ARTES
237
SCIENTIA
LIBRARY VERITAS OF THE
UNIVERSITY OF MICHIGAN
TCEBOR
41-QUERIS PENINSULAM-AMCENAM
CIRCUMSPICE
The
George E. Wantz
(UM Medicine 1946)
Collection
Call NOP





A
TREATISE
ON
RUPTURES.
BY
PERCIVALL POTT,
SURGEON to St. Bartholomew's-Hofpital.
Chirurgia non quidem medicamenta atque victus ratio-
nem omittit, fed manu tamen plurimum præftat;
eftque ejus effectus inter omnes medicinæ partes evi-
dentiffimus.
A. CORN. CELSUS
LONDON:
Printed for C. HITCH and L. HAWES, at the
Red-Lion, Pater-nofter-Row. M.DCC.L.VI.

Taubman Rare
Book Boom
RD
1621
•P67

TOT
Mr. Edward Nourfe.
I
SIR,
HAVE always thought
myſelf much obliged
to you for your repeated
advice to me, in the early
part of my life, to apply
myfelf to anatomy and the
theory of our profeffion.
Whether I have profit-
ed by it or not, the advice
A 2
was

DEDICATION.
was good, and my obliga-
tion is the fame; I there-
fore defire your acceptance
of the following Treatife,
not only as a proof of my
eftimation of your judg
ment, but as a mark of
the gratitude, of
SIR,
your moſt humble fervant,
Watling-ftreet,
Feb. 9, 1756.
PERCIVALL POTT.

PREFACE.
TH
HE benefits derived to
mankind from the art of
furgery are fo many, and fo great,
that the ſmalleſt attempt toward
an improvement in it has a claim
to a favourable reception.
The many ufeful and inftruc-
tive books which have been pub-
lifhed within the laft half cen-
tury, and the many able and
judicious practitioners with whom
all Europe, and particularly this
A 3
coun-

vi
PREFACE.
country, abounds; may be
thought to render the following
treatiſe unneceffary: I am, my-
felf, fatisfied that it is fo with
regard to the majority of the
profeffion; but as fome part of
it may, without offence, be pre-
fumed to be lefs informed (not
having had the fame opportuni-
ties of information) I hope to be
excufed attempting to convey
inftruction to thofe who may
ftand in need of it, and fhall al-
ways be glad to receive it my-
felf.
From the difeafe which is the
fubject of the following tract,
no age or fex, no rank or con-
dition of life is exempt; upon the
proper or improper treatment of
it

PREFACE.
vii
it the life of the patient frequent-
ly depends; it fometimes re-
quires one of the niceft opera-
tions in furgery; and has, in all
times fubjected mankind to the
groffeft and moft iniquitous
frauds, impofed upon them by
knavifh and ignorant pretenders,
who have neither anatomical nor
furgical knowledge to fupport
them, and whofe credit is built
on the credulity and bafhful-
nefs of thoſe who fall into their
hands.
The truffes put on abfceffes,
bubo's, hydroceles, and unre-
duced ruptures, are melancholy
proofs of their ignorance: the
number of deluded people who
have paid largely for attendance
A 4
on

Vill PREFACE.
on ideal ruptures, and the ftill
greater number who have been
at great expence for cures which
were never performed, are well
known proofs of their difho-
nefty.
long
The generality of mankind
look upon a rupture as a kind
of imperfection in their form,
and as a diſeaſe which impairs
their ftrength and abilities; and
the more modeft and bafhful
are fearful of having their difor-
der known from the mere fitua-
tion of it.
With this opinion and this
fear, thefe pretenders are well
acquainted, and very lucrative
ufe do they make of them; they
well

PREFACE.
ix
well know, that the man who
looks on his diforder as a material
imperfection in his form, or as the
caufe of any debility, will be glad
to be rid of it at almoft any ex-
pence or trouble: hence the ig-
norant and credulous are fubject-
ed to tedious confinements, pain-
ful applications, and hazardous
operations, while the timorous
and bashful are cheated out of
large fums of money for ima-
ginary difeafes or pretended cures.
Complaints of this kind com-
ing from the profeffion are re-
ceived but ill, and fet to the ac-
count of prejudice, intereft, and
phyfic-craft; but in this man-
kind do us much injuftice: a
rupture is a diſeaſe which, if ju-
dicioufly

X
PREFACE.
diciouſly and properly treated
from the firft, cannot be pro-
ductive of much profit to the
furgeon; it requires very little
attendance, and neither external
application nor internal medi-
cine; and though his hand and
judgment are neceffary to return
the inteftine and direct the appli-
cation of a proper bandage, yet
it must be obvious that no great
emolument can'arife from thence:
if the profeffion may be allowed
to be impartial in any thing which
relates to themſelves, I think
they may in this, from which
they never can receive any con-
fiderable profit, unless they are
called to accidents arifing from
great negligence of the patient,
or the mifconduct of pretenders.
vticipib
Hac

PREFACE.
Xi
Hac fonte derivata clades.
slot toward basarism
I have no intention to write
a panegyric on furgery or fur-
geons; they, like all other bo-
dies of men, and indeed like
every individual, muft ftand or
fall by their own conduct and
merit. But as the fpecious pre-
tence for the encouragement of
quacks made ufe of both by them-
felves and their patrons is, that
through mere obftinacy we never
depart from the cuftoms of our
anceſtors, nor attempt any thing
new, though mankind might be
much benefited thereby; I muft
beg leave to be indulged a few
words on this fubject.
That

xii PREFACE.
That many of our anceſtors
had great merit, and have left
many noble proofs both of their
fagacity and dexterity, is known
to every man who is at all ac-
quainted with them.
On the other hand it muft al-
fo be allowed that they laboured
under many diſadvantages, both
in their theory and in their prac-
tice.
Thefe difadvantages were prin-
pally owing to the imperfect ftate
of their anatomy, in the cultiva-
tion of which kind of knowledge,
the people of the prefent age have
had fuch affiftance, as would con-
vert

PREFACE.
xiii
vert ignorance into a vice, and
render them inexcufable.
This is the only true and fo-
lid bafis on which furgery can
firmly ftand; this muft for ever
fupply the firſt elements of all
medical knowledge, and give to
an operator that due mixture of
coolness and boldnefs which will
equally guard him againſt the
inconveniences arifing from too
much or too little caution, and
enable him to fulfil the advice
of the elegant author of my
motto--Non magis quam res
defiderat properet, vel minus
quam neceffe eft fecet.
By anatomy I would not be
underſtood to mean the feriæ
nuga

xiv
PREFACE.
nuga of mifcrofcopical anatomy;
but a perfect knowledge of all
the obvious and apparent parts of
the human ftructure, the laws
of its œconomy, the rules by
which its health is maintained,
the manifeft caufes of difeafes,
their fymptoms in the living,
and their appearance in the
dead.
This fcience has, within thefe
fifty years, been very affidu-
oufly cultivated; many ufeful
diſcoveries have been made, and
the practice both of phyfic and
furgery been thereby confider-
ably improved: in different
parts of Europe many emi-
nent men have appeared, Bidloo,
Cowper, Ruyfch, Swammerdam,
4.
the

PREFACE.
XV
the late ingenious Dr. Doug-
lafs, Heifter, Morgagni, Albinus,
Winflow, Monro, Haller, Hoff-
man, Nichols, Hunter, and others,
who have traced and explained
the animal ftructure, with fuch
indefatigable pains and induftry,
as will derive honour both to
themſelves and their fcholars,
and preferve their reputation as
long as anatomical knowledge
fhall be thought ufeful or ne-
ceffary.
And that this has not been
confined to the diffecting rooms
of anatomifts, or ferved only for
the amuſement of the fpecula-
tive; the many improvements
that have been made in the prac-
tice of furgery, and the many
in-

xvi PREFACE.
4
ingenious and practical obferva-
tions that have been publifhed in
the feveral parts of Europe, with-
in theſe few years, will appear as
proofs.
The practical part of the an-
tient furgery was coarfe, and load-
ed with a farrago of external ap-
plications; fome of which were
unneceffarily painful, and others
abfolutely ineffectual, to fay no
worfe of them: and the opera-
tive part of the art was encum-
ber'd with a multiplicity of
aukward unmanageable inftru-
ments.
The moderns have brought
the practice into a much nar-
rower compafs, have rendered
it

PREFACE.
xvii
it more intelligible and lefs pain-
ful: They have made many be-
neficial alterations in the opera-
tive part; and by a reduction of
the number of inftruments, and
a perfect fimplicity in the ftruc-
ture of thoſe in ufe, they have
confiderably affifted the dexterity
of an operator, as well as fhorten-
ed the time of an operation.
We now know from expe-
rience, that fome of thofe cafes
which uſed formerly to be treat-
ed with much feverity with e-
fcharotic and cauftic medicines,
are to be brought into a kindly
and healing ftate, by means that
are rather lenient than painful:
and though cauftic applications
are ftill ufeful, and in fome few
2
cafes

xviii
PREFACE.
cafes abfolutely neceffary, yet
we are much more fparing in
the ufe of them, and find that
we can obtain the fame end by
means which are milder, and
not productive of fuch indelible
marks.
The prefent eafy method of
treating wounds made by gun-
fhot; the difufe of long probes
and long forceps, armed with
teeth, for the extraction of fo-
reign bodies; with the liberty
which the prefent practitioners
have taken of varying from an
old eſtabliſhed rule, viz. that all
fuch bodies must be extracted at
all events, has faved many a
limb and life in our
fleets and
armies ;

PREFACE. xix
ex-
armies; and will in its confe-
quence have a ftill more
tenfive and beneficial influence,
by inculcating a precept which
fhould ftand at the head of the
monita chirurgica, and never be
out of the mind of a practi-
tioner, viz. that it will fome-
times happen, that the lefs he
does, the better he will fucceed,
as he will thereby give nature
an opportunity of availing her-
felf of thofe powers and fa-
culties with which her Almighty
Author has endued her, which
will frequently be found fuffi-
cient for all her purpoſes, and
to affift which, fhould be the
a 2
whole
† See Mr. Serjeant Ranby's treatife on
gun-fhot wounds.

XX
PREFACE.
whole aim both of phyfic and
furgery.
The improvements made in
the operative part of furgery are
as confpicuous.
The double incifion in am-
putations, by which fo much
fkin is preferved, as to produce
a more feemly and lefs painful
ftump, and by which it is much
fooner healed.
The prefent manner of re-
moving cancerous breafts and en-
cyfted tumours, by which large
frightful fears are avoided, and
much time faved.
The lateral operation for the
ftone.
The

PREFACE.
xxi
The cutting gorget calculated
for the more eafy and expedi-
tious extraction of the ftone from
the bladder.don't
The extraction of the opake cor-
pus chryftallinum from the eye.
The operation of amputation
in the joint of the fhoulder.
Drawing off all the water at
once in a dropfy.
The certain and expeditious
manner in which we now, by a
very fimple piece of machinery,
cure thofe two terrible deformi-
ties in the ankles and feet of in-
fants, called vari and valgi;
with
a 3

xxii
PREFACE.
with many others which might
be named, are certain and un-
doubted improvements in the
art, improvements made by the
moderns, and fuch as man-
kind are much benefited by, as
their pains are hereby leffened,
the elegance of their figure pre-
ferved, and the time of their
confinement fhortened; all which
will, I prefume, be allowed to
be advantages while human na-
ture fhall remain fenfible of pain,
while fcars fhall be thought de-
formities, or confinement be
deemed irkfome.
But though thefe, and many
-other valuable amendments, have
been made, it is not denied but
that large room is ftill left for the
in-

PREFACE. xxiii-
induſtry of us and our fuccef-
fors.
Some of the operative parts
of furgery are ftill capable of
amendment; fome difeafes re-
main incurable; and the imme-
diate caufes of fome others are
unknown to us: the operation
of lithotomy is ftill frequently
neceffary, notwithſtanding all our
boafted lithontriptics; fchirri re-
main indiffoluble; cancers con-
tinue their ravages, unchecked
by art; and the various mifchief
arifing from injuries done to the
head by blows, falls, &c. are
fo undiftinguifhed from each
other, as to create much trouble,
uncertainty, and vexation in prac-
tice.
a 4
Poffibly

xxiv PREFACE.
Poffibly the induſtry of future
practitioners may difcover fome-
thing whereby mankind may be
relieved in thefe diforders: the
lues venerea and intermittent fe-
vers had afflicted the world long
before their ſpecific remedies
were diſcovered; and mankind
had laboured under pain long
before opium, that folamen mi-
feris, came to their relief; fchirri
and cancers may poffibly here-
after find a cure, and human
nature be thereby freed from
one of its moft fevere afflictions:
this remains for pofterity to fearch
after, and I heartily wifh they
may be fuccefsful in their en-
quiries.
But

