
known as that of the clamps, and that which involves the use of the
ligature.
THE METHOD BY THE CLAMPS.
This is an ancient mode of operating, having been transmitted to us
through many ages. It has received the sanction of long practice, and,
if not absolutely superior to all others, is possessed of qualities and
advantages which all who have employed it will freely acknowledge.
It is performed in two ways. One is the process of the _covered_, the
other of the _uncovered_ testicle. The covered operation is that in
which only a portion of the testicular envelopes are divided, the
scrotum and the dartos, the gland being left covered with the other
envelopes. On the other hand, in the uncovered operation, all the
enveloping membranes are divided, and the testicle is made to protrude
outside of the vaginal sac. The first three steps of this mode of
operating are understood to have been performed in the methods which we
have already considered as generally preliminary in all cases, in order
to obtain access to the cord.
[Illustration: FIG. 10.
ORDINARY CLAMP.]
[Illustration: INTERNAL FACE OF CLAMPS.]
The instruments necessary to operate in this case are a very sharp
convex bistoury, a pair of clamps, some strong twine, a castrating
forceps and a pair of scissors. The clamps are wooden or metallic
pincers, formed to embrace the cord and to be applied firmly upon it, in
order to hold it securely, and to confine the artery tightly enough to
prevent the occurrence of hemorrhage. The form most ordinarily used, and
probably most convenient, is made of wood, and consists of two
semi-cylindrical pieces (Fig. 10) joined at one end and resting together
by a flat and sometimes grooved surface, and measuring about six inches
in length. The material is a light but strong wood. They are rounded at
the extremities, in order to avoid chafing the soft tissues. A groove at
each end is designed to receive the twine, which is part of the
appliance. Before being used they are tightly tied together at one end,
in such a manner that they spring open if closed. This point is one of
the first importance. It requires considerable exercise of strength to
place them tightly enough on the cord they are to hold, but this firm
juxtaposition, so obtained, facilitates their removal, when that is
required. The groove which they carry on their flat surface is sometimes
filled with some merely lubricating greasy substance, usually simple
ointment, fresh lard, butter, or cream, though some veterinarians use a
caustic paste. This last mode of proceeding is strongly opposed by some
authorities, as likely to induce unnecessary inflammatory action,
through the formation of a scab, which may require for its removal a
process of sloughing, which may in some cases give rise to serious
complications. As I have stated, the clamps are not always made of wood,
and very many alterations and improvements, so called, have been from
time to time brought forward. In Fig. 11 a few of these clamps are
presented. The oldest form is the simplest, and possesses the further
advantage of being always easy to be obtained, while the more
complicated contrivances are not always easy of access.
[Illustration: FIG. 11.
VARIOUS SHAPES OF CLAMPS.
Screwed Clamp. Spring Clamp of Brandt. Hinge Clamp.]
[Illustration: FIG. 12.
FORCEPS TO HOLD THE CLAMP TOGETHER. VISE FOR THE SAME.]
The castrating forceps (Fig. 12) are used for bringing the clamps
together while they hold the spermatic cord between their branches.
There are several kinds of these, but in default of obtaining them
readily, the operator may find an eligible substitute in the
blacksmith’s nippers or the gasfitter’s tongs. We have used this latter
for a good many years, and have found it very well adapted to the
purpose required, by the presence of its set of double curved and
grooved jaws. The twine which it is necessary to use to keep the clamps
closed when they have been brought into perfect contact with the
castrating forceps, must be soft and strong. A piece of fishing line,
previously waxed, will answer the purpose very well. In order to
facilitate the traction which may be necessary to keep the clamps in
place, it is a good precaution to attach the ends of the twine to small
wooden handles to protect the hands from cutting by the string. It is
well, also, to prepare a reserve of clamps and twine against accidents
from breakage or the mislaying of these articles.
COVERED OPERATION.
