COMPLICATIONS AND TREATMENT OF THE OPERATION -- COLICS -- TEARING OF
THE CLAMPS -- HEMORRHAGE -- SWELLING OF THE SCROTAL REGION -- GANGRENE
-- ABSCESSES -- CHAMPIGNON -- EXTRA SCROTAL -- INTRA SCROTAL -- INTRA
ABDOMINAL -- VARIOUS TREATMENTS -- FISTULA OF THE SCROTUM -- INGUINAL
HERNIA -- PERITONITIS -- TETANUS -- AMAUROSIS -- COMPARATIVE VIEW OF
THE VARIOUS MODES OF CASTRATION.
COMPLICATIONS AND THEIR TREATMENT.
Though the operation of castration is comparatively simple in its
various methods and is generally successful in its results, still it is
not entirely free from accidents or complications. Indeed, among those
likely to meet our notice, there are some of quite a serious character,
which will develop themselves independently of the skill and care with
which the operation may have been performed or whatsoever attention may
have been bestowed upon the patient. Among these may be enumerated
_colics_, _hemorrhage_, _swelling_ of the scrotum, _gangrene_,
_abscesses_, _champignon_, _fistula_, _hernia_, _peritonitis_,
_tetanus_, and _amaurosis_.
COLICS.
This, we have already seen, usually appears a short time after the
completion of the operation, the suffering animal becoming uneasy,
restless in his stall, pawing the ground with his fore feet, and
sometimes lying down and rolling. As I have before stated, these
symptoms, as a rule, are of short duration, and subside without other
treatment than a little walking exercise. It is rarely the case that
they fail to yield to an anodyne, or a dose of chloral may be demanded
before the symptoms are subdued.
TEARING OF THE CLAMPS.
When this accident occurs it is commonly attributable to the omission of
a careless operator to secure the tail of the animal in such a manner as
to prevent its interference with those implements by its entanglement,
and tearing them from the end of the cord, as a consequence. The result
of this is the appearance of a hemorrhage from the spermatic artery,
which can only be controlled by either a reapplication of the clamps to
the end of the cord--if it can be thus secured--or by other means, which
will be considered when we reach the subject of bleeding in general as
connected with other causes.
HEMORRHAGE
May be primary or secondary. In the first instance it occurs in
consequence of the insufficiency of the means of hemostasis applied to
the end of the cord, as in the case of the operation by simple excision,
by cauterization, the too rapid crushing of the cord, torsion, or the
accident before referred to--when the clamps have been torn off and the
cord lacerated about the point of their application.
Secondary hemorrhage manifests itself after a longer interval following
the operation. It may occur, for example, after the removal of the
clamps, or when, during their removal, the mortified end of the cord is
too much interfered with by the sharp end of the instrument used in
cutting the string which confines them together, or from too forcibly
pulling upon the cord itself; and in some instances without any
assignable cause other than a diseased condition of the coats of the
artery. This secondary hemorrhage is usually, by reason of the
inflammatory condition of the blood vessels, of more threatening aspect
and more difficult to control than the primary variety. The treatment
indicated varies. When caused by the tearing of the clamps, or at the
time of their removal, it may be checked by the reapplication of the
instrument. But if the cord is retracted within the inguinal canal and
cannot be reached, and if it is already adherent to the surrounding
tissues, by granulations recently formed, the checking of the flow may
be very difficult. In many cases the application of cold water, either
in the shape of the cold douche over the part, or iced sponges, may
prove sufficient. But in other cases the cavity of the wound must be
packed with balls of oakum, wet either with water alone or any styptic
agent, such as a solution of perchloride of iron, the whole being kept
in place by a suspensory bandage, or if necessary, a few points of
suture.
These measures may be put in practice while the animal is on his feet;
but if they fail in their effect, the surgeon must at once proceed to
cast his patient and ligate the artery--an operation of delicate
execution, and not always easy to perform, by reason of the deep seated
position of the vessel. The use of the actual cautery has also been
recommended, but even when successful there are many objections to this,
one of which is the complication such an operation may bring on by the
introduction into the wound of a scab which must necessitate for its
expulsion a serious amount of inflammatory action. As a rule, however,
the operation of packing is all that is required, the oakum being left
undisturbed for twenty-four or even thirty-six hours. Its removal must
be undertaken with great caution.