PREFACE.
XXV
But from what has been faid,
I hope it will appear, that the
furgeons of the prefent time have
taken the liberty of varying
from their anceſtors, where they
thought they could do it with
fafety and to the advantage of
mankind (the only reafons that
could warrant fuch variations):
that though fome parts of the art
may ſtill appear defective, this de-
ficiency does not arife from want
of application, or from obftinacy,
in the practitioners, but from the
hitherto infcrutable nature of
fome difeafes, and the untame-
able fury of others: that inftead
of fupinely giving up their un-
derftandings, or lazily treading
in the beaten track of their fore-
fathers,

xxvi
PREFACE.
fathers, they have endeavoured
to advance the reputation and
utility of their profeffion by the
only means whereby it is capa-
ble of advancement, viz. a fe-
dulous application to anatomy,
the frequent examination of dead
morbid bodies, and making fuch
experiments on the living, as
they had great reafon to be-
lieve would prove beneficial:
The event has proved fucceſsful
multitudes have felt the benefit,
and pofterity will reflect on the
authors with gratitude.
As the following treatife has
lain by me fome time, I have
frequently altered and corrected
it as a more extenfive practice has
furniſhed me with reafon for fo
doing;

PREFACE. xxvii
doing; and as it is now prefented
to the public, I am not confcious
of there being any thing in it
which is not strictly true.
I have endeavoured to exprefs
myſelf on the difeafe, and its
proper treatment, in as plain,
explicit, and intelligible a man-
ner as I am capable of, and the
fubject will admit; being de-
firous, as much as in me lies, to
inform mankind of the true na-
ture of the diſeaſe, of the dangers
they incur, and the frauds they
are liable to from the ignorance
of one fet of quacks, and the
worfe qualities of another; to
fhew them what the art of fur-
gery, in honeft and judicious
hands, is capable of doing in this
4
dif

xxviii PREFACE.
difeafe, and how effentially the
conduct of an impoftor differs
from that of an honeft man,
who will never be afhamed to
acknowledge that he cannot do
what is not in his power.
Falfus honor juvat, et mendax infamia
terret,
Quem nifi mendofum et mendacem?
I as
With regard to the profeffion,
I have only to add, that as it is
principally defigned for thofe
whofe early time of life, or little
opportunity of learning bufinefs,
but from books, renders them
proper objects of fuch informa-
tion; the more experienced rea-
der ought not to be difpleafed at
what may appear to him trite.
And though I have prefumed to
be-

PREFACE. xxix
become an author on a fubject-
which I have taken fome pains
to confider, yet I am fatisfied,
many things may have efcap-
ed me, which may appear to
others, who may alfo fee the
fame circumftances in a different
light.
The general appearances of
diſeaſes will always be much the
fame, and confequently the ge-
neral deſcriptions of them will be
much alike alfo; where I have
taken the liberty to differ from
the general opinion or doctrine,
I am very fure I have done it
with diffidence, and I hope with
civility, inafmuch as I have no
inclination to cavil or find fault,
but

XXX
PREFACE.
but merely to inquire into truth,
for the improvement of myſelf
and others, and the general be-
nefit of mankind. gnid
oldw
21 bas
A

[1]
A
TREATISE
ON
RUPTURES.
B
SECT. I.
Y the term rupture, hernia,
or deſcent, is meant a tu-
mor produced by the fal-
ling down or protrufion of fome
part or parts which fhould na-
turally be contained in the cavity
of the belly.
B
The

2
A TREATISE ON
The places in which thefe
parts make their appearance in
order to form what is called a
rupture, are the groin, the fcro-
tum, the navel, the labia pu-
dendi, the upper and fore part
of the thigh, and every point of
the anterior part of the belly.
The parts principally liable to
fuffer this protrufion, or defcent,
are a part of the omentum or
caul, a portion of the intef-
tines, and fometimes (tho' very
rarely) a portion of the ftomach.
From theſe two circumftances
of fituation and contents, are de-
rived the different appellations by
which the different kinds of
rup-
MIU
tures

RUPTURES. 3
tures are diftinguiſhed from each
other.
From their fituation they are
called inguinal, fcrotal, femoral,
umbilical, or ventral ruptures,
as they happen to make their
ap-
pearance in the groin, fcrotum,
thigh, navel, or belly.
If the prolapfed body be a por-
tion of inteftine, the tumor is
called enterocele, hernia intefti-
nalis, or inteftinal rupture; if it
is omentum, it is called epiplo-
cele, hernia omentalis, or omen-
tal rupture; if both inteftine and
caul confpire to form the tumor,
the name is compounded of both
contents, and is called entero-
epiplocele.
B 2
The

4-
A TREATISE ON
The vulgar fuppofition that
thefe bodies defcend thro' paf-
fages forcibly made by breach or
laceration of the containing parts,
is not true; at leaft with regard
to the inguinal, fcrotal, femoral
and navel ruptures: the aper-
tures by which the three former
defcend are natural to every hu-
man body, as well thofe who
have not, as thoſe who have rup-
tures, and permit the tranfit of
the caul, or gut only by being
dilated. The principal paffages
are thoſe on each fide of the
lower part of the belly near the
groin, thro' the tendon of one
of the abdominal mufcles; and
the hollow formed under what
is commonly called Poupart's or
Fallo-

RUPTURES.
5
Fallopius's ligament, in the up-
per and fore part of the thigh;
through the former the fpermatic
veffels pafs to the tefticles in men,
and the ligamenta uteri in wo-
men; and thro' the latter the
great crural vein and artery
to the thigh and leg in both
fexes.
A fhort anatomical defcription
of thefe parts is fomewhat ne-
ceffary to underſtand rightly the
true nature and fituation of this
difeafe. The pair of mufcles
called obliqui externi or defcen-
dentes, cover all that part of the
belly which is without bone, and
the lower and fore part of the
thorax; they are fleſhy on the
fides, and tendinous in the mid-
B 3
dle

6
A TREATISE on
dle and lower part; they fpring
from the ſeventh and eighth ribs
and all below them, by fleshy
portions which indigitate with
correfponding portions of two
other mufcles called the ferratus
major anticus, and latiffimus dorfi,
and becoming tendinous are in-
ferted into the linea alba, fpine
of the os ileum and the os pubis.
What is called Poupart's or
Fallopius's ligament, is nothing
more than the lower border of
this tendon ftretched from the
fore part of the os ileum or
haunch bone, to the pubis: the
tendinous fibres of this muſcle
as they proceed obliquely down-
ward, diverge and leave feveral
fmall apertures for the paffage of
veffels

RUPTURES.
7
veffels and nerves, and as they
are inferted into the pubis they
crofs each other and are interwo-
ven, by which the infertion is
much ftrengthened.
At the lower part of the belly,
a little above the pubis, the fibres
of theſe tendons feparate from
each other, and form thereby a
large oval aperture on each fide,
juft above the groin, thro' which
pafs the fpermatic veffels to the
teſticles in men and the ligamenta
uteri in women, in whom this
aperture is much fmaller than it
is in men; as the ligamentum
uteri is alfo much fmaller than
the fpermatic chord.
B 4
The

8
A TREATISE on
The other muſcles of the belly
having no immediate concern
with the prefent fubject, I fhall
take no other notice of them
than only to obferve, that the
fpermatic chord does not pafs
thro' any openings in thefe, but
under the lower edge or border
of two of them, (viz. the obli-
quus internus, and tranfverfalis)
at fuch diftance and in fuch man-
ner, that no action of thefe mu-
fcles can make any ftricture up-
on it,
The infide of thefe mufcles,
and indeed the whole cavity of
the belly, is lined by a fmooth,
firm, but eafily dilatable mem-
brane called the peritoneum, a
minute

RUPTURES.
9
minute anatomical defcription of
which would lead me befide my
prefent purpoſe; let it fuffice to
obferve, that it lines the whole
cavity of the belly, and gives an
external coat to all the vifcera
contained in it.
Behind the peritoneum lies a
loofe cellular membrane called
its appendix; this is found in
very different quantity in differ-
ent places, in fome it is plenti-
fully stocked with fat, in others
it is void of fat, and is the fame
fort of cellular membrane as is
found all over the body.
This cellular membrane (void
of fat) enveloping the fpermatic
chord is called the tunica vagi-
nalis

IO
A TREATISE on
nalis communis, or tunica vagi-
nalis of the chord; which chord
thus enveloped, paffes out from
the cavity of the belly, under
the edge of the tranfverfalis, and
internal oblique muſcles, and
thro' the aperture in the tendon
of the external oblique, juft a-
bove the groin.
The hernia or rupture in its
fac (foon to be defcribed) is pufh-
ed from the cavity of the abdo-
men thro' the fame aperture, and
infinuates itſelf into the tunica
vaginalis, in fuch manner, as to
be totally enveloped by it, and
to lye anterior to the fpermatic
veffels, or chord.
The

RUPTURES.
II
The tunica vaginalis teftis is a
diftinct membrane, forming a di-
ftinct cavity, including the tefticle
and a fmall quantity of limpid
Auid.
The acknowledged ufe of the
muſcles of the belly is to expel the
fæces and urine, to help the di-
geftive organs by gentle and
frequent compreffion, to affift in
the act of vomiting, and by de-
preffing the ribs and forcing the
diaphragm upward to contribute
to expiration.
By the action of theſe and of the
mufcles of refpiration, the con-
tents of the belly are continually
preffed upon, and in fome actions
I
and

12
A TREATISE ON
and exertions of ftrength preffed
on with great, and fudden force,
and as our erect pofture favours
the deſcent of the contained parts
toward thoſe places which lie low
and are little defended, a portion
of gut, or caul will fometimes
flip through, and the lefs the
natural ftrength of the fubject,
the more likely will this be to
happen, which is one reaſon why
children are more fubject to this
diforder than adults.
This is the moft probable and
natural account of the origin of
the ruptures of children and
adults, but will not account for
thofe of infants, in whom we
very frequently find them foon
after birth, when erect pofture
can

RUPTURES.
13
can have had no fhare in their
production.
If the teſticles of a fœtus were
down in the fcrotum, depen-
dent from the fpermatic chord,
as they are in an adult, they
would in fome poftures and dif-
pofitions of the child at the time
of parturition be very liable to be
hurt; to prevent which, and
poffibly for other reafons alfo,
the tefticles of a foetus during
its refidence in the uterus, lie
within the abdomen, behind the
peritoneum, defended by the
bone; foon after, birth, when the
lungs come to be diftended with
air and prefs on the diaphragm,
when the muſcles of refpiration
act, and thofe of the abdomen
be-

14
A TREATISE on
begin to fqueeze the contents of
the belly, the testicles are puſhed
out thro' the apertures in the ab-
dominal muſcle (called the rings)
into the upper part of the fcro-
tum: This paffage of the tefticle
from the belly into the fcrotum,
I take to be the principal caufe
of the ruptures of infants, for
the ring or aperture being by
this means dilated, a portion of
caul or gut has an opportunity
of flipping thro' before the aper-
ture has had time to contract it-
felf again, and which protrufion
will be forwarded by the con-
tinual efforts of the child in
crying.
This has always appeared to
to me to be the cafe; and in this
I

RUPTURES. 15
am more confirmed by obferv-
ing that almoft all the infants
that are ruptured within the first
five or fix months of their life,
are males. But whether this is
the cafe or not, certain it is, that
the greater part of ruptures have
their rife in early infancy, are
produced gradually, are very
fmall at their firft appearance,
and are feldom feen or regarded
in children, till they have got be-
low the groin, more or lefs into
the fcrotum.
This defcent or protrufion will
happen frequently, when the in-
fant ftrains to cry, or to empty
the inteftines of fæces, and will
return up again as foon as the
child is quiet; the nurſes call it
wind,

16
ATREATISE ON
wind, and it is generally at firft
neglected, the child not being
apparently injured, and the peo-
ple about it not knowing the
confequence.
Neither the inteftine nor o-
mentum can defcend thro' either
of the above-mentioned aper-
tures in the groin or belly, with-
out thrufting before them a por-
tion of the peritoneum, in form
of a bag or pouch, not unlike
what is called a thumbftal, in
which the piece of gut or caul
is included; this is called the
hernial fac; and as this defcent
will frequently happen unregard-
ed, from the manner in which
our children are cloathed, and
the few opportunities we have of
fee-

