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 oedema, 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 oedema of the scrotal region assumes, and by its characteristics of coldness, loss of sensibility, and crepitant feeling, but by the foetid 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, foetid 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.

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.

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.

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