_Modus Operandi._--The animal being thrown on either side, as already
described, and kept as nearly as possible on his back by bundles of
straw packed under him on the lower side, and the right hind leg secured
in its proper position, and the instruments placed within easy reach,
the surgeon proceeds with the fourfold steps of the operation,
consisting first, in the prehension of the left testicle, or lowest in
position; second, the incision through the envelopes; third, the
enucleation of the testicle; and fourth, the application and
constriction of the clamps.
_First step._--The operation must always begin with the prehension of
the gland which corresponds with the side--the lower--upon which the
animal is lying. This obviates any danger of interference by any little
hemorrhage which might occur, and so facilitates the application of the
clamps. Then, placing himself toward the back of the patient, the
operator reaches over and grasps the lower testicle with both hands,
bringing it downwards in such a manner as to stretch the scrotum over
its surface. This manipulation is not always of easy performance, the
contraction of the cremaster muscle being sometimes so powerful that the
gland successfully resists all the operator’s efforts of traction. It is
sometimes necessary to divert the attention of the animal, in order to
facilitate this part of the process, by pricking him with a pin on the
lips or about the anus, the effect of the new sensation being such that
his opposition is withdrawn, and the contraction ceasing, he suffers
passively the traction of the envelopes over the organ. Or, the same
advantage may be obtained by the inhalation of a little ether or
chloroform. Then grasping the cord with the left hand and bringing the
organ well forward, the surgeon proceeds to the
_Second step_, or that of the incision of the envelope. Holding the
sharp convex bistoury in his right hand, he takes, with the thumb, a
_point d’appui_ upon the prominent organ, and carries it carefully over
the surface of the scrotum in a direction parallel with the median raphè
(described in the first chapter), and following the great curvature of
the testicle, and being careful with the first movement of the
instrument to divide only the scrotal skin and the dartos, until the
most superficial layers of the cellular tissue of the third testicular
envelope are reached. The skin and the dartos being divided, the edges
of the wound separate, and the testicle, still pressed downwards and
outwards with the left hand, protrudes more or less, still included, as
it is, within its fibrous covering. A careful dissection, with a few
light strokes of the bistoury, or laceration with the thumb nail of the
hand, now suffices for the separation of the fibrous envelope from its
external covering, an entire separation of both of which can thus be
easily obtained by pressing the most external layer upwards through the
laceration of the cellular coat which unites them.
_Third step._--The operator now relieves himself of his instrument--not,
we may venture to suggest, by placing it between his teeth, as some
careless surgeons are apt to do, but by handing it to an assistant--and,
changing his position, places himself in front of the inguinal region,
and facing it. He then proceeds to the enucleation of the testicle, by
separating the adhesion which exists between the internal face of the
dartos and the external surface of the cremaster muscle and of the
fibrous tunic. The separation being completed, and the scrotum and
dartos being carefully pushed upwards, the patient is now ready for the
last step of the operation.
_Fourth step._--The testicle, well enucleated from its superficial
envelopes, but still covered by the fibrous coat, and the vaginal sac
still remaining intact, the operator, facing, as before, the inguinal
region, proceeds to the application of the clamps. The cutaneous
covering and the dartos being pushed well upwards, the clamp is placed
upon the cord above the epididymis, from before backwards, the
assistant, armed with the castrating forceps, taking both of its
branches between the jaws of that instrument, carefully bringing them
together, and closing them as tightly as possible. The instant of the
pressure of the clamp upon the cord is marked by very severe pain, and
the suffering animal is excited to powerful struggling. It is important
that the assistant should be aware of this, and he should be forewarned
to refrain from pulling on the cord, and reminded, in order to avoid
injury from this accident, to keep the clamps and the forceps steadily
in contact with the inguinal canal. It is probably with a view to the
avoidance of this possible injury that the use of a peculiarly
constructed vise or forceps has been recommended. The forceps being in
place, and tightly confining the branches of the clamps, well adjusted,
the operator now applies the twine, and after taking several turns
around the grooves of the free ends of the clamps, secures it carefully
with a double knot.
The operation is then repeated on the right or uppermost testicle in the
same manner, and with the same precautions.