RUPTURES.
エウ
​feeing them naked, this fac, con-
fifting of a fine and eafily dilata-
ble membrane, will by each de-
ſcent be prolonged or lengthened,
and pafs gradually from the groin
into the fcrotum.
It has been the opinion of fome,
and, among the reft, of Mr. Che-
felden, that the fac of a hernia
is not an elongation of the peri-
toneum, but formed like the fac
of an aneurifm, and that of fome
other tumors, by the thickening
of the common membranes from
preffure and obftruction: how-
ever true this may be in fome
cafes, it moft certainly is not fo
with regard to the prefent, the
hernial fac being clearly and de-
monftrably a portion of the
C
pe-
ritoneum,

18
A TREATISE on
ritoneum, lengthened gradually
by the deſcent of its contents,
and becoming thicker as it is
lengthened.
Whether the fac in its infant
ftate, while it is very thin and
has contracted no adhefions, ever
re-afcends into the belly with
the inteftine, I will not pretend
to determine; but am much in-
clined to think it does not, from
the facility with which the parts
compofing a rupture defcend,
after they have been few times
down, and from a fulnefs which
may generally be felt along the
procefs of fuch children as have
been ruptured; fome few of
which I have had an opportunity
of opening after death, and have
al-

RUPTURES. 19
always found the fac in the
fcrotum.
From the natural laxity of the
whole frame of infants, from the
foftneſs and flexibility of their
fibres, and from their frequent
efforts in crying, this protrufion
or deſcent will happen frequent-
ly; when down, the nurfe's hand
or a warm cloth generally ferve
to return it; and, as I faid be-
fore, it paffes for wind and is
neglected, till it happens to be
feen by fome perfon of judgment,
or creates trouble to the child.
This is the general date, ori-
gin, and firſt riſe of this diſeaſe;
but to this there are feveral ex-
ceptions: There are many in-
C 2
ftances

20 A TREATISE ON
ftances of ruptures making their
firft
appearance in adults, who
have not been ruptured while
they were infants; and there are
feveral inftances of ruptures pro-
duced by efforts, blows, &c. in-
ftantaneoufly: but the moft fre-
quent origin is that which I have
mentioned; and by what has
come within my obfervation, it
has appeared to me that the ge-
nerality of the fcrotal hernias of
adults have been derived from
childhood, and thofe ruptures
which have made their firft ap-
pearance in mature age, have ge-
nerally remained inguinal rup-
tures.
I take no notice of the old dif
pute about the dilatation or la-
ceration

RUPTURES.
21
ceration of the peritoneum, as it
is agreed by every body, and in-
deed is plainly demonftrable
that the peritoneum is dilated to
form the hernial fac, but tho'
dilated to a very great degree,
yet always remains entire; the
cafe, quoted by Mr. Sharp, of
the inteftine being found in con-
tact with the tefticle, being an
accidental thing, and to be rank-
ed as fuch, or as one of the lu-
fus naturæ.
The figns of an inguinal or
ſcrotal rupture are a tumor in
the groin or upper part of the
fcrotum, beginning at the ring
of the abdominal mufcle, and
extending more or lefs down-
ward; which tumor appears dif-
C 3 ferently

22
A TREATISE on
ferently to the touch, according
to its different contents.
If a portion of inteftine forms
the tumor, and that portion is
not a very fmall one, its furface
is fmooth and renitent, but
much more fo upon the actions
of coughing, fneezing, &c. up-
on every effort of which it feels
as if it was blown into.
Hom
If a piece of omentum has
flipped down, it has a more flab-
by feel, feems to have a more
unequal furface, makes lefs re-
fiftance to the finger, and gives
the fcrotum a lefs round figure;
and if the portion is large and
the fubject adult, it is in fome
meafure diftinguishable by its
weight;
3

RUPTURES.
23
weight; if it confift of both in-
teftine and omentum, the judg-
ment to be formed by the touch
will be lefs clear and diftinct; but
in this as well as many other parts
of furgery, there is a tactus eru-
ditus, which may be obtained
by practice and reflection, but
of which no clear idea can be
verbally conveyed.
The inteftine moft frequently
found in a fcrotal hernia, is a
portion of the ileum, though it
is no very uncommon thing to
find a portion of the colon and
the cœcum with the appendicula
vermiformis.
The only diſeaſes with which
this can poffibly be confounded
C 4
are

24
A TREATISE on
are the hydrocele, and that de-
Aluxion on the tefticle called her-
nia humoralis. In the hernia
humoralis the tefticle and epidi-
dymis are plainly to be felt, and
their hardneſs difcovered; and
in the hydrocele, however full
the cyft may be, it plainly ter-
minates at the ring of the muf-
cle; befide which, the fluctua-
tion of the water, and the ab-
fence of painful fymptoms, will
plainly point out this diſeaſe,
and diftinguish it from a hernia,
to any man at all acquainted
with either.
Upon the reduction of the
parts by the hand, if the rupture
confifted of a portion of inteftine
only, it generally flips up at
once,

RUPTURES.
25
once, makes a kind of gugling,
which may fometimes be heard,
but always may be diftinguiſhed
by the finger, and leaves the
fcrotum quite free from any pre-
ternatural body; if it confifted
of a piece of omentum, it re-
turns up more gradually and
without any of that fenfation to
the finger which the inteftine
produced; if it confifts of both
inteftine and omentum, the in-
teftine generally goes up firft,
leaves a flabby kind of body be-
hind which is returnable alfo,
but not in the fame manner as
the inteftine, inafmuch as it re-
turns more gradually and gene-
rally requires to be followed by
the finger to the laft,
Rup-

26
A TREATISE on
Ruptures differ from each o-
ther, not only in the place of
their appearance, and in their
contents, which make their ge-
neral difference; but each in-
dividual rupture has fome parti-
cular circumftances which are
neceffary to be confidered in or-
der to form a right judgment of
it: Theſe are the fubject in
whom it appears, its date, its
fymptoms, and the probability
or improbability of its being re-
turnable.
If the ſubject is an infant it is
not often attended with much
difficulty or trouble, the foft-
nefs and ductility of their fibres
generally render reduction eafy;
and

RUPTURES.
27
and though from neglect or inat-
tention it may fall down again,
yet it is again eafily returned,
and at this time of life feldom
produces any miſchief. I fay
feldom, becauſe there are in-
ftances to the contrary, and I
have, myſelf, feen an infant un-
der a year old die of a ftrangu-
lated hernia, with all the fymp-
toms of mortified inteftines, tho'
the rupture had been down but
two days.
If the ſubject is adult, and in
the vigor of life, the confe-
quences of neglect or male-treat-
ment are more to be feared than
at any other time of life, for rea-
fons which are very obvious.
The

28
A TREATISE on
The great and principal mif-
chief to be feared, in all de-
fcents of the inteftine, is a ftric-
ture; this ftricture is made by
the borders of the aperture in
the tendon, through which the
inteftine paffes from the belly in-
to the groin or fcrotum; and it
muſt be obvious, that the more
the natural ſtrength of the fub-
ject is in general, and the more
liable to inflammation, the more
probability there will be of ftric-
ture, and the more mifchief that
ftricture will be likely to pro-
duce.
Hence it muft evidently ap-
pear, that if the fubject is adult
and in the vigor of life, at which
3
time

RUPTURES.
29
time the folids are moft elaftic,
the impulfe of the heart ftrong-
eft, and the circulation of the
fluids moft brifk, that the con-
fequences of neglect or mif-
conduct must be more hazard-
ous than in the foft, flaccid
ftate of infancy, or the languid
circulation of old age.
In very old people the fymp-
toms do not ufually run fo high
as in young, as well on account
of more languid circulation, as
that their ruptures are generally
of antient date and the parts
much relaxed. But then it fhould
alfo be obferved, that they are by
no means exempt from inflam-
matory fymptoms, and that
when fuch do occur, the una-
voidable

30
A TREATISE on
voidable infirmity of old age is
no favourable circumftance in
the treatment which may become
neceffary.
With regard to the date of the
difeafe, if it is of fome ftanding,
has been neglected, and has been
frequently down without giving
any trouble, the aperture in the
tendon and the hernial fac may
both be prefumed to be large;
which circumftances render im-
mediate reduction rather lefs ne-
ceffary; on the contrary if the
hernia be recent, or (tho' old)
has been generally kept up, its
immediate reduction is abfolute-
ly neceffary, inafmuch as the
rifque of ftricture is in thefe cir-
cumftances much greater.
If

RUPTURES.
SI
If the rupture is very large
and antient, the patient far ad-
vanced in life, the inteftine does
its duty in the fcrotum, and no
other inconvenience attends it
than that produced by its weight,
it will be better not to at-
tempt reduction, inafmuch as it
will moft probably be fruitless,
and the neceffary handling may
prove troublefome: this muft be
underſtood of thofe which are
not attended by any ſymptoms
of ftricture, fuch fymptoms mak-
ing reduction abfolutely neceffary
at all times, and in every cir-
cumftance.
With regard to contents, if
it is omentum only, and has
been

32
A TREATISE 072
been gradually formed, it feldom
produces any bad fymptoms;
though its weight may become
very troubleſome; but if pro-
duced fuddenly by effort or vio-
lence, it will fometimes prove
very painful, and caufe very
troubleſome ſymptoms, the con-
nection between the omentum
and ftomach being fuch as to
make the defcent of a large piece
of the former productive of nau-
fea, and vomiting: when en-
gaged in a ftricture it has been
the cauſe of ſtill worfe fymptoms
by becoming gangrenous; and
though it fhould not be attended
by any bad fymptoms dependent
on itſelf, as a mere omental
rupture, yet it may, upon any
extraordinary effort or exertion
of

RUPTURES.
33
of ftrength, be productive of an
inteftinal hernia and all its con-
fequences by keeping the ring
and fac conftantly open.
If it is a portion of inteftine
only which forms the hernia,
the rifque is greater, ftrangula-
tion being more likely to hap-
pen and more productive of mif-
chief when it has happened; the
fmaller the portion of gut is
which is engaged, the tighter
the ftricture binds, and the more
hazardous the confequences. I
have ſeen a fatal gangrene in a
bubonocele in less than thirty
hours, in which the piece of
gut did not exceed an inch, and
had never been down before.
D
Every

34
A TREATISE an
Every thing confidered, I
think, it may be allowed, with
fome few exceptions, that an
inteftinal rupture, confidered in a
general fenfe, is fubject to fymp-
toms and to danger, which an
omental rupture is not fubject
to; that bad fymptoms are more
likely to attend recent ruptures
than old ones; that a defcent
of inteftine only, is rather more
likely to produce mifchief than
when it is accompanied by a
piece of omentum; and that no
true and proper judgment can be
formed of any hernia, unleſs e-
very circumftance relative to it is
duly confidered.
The

RUPTURES.
35
The cure of a rupture has al-
ways been divided into perfect
or radical, and imperfect or pal-
liative; a diftinction, which tho'
juft and true, and founded upon
reafon and experience, has, by
being miſunderſtood, been the
occafion of much undeferved
cenfure on the profeffion.
The means ufed to procure
both kinds of cure are exactly
the fame, and the event is de-
pendent on caufes which the fur-
geon can neither forefee nor di-
rect.
This is a feeming paradox
which mankind in general do
not underſtand, an anatomical
D 2
ac-

36
A TREATISE 072
acquaintance with the parts con-
cerned in the difeafe being
abfolutely neceffary to fuch
knowledge. They conceive that
the means made ufe of to pro-
duce a radical cure are, or fhould
be very different from thofe made
ufe of merely to palliate; and
this conception, or rather mif-
conception, lays them open to
all the fraud and delufion of im-
poftors.
To labour under a trouble-
fome diforder, perhaps in the
moft active and joyous part of
life, and to be told that a pal-
liative cure by wearing a ban-
dage is all that can be ex-
pected is very difagreeable; the
true reafon of this, they are
not

RUPTURES. 37
not acquainted with, and are
eafily induced to believe what is
infinuated to them, viz. that the
regular part of the profeffion are
deficient in the knowledge of the
proper treatment of this diſeaſe;
their application is therefore made
to thoſe who promife moft; quod
volumus facile credimus; igno-
rance of the true nature of the
difeafe, and a ſtrong defire to be
cured on one fide, and bold and
plaufible affurances on the other,
carry on the delufion, till time
and the continuance of the rup-
ture evince the truth and prove
the fraud, which the patient,
tho' perfectly convinced, will
often join in concealing, either
to avoid being laughed at for
D 3
his
Jon

38
ATREATISE on
his credulity, or to prevent a dif-
covery of his infirmity.
All that can be done by fur-
gery toward the cure of a her-
nia, is to replace the prolapfed
body or bodies in the cavity of
the belly, and to prevent them
from flipping out again.
This is all that art can do in
either fex and in every age; but
nature, according to the age of
the patient, the date of the rup-
ture, the fort of rupture, and
fome other circumftances, is ca-
pable when properly affifted,
(and not interrupted) of doing
more, and of confirming that
as a perfect cure in fome, which
in

