CHAP. XIX. GENERAL DIRECTIONS FOR OPERATIONS IN THE FOREGOING DISEASES ABOUT THE TESTICLES.
These disorders being known, we must proceed to treat of their cure: in which some things are common to them all, some proper to the particular kinds. I shall first speak of the general: and now treat of those, which require the knife. For those, that are either incurable, or ought to be treated in a different manner, I shall take notice of, when I come to the particular species. Now the incision is made sometimes in the groin, sometimes in the scrotum. In either method it is necessary for the patient to drink water for three days before; and the preceding day even to fast: on the day of the operation, he must be laid on his back; and if the incision is to be in the groin, and that is covered with hair, it must first be shaved; then the scrotum being extended to render the skin tense, the incision must be made at the bottom of the belly, where the inferior coats are joined to the abdomen. It must be opened boldly, till the external coat, which is the scrotum itself, be cut, and the middle one come in view. When the wound is made, there is an opening toward the inferior parts. Into that the fore finger of the left hand must be introduced, that by separating the intervening membranes it may enlarge the sinus. And an assistant taking hold of the scrotum with his left hand, must extend it upward, drawing it away as much as possible from the groin; at first with the testicle, while the physician cuts away by the knife, if he cannot separate them by his finger, all the small membranes, that are above the middle coat; after this, letting go the testicle, that it may slip down, and come near to the wound, and be brought out thence by the finger, and laid upon the belly with its two coats. And if any part of it is corrupted, it must be cut off. And as several veins are dispersed upon it, the small ones may be cut at once, but the larger should be first tied with a pretty long thread, to prevent a dangerous hemorrhage from them.
But if the middle coat be affected, or the disease lies below it, it must be cut out in such manner, that in the higher part close to the groin it should be clean cut off: but the whole must not be taken away below; for what is strongly connected at the base of the testicle with the innermost coat, cannot be cut off without the greatest danger, and for that reason must be left there.
The same method is to be taken in the innermost coat too, if that be injured. But it must be cut off, not at the top of the wound in the groin, but a little below that; lest it bring on inflammations by wounding the membrane of the abdomen. Neither on the contrary must too much of it be left; lest afterwards it form a sinus, and afford a receptacle to the same distemper.
The testicle being thus cleansed must be gently let down through the wound, with the veins, and arteries and its nerve; and care must be taken, that no blood fall into the scrotum, and that it does not remain coagulated in any part: which will be prevented, if the physician has been careful to tie the veins. The threads, by which their ends are secured, must hang without the wound: and when a suppuration comes on, they will fall off without any pain. Upon the wound itself must be put two fibulæ; and over them an agglutinating medicine.
It is sometimes necessary to cut off something from one of the lips, that the cicatrix may be larger and broader. When this is the case, the lint must not be pressed down upon it, but only laid on lightly; and over it some medicines to repel an inflammation, such as sordid wool, or spunge squeezed out of vinegar; every thing else must be used as when a suppuration ought to be excited. But when it is necessary to make the incision beneath, the patient being laid on his back, the left hand must be put below the scrotum; and a strong hold must be taken of it, and the incision made; if the seat of the disorder be small, the incision must be moderately sized, so as to leave a third part of the scrotum below entire, in order to support the testicle; if it be larger, the wound may be greater, a little at the bottom only being left entire, upon which the testicle may rest. But the knife at first should be held in a straight direction, with a very light hand, till it divide the scrotum itself; then the point of it must be turned aside a little, to cut the transverse membranes, that are between the external and middle coats. But the middle coat ought not to be touched, if the disease lie above it; but if it lies below the middle coat, that must be cut too; as likewise the third, if that cover the malady. Wherever the disorder is found, the assistant should squeeze the scrotum gently at the lower part; and the physician having separated the inferior part by his finger, or the handle of the knife, should bring the coat out of the wound, and make such an incision with an instrument, which from its figure is called corvus, that he may introduce his fore and middle fingers: when this is done, the remaining part of the coat must be cut, and the knife must pass between the two fingers, and whatever is noxious must either be taken out, or be allowed to run out.
Whatever coat is injured in the operation must be cut off; and the middle one, as I observed before, as high as possible at the groin; the innermost one a little lower. But before they are cut off, the vessels ought to be tied very carefully by a thread; and the ends of this thread must be left without the wound, which must be done also in other veins, where the ligature is requisite.
When that is done, the testicle must be returned into its place: and the lips of the scrotum joined together by a suture: and the stitches must not be too few, lest they be not agglutinated, and the cure prove tedious; nor yet too many, lest they increase the inflammation. And in this case too we must be cautious, that no blood remain in the scrotum: afterwards agglutinants must be applied.
If however blood has made its way into the scrotum, or any coagulated blood has fallen down into it, an incision should be made below it; and after cleansing it, a spunge moistened with sharp vinegar must be applied round it. A wound that has been made for these reasons, after it is tied up, if there be no pain, must not be opened for the first five days; but either the wool or spunge, that lies over it, must be sprinkled twice a day with vinegar alone; if there be pain, it must be opened on the third day; and where there are fibulæ, they must be cut; and where lint, that must be changed; and what is put on, must be wet with oil of roses and wine. If the inflammation increases, to the foregoing applications must be added a cataplasm of lentils and honey, of pomegranate bark boiled in a rough wine, or a mixture of these. If the inflammation does not give way to them, after the fifth day, the wound must be fomented with plenty of hot water, till the scrotum itself be both extenuated, and become more wrinkled; then a cataplasm must be applied of wheat meal, with an addition of pine resin; which, if the patient be a robust man, must be boiled up with vinegar; if more delicate, with honey. And whatever the disorder has been, if there be a great inflammation, without doubt medicines to promote a suppuration must be applied.
But if pus is generated within the scrotum, a small incision ought to be made to give a vent; and so much lint is to be applied as to cover the orifice. When the inflammation is removed, upon account of the nerves, the last-mentioned cataplasm, and then cerate must be used. This is the peculiar treatment of wounds of this kind. All other things both in regard to the manner of dressing, and the diet, should be conformable to the directions we have given about other wounds.