UNCOVERED OPERATION.
The four steps of this operation are the same as those of the previous
method, the first requiring the same manipulations and observing the
same order, but the second involving some variations. In this the same
careful dissection is dispensed with, and one free incision suffices,
including all the various envelopes, in order to expose the testicle
freely and at once. The incision is made with one free stroke of the
bistoury extending from the posterior to the anterior extremity of the
testicle, and dividing at once scrotum, dartos, and the fibrous and
serous coats. Though this is to be done without hesitation, it is by no
means necessary to adopt the practice of some operators, who not only
divide the envelopes, but even make a large incision in the testicular
structure itself, inflicting thus an unnecessary amount of pain from
which the animal might, with a little care, have been spared.
When the surgeon reaches the third step of the operation, and seizes the
testicle with the right hand, in order to draw it downward and outside
of the vaginal sac, he may encounter great resistance to his traction,
from the powerful opposition of the white muscular tissue running along
the posterior septum of the cord. He must then slowly and steadily draw
the testicle down, and at a given moment, with a single stroke with a
sharp pointed bistoury, divide the serous band of the posterior septum,
cutting at once the muscular fibres, the efferent canal and the small
testicular artery. This being effected, the resistance will terminate,
and the testicle may be drawn down without further difficulty. The
division of the septum is not always resorted to. Still, the verdict of
experience is strongly in favor of the measure. The application of the
clamps (Fig. 13) is effected in the same manner as in the covered
operation, but in this instance the clamp is placed higher on the cord.
For this reason the assistant must be especially careful during the
struggles of the patient when the clamps are tightened, the danger of
inguinal hernia at this point being too serious to be overlooked. The
clamps being in place, and properly secured, the testicles are either
left in place and allowed to slough away, or are amputated a short
distance below the clamps, as the case may be. The parts being carefully
washed out, the animal is allowed to rise, and is returned to his stall.
[Illustration: FIG. 13.
CASTRATION WITH UNCOVERED TESTICLE.]
An objection frequently urged against this mode of operation is that it
requires a second visit of the surgeon when the time has arrived for the
removal of the clamps. Estimating this objection at its proper value,
we consider that it is more than balanced by the advantages attendant
upon this special mode of castration, and while we fully appreciate the
difficulty and inconvenience to which the surgeon may be subjected by
this second visit, we cannot approve of its omission, either from a
surgical point of view or in that of the interests of the employers, in
whose behalf all care and responsibility should be exercised, until the
patient is at least enjoying a fair prospect of recovery.
The question now arises, at what time can the clamp be removed with
safety? It must be understood that there may sometimes be peculiar
surgical conditions under which their removal is contra-indicated, and
when they must be allowed to slough off without further interference on
our part. But even in ordinary cases and under favorable circumstances,
this time appears to vary. By some they are removed after thirty-six
hours, while others allow them to remain for a period of four or five
days. Taking a fair average, we are of opinion that it may be safely
done on about the third day, and that at that period the closing of the
artery is sufficiently assured to remove all further pressure.
If the clamps have been secured with twine, and especially if they were
properly prepared previously to their application, the process of
removal is a very simple one. The assistant, raising one of the
patient’s hind legs, the operator places himself directly behind the
animal, and bending down, with a sharp sage-knife, cuts the twine where
it has secured the posterior ends of the clamp. If it retains the
springiness it ought to have possessed at the time of its original
application, the branches readily spring open, and it falls to the
ground. If this does not occur, or if they should be held by adhesions
with some dried parts of the cords which have been pressed between the
branches of the clamps, they must be carefully separated by moving from
below upwards, when they will easily become detached. But this last
manipulation must be very carefully performed, if we would escape a
hemorrhage which might require serious measures to control. When clamps
of another make are used, the process of removal will vary according to
existing peculiarities in the construction of the instrument. The clamp
having been removed from one side, the separation from the other will,
of course, be managed in a similar manner.
THE LIGATURE.