RUPTURES.
39
in others fhe is obliged to leave
imperfect, and conftantly requir-
ing the affiftance of art.
When the portion of gut or
caul, or whatever formed the
tumor, is perfectly and properly
replaced in the belly, and an op-
portunity thereby given to the
tendinous aperture to contract
itfelf, and for a proper bandage
to bring the fides of the entrance
of the hernial fac as near toge-
ther as it will admit, the fur-
geon has done his part, the reft
is nature's; and whether thefe
parts will fo contract as to pro-
hibit a future defcent or not, is
matter of uncertainty and not to
be known but from the event.
D 4
This

40
A TREATISE on
This every judicious man
knows, and every honeft man
will fay.
All the pretenfions which have
in all times been made by dif-
ferent people to remedies endu-
ed with fuch virtues as to be
capable of confolidating the parts
fuppofed to be tore, or of con-
ftringing thoſe which are dilated,
have all proved inefficacious, and
delufive, to fay the best of them;
the parts moft immediately con-
cerned in this difeafe are quite
out of the reach of any appli-
cations; and all the relief which
the patients of theſe pretenders
have found has been from the
long reft to which they have
been

RUPTURES.
4.I
been fubjected, or the ftrict ban-
dage which they have wore.
Many of theſe people having
never worn any bandage at all
before, are eafily perfuaded that
the relief which this has given
to them, has been produced by
the applications which have been
made to the part, or by the me-
dicines which they have taken,
all which were ufed merely to
deceive them, and which never
had, nor ever can have, any fhare
in the cure of a rupture.
By what has been faid, I
would not be underſtood to
mean, that when the gut or caul
are once replaced, the patient
can receive no farther benefit
from furgical affiftance: nor that
every

42
A TREATISE on
every rupture in adults or perfons
of mature age is incapable of
cure: this is far from my mean-
ing, and far from truth: there
are many circumftances in rup-
tures and ruptured patients which
require frequent affiftance, with-
out which the probability of a
cure will be much lefs: and
there are many ruptures in per-
fons of mature age which will
admit of perfect cure, if proper-
ly and judicioufly managed from
the firft.
FIL
I only mean to obviate the
vulgar prejudice fo conftantly en-
couraged by all quacks, that there
are medicines and applications
which are ſpecific in the cure of
this diſeaſe; and of which they
2
are

RUPTURES. 43
they are poffeffed; neither of
which is true.
A few words may ferve to ex-
plain this matter. The general
doctrine is, that the ruptures of
infants, and thofe of very young
fubjects, generally admit of per-
fect cure: thofe of adults lefs
frequently, and thofe of old peo-
ple hardly ever
in general, true,
all which is,
volg log
The difference between thefe
three general ftates is principally,
if not entirely, owing to the
different ftate of the hernial fac
and tendinous aperture at theſe
different ages.
The

44
A TREATISE on
The hernial fac has been de-
fcribed as being a production or
elongation of the peritoneum,
thruft down before the body,
which by its deſcent from the
belly forms the hernia; at firft
(that is while the hernia is re-
cent) this fac is fmall and thin,
and, as I obferved before (to ufe
a familiar image) like a thumb-
ftal, or the extremity of a fin-
ger of a glove cut off; it hard-
ly ever (if ever) returns into the
belly after it has been once down,
but by repeated defcents of the
caul or gut into it, being of a
very dilatable nature, is con-
tinually lengthened and inlarged;
when it has got below the groin
into the fcrotum, it acquires a
pyriform or pear-like figure, with
its

RUPTURES.
45
its neck or narrow part next the
abdomen, and its broadeft part
expanded more or lefs in the
fcrotum, according to the fize,
date, and quantity of contents;
in young fubjects, and recent
ruptures, it is very thin, but in
proportion as it is extended in
length it increafes in thickness,
and in time acquires a very con-
fiderable degree of thickness,
firmneſs and hardnefs.
In infants, in very young fub-
jects, and in recent cafes, this fac
from its thin foft ftate, is ca-
pable of having its upper nar-
row part or neck fo compreffed
by proper bandage, as poffibly
to procure an unition of the
fides of it, at leaft fo to leffen
the

46
A TREATISE on
the paffage of it as to prevent
the future defcent of any thing
into it from the abdomen; which
produces a perfect cure.
In thofe of mature age, or
whofe ruptures are of fome ftand-
ing, and confequently the neck
or entrance of the fac large in
proportion to the age, fize of
the fubject, and date of the rup-
ture, the membranes compofing
it being more thick, firm, and
hard, the compreffion of its
neck fo cloſe as to prevent the
paffage of any thing through
it, is more difficult, and
uncertain. In old age, and
old ruptures, the ftill greater
firmneſs and hardneſs of the
fac, render it lefs compreffible,
and

RUPTURES. 47
and confequently the occlufion
of the paffage by this means ftill
more impracticable.
From this account of the dif-
ferent ftate of the hernial fac it
muft appear, that all thefe cir-
cumſtances will be very various in
different perfons; that not only
the difference of age in the fub-
ject, and date of the rupture,
but that of habit, conftitution,
&c. muft produce a great va-
riety in theſe cafes, and confe-
quently that the precife age and
fubject that will or will not ad-
mit a perfect cure, muft be very
uncertain, and not in the power
of the moft judicious man to
determine abfolutely, tho' from
many circumftances he will ge-
nerally

48
on
A TREATISE on
nerally know when it is very
improbable or impoffible.
From the fame confiderations
it will appear that recent rup-
tures, if immediately and
pro-
perly taken care of, admit a
perfect cure at almoft any age;
as do alfo moft of thofe which,
tho' in adult fubjects, are got no
lower than the groin.
From the fame confideration, it
will
appear, that tho' the firmness
of the hernial fac, and the large-
nefs of the abdominal aperture
are always mentioned as two
caufes of the difficulty or im-
practicability of the cure of old
ruptures, yet, in fact, the latter
is the effect of the former; a
thick,

RUPTURES.
49
thick, tough, incompreffible
purfe paffing thro' the aperture,
and continnually dragged down-
ward by a weight at its bottom,
being a conftant caufe of dilata-
tion.
Hence alfo will appear the
abfurdity of all external applica-
tions, they being defigned, if they
are ufed with any medical defign
at all, either to conftringe the
aperture by which the rupture
has defcended, or to leffen the
diameter of the neck of the fac
fo as to prevent any future de-
fcent: The conftriction of the
aperture is abfolutely impoffible
while fuch a wedge as an old,
tough, hernial fac remains in it,
which wedge will for ever re-
E
main,

50
A TREATISE on
main, as it is not returnable in-
to the belly whence it came,
from adhefion to the fpermatic
chord and other parts: and the
diameter of the neck can be lef-
fened by no applications, unlefs
fuch could be found as could
render the fac thin, foft and
compreffible; which from the
nature of things, and from all
experience, is abfolutely impof-
fible.
It is fcarcely credible, how
very fmall an opening will ferve
for a portion of gut or caul to
infinuate themſelves into at fome
times: and though in many per-
fons of mature age it proves
practicable fo to comprefs the
mouth of the fac as abfolutely to
im-
clofe

RUPTURES.
51
clofe it, yet by the conftant ufe
of a well made bandage, it may
be fo leffened as to make the de-
fcent of any thing from the belly
more difficult; from whence we
may learn, the great confequence
of having the part compleatly
returned before the application
of a bandage, and the danger
that may be incurred by difufing
or laying it by after it has been
wore fome time: for whatever
can make the defcent from the
belly lefs eafy, muft neceffarily
make the return of any part that
may have flipped down while the
bandage was off, more difficult,
the confequence of which is ob-
vious. And from hence alfo we
may learn, why the bandage
fhould be long and unremitting-
E 2
ly

52
A TREATISE on
ly wore by fuch young patients
as have reafon to expect a per-
fect cure; one half of the fcro-
tal hernias of adults proceeding
from the negligent manner in
which fchool-boys wear their
truffes. With a trufs properly
made, and carefully wore, the
meaner kind of people may be
rendered fit for all the offices of
life, will be capable of labour
of any kind, of walking, of ride-
ing, &c. as all thofe find them-
felves to be, who are willing to
do theſe kind of things: and with
regard to very old people with
very old ruptures, no confine-
ment however long, nor any ban-
dage however ftrict, is capable
of producing a perfect cure:
that bandage which proves reten-
tive

RUPTURES.
53
tive of the parts after they have
been returned, will ferve all the
purpoſes of life, and in the cir-
cumftances of thefe people, an
attempt by a ftricter kind of ban-
dage has more than once proved
fatal.
45
E 3 SECT.

54
A TREATISE on
T
SECT. II.
O replace the portion of
inteftine or caul which
formed the tumor, and to re-
tain it when replaced, has been
allowed to be all that the art of
furgery ultimately pretends to,
toward the cure of a rupture;
but as there are many different
circumftances attending thefe
parts, while in the groin or
fcrotum, the treatment of them,
in order to accomplish thefe two
ends, muft neceffarily be differ-
ent. Thefe circumftances are
reducible to four general heads,
under which may be compre-
hended all the fpecies of rup-
tures, with every particularity
by

RUPTURES. 55
by which they differ from each
other.
The firft comprehends thofe
which are in fuch a ftate as to be
capable of immediate reduction,
and are
not attended by any
troublefome or bad fymptoms.
The fecond, thoſe which have
been fo long in the fcrotum as
to have contracted adhefions and
connections, by which they are
rendered incapable of reduction
at all.
The third, thofe in which
fuch ftricture is made on the
prolapfed parts, as to bring on
pain and trouble; and to render
E 4
the

56 A TREATISE on
the reduction difficult as well as
neceffary.
The fourth, thofe in which
reduction, by the fimple opera-
tion of the hand, is impractica-
ble, and the patient's life can
be faved only by a furgical ope-
ration.
The firft is moft frequently
the cafe of infants, whofe rup-
tures have been often down be-
fore they have been taken no-
tice of; many of them, after they
have been obferved, are only
preffed back by the hand of the
nurfe, as often as they come
down, or elfe return, fua fponte,
upon the child being quiet or
3
laid

RUPTURES.
57
laid fupine; not but there have
been inftances of bad effects from
ftricture even in infants.
An error which generally pre-
vails among nurſes, and has prov-
ed detrimental to many a child
is, that no proper bandage can
be put upon them till after they
are three or four years old.
Upon this fuppofition they
content themſelves with a di-
mity-belt or fome more fooliſh
contrivance of their own; by
which the child lofes fo much
time, and is daily in danger of
farther mifehief: whereas there
is no age in which a proper ban-
dage may not be wore; and by
the timely ufe of fuch, fome
chil-

58
A TREATISE 022
children will have obtained a
perfect cure by the time that
others begin to uſe their ban-
dage.
The manner of returning the
parts is the fame at all times;
therefore I fhall defer faying any
thing about it here, and fhall de-
fcribe it once for all hereafter.
If any difficulty attends it in
fuch young fubjects, it will al-
ways be adviſeable to try the ef-
fect of bleeding, and a glyfter or
two, before any violence is offer-
ed to the part.
Children, efpecially very young
ones, bear the lofs of blood ill;
that is, they are very apt to fwoon
upon

RUPTURES. 59
upon lofing a fmall quantity; and
if while the child is bleeding the
tumor be properly grafped, and
the opportunity of the deliquium
embraced, there are few that will
not return during that relaxa-
tion: it is an eafy experiment,
can do no harm, and may pre-
vent the pain that the neceffary
handling fo tender a part in a
young child muft produce. The
time of the fwoon will alſo be
attended by another advantage,
viz. that of the child being quiet,
and not refifting the attempt by
crying,
When the contents of the her-
nia are returned, a proper ban-
dage fhould be immediately put
on and wore without remiffion,
care

60
A TREATISE 072
care being taken to keep the child
from being galled, by waſhing
all the parts frequently where
the trufs makes any preffure, and
keeping both child and bandage
perfectly clean; by which cau-
tion the trufs will be very little
trouble to the infant, and the
perfect cure may almoft certain-
ly be depended upon. The pro-
per make and adjuſtment of the
trufs, at this age, fhould be very
carefully attended to by the fur-
geon, inafmuch as the child can
make no complaint, that will
inform him of its being unfit, till
fome injury is done.
The most frequent mifchief
aring from an ill made trufs, in
an infant, is an inflammation and
fwel-

