De Medicina (Celsus)

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	De Medicina Author: Celsus	Translator: Walter George Spencer
169	Nonnumquam autem uenter ictu aliquo perforatur , sequiturque ut intestina euoluantur . Quod ubi incidit , protinus considerandum est , an ea integra sint , deinde an is color suus maneat . Si ten uius intestinum perforatum est , nihil profici posse iam rettuli . Latius intestinum sui po test , non quo certa fiducia sit , sed quo dubia spe s certa desperatione sit potior : interdum enim glutinatur . Tum si utrumlibet intestinum liuidum aut pallidum aut nigrum est , quibus illud quoque necessario accedit , ut sensu careat , medicina omnis inanis est . Si uero adhuc ea sui coloris sunt , cum magna festinatione succurrendum est : momento enim alienantur , externo et insueto spiritu circumdato . Resupinandus autem homo est coxis erectioribus ; et si angustius uulnus est , quam ut intestina commode refundantur , incidendum est , donec satis pateat . Ac si iam sicciora sunt intestina , perluenda aqua sunt , cui paulum admodum olei sit adiectum . Tum minister oras ulceris leuiter diducere manibus suis uel etiam duobus hamis interiori membranae iniectis debet : medicus priora semper intestina , quae posteriora prolapsa sunt , condere sic , ut orbium singulorum locum seruet . Repositis omnibus , leuiter homo concutiendus est ; quo fit , ut per se singula intestina in suas sedes deducantur et in his considant . His conditis , omentum quoque considerandum est , ex quo , si quid iam nigri est , forfice excidi debet ; si quid integrum est , leuiter super intestina deduci . Sutura autem neque summae cutis neque interioris membranae per se satis proficit , sed utri usque . E t quidem duobus linis inicienda est , spissior quam alibi , quia et rumpi facilius motu uentris potest , et non aeque magnis inflammationibus pars ea exposita est . Igitur in duas acus fila coicienda , eaeque duabus manibus tenendae ; et prius interiori membranae sutura inicienda est sic , ut sinistra manus in dexteriore ora , in sinisteriore dextra a principio uulneris orsa ab interiore parte in exteriorem acum mittat . Quo fit , ut ab intestinis ea qu idem pars semper acuum sit , quae retusa est . Semel utraque parte traiecta , permutandae acus inter manus sunt , ut ea sit in dextra , quae f uit in sinistra ; ea ueniat in sinistram , quam dextra continuit ; iterumque eodem modo per oras immittenda e sunt ; atque ita tertio et quarto deincepsque permutatis inter manus acubus , plaga includenda . Post haec eadem fila , eaedemque acus ad cutem transferendae , similique ratione ei quoque parti sutura inicienda , semper ab interiore parte acubus uenientibus , semper inter manus traiectis . Dein glutinantia inicienda , quibus aut spongia m aut sucidam lanam ex aceto expressam accedere debere manifestius est , quam ut semper dicendum sit . Inpositis his , leuiter deligari uenter debet .	16 Sometimes the abdomen is penetrated by a stab of some sort, and it follows that intestines roll out. When this happens we must first examine whether they are uninjured, and then whether their proper colour persists. If the smaller intestine has been penetrated, no good can be done, as I have already said. The larger intestine can be sutured, not with any certain assurance, but because a doubtful hope is preferable to certain despair; for occasionally it heals up. Then if either intestine is livid or pallid or black, in which case there is necessarily no sensation, all medical aid is vain. But if intestines have still their proper colour, aid should be given with all speed, for they undergo change from moment to moment when exposed to the external air, to which they are unaccustomed. The patient is to be laid on his back with his hips raised; and if the wound is too narrow for the intestines to be easily replaced, it is to be cut until sufficiently wide. If the intestines have already become too dry, they are to be bathed with water to which a small quantity of oil has been added. Next the assistant should gently separate the margins of the wound by means of his hands, or even by two hooks inserted into the inner membrane: the surgeon always returns first the intestines which have prolapsed the later, in such a way as to preserve the order of the several coils. When all have been returned, the patient is to be shaken gently: so that of their own accord the various coils are brought into their proper places and settle there. This done, the omentum too must be examined, and any part that is black dead is to be cut away with shears; what is sound is returned gently into place in front of the intestines. Now stitching of the surface skin only or of the inner membrane only is not enough, but both must be stitched. And there must be two rows of stitches, set closer together than in other places, partly because they can be broken here more easily by the abdominal movement, partly because that part of the body is not specially liable to severe inflammations. Therefore two needles are to be threaded and one is to be held in each hand; and the stitches are to be inserted, first through the inner membrane, so that the surgeon's left hand pushes the needle from within outwards through the right margin of the wound, and his right hand through the left margin, beginning from one end of the wound. The result is that it is the blunt end of the needle which is always being pushed away from the intestines. When each margin has been once traversed, the hands interchange needles, so that into the right hand comes the needles which was in the left, and into the left the needle which was in the right; and again, after the same method they are to be passed through the margins; and when for the third and fourth time, the needles have changed hands the wound is to be closed. Afterwards the same thread and the same needles are now transferred to the skin, and stitches are to be inserted by a like method into this as well, always directing the needles from within outwards, and with the same change, between the hands. It is too obvious to need constantly repeating that agglutinants are then to be put on with the addition either of a sponge or of greasy wool, squeezed out of vinegar. Over this application the abdomen should be lightly bandaged.