SWELLING OF THE SCROTAL REGION.
This, as we have seen, is an almost necessary consequence of the
operation, the swelling making its appearance a short time after the
alteration is accomplished. It usually first affects the parts
immediately around the edges of the wound, and spreads forwards and
upwards in such a manner that the entire scrotum and sheath become the
seat of it. It is somewhat warm, tense, and slightly painful. If there
is no increase beyond these limits, there is no occasion for alarm, as
by exercise, fomentations, and scarifications, with the administration
of diuretics, it ordinarily subsides. But if it continues to increase,
and extends upwards and backwards, involving the inside of the thighs
and the perineum, loses its character of heat and soreness, to become
cold and painless, crepitating under pressure, we must prepare to
encounter the most severe of all complications, that of gangrene,
requiring the most prompt and vigorous treatment, as we shall presently
see. It may also happen that even while retaining the characteristics of
healthy œdema, it may assume such dimensions that the penis becomes so
involved that phymosis and paraphymosis may supervene, to add to the
other complications. These, however, are not serious sequelæ, as by
proper care, with fomentations or scarifications, and the use of a
suspensory bandage, they may be readily overcome.
GANGRENE.
This accident may be looked for from the fourth to the eighth day,
manifesting itself not only by the extent which the œdema of the
scrotal region assumes, and by its characteristics of coldness, loss of
sensibility, and crepitant feeling, but by the fœtid odor proceeding
from the wound, and by a change in the character, or the disappearance
of the suppuration, which is succeeded by a sanious, bloody and
offensive discharge. To this series of symptoms are to be added a marked
increase of the general disturbance, manifested by increased thirst,
anorexia, fœtid mouth, change of color in the mucous membrane to a livid
hue, increase of pulse, with weakening, increased respiration,
temperature at first elevated and then diminished, and after five or six
days a final termination in the death of the patient.
The progress of this complication is so rapid, and the chances of
recovery are so few, that the necessity for prompt treatment becomes at
once obvious. All the diseased and mortified parts must be removed at
once, and means instantly employed to prevent the absorption of
gangrenous matter. Friction with ammoniacal and turpentine liniments
must be used over the swelling; the parts must be subjected to the
actual cautery at white heat, and disinfecting agents of all kinds must
be freely used, as chloride of lime, carbolic acid, and permanganate of
potash, while internal treatment must immediately be instituted by the
administration of stimulants and antiseptics in the form of ammonia and
phenic acid, or its preparations.
ABSCESSES.
When these are likely to result from a too rapid closure of the edges of
the scrotal envelope, the premature union may be readily prevented, as
we have before stated, by the careful introduction of the finger into
the wound while it is still suppurating. But notwithstanding this
precaution they will sometimes occur as the result of the infiltration
and accumulation of the suppurative matter. A free incision and proper
attention to the cavity of the abscess, is all that this accident
requires. A careful examination of the parts will, however, reveal
another cause for the formation of these abscesses. It is then against
these causes that the therapeutic treatment must be directed. We refer
now to the complication known as the formation of a
CHAMPIGNON.
This name is applied to an indurated condition of the end of the cord,
or in its thickness, of a tumefied character, varying in size and
extent, and slow in its growth. It results from an excess of
inflammatory action, attributable to the manipulations which become
necessary during the performance of the operation. The name “champignon”
(or mushroom) is applied to it by the French, on account of the
pedunculated appearance which it sometimes assumes, and which causes it
to greatly resemble that fungus in its outward figure. It is also known
as schirrous or indurated cord. The tumor is sometimes situated on the
outside of the envelopes, when it is known as _extra-scrotal_, but more
commonly it is found covered by the skin, in which case it is better
known as _intra-scrotal_. In this latter condition it may be merely a
growth at the end of the cord, becoming, as determined by its location,
of an _extra-inguinal_ character, or if the diseased process extends as
far as the upper inguinal opening, or beyond it, it becomes, and is so
denominated, _intra-abdominal_. There is also an _extra-intra-scrotal_
growth, when it is partly within and partly external to the scrotum.