RUPTURES. 61
fwelling of the fpermatic chord
and tefticle, which is not only
painful in itſelf, but prevents the
wearing the bandage till it is
gone off.
Many adults alfo have ruptures
in the fame circumftances as thefe
of infants, which give them
little or no trouble, are return-
able at any time by the hand,
and go up when the patient lies
down.
In moſt of theſe the aperture
in the abdominal mufcle is very
large, and if they put on a trufs,
which is not properly made and
fitted exactly, the gut will flip
down behind it in fome particu-
lar poſtures.
This

62
A TREATISE on
This is a circumftance well
worth the attention of the per-
fon who has fuch fort of rup-
ture; for though in thefe cafes
the aperture in the tendon is fo
large, as to leave little room to
apprehend a ftricture, yet pref-
fure made by the bolfter of a trufs
on a portion of inteftine, while
down in the fac, may prove
of
the moſt fatal confequence, and
therefore people in theſe circum-
ftances are fafer without any
trufs at all than with a bad one,
or one that will not keep the gut
from coming down. This ap
pearance of fafety, from a large
aperture and eafy reduction, is
not to be depended upon as cer-
tain, many things may happen
to

RUPTURES.
63
to alter this ftate; an inflam-
mation of the inteftine while in
the fcrotum, the acceffion of a
new portion of gut and mefen-
tery, with many other circum-
ftances which may happen to
render the return now difficult
which before was eafy; all which
are ftrong and good reafons, for
conftantly keeping up the parts
by a well made trufs, the wear-
ing which cannot poffibly be fo
troubleſome as the weight of the
parts in the fcrotum; to fay no-
thing of the fafety of one me-
thod, and the conftant hazard of
the other.
I know a gentleman who has,
for fome years, had an omental
rupture, which being neglected
while

64
A TREATISE on
while he was young, having
a lax habit, and the abdomi-
nal ring naturally large, makes
it extremely difficult for him
to keep it up with the beft
made trufs, behind which it will
fometimes flip down; when this
happens, it gives him fuch im-
mediate and acute pain at the
bottom of his ftomach, and
makes him fo intolerably fick,
that he is obliged to throw him-
felf upon his back immediately
and procure the return of the
omentum, which, from the fame
cauſe that makes its defcent fo
eafy, is eafily accompliſhed.
SECT.

RUPTURES. 65
T
SECT. III.
HE ruptures comprehend-
ed under the fecond head,
are thoſe which from the large-
nefs of the prolapfed parts, from
the antient date of the hernia,
and from connections and adhe-
fions, are become irreducible, but
are not attended by any bad
fymptoms.
Of this fort there are many,
who from a natural laxity of ha-
bit, from having the abdominal
aperture naturally large, and
from having long neglected their
complaint, have carried a large
quantity of caul or inteftine, or
both, in the ſcrotum for a great
F
length

66
A TREATISE ON
length of time, where the in-
teftine has executed its office
without interruption, and the
patients have contented them-
felves with wearing a fufpen-
fory or bag-trufs, to fupport the
weight.
Moſt of theſe might have been
returned at firft; but, by neglect
and length of time, become in-
capable of any other remedy than
the laft mentioned, the fufpen-
fory.
For the contents of the hernia,
by long confinement in fo nar-
row a ſpace, and by little flight
inflammations, contract adhefions
to each other, and to the internal
furface of the fac, efpecially in
its

RUPTURES.
67
its narrower part or neck, in fuch
manner as to make reduction im-
practicable.
When this is the cafe, the
only relief is a bag-trufs, fo
made, as to render the weight
of the tumor as little trouble-
fome as poffible.
People in this fituation fhould
be particularly careful not to
make any attempts beyond their
ftrength, nor aim at feats of agi-
lity, and fhould take care to
keep the loaded fcrotum out of
the way of being hurt; when
the tumor is very large, a foft
quilted bolfter fhould be con-
ftantly wore in the bag, under
the bottom of the fcrotum, and
fre-
F 2

68
A TREATISE on
frequently fhifted to prevent ex-
coriation which in corpulent peo-
ple, and when the tumor is very
large, frequently happens, and
which, by being neglected, will in
fome habits be productive of ftill
worfe confequences. They fhould
alfo take care to keep their body
open, that there may be no im-
pediment to the perfect and free
execution of the office of the in-
teſtinal canal, any obſtruction in
which, would be very prejudi-
cial in thefe circumftances.
By this means, and with thefe
cautions, many people with ir-
reducible ruptures have paffed
their time free from pain or dif-
eafe on this account.
Not

RUPTURES. 69
Not that the quiet and inof-
fenfive ftate of thefe old irredu-
cible ruptures is to be abfolutely
depended upon; for an inflam-
mation of that part of the in-
teftine which is in the fcrotum,
and which may happen without
any ftricture; obftruction to the
paffage of the fæces from any
caufe; in fhort, whatever can
difturb the proper office of the
inteftinal canal, may bring on
mifchief in this part: to which
may be added, what fometimes
happens, viz. the acceffion of
a new piece of inteftine, which
may be ftrangulated, and then
it becomes, to all furgical in-
tents and purpoſes, a recent
F 3
her-

fo
ATREATISE on
hernia, and muft be treated as
fuch.
I am well aware, that among
the number of thofe which have
been thought to be in this irre-
ducible ftate, and have been treat-
ed as fuch, there have been feve-
ral, which upon more cloſe exa-
mination and proper treatment,
have been found capable of re-
duction.
When this is fufpected to be
the cafe, the proper method is
by abfolute reft for a length of
time; by a fupine pofture, and
a courfe of evacuants; to en-
deavour fo to leffen the fize of
the prolapfed parts, as to render
them
41

RUPTURES. r
them capable of paffing back
again into the belly.
This method has fometimes
fucceeded, but previous to the
attempt, there fhould be fome
circumftance which makes fuc-
cefs probable; and there fhould
be alfo good reafon to believe
that the patient's habit and age
will bear the neceffary confine-
ment and evacuation, otherwife
he may chance to be a great lofer
by the exchange of his difeafe.-*
If the attempt fucceeds, a
proper trufs muſt be put on
immediately, and wore con-
ftantly, to prevent the parts
from falling down again, which
from the largenefs of the tendi-
F4
nous

72
A TREATISE on
nous aperture, from the thick-
nefs and hardneſs of the hernial
fac, and the great relaxation of
the mefentery, is fometimes very
difficult to accompliſh, a large
opening from the belly into the
fac always remaining when the
parts have been in this ftate any
time.
An omental rupture, which
has been gradually formed, and
fuffered to remain in the fcro-
tum, is feldom attended with
any bad fymptoms, confidered
merely as a fimple defcent of
the omentum; but by its refi-
dence in the ſcrotum, having al-
ways kept the mouth of the fac
diftended, it may thereby be the
occafion of a defcent of a por-
tion

RUPTURES.
73
tion of inteftine, and all its con-
fequences.
The omentum become adhe-
rent, may inflame, and depofit
in the fac a quantity of an acrid
kind of fluid, which will give
pain and trouble; or it may fup-
purate in confequence of its in-
flammation, and will thereby
make it neceffary to open both
fcrotum and fac; an inftance of
which I had an opportunity of
feeing not long ago.
I was defired to look
upon a
gentleman from whofe fcrotum
near a pint of ftinking brown fe-
rum had been diſcharged two or
three days before by a trocar.
The

74
A TREATISE on
The account he gave of him-
felf was as follows; that he had
for, fome years been fubject to
the defcent of a foft flabby kind
of body into the fcrotum, which
he could put up again when he
pleafed, and which always re-
turned when he was in bed; be-
ing naturally fhy and bafhful, he
had never fuffered any body to
fee it, and was himfelf quite un-
acquainted with the nature of
his diſorder.
From the fudden fpring of an
unruly horfe, he ftruck his fcro-
tum againft the pummel of his fad-
dle, which gave him great pain;
the next day it fwelled and became
more

RUPTURES. 75
more painful; ftill fearful of men-
tioning his diforder, he contented
himfelf with daubing it over with
fome ointment, till at laft it be-
came fo painful that he could no
longer conceal it.
The perfon to whom he fhew-
ed it took it for an hydrocele,
tapped it, and let out the quan-
tity and fort of fluid juft men-
tioned; in few days after this
I faw it, and found the fcrotum
much diftended, very thick, in-
flamed, and painful.
and
The orifice made by the trocar
was floughy, and feemed likely
to caft off, and thereby become
larger; he had a degree of heat
and fever upon him, which for-
bade

76
A TREATISE on
bade any operation at that time,
and therefore I defired that he
might be dreffed with a digeftive
medicine and foft poultice, lofe
fome blood, and have a glyf-
fter.
By the application to his fcro-
tum, and by the ufe of proper
medicines for his febrile heat, in
few days the latter was removed,
and the flough on the former
cafting off largely, I could plain-
ly diſcover the putrid floughy
omentum within; I would have
laid the whole open, but was not
permitted, and could only ob-
tain leave to inlarge the prefent
orifice about a couple of inches;
in doing which, I cut through
a hernial fac of great thickness
7
and

RUPTURES. 77
and very hard: what part of the
omentum was loofe, I pulled
away with my foreceps, but the
feparation of the whole took a
great deal of time, and the hard
hernial fac caufed fo many ab-
fceffes in the integuments of the
fcrotum, and the diſcharge upon
the whole was fo large, that be-
ing a valetudinary kind of man,
he had cetainly funk under it,
had it not been for the free ufe
of the bark.
If inftead of this method of
treating it, I had been permitted
to have laid it open through
its whole length, removed the
omentum, and retrenched the
hernial fac, the cure would have
been much fhortened, and the
fcro-

78 A TREATISE on
fcrotum would have been left in
a much better ftate.
That an omental rupture which
has fo long refifted all attempts
for reduction, as to produce a be-
lief of its being irreducible, may
fometimes, by long reft and ab-
ftinence, be fo altered, as to be-
come capable of return, I make
no doubt, and not long ago had
a man, in St. Bartholomew's-Ho-
fpital, who had a ſmall omental
hernia, which myfelf and many
others had ineffectually tried to
reduce; it was very little below
his groin in the very upper part
of the fcrotum.
dognol
This man being confined to
his bed, and a ftrict diet after the
ope-

RUPTURES.
79
operation for the radical cure of
an hydrocele on the fame fide,
got rid of both his diſeaſes at the
fame time, for after he had been
in bed about ten days, his omen-
tum returned of itfelf into the
abdomen. did and
mon
In performing the operation
on this man, the two facs, viz.
that of the hydrocele made by
the tunica vaginalis teftis, and
that of the hernia formed by the
peritoneum, was very apparent
and fatisfactory.
nisq
5145A
It fometimes happens in the
cafe of an old defcent of both
gut and omentum, that the gut
is returnable and the omentum
not. When this is found upon
trial

80
A TREATISE on
trial to be fo, the gut fhould be
returned and kept up by a
trufs, the pad of which may be
fo conftructed, as to keep the
inteftine up without preffing on
the omentum, fo as to do it any
injury; by which means the
rifque of miſchief from ftricture
of the gut will be avoided, and
the patient thereby freed from a
conftantly impending evil.
Not long fince, I faw a large
portion of omentum in the fcro-
tum, a part of which had the
knotty hardneſs, the acute pain,
and indeed every ſymptom of a
cancer.
SECT.

