De Medicina

18 Now I come to those lesions which are apt to arise in the genital parts around the testicles; and to explain them more easily, the nature of the said region must briefly be described first. The testicles then are somewhat like marrow, for they do not bleed and they lack all feeling; but the coverings by which they are enclosed give pain both when injured and inflamed. Now the testicles hang from the groins, each by a cord which the Greeks call the cremaster with each of which descend a pair of veins and a pair of arteries. And these are ensheathed in a tunic, thin, fibrous, bloodless, white, which is called by the Greeks elytroides. Outside this is stronger tunic, which at its lowest part is

closely adherent to the inner one; the Greeks call it dartos. Further, many fine membranes hold together the veins, and the arteries, and the cords aforesaid, and also in between the two tunics there are some fine and very small membranes, descending from the parts above. Thus far the coverings and supports belong to each testicle separately; next common to both and to all within is the pouch which is now visible to us; the Greeks call it oscheon, we the scrotum; and at its lowest part this is slightly connected with the middle coverings, higher up it is only surrounded by them. Now, underneath the scrotal covering many lesions are apt to occur, sometimes after the rupture of the coverings which, as I have said, begin from the groins, sometimes when they are uninjured. Since at times either owing to disease there is first inflammation, then afterwards a rupture from the weight; or after some blow there, there is a direct rupture of the covering which ought to separate the intestines from the parts below; then either omentum, or it may be intestine, rolls down by its own weight; this having found a way gradually from the groins into the parts below as well, there separates by its pressure the coverings which are fibrous and therefore give way. The Greeks call the condition enterocele and epiplocele, with us the ugly but usual name for it is hernia.

Now if omentum has come down, the tumour in the scrotum never disappears, either if the patient fasts, or if his body is turned from side to side, or lies in some special position; again, if the breath is held, it does not increase to any extent; to the touch it seems uneven and soft and slippery. But if intestine has also come down this tumour is with-

out inflammation, sometimes it diminishes, sometimes increases, and it is generally painless and soft. When the patient is quiescent or lying down, it disappears, at times altogether; sometimes it becomes divided so that very small remnants stay in the scrotum. But after shouting or over-eating, or if the patient has been strained by a weight of any sort, it increases; under all kinds of cold it shrinks, under heat it enlarges; then the scrotum becomes globular and smooth to the touch; and within the scrotum the intestine slips about, when pressed upon it reverts towards the groin, when released it rolls down again with a sort of murmur. That is what happens in slight cases; but at times, when faeces have been taken in, it swells more largely, it cannot be forced back, and it then brings on pain both in the scrotum and in groins and abdomen. At times the stomach also becomes affected, and there is an issue from the mouth, first of red, then of green, and even in some of black bile. At times too, whilst the membranes remain entire, fluid distends the scrotum. There are two forms of this affection: for the fluid collects either between the coverings or in the membranes surrounding the veins and arteries, and then these membranes become thickened and weighted down. And even if the fluid lies between the membranes it is not confined to one place; it may lie between the superficial and middle membrane, or between the middle and inner membranes. The Greeks have one general name, they call it hydrocele, whichever kind it is; our people, not knowing enough perchance to make distinctions, call it by the same name as the preceding disorder. Now there are signs, some common to all cases, some particular: the common one is the existence of the fluid; the particular, the situation of it. We learn that there is fluid underneath, if the swelling never disappears entirely although it is at times less, whether from fasting or feverishness, and especially in boys; the tumour is soft when the fluid contained is only small in amount; but if it increases to a great extent, the tumour becomes tense like a wineskin which has been filled and tightly tied. Also veins in the wall of the scrotum are distended; and upon pressure with the finger the fluid recedes, and as it flows round raises up the part where there is no pressure and is seen through the scrotal wall as if it were contained in a glass or horn vessel; and however much is there is no pain. But the situation of the fluid is recognized as follows: if it is between the scrotal wall and the middle membrane, when we press with two fingers, the humour gradually comes up, returning as the fingers are withdrawn; the scrotal wall is whiter than natural; if it is drawn upon, it stretches either not at all, or very little; the testicle on that side cannot be seen or felt. But if it is under the middle membrane, the scrotum is stretched and more raised up, so that the root of the penis is concealed under the swelling. Besides the above a varicose affection which the Greeks call cirsocele occurs, in which also the membranes are intact. The veins become swollen, and when twisted, and massed together at the upper part, they distend the scrotum generally, or the middle or the inner covering; sometimes they grow even beneath the inner covering around the actual testicle and its cord. Of these the veins in the scrotal wall can be seen; but those situated in the middle or inner coverings, being more deeply placed, are not indeed equally visible but even these can be seen, especially because there is a certain amount of swelling in proportion to the size and form of the veins, and this is more resistant to pressure, and also is rendered irregular owing to the bulgings of the veins, whilst the testicle on that side hangs lower down than it ought. But when the disease has spread also over the testicle and its cord, the testicle sinks a little lower, and becomes smaller than its fellow, in as much as its nutrition has become defective. Sometimes, though rarely, flesh also grows between the tunics; the Greeks call this sarcocele. At times also the testicle itself swells owing to inflammation and this causes fever as well. And unless this inflammation quickly subsides, pain spreads to the inguinal and iliac regions, and these parts swell; the cord from which the testicle hangs becomes fuller, and at the same time it hardens. Besides this it happens sometimes that the groin is occupied by a rupture; they call it bubonocele.