170	Interdum tamen uel ex ictu aliquo uel retento diutius spiritu uel sub graui fasce interior abdominis membrana superiore cute integra rumpitur . Quo d feminis quoque ex utero saepe euenire consueuit ; fitque praecipue circa ilia . Sequitur autem , cum superior caro mollis sit , ut non satis intestina contineat , isque intenta cutis indecore intumescat .— Atque id quoque aliter ab aliis curatur . Quidam enim per acum duobus linis ad imam basem inmissis sic utrimque deuinciunt , quemadmodum et in umbilico et in uua positum est , ut quicquid super uinculum est emoriatur : quidam medium tumorem excidunt ad similitudinem myrtei foli , quod semper eodem modo seruandum esse iam posui , et tum oras sutura iungunt . Commodissimum est autem resupinato corpore experiri manu , qua parte is tumor maxime cedat , quia necesse est ea parte rupta membrana sit ; quaque integra est , ea magis obnitatur ; tum qua rupta uidebitur , immittendae scalpello duae lineae sunt , ut excisso medio interior membrana utrimque recente m plagam habeat , quia quod uetus est , sutura non coit . Loco patefacto , si qua parte membrana non nouam plagam sed ueterem habet , tenuis excidenda habena est , quae tantum ora s eius exulceret . Cetera , quae ad suturam reliquamque curationem pertineant , supra conprehensa sunt . Praeter haec euenit , ut in quorundam uentribus uarices sint ; quarum quia nulla alia curatio est , quam quae in cruribus esse consueuit , † tum eam partem explanaturus , hanc quoque eo differo .	17 Sometimes, however, whether from some blow, or from holding the breath too long, or from carrying a heavy weight, the inner membrane of the abdomen is ruptured, whilst the skin over it is entire. This often occurs too in the case of women from childbearing, and it particularly takes place in the iliac regions. But it follows since the overlying flesh is soft, that it does not hold the intestines properly in place and that the skin is stretched by them and forms an ugly swelling. And this too is treated differently by different surgeons. For some pass two threads through the base by means of a needle, and then tie on each side, as has been described for the navel and for staphyloma, in order that what is beyond the ligature may mortify; some excise the middle of the swelling by a myrtle-leaf shaped incision, which as I said is the method which should always be adopted, and then they unite the edges by stitching. But the best way is with the patient on the back, to try with the hand in which part the swelling is most yielding, for of necessity it is at that part that the inner membrane is ruptured, and where it is entire the swelling is more resistant. Where the rupture is seen to be, two linear incisions are made with a scalpel, so that when what lies between has been excised, the inner membrane has a wound freshly made on each side, because stitching will not unite a lesion of long standing. When on exposure any part of the membrane presents not a recent but an old rupture, a thin strip is to be pared away, which only just makes the margins raw. All the directions for stitching and further treatment have been given above. Besides the above there are sometimes varicose veins upon the abdominal wall, and because there is no other treatment for these than what is usual for the legs since I shall treat of that part later, I will defer this too till then.