RUPTURES.
81
SECT. IV.
THE
HE third divifion compre-
hends thofe ruptures which
are reducible; but whofe reduc-
tion is difficult and attended with
pain and trouble.
This difficulty of reduction
may be owing to feveral different
caufes; a large piece of omen-
tum, a large portion of inteftine
and mefentery, the inteftine be-
ing inflamed, loaded with faces,
or diftended by flatus, fmallnefs
of the abdominal ring, &c. &c.
&c. but to whatever caufe the
difficulty is owing, the means
to be uſed for its relief are the
fame.
G
The

82
A TREATISE 072
The hernia in this ftate is cal-
led an incarcerated hernia, aftran-
gulated hernia, or a hernia with
ftricture, which ftricture is more
or lefs in degree in different cafes;
its fymptoms are a fwelling in
the groin and upper-part of the
fcrotum, larger or fmaller ac-
cording to the quantity of con-
tents, very painful to the touch,
and renitent or refifting the im-
preffion of the fingers; the pain
is increafed by coughing or fneez-
ing, or ftanding upright, a fre-
quent vomiting, a fuppreffion
of all difcharge per anum; to
which may be added fever, with
quick and hard pulfe. Thefe
are the ſymptoms of a beginning
ftrangulation, and confequently
fymp-

RUPTURES.
83
fymptoms of impending mifchief,
fymptoms which if not foon re-
lieved by art, nature muft fubmit
to.
A ftricture made by the bor-
ders of the aperture in the ab-
dominal muſcle on the prolapfed
part or parts, is the primary and
principal cauſe of theſe fymp-
toms, and nothing can appeafe
or remove them but what will
take off that ftricture; the two
methods of accomplishing this
end, are, removing the parts by
replacing them in the belly
whence they came, or dividing
the ftricture itfelf: the former is
always moft eligible when practi-
cable, and is the fubject of our
prefent purpoſe.
G 2
A

84
A TREATISE ON
A portion of inteftine will,
(as has been obferved before) while
there is no ftricture above nor any
inflammation below, remain per-
fectly quiet in the fcrotum, and
will there execute all its offices
freely and perfectly; but the
inftant it becomes ftraitened
above, the cafe alters: the free
paffage of the fæcal part of the
food is interrupted or ftop-
ped, the periftaltic motion o
the inteftines perverted, and the
circulation of the blood through
the incarcerated portion fo im-
peded, that if the impediment
is not foon taken off it muſt
ftop, the confequence of which
is obvious.
All

RUPTURES.
85
All the fymptoms of an in-
carcerated rupture are from thefe
caufes eafily deducible and fairly
to be accounted for.
The tumor, the pain, the
fever, the vomiting, the tenfion
of the belly and fuppreffion of
ftools, are fo many links in a
chain of fymptoms, all evidently
and certainly produced by one
cauſe, the removal of which only
can remove them.
The manner of attempting the
reduction is thus: The patient
fhould be laid in a fupine pofture,
with his buttocks and thighs con-
fiderably raiſed above his breaft,
when the furgeon taking up the
G 3
tu-

86
A TREATISE on
tumified fcrotum, is to endea-
vour to procure the return of the
prolapfed parts thro' the aperture
in the muſcle by gentle and repeat-
ed preffure of them towards the os
ileum with one hand, while with
the other he prevents their efcape
to the lower part of the fcrotum.
This is a general defcription of
it; but the exact and proper
manner of handling the tumor,
and endeavouring the return of
the parts, is one of thofe opera-
tions, which having once done,
or having feen it properly done,
will convey a better and clearer
idea of, than the moſt elaborate
defcription; a competent know-
ledge of the anatomical ftructure
and fituation of the parts, will
fully

RUPTURES.
87
fully inftruct any one how to go
about it properly, and without
fuch knowledge, though he may
fometimes and by accident fuc-
ceed, yet he may full as often
do mifchief, and his furgery will
be fomewhat like that of the man
who replaced his companion's
diflocated jaw, by giving him a
fmart blow in the face.
Great affiftance is to be obtain-
ed in this operation from pofture,
by raifing the hips above the
trunk; and indeed the nearer the
poſture approaches to that of
ftanding upon the head (as it is
called) the better, as it makes the
whole pacquet of inteftines hang,
as it were, by the portion engaged
in the ftricture, and which will
there-
G4

88 A TREATISE on
therefore be more likely to fol-
low.
A little time and pains fpent
in this manner, will frequently
be attended with fuccefs, and ob-
tain a reduction; but if it does
not, and the handling is very
painful, and the patient much fa-
tigued, it will be better to de-
fift for few hours, take away a
large quantity of blood, (as much
as the ftrength and circumftances
will admit) give a ftimulating
glyfter or two, cover the whole
tumor and ſcrotum with an emol-
lient poultice, and confine the
patient to bed.
This is the general doctrine
and the general and moft ap-
proved

RUPTURES. 89
proved practice, and founded on
reafon and experience.
The glyfters will not only emp-
ty the rectum and the greateſt
part of the colon of what may be
there, but the ftimulus may per-
haps do fomething more; and
the poultice will relax the fkin,
and render the diftenfion of that
lefs painful, and therefore neither
of them fhould ever be omitted;
but the fheet anchor in this cafe is
large bleeding frequently repeated.
Perhaps there is no difeafe
which affects the human body,
not excepting pleurify and pe-
ripneumony, in which bleeding is
more immediately ferviceable than
in this, and which, if there are no
4
very

90
A TREATISE on
very particular circumftances in
the conftitution to forbid it, fhould
be done very freely and frequently,
never forgetting to embrace the
opportunity of a deliquium.
A warm bath or femicupium
are alfo uſeful in this ftate, from
the general relaxation which they
induce,
Heifter and fome others, have
faid a great deal in commenda-
tion of glyfters of the fume of
tobacco, repeated frequently,
which as they can do no poffible
harm, may be worth trying.
Many very good writers have
recommended, and many able
practitioners ftill continue to ufe
purg-

RUPTURES.
91
purging medicines, in this ftate of
the diſeaſe, given in fmall dofes,
and frequently repeated; but I
very much doubt, whether any
part of the fuccefs they have had,
has been deducible from thefe
medicines. The advantage fup-
pofed is, that by accelerating the
periſtaltic motion the gut may be
difengaged from the ftricture and
be drawn back into the belly.
But when the ftricture is fo tight
as to have brought on bad fymp-
toms, I much doubt the fuccefs
of the experiment.
Lenient medicines, whofe form
(whether folid or fluid) cannot be
fmall, will not be retained by
the ftomach; and irritating medi-
cines, whofe bulk is fmall, are,
4
I

92
A TREATISE on
I think, more likely to add to
the tenfion of the belly, already
become very troubleſome, than to
difengage the inteftine. If they
do not anſwer that end, they can
be of no fervice at all, and if
they do no real fervice, 'tis much
to be feared, they will do fome-
thing worse than nothing.
They muft increaſe the fulness
of the ſmall inteftines above the
confined portion, and confe-
quently the tenfion of the belly;
they must add to the irritation
made againſt the ftricture, and
to the fever, and thirft, as all ir-
ritating purges do at all times
and in all bodies; however, this
muſt be left to every man's own
experience and judgment.
After

RUPTURES. 93
5da sol and
After few hours reft and a large
bleeding, freſh trial fhould be made
in the fame manner as the firft, al-
always remembering that the lefs
force is ufed the better, and that
with regard to confequences, all
violent attempts if they do not fuc-
ceed are worfe than ineffectual.
Hernias are in nothing more
various than in the time which
they will fafely admit for at-
tempting the reduction; fome
have been fuccefsfully reduced af-
ter ten days, others have produced
fatal fymptoms in twice as many
hours; this difference may arife
from difference of conftitution,
habit of body, or from fome par-
ticular circumftance in the hernia
itfelf;

94
A TREATISE on
itſelf; but let the caufe of this
difference be what it will, as it
can never be forefeen it fhould
never be trufted, and the fooner
the reduction is made, the fooner
the patient is out of danger from
the ftricture, and the more like-
ly to get rid of the fymptoms it
has already produced.
Recent ruptures are rather
more fubject to ftricture than
old ones, inafmuch as the aper-
ture in the muſcle and the en-
trance of the fac in antient hernias
are more patent, and lefs likely
to bind than in recent, in which
the contrary, moft probably, is the
cafe, though when old ones are
attended by ftricture, the fymp-
toms are not at all lighter.
Omental

RUPTURES.
95
Omental hernias in general
are not fubject to ftricture, or
to any bad ſymptoms, though
fometimes they will accidental-
ly become very painful, and
by the connection of the omen-
tum with the ftomach, will
occafion a very difagreeable fen-
fation, a naufea and vomiting;
nay writers of undoubted cre-
dit have related a paffio ilia-
ca, in all its force and fymp-
toms, from a mere epiplocele,
without any portion of intef-
tine.
In the cafe of a large omental
rupture, that has been down
fome time, it has been recom-
mended to be content with a bag-
trufs

96
A TREATISE on
trufs to fufpend the weight, tho'
the portion of omentum fhould
be returnable; upon a fuppofition
that if returned it will lie uneafy
in a lump at the bottom of the
belly. This feems to me to be
one of thoſe precepts which au-
thors have taken from each other
implicitly, without fufficiently at-
tending to the confequences which
it may produce. It may be true
in fome particular cafes, but furely
is by no means fit to be eſtabliſh-
ed as a general rule; and it muft
always be worth while to try how
it will lie before it be given up to
fuch a method, as hardly deferves
the name of palliative, and which
may be productive of other mif-
chief.
The

RUPTURES.
97
The prolapfed parts replaced,
the next confideration is how to
keep them from falling down
again. This can only be done by
a proper bandage, fo conftructed,
as to keep a gentle preffure againft
the aperture in the tendon thro'
which the parts had paffed, and
to prefs the fides of the entrance
of the fac as near together as pof-
fible.
in
The bandage now in general
ufe for this purpoſe, is a trufs;
the conftruction of, and adapting
which to the part, fome ingenuity
is neceffary; if it is not fo made
as to do good, it must do mif-
chief; if it does not keep the
parts up, the patient is more
H
likely

98
A TREATISE ON
likely to incur mifchief with his
trufs on than without it; it will
make a preffure on the inteftine
while down, which may prove
very pernicious, and has often
been the fole occafion of a gan-
grene, in cafes where there has
been no ftricture; therefore it
behoves every furgeon to fee that
the trufs applied is well made,
and does its duty, left all his
pains fhould be baffled by the
bad conftruction or injudicious
application of this piece of ma-
chinery.
If the ſymptoms of pain and
inflammation, &c, ran high be-
fore the reduction, they will not
always ceafe upon its being ac-
compliſhed; and as what fymp-
toms

RUPTURES.
99
toms remain, after the inteftine
is returned, arife moft probably
from its being inflamed, all fuch
remedies as are proper and ne-
ceffary in an inflammation of the
inteftine, muſt be proper and
neceffary here; but above all,
the body must be kept open un-
til all pain and tightneſs, and in
fhort, till every complaint of the
parts about the abdomen is ab-
folutely removed, and the in-
teftine performs all its offices
freely and without trouble or ob-
ftruction.
H 2
SECT.

100
A TREATISE ON
SECT. V.
UNDE
NDER the fourth and laft
head are comprehended
thofe which are in fuch a ftate,
that the reduction, by the hand,
is impracticable, and the patient's
life can be faved only by a furgi-
cal operation.
The impoffibility of reduction
is owing to the fame caufe as
the difficulty in the former fec-
tion, viz. the ftricture made up-
on the prolapfed parts by the ab-
dominal ring, with this difference,
that in the former cafe the re-
duction was practicable though
difficult, in this it is abfolutely
impracticable.
The

RUPTURES.
ΙΟΙ
The degree of ftricture which
renders reduction either difficult
or impracticable, is productive of
what are called the fymptoms of
an incarcerated hernia, all which
arife either from the occlufion of
the inteſtinal canal, or the ftop-
page of the circulation of the
blood thro' the veffels of the in-
carcerated parts.
The fymptoms were related
in the former fection, as far as
they were attendant on that de-
gree of the difeafe, and are, tu-
mor in the groin or upper part
of the fcrotum, creating exceffive
pain in that part, and all over
the belly; fever, naufea, vomiting,
and fuppreffion of all difcharge
H 3
per

102
A TREATISE on
per anum; thefe are the firft
fymptoms, and which, if they are
not removed by the reduction of
the parts, are foon exafperated,
the vomiting continues, the pain
and tenfion of the belly increaſe,
the fever is higher, and the pulfe
harder, fuller, and quicker;
when matters are come to this,
no time is to be loft, a very lit-
tle delay is of the utmoft confe-
quence, and often produces a fa-
tal alteration.
The vomiting is exchanged for
a convulfive hiccup and frequent
gulping up of bilious matter, and
in very little time after this, the
parts within become gangrenous;
the pulfe now is low, languid,
and interrupted; the fkin cold
and

RUPTURES. 103
and moift, efpecially on the
limbs; the eyes have a glaffinefs
and languor not to be defcribed;
the part is eafy, the tumor fub-
fides, and in fome cafes changes
its natural colour for a livid
hue; but whether it changes
colour or not, it has to the touch
an emphyfematous feel, a kind
of crepitus, which will eafily be
conceived by any man who is
acquainted with it,
fo eafily defcribed.
but is not
This crepi-
tus is the too fure indication of
gangrenous mifchief within, and
in this ftate the gut generally
goes up either fpontaneously, or
with very little preffure, a dif-
charge is made per anum, and
the patient is much pleafed at
the eafe he finds; but this plea-
H 4
fure

104
A TREATISE on
fure is of fhort duration, for the
hiccup and cold fweats continu-
ing, with the addition of fpaf-
modic rigors, and fubfultus ten-
dinum, the tragedy foon finiſhes.
Theſe are the ſymptoms of a
ftrangulated inteftine, and this
the confequence of not relieving
them. The firft clafs of them
are not in themſelves fatal; the
latter frequently fo.
The only means whereby the
former can be relieved, and the
latter prevented, is the opera-
tion; and when the worft fymp-
toms are arrived, if the poor pa-
tient has any chance at all, it is
ftill by the operation, though it is
indeed a very fmall one; all that
can

