The membrane called tunica adnata in our translation is the “ima tunica” of Celsus, and the “panniculus proprius” of the Arabian translation of Albucasis, and seems to be the same as the tunica albuginea of modern anatomists.
Sprengel gives an excellent history of the operation of hydrocele. (Hist. de la Méd. 18, 8.)
SECT. LXIII.—ON SARCOCELE AND TOPHI OF THE TESTICLES.
When flesh is formed in any part of the bodies which are connected by the scrotum, it gives rise to the disease called sarcocele. This arises either from some obscure cause, the testicle being attacked with a defluxion and becoming indurated, or from a blow, or from unskilful treatment after the operation for hernia. Its consequences are, a swelling of the same colour, with hardness; when the swelling is of a scirrhous nature, it is devoid of colour and sensibility; and when it is malignant there are sharp pains. When going to operate we place the patient as in the former case, and make the incisions in like manner; and if the complaint is occasioned by the growth of a fleshy tumour to the testicle, we divide the dartos and tunica vaginalis in like manner; then stretching the testicle and bringing it to the outside of the vaginalis, we separate the cremaster from the vessels, tie a ligature round the vessels, and cut the cremaster; then we remove the testicle affected with the fleshy tumour as a foreign body. But if the fleshy tumour be formed about any of the coats of the testicle or its vessels, having divided the scrotum and the membranes lying under the flesh, we must dissect out the whole fleshy tumour. But if the posterior process (“epididymis”?) be affected with sarcocele, having dissected all the surrounding parts, we remove the testicle along with it; for it is impossible for the testicle to continue without it. If tophi be formed about the testicle and the tunica vaginalis, they may be distinguished from sarcocele and hydrocele by their resistance, hardness, and inequality, and are to be operated upon as sarcocele.
Commentary. Celsus describes and recommends the same operations. He directs us to divide the nerve by which the testicle is suspended (the cremaster?), then to tie the veins and arteries at the groin with a thread, and cut them below the ligature. When a fleshy tumour is formed between the coats he recommends us to cut it out. (vii, 22, 23.) When the parts are indurated he forbids us to meddle with them.
Albucasis directs us to separate the cremaster from the vessels, to tie the vessels, and then remove the testicle from the surrounding parts. When the disease consists of a fleshy tumour which adheres to the testicle he directs us to cut it out. After the operation the wound is to be filled with rose-oil and wine. (Chirurg. ii, 63.) The other Arabians treat of the operation less minutely, with the exception of Haly Abbas, who describes it exactly as Albucasis. (Pract. ix, 48.)
SECT. LXIV.—ON CIRSOCELE AND PNEUMATOCELE.
When the vessels about the scrotum or darti are in a varicose condition, they are called simply varices, but if the nutrient vessels of the testicles be in a varicose state, the affection is named cirsocele. The symptoms of it are obvious. There is a collection attended with swelling, and somewhat curved, of a botryoidal shape, and accompanied with relaxation of the testicle. It also occasions certain inconveniences, especially in running, exercising, and walking. We may operate upon it thus. After putting the patient in a convenient posture, we must lay hold of the scrotum and push the cremaster to the under part; it is easily distinguished from the vessels, being more slender, firmer, and elastic, as being strong and firm; the patient also feels pain upon pressure, and moreover it is connected with the penis. Having secured the vessels in the scrotum by our own fingers and those of our assistant, and stretching them strongly, we press obliquely the point of a scalpel direct upon the vessels; then having transfixed the parts with hooks and dissected what lie under the skin, and having exposed the vessels, as mentioned in the operation of angiology and that for aneurism, and pushing through them a needle having a double thread, and cutting the loop of the thread, we tie the ligatures round the vessels where the varices arise and where they terminate, and make a straight incision in the intermediate space. Having evacuated the blood collected in the tumour, we apply the treatment for suppurations until the ligatures with the vessels themselves fall out of their own accord. Leonides says, that when a few of the vessels which nourish the testicles are in a varicose state this operation should be performed, but that when all are affected, the testicle should be cut out along with them, lest being deprived of its nutrient vessels it should decay. Pneumatocele being a species of aneurism, Leonides forbids us to operate upon it for fear of a hemorrhage, which cannot be restrained from taking place at the time; but, there being two kinds of it, the one occasioned by the four vessels which nourish the testicle, and the other by the arteries of the darti and scrotum being affected, the moderns refrain from meddling with the latter, but operate upon the former. We distinguish them from one another, inasmuch as that which arises from the arteries is easily made to disappear upon pressure with the fingers, whereas that from the nutrient vessels of the testicles, not at all or with much trouble. We operate upon it as for cirsocele, taking up each of the veins and securing it with a thread.
Commentary. Celsus thus describes the cirsocele: “Venæ intumescunt; eæque intortæ conglomeratæque a superiore parte, vel ipsum scrotum implent, vel mediam tunicam vel imam: interdum etiam sub imâ tunicâ, circa testiculum nervumque ejus, increscunt.” (vii, 18.) He describes the operation at great length afterwards. If the varicose tumour is upon the scrotum he directs us to burn it with slender and sharp irons, which are to be applied to the veins themselves, but in such a manner as to burn them alone. Then suitable dressings are to be applied for producing cicatrization. When the varicose veins are situated above the middle tunic, an incision is to be made in the groin, the tunic drawn out, and the veins separated from it with a finger or the handle of a scalpel. The veins are afterwards to be tied with a thread above and below; then they are to be cut below, and the testicle restored to its place. When the disease is situated above the third tunic (tunica albuginea?) the middle one must be cut out. Then if only two or three veins are in a varicose state they may be tied, as above directed, at the groin and where they join the testicle and cut out. When the disease is situated between the internal coat and the testicle, he says, there is no other remedy but the removal of the testicle. For this purpose he directs us to secure the arteries and veins with a thread, divide them, and then to cut the nerve by which the testicle is suspended (the cremaster?). (vii, 19 and 22.) He does not treat of pneumatocele. It must be obvious that the pneumatocele of our author was an aneurismal varix or erectile tissue. We see no good reason, therefore, for the animadversions which Heister makes upon his account of it. (See Surgery.)