HYDROCELE, ORCHITIS, SCIRRHOUS CORD Hydrocele An accumulation of fluid within the tunica vaginalis reilexa.
A similar condition may affect the spermatic cord itself, either in the form of a cyst or as a collection of fluid in the cellular tissue of the cord, between the layers of the tunica vaginalis propria (spermatocele).
Hydrocele is not a common condition in the domesticated animals, although a slight excess of fluid is not uncommonly met with when castrating, and is discharged with some force when the testicle is firmly held and an incision made through the scrotum. The origin of hydrocele may be congenital or it may develop even late in life as a result of orchitis, injury to the cord and its membranes, or possibly owing to structural or functional changes occurring in the tunica vaginalis.
Congenital hydrocele is often associated with inguinal hernia in foals, and may be due to escape of peritoneal fluid into the sac of the tunica vaginalis through the over-dilated internal abdominal ring.
There should be but little difficulty in dis tinguishing between hydrocele and uncom plicated hernia. The former usually forms a pear-shaped swelling easily compressible and free from tenderness or pain. Excepting when the amount of fluid present is very great or when spermatocele exists, the swelling tapers away from below upwards and at the abdominal ring the cord may be felt to be normal in size. In hernia the greatest swelling is at the upper end of the cord; it is usually more or less in compressible, and the size of the enlargement often varies from time to time and may even disappear entirely for a period.
Hernia can often be reduced, but it must be remembered that hydrocele when congenital can be caused to disappear momentarily by pressure, the fluid contents returning to the peritoneal cavity and again trickling back when the hand is removed.
The testicle is easily felt at the lowest part of the scrotum in hernia, but in hydrocele, being surrounded by fluid, often in considerable quantity, it may be difficult or impossible to detect.
Treatment.When called for, either from absolute necessity or from desire on the part of the owner to remove an eyesore which depreciates the animal's value, treatment must be operative. External applications seldom bring about any marked improvement.
Puncturing the swelling in a number of places with a large needle may permit the fluid to escape into the cellular tissue of the scrotum whence it is absorbed. This treatment is often only palliative. Radical treatment consists in puncturing and withdrawing the contents by means of a trocar and cannula, and subsequently injecting an irritant fluid which will set up inflammation and prevent fresh exudation.
Formerly equal parts of port wine and water were successfully employed. Zinc sulph. 3i. in water' 3 viii. is also sometimes successful. More recently iodine solution has been used. Two per cent solution of iodine in water with the addition of 4 per cent pot. iodid. or one part of tinct. iodi to three parts of lukewarm water make suitable injections. Lime-water has also been recommended.
Considerable swelling usually follows, but dis appears in a few days or a week. The opera tion may be repeated every three weeks until a cure is effected.
As a rule the condition recurs after a short period.
Orchitis Inflammation of the testicle is quite a rare condition among the domesticated animals. In man its most common origin is urethral infection, but as specific disease of the genera tive organs, with the exception of dourine, is uncommon in our patients, we must seek other causes. Traumatic injury may be respon sible in many cases, particularly in the dog, and in the horse orchitis has been known to follow influenza, whilst abscess formation may in extremely rare instances occur in the testicle during an attack of strangles. As the majority of colts are castrated as yearlings a comparatively small number of entire animals become affected with the disease, and so secondary lesions in the testicle are rarely met with. PyEemie abscesses may also occur in this region from infection with other pyogenic organisms.
Tuberculosis and glanders also are occasion ally met with affecting the testicle.
Symptoms. These vary considerably accord ing to the actual cause and whether the condi tion is the result of infection or traumatism.
The principal symptom is swelling of the testicle. The enlargement may be confined to this organ or it may extend to the tunica vaginalis and the scrotum (periorchitis). When the inflammatory symptoms result from external violence, all these tissues may become involved and adhesions may occur between them, or the inflammation may subside without complica tion. Haemorrhage sometimes takes place into the tunica vaginalis (hmnatocele) or blood may be extravasated into the spermatic cord. In most cases, however, absorption occurs natur ally unless there be wounding of the scrotum with resulting infection from without.
Abscess formation within the testicle is practically always accompanied by periorchitis. In favourable cases the pus makes its exit through the scrotum, which will have by this time become adherent to the tunica vaginalis and testicle. In other instances infection will extend into the spermatic cord and will give rise to fatal peritonitis.
Chronic orchitis is sometimes associated with tuberculosis, more rarely with glanders. There is usually swelling of the testicle with indura tion, and frequently the tunica vaginalis becomes distended with serous fluid (hydrocele).
In acute orchitis severe pain is always mani fested, and in the horse the early symptoms may be mistaken for those of colic. When the testicle is enlarged the gait becomes straddling and movement is restricted. Fever is usually present, especially when infection occurs.
In cases of chronic orchitis pain may be absent, and the only inconvenience to the animal may lie in the size and weight of the scrotum and its contents. We have observed unilateral tuberculous orchitis in a donkey in which the scrotum was of the size of a football, though the greater portion of this swelling arose from hydrocele.
Treatment. In acute orchitis an aperient should be administered at once, and seda tives and febrffuges may be employed as re quired.