This tumor will vary greatly in size, being sometimes very small in
dimensions, and at others having those of a man’s fist. We have
ourselves observed it equalling a child’s head in size.
The causes from which it originates are obscure, and cannot be very well
defined. Still, they may be arranged under the heading of any of the
morbific causes which may excite an excess of inflammatory action at the
end of the cord. Amongst these may be enumerated all violent tractions
upon the cord at the time of the operation; all unnecessary
manipulations during the process of cicatrization, such as the too
frequent introduction of the finger into the wound with destruction of
the granulations already adherent to the cord, and the application of
the appliances for its division too low down upon it, leaving that organ
hanging too much, and the retraction of the organ being insufficient to
retain it in the inguinal sac. Still, as a champignon may be developed
in the absence of all these causes, it would seem that their growth may
be attributed also to some specific idiosyncrasy in the animal affected,
the true nature of which cannot be very accurately or easily understood.
It is held, however, by certain German and Russian authors that
exposure to cold exercises a great deal of influence in the development
of this affection, and observation has largely established the fact of
its greater prevalence during cold seasons.
_Symptoms of extra-scrotal champignon._--This is otherwise known in the
terminology of some pathologists as _true_ or _superficial champignon_.
It develops itself at the cut extremity of the cord as a granulating
mass, of a red color, varying in size, its growth, nevertheless,
allowing the cicatrization of the skin to progress in such a manner that
it forms a point of attachment from which the tumor seems to proceed.
This form of it is usually of little account, as it may easily be
removed before it has attained to troublesome dimensions. When of
considerable proportions, however, it may interfere materially with the
act of locomotion by causing pain in the cord, upon which it drags more
or less. It is not often or necessarily accompanied by constitutional
disturbance, excepting in cases of excessive suppuration, which may
sooner or later undermine the general health by exhausting the stamina
of the patient.
If instead of showing its greatest development on the surface of the
scrotum, it occurs beneath it, a greater or less degree of swelling will
appear on one or both sides of the inguinal region, the swelling being
somewhat hard, possibly the seat of one or more fistulous tracks
resulting from abscesses which have at times opened, discharged, and
closed; the animal showing a certain amount of stiffness in the action
of the hind legs. In this case we shall have to adapt our treatment to
the _deep champignon_ of Zundel, under one of its three forms of
_extra-inguinal_, _intra-inguinal_, and _intra-abdominal_.
Under the first head we shall often discover, upon inquiring into the
history of the case, that for a length of time, varying from months,
perhaps, to years, the animal had been affected with a swelling which
would gather, break, and slowly heal, leaving no mark as an apparent
indication of a diseased condition, excepting that a certain degree of
lameness would have been observed to be present. Upon exploring the
testicular region it would then be observed to be the seat of a tumor,
either spherical or pysiform, seldom painful, and more or less adherent
to the envelope that covered it. Above this the end may be felt free
from diseased process, and this is the champignon in its chronic form.
In this condition it is not incompatible with the general health of the
animal affected, and forms no hindrance to his usefulness. This
condition of extra-inguinal growth will sometimes dissolve away by an
abscess-formation, and quite disappear. But if the induration of the
spermatic cord extends to the upper portion, or that which is enclosed
in the inguinal canal, in such a manner as to interfere with locomotion,
the leg corresponding with the diseased side being carried in abduction,
with numerous fistulous tracks existing on the surface of the scrotum,
the intensity of the symptoms varying with the extent of the diseased
process, the condition of the cord will be easily discovered by an
examination of the parts, and the presence of an _intra-inguinal
champignon_ established. If, besides these symptoms, we discover by
rectal examination that there is in front of and above the pubes a tumor
more or less ovoid, or giving the sensation of a cylindrical mass, of
size varying to the touch--which is the diseased indurated cord--the
case is judged at once to be one of _intra-abdominal_ nature. At times
the inflammation may extend to the sub-lumbar region, when the hand
introduced into the rectum may discover in that locality an ovoid tumor
or abscess which may be of great size. This form of champignon is
incomparably the most serious of them all; an intense and persistent
reactive fever is always present, and this at length terminates together
the life and suffering of the animal. The abscess may sometimes open
externally, and in some cases it may accumulate within the thickness of
the cord and form large collections; or, again, it may find its way into
the abdominal cavity, where it may excite a fatal peritonitis.