This method of castration consists in the application of a circular
ligature upon the entire cord, or a portion of it, for the purpose of
completely closing it, with the various parts entering into its
formation. It was in practice so long ago as 1734. The operation is
divided into several varieties, viz., that of the cord with its
envelopes; that of the cord only, either by the covered or uncovered
method; that of the spermatic artery alone; that of the efferent canal;
and that by the subcutaneous process.
The ligature used in these various modes of operation is formed of
waxed silk; sometimes of strong twine, as fishing line, for example; or,
as more recently introduced in surgery in the removal of living growths
and tumors, an elastic cord.
_Ligation of the cord and its envelopes._--This process is principally
used upon small animals, although, since the elastic cord has been
brought into use, a few attempts have been made to make it applicable to
the larger kinds. The experiments, however, have been as yet so few, and
the results so unsatisfactory, and in so many cases fatal, that it can
scarcely be recommended, except for small subjects. The application of
this is very simple. It consists, after securing the patient, in
bringing the testicles as far down into the scrotum as may be thought
needful, and after applying the ligature two or three times around the
cord, a short distance above them (Fig. 14), slowly and steadily
tightening it until a sufficient amount of force has been employed to
close the calibre of the blood vessel and cut off the circulation from
the parts situated below the point of ligation. This mode of operating
has, in our hands, proved very successful in small animals, and when the
elastic ligature has been used. Mortification has taken place in a few
days, the testicles slowly detaching themselves at the point of
ligature, and when falling off leaving but a very small superficial,
cutaneous scab, and healing in a short time.
[Illustration: FIG. 14.
CASTRATION BY LIGATION OF THE CORD AND ENVELOPES.]
_Ligature of the cord only; covered operation._--The first three steps
of the operation having been accomplished, and the testicle enucleated,
the ligature is placed around the cord, still covered by its fibrous
envelopes and the cremaster muscle. A piece of twine or an elastic
ligature may be employed for this purpose. In this operation the
testicles are allowed to remain not less than twenty-four hours, before
amputation is performed, in order that if the pressure has been
insufficient, and the parts should fail to exhibit symptoms of loss of
vitality after that time, another ligature may be applied.
_Uncovered operation._--The only variation between this method and the
one last considered is found in the fact that in this, the testicle and
cord being exposed as in the process of castration with the clamp, the
ligature is applied either on the cord as a whole, or only on its
anterior fasciculus. In this case the testicle is amputated immediately
after the application of the ligature. But as there is a possibility of
the slipping off of the ligature, great care must be taken lest the
amputation be performed too near the point where the constriction is
made. And again, as there is a possibility of the truncated cord being
drawn too far up, even up into the abdominal cavity, it becomes a
precaution of prudence, as recommended by Mr. Bouley, to leave a
sufficient length of the ligature hanging outside of the scrotal wound,
and even to secure it on the edges of the skin.
_Legation of the spermatic artery._--This is a mode of castration which,
if we are not mistaken, was held in high estimation by certain
practitioners in the city of Boston. It consists simply in the
application of a ligature of silk to the spermatic artery. The cord
being exposed, and the posterior septum being divided, a curved needle
armed with the ligature is made to pass around the whole mass of the
anterior fasciculus, and the entire vascular cord is surrounded by the
ligature and firmly tightened. The fact of the various and irregular
flexuosities peculiar to the spermatic artery, with both ascending and
descending portions, explains the necessity of including the entire
arterial mass under the ligature, since, if only the simple cord of the
artery were ligated, it might be an ascending portion only, and the
amputation of the testicle might be followed by a troublesome hemorrhage
from one of the descending loops.
_Ligation of the efferent canal and the subcutaneous ligation of the
cord._--These two modes of operating have not yet yielded sufficient
evidence in the form of satisfactory results to be entitled to more than
passing mention at the present time. We may say further, moreover, that
among all the methods of castration by ligation, none of them have been
subjected to a sufficient amount of practical test to be accepted as a
process which will justify a strong recommendation or unqualified
approval.