RUPTURES. 105
can be faid is, that if the gut is
return'd, or returns fpontaneoufly,
in this ftate, death is inevitable;
and there are inftances of people.
in thefe circumftances who have
efcaped by being cut.
Perhaps there is not in the
practice of furgery a more nice
point to determine than the pre-
cife time beyond which we ought
not to delay this operation. The
time in which the contents of a
hernia are damaged, that is, be-
come gangrenous, or get into
fuch a ftate as to approach that
of a gangrene, is extremely un-
certain, and dependent on cir-
cumftances which no man can
foreſee or prevent.bod
There

106
A TREATISE 072
There have been feveral in-
ftances of ftrangulated ruptures
attended by all the fymptoms of
ftricture, which have been re-
turned at the end of feveral days
found and unhurt, or the ope-
ration becoming neceffary, have
been found in fuch ftate at the
fame length of time; and there
are feveral inftances of the gut
going back, or being found, by
an operator, in a ftate of mor-
tification in lefs time than two
days.
I have feen a portion of the
inteftine gangrenous in one day.
The direction given by writers
on this fubject is hardly to be
truft-

RUPTURES.
107
trufted; the ſymptoms which are
generally mentioned by them as
indications that the time for the
operation is come, are moft fre-
quently figns that the proper
time is juft elapfed.
On the other hand, to propofe
an operation of fo much confe-
quence, as this is thought to be,
before it fhall appear abfolute-
ly neceffary, may be cenfured;
nor do I know any fituation in
which a judicious and prudent
man can be put, in which it will
behove him to be more wary
and circumfpect. There are two
circumftances in this cafe, which
though really of fome weight,
have been perhaps too much re-
garded,
One

108 A TREATISE on
One is an apprehenfion of
much danger from the operation,
confidered fimply and abftracted-
ly; and the other is a fear of bring-
ing difgrace on it, by performing
it after it is thought too late, or
in the words of Celfus, ne occidiffe
nifi fervaffet videretur.
That the operation confidered
abſtractedly, is not void of dan-
ger, every man who knows any
thing of the nature of wounds
of tendinous and membranous
parts muft allow, thefe being
frequently attended by fever and
inflammation, and being flow
and difficult of digeftion; but
ftill I am from experience in-
clined to think this fear much
too great.
This

RUPTURES.
109
This dread is the reafon why
we do not know for certain what
trouble or hazard would attend
the operation, confidered fimply;
for it produces a delay, by which
all the circumftances of dan-
ger are increaſed, and which the
moft judicious man can neither
guard against nor prevent: nor
do I fee any method whereby
we can be informed of the point
in queftion, but by performing
the operation fooner than it is
generally performed: I mean
very foon after bad fymptoms
have made their appearance; for
although, upon a divifion the
parts are not found gangrenous,
yet that is no fort of proof that
what-

110
A TREATISE on
whatever happens afterwards is
to be fet to the account of the
operation; that degree of inflam-
mation of the inteftine which is
juft on this fide becoming gan-
grenous, is furely no ftate of fafe-
ty; nor is the fame ftate of the
hernial fac a defirable circum-
ftance, fince in this cafe we are
far from being fure that taking
off the ftricture will remove the
fymptoms or the hazard; the
contrary is much to be feared:
and thus the rifque of the ope-
ration becomes complicated with
that arifing from the ftate of the
parts within; a ftate of difeafe,
and generally brought on by de-
lay and fear of the operation.
I

RUPTURES. 111
I am fenfible that I differ from
many practitioners, for whofe
judgment I have great regard,
and I fhould be forry to be
thought too partial to my own
opinion; but yet I cannot help
faying, that I have taken a good
deal of pains to attend to all op-
portunities that have offered
themſelves to me in this difeafe;
that I have performed the opera-
tion many times in all its ftates,
and can venture to affirm that
when it has been performed in
time, it has always been fuc-
cefsful, and that I do not recol-
lect to have loft one whofe death
could fairly be attributed to the
operation, the very precife time
for doing which is fo extremely
difficult to fix, and the perform-
ing

112
A TREATISE ON
ing which too foon cannot poffi-
bly be attended with the hazard
that performing tho' ever fo little
too late muft be. To which I will
venture to add, that when the
inflammation of the gut is very
great, the fever high, the tumor
full, and the fcrotum upon the
ftretch, I verily believe, and am
convinced that the neceffary hand-
ling the parts in attempting re-
duction in fuch ftate, is nearly,
if
not full, equal both in pain and
hazard to the operation.
I muft defire in this place not
to be miſunderſtood, as if I would
advife the operation to be per-
formed before proper attempts
for reducing the parts had been
made, or before the fymp-
toms of ftricture became pref
I
fing;

RUPTURES.
113
fing; much leſs that I would re-
commend it as a means of pro-
ducing a radical cure of a rup-
ture, not attended with ftric-
ture, a thing much adviſed by
pretenders, but not to be thought
of by any man who has either
fenfe or humanity.
The only intent of the opera-
tion fhould be to preferve life, by
removing the hazard of mortifi-
cation arifing from the ftricture;
and tho' I have preffed the time-
ly performance of it in fuch cir-
cumftances and with fuch view,
and think the hazard from the ope-
ration much lefs than that from
the ftricture, yet I fhould be
yery forry to have it thought that
I
I

114 A TREATISE ON
I encouraged the performance of
it wantonly or unneceffarily.
And with regard to its ufe, as
a means to obtain a perfect cure,
or prevent the neceffity of wear-
ing a trufs, every man who
knows any thing of the matter,
knows that it very often fails in
producing that end. That fome
of thoſe who have neceffarily fub-
mitted to the operation, to pre-
ferve their life, have been obliged
to wear a trufs afterward to pre-
vent the inteftine from flipping
down behind the cicatrix into the
groin; and that the operation is
by much too painful and too ha-
zardous to be propofed or under-
taken

RUPTURES. 115
taken (with this view) by any man
who has the leaft regard either
for his own character or his pa-
tient's fafety, or, in fhort, for any
thing but money.
When the operation fhall be
thought neceffary, the manner
of performing it is this:
The pubis and groin muft be
fhaved clean, and the patient laid
upon a table of convenient height,
on his back, with his legs hang-
ing eafily over the end of it, then
with a ftraight diffecting knife
an incifion must be made thro'
the ſkin and membrana adipofa,
beginning juft above the ring of
the abdominal mufcle, and con-
tinuing quite down to the infe-
I 2
rior

116 A TREATISE ON
rior part of the fcrotum; upon
the divifion of the membrana adi-
pofa fome fmall tendinous bands
appear diftinct from each other,
lying cloſe upon the furface of the
hernial fac, which is next to be
divided; the fame knife with
which the firft incifion was
made will be the beft to make
this alfo: here fome caution and
a fteady hand are neceffary, the
fac being in fome cafes much
thinner than in others, and
confequently more eafily cut
through.
The incifion in the fac is beft
made about an inch and half or
two inches below the ftricture, and
need be no more than fuch an
aperture as will juft admit the ex-
tremity

RUPTURES. 117
tremity of the fore-finger, which
confidering the great dilatability
of thefe membranes, will be a
very fmall one; the fore-finger
introduced into this aperture is the
beft of all directors, and upon
that finger a narrow bladed,
curved knife, with a bold probe-
point, will be the only inftru-
ment neceffary to finish the ope-
ration with.
With this knife on the finger,
the fac fhould be divided quite up
to the ring, and down to the bot-
tom of the fcrotum.
Upon the first divifion of the
hernial-fac, a fluid is difcharg-
ed of different quantity, color,
and confiftence, according to
13
the

118 A TREATISE on
the different age, and circum-
ftances of the hernia, limpid if
the rupture be recent, brown or
bloody if antient.
This fluid has been mentioned
by fome as a defence againſt any
accident from the knife in the
firft divifion of the fac, as if it
kept the fac at ſuch diſtance from
the gut as thereby to leffen the
hazard; but this is a very falla-
cious circumftance, and not to be
trufted to: in the divifion of the
fac all the fecurity is a fmall open-
ing, made by a ſteady hand, and
directed by an attentive eye.
Many different inftruments
have, by different people, been
devifed and conftructed for this
ope-

RUPTURES.
119
operation, the biftouri cache, the
biftouri herniare, the winged di-
rector, blunt pointed fciffars, &c.
all which are calculated for the
defence and prefervation of the
inteftine in dividing the fac and
ring; but whoever will make ufe
of the two knives juft mentioned,
will find that he will ftand in
need of no other inftruments,
and that he will be able to per-
form the operation with more fa-
cility to himſelf, with more ap-
parent dexterity, and with lefs
rifque to his patient with thefe
than with any other.
The fac being fairly divid-
ed up to the ring, if the her-
nia is of the inteftine (the only
one which can require this ope-
I 4
ration)

120
A TREATISE on
ration) it puſhes out immediate-
ly, and appears to be much more
in quantity than it feemed while
confined in the fcrotum.
This is the time to try whe-
ther, by gently pulling out a lit-
tle more of the inteftine, the
bulk cannot be fo leffened as to
be capable of paffing through the
ring without dividing it; if the
portion of gut be fmall, it is more
likely than if large, the difficul-
ty of returning a large one in
this, as well as in the taxis, de-
pending a great deal on that part
of the mefentery which comes
down with a large portion of gut,
and which is engaged in the ftric-
ture: if this does not fucceed, the
probe-pointed knife, conducted
on

RUPTURES.
121
on the fore-finger, will imme-
diately divide the upper part or
border of the aperture in the ten-
don and fet all free. It is ge-
nerally adviſed to make this in-
cifion in the tendon freely, as
well to give room to return the
part without much handling,
as to avoid any inconveniences
which may arife from a fmall di-
vifion of a tendinous body; the
advice is good, with certain li-
mitation, but it fhould alfo be
remembered, that the incifion
may be fo large as to be pro-
ductive of great inconvenience.
The fpermatic chord and epi-
gaftric artery, which fome writers
have cautioned an operator againſt
injuring, are fufficiently out of
the

122
A TREATISE 072
the way of being hurt in their
general difpofition, and the lufus
naturæ no man can guard againft,
but muft act according to the
prefent exigence. b
It has by fome theory-wri-
ters been advifed to divide the
ring only, and to endeavour to
return the hernia in its fac with-
out opening it, from a fuppofi-
tion of mifchief being producible
by the influence of the air on the
inteftine; but there are many
objections to this, fuppofing it
practicable, (which from the ad-
hefion of the hernial fac to the
fpermatic chord can feldom if
ever be the cafe): it would pre-
vent all knowledge of the ftate
of the included parts; it muft
re-
4

RUPTURES. 123
return into the belly all the liquor
contained in the fac, which can
ferve no good purpofe; and it
may poffibly prove no alleviation
of the fymptoms.
The fac and ring divided, the
contained parts come next in
view.
Thefe, according to the dif-
ferent circumftances of the her-
nia, muft be in different ftates,
and require different treatment.
SECT.