In traumatic orchitis the scrotum should be suspended by a many-tailed bandage, and should be surrounded by a warm kaolin poultice (pre pared by rubbing down powdered kaolin in a mortar, with hot water and treacle or glycerine, into a soft paste). Some practitioners prefer cold applications and astringent lotions. Bella donna relieves pain to some extent and may with advantage be combined with iodine and camphor in an ointment mixed with an animal fat, as lard or lanoline.
Septic orchitis and enlargements arising from tuberculosis will only be benefited by castra tion, though the operation entails considerable risk, especially when periorchitis exists. At any rate, animals so affected are seldom useful, and the value of the operation usually justifies the risk.
In acute cases Moller recommended deep scarification followed by antiseptic treatment.
In human practice strapping the testicle with adhesive plaster as tightly as can be borne helps to remove the enlargement resulting from orchitis. The operation should be commenced around the cord immediately above the testicle. The other layers are applied, each below and overlapping the last. This method has been recommended for veterinary patients.
Scirrhous Cord Scirrhous cord is a chronic enlargement of the divided end of the spermatic cord, developing after castration.
A considerable amount of thickening is not uncommonly met with after the operation. It may always be detected upon palpation during the succeeding week, and generally decreases until about the second or third week, when healing will usually be complete.
When scirrhous cord occurs instead of this, a fistula remains which discharges a thick creamy pus. At the same time the cord becomes gradually larger. The discharge of pus may cease after a while and the fistula may close, without, however, any diminution in the size of the enlargement taking place. The latter may at this stage be of the size of an egg or a tennis-ball, very hard, and in all probability adherent to the scrotum. Sometimes a doughy or even fibrous swelling occurs simultaneously in the same side of the sheath, which thus becomes noticeably deformed.
After a period varying from a few days to months, suppuration will occur in a fresh area within the enlargement, and after a time will break through the skin of the scrotum, giving rise to a fresh fistula.
The enlargement continually increases in size and may weigh anywhere from a few ounces to a hundredweight. In the larger specimens the bulk of the swelling usually lies within the abdomen, to which region it has extended through the inguinal canal.
Rectal exploration affords valuable informa tion as to the extent of the enlargement, and whether it is in part contained within the abdomen, though the limits of growths of moderate size can be determined by palpation of the scrotal region.
During the acute inflammatory stage, and when suppuration is in progress, the animal exhibits symptoms of pain and soreness when the parts are handled, and he may show mild fever and a varying degree of lameness. The limb of the affected side is abducted and carried stiffly forwards with a shortened stride. These symptoms are much more in evidence when the animal is travelling downhill, particularly when forced to keep back a load.
In other cases the growth appears to reach a certain stage of development and then becomes chronic, and may thus remain indefinitely, unless any circumstance should arise which might lower the natural resistance to the in fection. A large number of horses are thus affected, and since the days of castration in the standing position, particularly in districts where the operation is performed by amateurs whose surgical outfit is often limited to a clasp-knife, a pair of bent hazel twigs, and some binder twine, cases of scirrhous cord are more common.
In conducting examinations as to soundness we may frequently meet with unsuspected scirrhous cords, which have apparently caused no symptoms or inconvenience.
"Champignon formation"is a term used to denote a granulating and swollen protrusion of the cord through the original skin wound. It is not of the same nature as scirrhous cord, but is due to imprisonment of the divided end of the cord in the wound. The latter may not have been made sufficiently large at the time of operation, or undue traction may have been applied to the testicle or cord with rupture or paralysis of the cremaster muscle as a result.
The actual cause of scirrhous cord is un doubtedly infection, and this may apparently remain latent for years, although moderate swelling may exist without being recognized. We have observed in a mule, considerably over twenty years of age, a suppurating scirrhous cord which appeared quite suddenly. As far as could be ascertained no symptoms had been previously observed, although doubtless some enlargement had existed unsuspected.
The actual organism responsible for scirrhous cord is in all probability botryomyces, though the infection is invariably a mixed one. The common pyogenic organisms are usually present, particularly staphylococci.
The predisposing causes are undue traction upon the cord, too small an incision, faulty technique, particularly as regards asepsis and unusual conditions which predispose to infection. So-called"operating-beds,"which are usually composed of dusty germ-laden straw, and certain pastures, frequently carry the causal organisms.
Scirrhous cord more often appears in horses which have been castrated by clam or ligature than in those operated upon by other methods. The old-fashioned iron and clam method appears in practice to be least often followed by this condition.
Treatment.Internal medication does not yield uniform results. We have observed the apparent disappearance of small growths on the end of the cord, which have been diagnosed many months after castration, following daily administration of two drachms of pot. iodid. In some instances these have become larger and have suppurated after cessation of this treatment, but have again diminished in size upon its resumption. Other cases have not been benefited at all by pot. iodid. even in large doses, nor has any good result followed the injection of fibrolysin and plugging the sinuses with biniodide of mercury ointment. Although in cases where there is extension into the abdomen we are justified in attempting to reduce the enlargement by any of these methods, the only treatment likely to produce a per manent cure is operation, and this should be resorted to whenever the size of the growth does not influence prognosis too unfavourably.
