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.
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.
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.