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.

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.

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.

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.

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.

---