Surgical intervention should, however, be postponed if the enlargement is in a state of active inflammation or is developing a fresh abscess, and should be practised when the growth is as small and inactive as it is likely to become.
The methods practised are mostly similar, excepting that the cord itself may be divided by varying processes as in ordinary castration.
The horse is cast and anesthetized. Some operators decry the use of chloroform, owing to the amount of hemorrhage to be expected, but, properly performed, the operation in the average case is not accompanied by serious bleeding. A narrow elliptical piece of skin, in length corresponding with the diameter of the growth, is removed. This, if possible, should include one, at least, of the fistulous openings. Below this will usually be seen a number of varicose veins, especially if the patient be of a fat nature. If these cannot be held aside with ease and safety they should be ligatured and divided. The first two fingers of each hand must then be employed to tear away the con nective tissue surrounding the enlargement. A pair of blunt-pointed curved scissors may be used to divide any tissues which are beyond the power of the operator's fingers. By in serting the fingers of each hand side by side, and then forcibly drawing them apart and repeating the process at various parts of the growth, it is quite possible to dissect it out to its origin at the spermatic cord without causing any appre ciable loss of blood, whereas if a scalpel be employed to divide the tissues copious haemo rrhage results.
The actual method of division of the cord is a matter for the operator's own judgment.
We prefer to enclose it in an ordinary flat metal castrating clam. Below the clam we apply a ligature of boiled whipcord as tightly as possible whilst we divide the cord above the clam either by the ecraseur or the hot iron. The ends of the ligature are left sufficiently long to extend about six inches below the skin wound.
The cavity should then be tightly packed with boiled tow or wool saturated with an antiseptic solution. Eusol, potass. permang., or very weak iodine solution may be employed for this purpose. The skin should be brought into apposition by means of closely-inserted sutures. Forty-eight hours later the plugs may be removed, the cavity irrigated, and a light plug inserted. Probably by this time a con siderable degree of swelling of the sheath and scrotum will have ensued, but is of no account. The horse should have walking exercise for half an hour twice or thrice daily from now onwards. The ligature around the cord must be removed about the ninth or tenth day, when it will, in most cases, come away easily, but it may be left longer without danger if it is found difficult to free it at this time.
When the growth extends through the inguinal canal so that its upper extremity lies beyond the reach of the surgeon, the scalpel should be drawn transversely around the highest point of the enlargement which is visible. By thus dividing the thickened tunica vaginalis the mass can often be drawn down the canal and its superior extremity brought within reach. If this be still impossible a large needle carry ing a double length of whipcord may be passed through the middle of the highest point of the growth which can be thus pierced, and the corresponding ends of the cords tied as tightly as possible so as to ligature the growth in two separate halves, leaving four ends to hang down outside the skin wound. When the ligation is completed the mass may be divided at least half an inch below the ligatures, and the stump should be seared with a hot iron if it can be brought within easy reach. The portion of the growth below the ligatures will slough off in about a fortnight, if ligation has been efficiently performed, when it may be removed by traction on the ends of the ligatures.
A horse may be thus rendered workable for a considerable time, and in some cases the portion of the enlargement left behind will atrophy and recovery will result with healing of the fistula. As a rule, however, healing is not complete unless the whole of the enlargement has been removed, a small aperture remaining, but this does not greatly inconvenience the animal, neither is it apparent without close examination.
Some operators prefer the ecraseur for the removal of these large growths, but as secondary haemorrhage is of frequent occurrence, and as the density of the tissues or the thickness of the mass often causes the chain to break, its use is open to grave objection. We have seen fatal hemorrhage ensue five hours after opera tion by means of this instrument.
Growths of the"champignon"type must be removed by opening up the original skin wound and exposing the spermatic cord above the granulating mass. The ecraseur may be safely employed in this case to divide the cord.
Occasionally, when operating for a supposed scirrhous cord the enlargement will be found to be composed of a mass of enlarged and frequently suppurating lymphatic glands. No evidence of local infection, as of the skin or penis, can be discovered in most cases, and we must conclude that the infection dates from the time of castration, although frequently years have elapsed.
Removal of the affected glands has always, in our experience, resulted in recovery with healing of the fistula. Sinus formation in the inguinal region may also communicate with an abscess cavity lying between the abdominal muscles. Its situation is usually underlying the external oblique muscle of the abdomen or its tendon, and as the latter forms the posterior wall of the inguinal canal, this is the outlet which affords the least resistance to its exit. A distinct swelling can sometimes be seen mid way between the angle of the haunch and the stifle-joint, or just in front of the latter.
The abscess should be laid open at this point, or, if of long standing, its walls will be found to be greatly thickened and it can be dissected out entire. The abscess may sometimes open inside the thigh or just below the inner surface of the patella, instead of through the inguinal canal.
Occasionally a form of botryomycosis may be observed affecting the sheath only. The lesions consist of fibrous thickening with occasional abscess formation. Sometimes a minute sinus persists. Administration of pot. iodid. with local application of an ointment containing iodine 1 part, pot. iodid. 2 parts, lard 8 parts, usually results in recovery.