171	Venio autem ad ea , quae in naturalibus partibus circa testiculos oriri solent ; quae quo facilius explicem , prius ipsius loci natura paucis proponenda est . Igitur testiculi simile quiddam medullis habent : nam sanguinem non emittunt et omni sensu carent : dolent autem in ictibus et inflammationibus tunicae , quibus i continentur . Dependent uero ab inguinibus per singulos neruos , quos cremasteras Graeci uocant , cum quorum utroque binae descendunt et uenae et arteriae . Haec autem tunica conteguntur tenui , neruosa , sine sanguine , alba , quae ely troides a Graecis nominatur . Super ea ualentior tunica est , quae interiori uehementer ima parte inhaeret : darton Graeci uocant . Multae deinde membranulae uenas et arterias eosque neruos conprehendunt ; atque inter duas quoque tunicas a superioribus partibus leues paruulaeque sunt . Hactenus propria utrique testiculo uelamenta et auxilia sunt : communis deinde utrique omnibusque interioribus sinus est , qui iam conspicitur a nobis : oscheon Graeci , scrotum nostri uocant ; isque ab ima parte mediis tunicis leuiter innexus est , a superiore tantum circumdatus . Sub hoc igitur plura uitia esse consuerunt ; quae modo ruptis tunicis , quas ab inguinibus incipere proposui , modo his integris fiunt . Siquidem interdum uel ex morbo primum inflammatur , deinde postea pondere abrumpitur ; uel ex ictu aliquo protinus rumpitur tunica , quae diducere ab inferioribus partibus intestina debuit ; tum pondere eo deuoluitur aut omentum aut etiam intestinum ; idque ibi reperta uia paulatim ab inguinibus in inferiores quoque partes nissum subinde neruosas tunicas et ob id eius rei patientes diducit : enterocelen et epiplocelen Graeci uocant : apud nos indecorum sed commune his hirneae nomen est . Deinde , si descendit omentum , numquam in scroto tumor tollitur , siue inedia fuit , si ue corpus huc illucue conuersum aut aliquo modo conlocatum est ; itemque , si retentus est spiritus , non magnopere increscit ; tactu uero inaequalis est et mollis et lubricus . At si intestinum quoque descendit , tumor is sine inflammatione modo minuitur , modo increscit estque fere sine dolore et cum mollitie . Cum quiescit aliquis aut iacet , interdum ex toto desidit ; interdum sic diuiditur , ut in scroto exiguae reliquiae maneant . At clamore et satietate , et si sub aliquo pondere is homo nisus est , crescit : frigore omni contrahitur , calore diffunditur ; estque tum scrotum et rotundum et tactu leue : idque , quod subest , lubricum est ; si pressum est , ad inguina reuertitur , dimissumque iterum cum quodam quasi murmure deuoluitur . Et id quidem in leuioribus malis euenit : nonnumquam autem stercore accepto uastius tumet , retroque compelli non potest , adfertque tum dolorem et scroto et inguinibus et abdomini . Nonnumquam stomachus quoque adfectus primum rufam bilem per os reddit , deinde uiridem , quibusdam etiam nigram . Integris uero membranis interdum eam partem umor distringit . Atque eius quoque species duae sunt : nam uel inter tunicas is increscit uel in membranis , quae ibi circa uenas et arteria s sunt , ubi eae grauatae occal luerunt . Ac ne ei quidem umori , qui inter tunicas est , una sed es est : nam modo inter summam et mediam , modo inter mediam et imam consistit . Graeci communi nomine , quicquid est , hydrocelen appellant : nostri , ut scilicet nullis discriminibus satis cognitis , haec quoque sub eodem nomine quo priora habent . Signa autem quaedam communia sunt , quaedam propria : communia , quibus umor deprehenditur ; propria , quibus loc us. Vmorem subesse discimus , si tumor est numquam ex toto se remittens , sed interdum leuior aut propter famem aut propter febriculam , maximeque in pueris ; isque mollis est , si non nimius umor subest : at si is uehementer increuit , renititur sicut uter repletus et arte adstrictus . Venae quoque in scroto inflantur , est , si digito pressimus , cedit umor circumfluens que id , quod non premitur , attollit et tamquam in uitro cornuue per scrotum apparet , estque , quantum in ipso est , sine