19 When these lesions have been recognized their treatment must be discussed; in this some methods are common to all, some peculiar to particular kinds. I shall discuss first what is common to all. But I shall now speak of those cases demanding the knife: for those which are incurable, or should be cared for otherwise, will be mentioned as I come to the separate kinds. Now sometimes the inguinal region has to be cut into, sometimes the scrotum. In either case the man for three days

before should drink water, and for the day before abstain also from food: on the day itself he must lie on his back; next if the groin has to be cut into, and if the pubes is already covered by hair, this is to be shaved off beforehand: and then after stretching the scrotum, so that the skin of the groin is rendered tense, the cut is made below the abdominal cavity, where the membranes below are continuous with the abdominal wall. Now the laying open is to be done boldly, until the outer tunic, that of the scrotum itself, is cut through, and the middle tunic reached. When an incision has been made, an opening presents leading deeper. Into this the index finger of the right hand is introduced, in order that by the separation of the intervening little membranes the hernial sac may be freed. Next the assistant grasping the scrotum with his left hand should stretch it upwards, and draw it away as far as possible from the groins, at first including the testicle itself until the surgeon cuts away with the scalpel all the fine membranes which are above the middle tunic if he is unable to separate it with his finger; then the testicle is let go in order that it may slip downwards, and show in the wound and then be pushed out by the surgeon's finger, and laid along with its two tunics upon the abdominal wall. There whatever is diseased is cut round and away, in the course of which many blood vessels are met with; the smaller ones can be summarily divided; but larger ones, to avoid dangerous bleeding, must be first tied with rather long flax thread. If the middle tunic be affected, or the disease has grown beneath it, it will have to be cut away even as high as the actual groin. Lower down, however, not all is to be removed: for at the base of the testicle there is an intimate connexion with the inner tunic, where excision is not possible without extreme danger; and so there it is to be left. The same is to be done if the inner tunic is the seat of the disease. But the cutting away cannot be done quite completely at the inguinal end of the wound, but only somewhat lower down, lest the abdominal membrane be injured and set up inflammation. On the other hand too much of its upper part should not be left behind, lest subsequently there forms a pouch which continues to be the seat of the same malady. The testicle having been thus cleared is to be gently returned through the incision, along with the veins and arteries and its cord; and it must be seen that blood does not drop down into the scrotum, or a clot remain anywhere. This will be accomplished if the surgeon takes the precaution of tying the blood vessels; the threads with which the ends of these are tied should hang out of the wound; following upon suppuration they will fall off painlessly. Through the margins of the wound itself two pins are then passed, and over this an agglutinating dressing. But it becomes necessary sometimes to cut away a little from one or other of the edges of the skin-incisions in order to make a broader and thicker scar. When this occurs the lint dressing must not be pressed on but must be applied lightly, and over it such things as repel inflammation, unscoured wool or sponge soaked in vinegar; all the other treatment is the same as when suppuratives have to be applied.

But when an incision is required lower down, then with the man on his back, the left hand is to

be passed under the scrotum; next this must be grasped firmly and the incision made. If the disease is small in extent, the incision is limited, so as to leave intact the lower third of the scrotum in order to support the testicle; if more extensive, the incision is prolonged so that just a little is left at the bottom to support the testicle. But the scalpel at first should be held in a very light hand, with its edge vertical to the skin, until the wall of the scrotum has been divided; then the edge is sloped sideways so as to cut across the membranes between the scrotal wall and the middle tunic. And if the disease is in the wall of the scrotum there is no need to touch the middle tunic; if it also lies under the middle tunic, this too has to be cut through, and the inner tunic as well if that covers the lesion. Now wherever the disease is found to be, the assistant should press the scrotum gently upwards; the surgeon either with his finger, or with the handle of the scalpel, separates the middle tunic from its connexion with the scrotal wall, and brings it forwards; then with a knife, called from its shape 'the raven,' he lays it open so that his index and middle finger can enter. With these fingers so introduced the remainder of the tunic should be brought forwards, and the knife inserted in between the two fingers, and any diseased matter taken away or let out. If one of the tunics has been injured it also should be cut away; the middle one, as stated above, as far up as the groin; the inner one to a little below the groin. But before they are cut away, the blood vessels above too should be ligatured with flax thread, the ends of which are to be left hanging out of the wound, as in the case of other blood vessels that have had to be tied. This done, the testicle is to be replaced inside, and the scrotal margins united by stitches, not too few lest the edges fail to unite and the treatment is prolonged, and not too many lest they augment the inflammation. Here also it must be seen to that no blood remains in the scrotum. Then agglutinants are put on. But if at any time blood trickles down into the scrotum, or any clot collects in it, an incision should be made below, and after clearing out the blood, a sponge soaked in strong vinegar is put on. Further, all such wounds made for the above reasons, after having been bandaged up, when there is no pain, should not be dressed until the fifth day, but the wool or sponge is to be saturated sufficiently with vinegar twice a day; if there is pain, and when pins have been inserted they are then to be taken out; when lint has been used it must be changed and the fresh lint wetted with rose oil and wine. Should inflammation increase, to the previously mentioned applications add a plaster of lentils and honey or of pomegranate rind boiled in dry wine, or of the two combined. If the inflammation does not subside under these applications, after the fifth day the wound is to be fomented freely with hot water, until the scrotum itself both shrinks and becomes wrinkled; then apply a wheat flour plaster with pine resin added; which, for a robust patient has been boiled in vinegar, and for a delicate one in honey. Whatever the application used, there is no doubt that if there is much inflammation, suppuratives must be applied. But if pus collects in the scrotum itself, it must be let out through a small incision; and enough lint must be put on to cover the opening. When the inflammation is at an end, for the sake of the cords first the plaster and then a cerate is to be used. Such is the proper treatment of wounds of this sort. For the rest as regards both treatment and diet, these should conform to what has been prescribed for other sorts of wounds.