This rapid examination of the various forms of deep champignon will
enable us easily to realize the difficulty of the progress in the case.
While the pedunculated form, exterior to the scrotum, is not,
comparatively, a very serious matter, it becomes, on the contrary, a
very grave occurrence when it assumes the characters of the
intra-abdominal variety, and must in a majority of cases be recognized
as an incurable disorder.
_Treatment._--While champignon is an affection in which surgical
interference cannot usually be dispensed with, it is still essential
that the surgeon should avoid being over hasty in determining in favor
of an operation, and he should give the case a very careful
consideration before deciding upon his course. At first emollient
applications, appropriate topical treatment, and a few points of
cauterization, may be followed by a process of resolution. But in the
event of their failure four modes of operation present themselves. These
are, in their order, the application of the clamps; the ligature; the
linear crushing or ecraseur; and cauterization. When the case is one of
the extra-scrotal variety, the application of a ligature around the base
of the peduncle, or removal by ecraseur, will be the simplest mode of
treatment, unless there should exist a tendency to infiltration of the
cord, in which case the manipulations to be followed become the same as
those which are adapted to that of the deep or intra-scrotal form.
[Illustration: FIG. 25.
CURVED CLAMPS.]
_By the clamps._--When the application of the clamps is resorted to,
they may be similar to those used in ordinary castration, or may be
curved in form (Fig. 25). The animal to be operated on is to be thrown
on either side according to which cord is affected, and an incision
made through the envelopes as nearly parallel with the median line of
the body as the case permits, when the tumor and the cord are carefully
dissected and separated from their adhesions. If the tumor is suspended
from the end of the cord there will be no difficulty in applying the
clamp above it and upon a healthy portion of the cord. But if the
diseased process extends within the inguinal canal, there will be need
of great caution in dissecting the cord up to the healthy structure. In
doing this the safer mode will be for the operator to treat the
adhesions with the fingers or the blunt end of the scissors, rather than
to employ the sharp edge of the bistoury with the accompanying danger of
causing hemorrhage. If, on the contrary, the cord is diseased to an
extent that renders it difficult to reach a healthy portion, other modes
of operation--as by the ligature--become the wiser and more practicable
indication. When the clamps are used it is necessary to leave them in
place for several days, and sometimes they are allowed to slough off,
while the growth is usually suffered to remain for a few days after the
operation.
[Illustration: FIG. 26.
LIGATURE-CARRIER.]
_Ligature._--When this mode of procedure is adopted, the tumor having
been dissected and the cord well freed from its adhesions with
surrounding parts, and the ligature being applied, the tumor may either
be amputated immediately or be left to slough off in its own time. The
ligature may be either of twine, silk, or elastic cord. We have
ourselves operated by this method in the successful removal of growths
of very considerable size. So long as the upper portion of the cord,
which retains its healthy structure, can be reached, the application of
the ligature is attended with no difficulty, the manipulations required
being similar to those which attend the removal of all growths by the
process of ligation. But if the diseased process extends so far that the
ligature cannot be applied at the proper point, as in the case of
intra-inguinal champignon, it will be necessary to have resort to the
ligature-carrier recommended by Serres (Fig. 26). In using this
instrument the loop of the ligature being passed over the tumor around
the cord, is carried into the inguinal canal as high up as possible,
pressure being made by holding the instrument against the cord, while
strong traction is made on the ends of the ligature, which is then
secured by a knot upon a small stick placed across the opening of the
instrument, with a view to the prevention of slipping. If an increase of
pressure is found to be necessary, it can easily be obtained by
tightening the ligature from day to day as required. If the size of the
cord should be such as to prevent a proper application of a single
ligature, it may become necessary to divide it in applying a double,
triple, or multiple ligatures, in accordance with the rules for such
ligating.