dolore . Sedes autem eius sic deprehenditur . Si inter summam mediamque tunicam est , cum digitis duobus pressimus , paulatim umor inter eos * reuertens subit ; scrotum † ipsius albidius : si ducitur , aut nihil aut paruulum intenditur ; testiculus ea parte neque uisu neque tactu sentitur . At si sub media tunica est , intentum scrotum magis se attollit , adeo ut superior coles sub tumore eo delitescat . Praeter haec aeque integris tunicis ramex innascitur : cirso celen Graeci appellant . Venae intumescunt , eaeque intortae conglomerataeque a superiore parte uel ipsum scrotum inplent uel mediam tunicam uel imam : interdum etiam sub ima tunica circa ipsum testiculum neruumque eius increscunt . Ex his ea e , quae in ipso scroto sunt , oculis patent : eae uero , quae mediae imaeue tunicae insident , ut magis conditae non aeque quidem cernuntur , sed tamen etiam uisui subiectae sunt , praeterquam quod et tumoris aliquid est pro uenarum magnitudine ac modo , et id prementi magis renititur ac per ipsos uenarum toros inaequale est et , qua parte id est , testiculus magis iusto dependet . Cum uero etiam super ipsum testiculum neruumque eius id malum increuit , aliquanto long ius testiculus ipse descendit , minorque altero fit , ut pote alimento amisso . Raro sed aliquando caro quoque inter tunicas increscit : sarcocelen Graeci uocant . Interdum etiam ex inflammatione tumet ipse testiculus , ac febres quoque adfert ; et nisi celeriter ea inflammatio conquieuit , dolor ad inguina atque ilia peruenit , partesque eae intumescunt ; neruus , ex quo testiculus dependet , plenior fit simulque indurescit . Super haec inguen quoque nonnumquam † uarice inplicetur : bubonocelen appellant .	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.
172	His cognitis , de curatione dicendum est , in qua quaedam communia omnium sunt , quaedam propria singulorum . Prius de communibus dicam . Loquar autem nunc de is , quae scalpellum desiderant : nam uel quae sanari non possunt , uel aliter nutriri debeant , dicendum erit , simul ad species singulas uenero . Inciditur autem interdum inguen , interdum scrotum . In utraque curatione homo ante triduum bibere aquam , pridie abstinere etiam a cibo debet : ipso autem die collocari supinus ; deinde si inguen incidendum est , idque iam pube contegitur , ante radendum est ; et tunc extenso scroto , ut cutis inguinis intenta sit , id incidendum sub imo uentre , qua cum abdomine tunicae inferiores committuntur . Aperiendum autem audacter est , donec summa tunica , quae ipsius scroti est , incidatur , perueniaturque ad eam , quae media . Plaga facta foramen deorsum uersus subest . In id demittendus est sinistrae manus digitus index , ut deductis interuenientibus membranulis sinum laxet . Minister autem sinistra manu conprehendens scrotu m susum uersum debet extendere , et quam maxime ab inguinibus abducere , primum cum ipso testiculo , dum medicus omnes membranulas , quae supra mediam tunicam sunt , si digito deducere non potest , scalpello abscidat ; deinde sine eo , ut is delapsus ipsi plagae iungatur digitoque inde promatur , et super uentrem cum duabus suis tunicis collocetur . Inde si qua uitiosa sunt , circumcidenda sunt ; in quibus cum multae uenae discurrant , tenuiores quidem protinus praecidi possunt ; maiores uero ante longiore lino deligandae sunt , ne periculose sanguinem fundant . Si media tunica uexata erit aut sub ea malum increuerit , excidenda erit sic , ut alte ad ipsum inguen praecidatur . Infra tamen non tota demenda est : nam quod ad basin testiculi uehementer cum ima tunica conexu m est , excidi sine summo periculo non potest ; itaque ibi relinquendum est . Idem in ima quoque tunica , si laesa est , faciendum est . Sed non a summa inguinis plaga uerum infra paulum ea abscidenda , ne laesa abdominis membrana inflammationes moueat . Neque tamen nimium ex ea susum relinquendum est , ne postea sinuetur et sedem eidem malo praestet . Purgatus ita testiculus per ipsam plagam cum uenis et arteriis et neruo suo leuiter demittendus est , uidendumque , ne sanguis in scrotum descendat neue concretus aliquo loco maneat . Quae ita fient , si uenis uinciendo medicus prospexerit : lina , quibus capita earum continebuntur , extra plagam dependere debebunt ; quae pure orto sine ullo dolore excident . Ipsi autem plagae iniciendae duae fibulae sunt , et insuper medicamentum , quo glutinetur . Solet autem interdum ab altera ora necessarium esse aliquid excidi , ut cicatrix maior et latior fiat . Quod ubi incidit , lin amenta super non fulcienda sed leuiter tantum ponenda sunt , supraque ea , quae inflammationem repellant , id est ex aceto uel lana sucida uel spongia : cetera eadem , quae , ubi pus moueri debet , adhibenda sunt . At cum infra incidi oportet , resupinato homine subicienda sub scroto sinistra manus est ; deinde id uehementer adprehendendum et incidendum . Si paruolum est , quod nocet , modice , ut tertia pars integra ad sustinendum testiculum infra relinquatur ; si maius est , etiam amplius , ut paulum tantummodo ad imum , cui testiculus insidere possit , integrum maneat . Sed primo rectus scalpellus quam leuissima manu teneri debet , donec scrotum ipsum diducat ; tum inclinandus mucro est , ut trans uersa membrana secet , quae infra summam mediamque tunicam sunt . Ac si uitium in proximo est , mediam tunicam attingi non oportet : si sub illa quoque conditur , etiam illa incidenda est , sicut tertia quoque , si illa uitium tegit . Vbicumque autem repertum est malum , ministrum ab inferiore parte exprimere moderate scrotum oportet ; medicum digito manubriolou e scalpelli deductam inferior e parte tunicam extra conlocare ; deinde eam ferramento , quod a similitudine coruom uocant , incidere sic , ut intrare duo digiti , index et medius , possint . His deinde * coniectis , excipienda reliqua pars tunicae , et inter digitos scalpellus inmittendus est , eximendumque aut effundendum quicquid est noxium . Qua mcumque autem tunicam quis uiolauit , illam quoque debet excidere ; ac mediam quidem , ut supra dixi , quam altissime ab inguine ; imam autem paulum infra . Ceterum antequam excidantur , eae quoque uinciri lino summae debent et eius lini capita extra plagam relinquenda sunt , sicut in aliis quoque [ uenis , ] quae id requisierint . Eo facto , testiculus intus reponendus est , oraeque scroti suturi s inter se committendae , neque paucis , ne parum glutinentur et longior fiat curatio ; neque multis , ne inflammationem augeant . Atque hic quoque uidendum est , ne quid in scroto sanguinis maneat . Tum inponenda glutinantia sunt . Si quando autem in scrotum sanguis deflu xit aliquidue concretum ex eo de sce ndit, incidi subter id debet , purgatoque eo spongia acri aceto madens circumdari . Deligatum autem uulnus omne , quod ex his causis factum est , si dolor nullus est , quinque primis diebus non est resoluendum , sed bis die tantum aceto inroranda lana uel spongia : si dolor est , tertia die resoluendum , et ubi fibulae sunt , eae incidendae ; ubi linamentum , id inmutandum est rosaque et uino madefaciendum id , quod inponitur . Si inflammatio increscit , adiciendum prioribus cataplasma ex lenticula et melle uel malicorio , quod in austeri uino coctum sit , uel ex his mixtis . Si sub his inflammatio non conquieuerit , post diem quintum multa calida aqua uulnus fouendum , donec scrotum ipsum et extenuetur et rugosius fiat ; tunc inponendum cataplasma ex triticea farina , cui resina pinea adiecta sit ; quae ipsa , si robustus cubat , ex aceto ; si tener , ex melle coquenda sunt . Neque dubium est , quodcumque in ditum est , si magna inflammatio est , quin ea , quae pus mouent , inponenda sint . Quod si pus in ipso scroto ortum est , paulum id incidi debet , ut exitus detur ; lin amentumque eatenus ponendum est , ut foramen tegat . Inflammatione finita , propter neruos priore cataplasmate , dein cerato utendum . Haec proprie ad eiusmodi uulnera pertinent . Cetera et in curatione et in uictu similia is esse debent , quae in alio quoque uulnerum genere praecepimus .	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.