In whatsoever manner the ligature may be applied, even when it is of the
elastic kind, the process of sloughing of the tissues is always a slow
one. It is for this reason that we agree with Prof. Bouley in
considering the treatment of champignon by the linear crushing very much
to be preferred.
_Ecraseur._--The steps of the operation with this instrument are similar
to those required in the other methods already considered. The
champignon is isolated from its surrounding parts, the chain is placed
on the cord above the base of the tumor, and the amputation is completed
by a slow pressure upon the cord, which, crushing it by degrees, permits
its immediate removal. It must be done slowly, occupying from ten to
twenty minutes for the complete separation of the champignon, according
to the size of the tumor. The operation being finished, the parts are
left in the condition of a simple wound, where no cause exists to
interfere with its rapid cicatrization.
_Cauterization._--This is a mode of treatment which we have never had
occasion to submit to trial, having always given the preference to the
process we have just referred to. It is recommended, however, by
European authorities. Some of these advocate the “melting” process, or
the introduction of sharp points deeply into the thickest parts of the
enlargement, while others advise a removal of a portion of the growth
and deep cauterization afterwards. If cauterization can be
advantageously employed, the best method, in our judgment, would be the
process of amputation with Paccalin, or with the galvanic cautery. We
may here, while referring to the application of electricity in this
connection, appropriately refer to our own experience of a number of
years ago, in treating an animal suffering with intra-scrotal
champignon, by electrolysis, and succeeding after two applications, in
obtaining the complete removal of the tumor. This method, however,
consumes too much time to justify its employment in general practice.
FISTULA OF THE SCROTUM.
Being already aware of several causes of this complication of the
operation of castration, we may readily appreciate the treatment they
require. It must be remembered that in a majority of cases, the cause of
this lesion is the presence of a foreign body in the wound, and that
until it is removed, it is in vain to look for a cure. Prof. Bouley has
reported a case in which the fistula was due to the presence of a pair
of clamps over which the skin had almost entirely cicatrized.
INGUINAL HERNIA; HERNIA OF CASTRATION.
By this is understood the protrusion of some portion of the contents of
the abdominal cavity through the inguinal ring, either a portion of the
omentum or of some part of the small intestines, creating either an
epiplocele or an enterocele. This complication may take place either
during the operation, or shortly afterwards, or at the period of the
removal of the clamps. It proceeds from the violent struggling of the
animal during the operation; to the colics which are so apt to
supervene; to his position when placed in a stall of which the floor is
too much inclined; or it may result from some of the various modes of
castration, as, for example, the uncovered operation.
At times the two forms of hernia may present themselves together,
constituting a case of entero-epiplocele. When the epiploan alone
protrudes, it need not give rise to any unnecessary anxiety, as it may
easily be either reduced and returned to its place, or ligated with the
clamps, or torn apart. If, on the contrary, it is a portion of the small
intestines which becomes involved, the first indication is to restore it
to its place by the proper taxis without delay, which may be readily
done, the animal being yet down and placed under an anesthetic, by the
rectal taxis combined with the necessary inguinal manipulations. When
this has been accomplished the intestine is kept in place by the
application of a clamp over the cord, upon which the fibrous coat of the
cremaster has been carefully drawn.
PERITONITIS.
This complication, considered as one of the most frequent following
castration, is also, beyond doubt, one of the most serious. It is
generally the result of exposure to cold, especially when its occurrence
accompanies the suppurative fever. But it also develops itself in
animals which have received the best hygienic care, its appearance being
attributed to an excessive dragging of the cord, or to the extension of
the local inflammation by continuity of tissues. It manifests itself
generally between the second and third day following the operation,
except when it becomes symptomatic, as of gangrene of the cord, when we
have seen it making its appearance towards the tenth day.
The symptoms of this traumatic peritonitis differ somewhat from those of
the acute inflammatory type. According to Gourdon, “the animal is dull
and refuses all food--the suppuration of the wound of the scrotum has
ceased, the bags and surrounding parts become the seat of a warm, hard
and painful swelling. The animal stands with his four legs brought close
together, the back is stiff and arched, the flanks are cordy, the
abdomen painful, the pulse hard, small and increased. As the disease
progresses, the symptoms are more marked, the enlargement of the
envelopes increases and is more diffuse, it extends down to the abdomen,
and even under the chest, passes along the thighs, is less warm, less
hard, less painful, and pits under pressure. There are slight colics,
the pulse gets smaller, intermittent, the respiration is increased, and
the animal dies towards the fifth or sixth day.”
The treatment to be recommended varies according to different authors.
While some prescribe depletive and sedative treatment, laxatives and
diuretics, many prefer tonics and stimulants. The Germans claim great
results from the use of tincture of arnica (in small doses) administered
internally. The external treatment consists in sinapisms, warm
fomentations, poultices, or fumigations under the abdomen.
TETANUS.
As with most cases of traumatic tetanus, this complication is generally
fatal, and it is, without doubt, the most dangerous of all and marked by
the greatest mortality. It is generally admitted that exposure to cold
and dampness is one of the most prolific causes, especially in animals
which, having but recently recovered, are too soon put to work. The
various modes of operation have also been considered to have some
influence upon its development, though there is probably no ground upon
which this theory can find a support. Whether the nature of the soil of
a district, or its atmospheric condition, may have any connection with
it, is also a question. We know that in some portions of Long Island,
cases of tetanus are commonly met with, at some seasons of the year,
after surgical operations of every kind. It may appear within a few days
following the castration, or it may defer its visitation for a period of
twenty days, or longer.
The treatment adopted for the tetanus of castration is that which is
applied to all cases of that traumatic affection.
AMAUROSIS.
This disease may also be included among those classed as the sequelæ of
castration, having been known to follow cases where hemorrhage of the
small testicular artery had occurred. Tonic treatment internally and
local stimulating applications may sometimes relieve this complication,
but it will generally be admitted to be incurable.
COMPARATIVE VIEW OF THE VARIOUS MODES OF CASTRATION.
The process by _simple excision_, by reason of the hemorrhage which
necessarily accompanies it, though not inevitably dangerous, must be
excluded from the domain of general practice.
That of _scraping the cord_ has not, so far as our knowledge extends,
been sufficiently tested, either in European or American practice, to
justify its recommendation.
The process of _torsion below the epididymis_ is too much subject to the
development of champignon, as well as that of _free torsion_ with the
hands, to be admitted by judicious operators, while the _limited
torsion_ is a method which has taken rank amongst safe operators,
notwithstanding the enormous swelling of the parts by which it is
commonly accompanied, and the necessity it involves of the introduction
of the fingers into the wound to prevent its premature closing.
The method by the _ecraseur_, though occupying a longer time in its
completion than some others, has secured very favorable results,
especially in the hands of American operators.
The operation by _cauterization_ is highly recommended by English
veterinarians. We believe, contrary to the statements of French authors,
that it is not widely in use on this Continent. The objections urged
against it are that the hemostatic effect upon the cord is less reliable
than in the method by the clamps or the ligature; that there is more or
less danger of cauterizing the surrounding parts by the effect of the
radiant heat from the cautery; and that the swelling which follows the
operation is always excessively great.
Castration by the _clamps_ is the best known and most extensively
practised. It is easy and quick in its performance; performs the most
certain hemostasis upon the artery, and notwithstanding some slight
objections, merits a preference over all others. The principal objection
alleged against it is that it is attended with great pain to the
suffering patient when the pressure of the instrument upon the soft
tissues is first felt. This is a doubtful question, and if this
excessive amount of pain really exists, it certainly cannot be of long
continuance, merely on account of the effect produced by the clamps
themselves.
Of the various methods by _ligature_, that of the ligation of the cord
with its envelopes is applicable to small animals only. That upon the
cord alone is liable to be followed by hemorrhage, or by the excessive
retraction of the cord into the abdominal cavity, drawing the ligature
with it. That of the efferent canal, and of the cord by the subcutaneous
mode are not admitted in general practice, while that of the artery
alone has not been extensively performed on large animals, so far as we
are informed, except by certain Massachusetts veterinarians.
The castration by _double subcutaneous twisting_, when extensively
applied to solipeds, will probably prove to be the safest mode of all,
and least likely to be followed by complications. We are not informed as
to the extent to which it has been practised in this country, even
amongst ruminants.