124 A TREATISE ON
TH
SECT. VI.
HEY will be found in a
found and healthy ftate,
capable of and fit for immediate
reduction
In a found ſtate, but (from fome
particular circumftances) incapa-
ble of immediate reduction;
Or, in an unfound difeafed
ftate, and requiring to be treated
accordingly.
If the hernia confifted of inte-
ftine only, and that neither difco-
loured nor adherent, the fooner
it is returned the better, and the
more gentle the handling, in or-
der to reduction, the better alfo.
4
If

RUPTURES. 125
If the inteftine is accompanied
by a portion of the omentum,
the omentum fhould be returned
firft.
In making the reduction, the
part laft protruded fhould be firft
returned; which is beft done by
preffing it gently and alternately
with the fore-fingers, applying
them rather to that part of the
inteftine which is connected with
the mefentery, than to the con-
vex part.
In this reduction great aflift-
ance is to be had from pofture;
the higher the buttocks are raiſed
above the thorax the better, as
the inteftines within the cavity
will

126
A TREATISE on
will more attract that part which
is without, and thereby facilitate
its reduction.
If the omentum appears found,
it fhould be all returned imme-
diately, let the quantity be what
it may, and with as little injury
from handling as poffible.
The confinement in the fcro-
tum will, in fome habits, in a
very fhort ſpace of time produce
flight adhefions by flender fila-
ments, which are eafily feparated
by the finger or fnipt by the fcif-
fars, whether the adhefion be of
the
parts of the inteftine inter fe,
or to the fac; if the adhefion be
of the former kind, and not
eafily feparable, it is better to
re-

RUPTURES.
127
return it without attempting fe-
paration, which may be attend-
ed by inflammation if nothing
worfe.
If the portion of omentum be
fmall in quantity, and fo very ad-
herent that the operator does not
care to divide it, it may very fafely
be left; part of it will melt down
with the fuppuration of the parts,
and the reft will fhrink fo as not
to hinder the healing of the fore,
or be at all troubleſome after it
is healed.
But if the quantity of omen-
tum be fo large and fo adherent
as not to be eafily feparable, all
that is below the adheſion may
very fafely be retrenched in a
man-

128 A TREATISE on
manner to be defcribed here-
after.
The prolapfed parts being re-
turned, the next confideration
is the hernial fac; which, if large
and hard, will prove very flow
and difficult of digeftion, and
much retard the time of healing,
by producing abfceffes in the
fcrotum, and thick, hard, and
very painful lips and edges to the
fore.
The greateft part of this fac
may be retrenched very fafely
and to great advantage, no part
of it being of any confequence
except the pofterior, which is
connected with the fpermatic
chord; all the reft of it which is
loofely

RUPTURES. 129
loofely connected with mem-
branes of the fcrotum is very ea
fily feparable, and much better
removed than left.
It has been propofed to pafs
a ligature round the mouth of
the fac, after the parts have been
returned, to prevent any relapfe,
by procuring an union of the
fides of the fac with each other;
but to this there are many mate-
rial objections.
It would prevent the exit of
the diſcharge, which for fome
days after the operation always
flows from the belly.
It would be very likely to
injure the fpermatic chord, if
included
K

130
A TREATISE ON
included within it; and if it be
tied at all tight, it would be pro-
ductive of mifchief below in the
fcrotum, which might be of
great confequence.
The next ftate is that of the
parts being fo adherent, as not
to be capable of being returned.
In this cafe it is adviſed to re-
move the ftricture by dividing
the fac and ring, and to leave
the prolapfed parts in the fcro-
tum as you find them.
I have mentioned this becauſe
it ftands in all books on this fub-
ject, even the lateft, and all
agree in this method of treating
it. It is a cafe I have never
feen, nor do I fuppofe it can hap-
pen

RUPTURES.
131
pen very frequently in the man-
ner it is related.
I have feen the inteftines very
adherent to each other, and to
the hernial fac, but never in fuch
a ftate of adhefion as to be infe-
parable and confequently unfit
for being replaced.
The adhefion of the parts of
the inteftine inter fe, are fre-
quently feparable; but if they
are not, it is allowed thefe ad-
hefions are no hindrance to the
inteftine being returned; and the
omentum, if very adherent, may
fafely be retrenched; fo that the
adheſion here meant must be that
of the inteftine to the fac: of
theſe two parts we are interefted
only
K 2

132 A TREATISE on
only in the prefervation of one,
and may make a little free with
the other; and though the fe-
paration may be tedious and
painful, yet if it can be ac-
compliſhed, furely it muſt be
much preferable to leaving a
quantity of inteftine loofe in the
fcrotum, which, from the removal
of the ftricture above, will be
liable to be increafed in quantity
by every unguarded motion, and
fubject to all the inconveniences
which the influence of the air
muft neceffarily produce on fuch
tender parts; not to mention the
great difficulty of managing the
fore in this ftate, and the pain
and other bad fymptoms that
muft arife upon the daily uncover-
ing the inteftine, fo great, that I
can-

RUPTURES. 133
cannot help thinking any fatigue
or pain, which may attend the
feparation, is to be fubmitted to,
rather than leave a man in fuch
a ftate as hardly deferves to be
called life, and muft make his ex-
iftence painful and difagreeable,
fuppofing the method of treat-
ment to be practicable, which I
muft acknowledge I have no idea
of as it is defcribed by writers.
For to leave the parts as they
were found, and as it is adviſed, is
impoffible; they are found con-
tained in the hernial fac and fcro-
tum, defended from the air, and
limited, as to quantity, by the
ftricture above; the neceffary
operation has removed that ftric-
ture, divided the fac and fcrotum,
and fet all loofe and free, and the
K 3
in-

134
ATREATISE 073
inteftine muft either be returned
after freeing it from its connec-
tions, or an anus muft be formed
in the groin, and then it becomes
another cafe.
SECT.

RUPTURES. 135
SECT. VII.
ITHERTO the parts
H' compofing a hernia have
been confidered as difplaced; as
inflamed; as having contracted
unnatural connections and adhe-
hefion, &c. but ftill fo unhurt
by the ftricture, as to remain
found and within the laws of the
circulation, fit to be returned in-
to the belly again, in the fame
ftate in which they were found,
and affording a good profpect of
fuccefs in the event.
But if the removal of the ftric-
ture has been too long deferred,
or if the inflammation ran fo
high as not to give way to the
K 4
pro-

136 A TREATISE on
proper treatment, the parts en-
gaged in the ftricture will be-
come difeafed and unfit for re-
duction.
The difeafe here meant, is
that of gangrene or mortifica-
tion, produced by the ftoppage
of the circulation of the blood
through the incarcerated parts:
This gangrenous or mortified
ftate of the parts will be more
or lefs in degree and extent in
different cafes and in different
circumftances; but however dif-
ferent theſe may be, one general
rule muſt be invariably obferved,
viz. that no altered or mortified
part, however ſmall the extent
of the alteration may be, fhould
ever be returned loofe into the
belly,

RUPTURES. 137
belly, the confequence being al-
moft certainly fatal.
If the omentum be down, and
fo much altered as to require re-
moval, the fooner it is done the
better.
The antient and indeed the
the general method of doing this
is by making a ligature on the
omentum juft above the altered
part, cutting it off juft below
the ligature, and returning the
upper part into the belly with
the ligature hanging out from the
wound, to be taken away when
caft off.
200
This method was calculated
to prevent the hazard which
might

138 A TREATISE ON
might arife from a hemorrhage of
the veffels of the omentum when
in the belly; but thefe veffels are
fo very inconfiderable as to leave
no room for fuch fear, and in
fome circumftances there is a
material objection to the ligature,
which is, that if the piece of
omentum be pretty large and the
ligature made high, it may, when
returned, prevent the colon from
taking its proper fituation, and
confequently from lying eafy,
which might be the occafion of
farther diforder.
The beft manner of retrench-
ing it is by a pair of fciffars, af-
ter it has been carefully expand-
ed, as well on account of its
more eafy divifion, as to avoid
in-

RUPTURES.
139
injuring any fmall portion of in-
teftine which may be enveloped
in it, if it be cut off juft below
the termination of the mortified
part, there can be no fear of bleed-
ing; nor can any objection lie
againſt this method of leaving a
very ſmall portion of the altered
part but what muft hold against
the ligature, as much being to
be caft off in one cafe as in the
other, and the wound, below in
the groin, being neceffarily open
a time fufficient for the difcharge
of any thing from the abdomen.
If a gangrene of the inteftine
confifts only of a ſpot, which by
cafting off may endanger the
fhedding its contents loofe into
the belly, that inconvenience is
4
to

140
A TREATISE on
:
to be avoided by connecting the
inteftine to the upper part of
the wound with a needle and
ligature, by which means it may
contract fuch adhefion as to dif-
charge the fæces at the wound
for fome time; after which it has
been known to contract gradual-
ly, and heal firmly but whe-
ther the event proves fo lucky
or not, this method of fecur-
ing it fhould never be omit-
ted, as the fhedding the con-
tents of the inteftines into the
belly, muft at all events be
wrong, and fecuring the gut
by this means to the wound
can be attended by no inconve-
nience.
If

RUPTURES.
141
If the altered portion be of fuch
extent as to require excifion, but
yet is not fo large as to prevent
the extremities of the divided
gut
from being brought into contact
with each other, their reunion
must be endeavoured by future;
in making which the ends of the
gut muft be made to lie a little
over each other by introducing
one a little way within the other,
by which means the future will
be ftrengthened, and the future
union become firmer; and when
the two ends are thus fewed toge-
ther, they muft both be faftened
to the infide of the belly, at the
upper part of the wound, with a
needle and ligature, that in cafe
the union does not take place,
the

142
A TREATISE on
the diſcharge of fæces may be de-
rived thro' the wound.
But if the gangrene is of fuch
extent as to prohibit the bringing
the portions of the divided gut
into contact with each other, the
method muſt be different.
As in this cafe it is impoffible
to preferve the continuity of the
inteftinal canal, the aim of the
furgeon is to prevent the contents
of the guts being fhed into the
belly, and to derive out by the
wound in the groin all that which
fhould pafs off by the rectum and
anus.
To accomplish this he muft
take care that, in removing the
7
mor-

RUPTURES.
143
mortified parts, neither end of
the inteftine flip from him, which
might occafion him a good deal
of trouble.
Then with a proper needle and
ftrong ligature each of their ends
is to be faftened to the infide of
the belly near the upper part of
the wound; the future by which
this connection is made fhould
not be too flight, left it caft off
too foon before the extremity of
the gut has contracted an adhe-
fion to the fide of the wound;
and the ftitch muft alfo be made
in the gut in fuch manner as to
preferve, as perfectly as may be,
the free paffage of its canal, upon
which all future hope depends.
The

144 A TREATISE ON
The dreffing to the external
wound fhould be as foft and as
eafy as poffible, the patient fhould
obferve the moſt rigid feverity in
the affair of diet, and the moft
perfect quietude both of body and
mind; and with regard to medi-
cine, whatever is exhibited in the
firft ftage muft tend to procure
reft and eafe, to quiet the febrile
heat, and keep the body folu-
ble; and if things fhould hap-
pen to take a favourable turn, the
floughs caft off, the tenfion of
the belly fubfide, and the fæces
diſcharge freely at the wound;
the Peruvian bark (managed in
fuch manner as neither to reftrain
the fæcal difcharge or prove pur-
gative) may be given to great ad-
vantage.

RUPTURES.
145
vantage. All the reft muft be
left to nature, who is by her
Great Creator furnifhed with
fuch powers as fometimes to pro-
duce very happy events, even in
thefe deplorable cafes.
This is the fubftance of the
beſt practice, and of the moft
approved doctrine upon this fub-
ject; and has been fometimes at-
tended with fuccefs; but the
practitioner, who is fo circum-
ſtanced as not to ſee much of bu-
finefs, fhould be apprifed how
very little reafon there is to hope
for or promiſe it.
More cenfure is incurred by an
unguarded prognoftic of fuccefs
if defeated, than by a fuccefslefs
L
event

146 A TREATISE on
event if properly and prudently
foretold; and if a man was to
form his judgment of this and
fome other difeafes from books
only, he would expect very lit-
tle of that trouble and difappoint-
ment which he will moft certain-
ly meet with in practice.
Obfervation-writers, who are
in general too much addicted to
tell their fucceffes only, are fond
of relating gangrenous cafes from
which large portions of inteftines
have been removed, the proper
operations perform'd with great
dexterity, and the cafes brought
to a happy iffue; and of theſe they
all give us inftances, either from
practice, from books, or perhaps
fometimes from imagination; by
which

RUPTURES.
147
which the young reader is made
too fanguine in his expectations.
That theſe extraordinary fucceffes
have fometimes happened, is be-
yond all doubt, and it is every
man's duty to endeavour at the
fame, when fuch cafes occur to
him; but the inexperienced prac-
titioner fhould alfo be informed
how many fink for one that is re-
covered, and how many lucky
circumftances muft concur, with
all his pains, to produce a happy
event, in theſe deplorable cafes;
without this caution he will meet
with very irkſome difappoint-
ments, and having been often
baffled where he thought he had
reafon to expect fuccefs, will
fometimes meet with it fo very
unexpectedly, that he will be in-
clined
L 2

148 A TREATISE on
clined to think the farcaftical di-
ftinction between cures and efcapes
not ill founded.
To fay the truth, the hazard
in thefe cafes is fo very great, and
the utmoſt power of art fo very
little, that what Japis faid to
Eneas may with great propriety
be faid here.
Non hæc humanis opibus, non arte ma-
giftra
Proveniunt: neque te Ænea, mea dextera
fervat:
Major agit DEUS.
SECT

RUPTURES. 149
SECT. VIII.
RUFTURES THROUGH THE ABDO-
MINAL RINGS OF FEMALES
A
RE fubject to the fame
fymptoms, and require the
fame treatment as the inguinal
ruptures of males, and like them
frequently admit of perfect cure,
if not mifmanaged or neglected:
the fame kind of trufs is alfo ne-
ceffary here, with the fame cau-
tions in regard to its application
and the manner of wearing it.
When not reducible by the
hand, and attended with fuch
fymptoms as require the opera-
tion, it muſt be performed in the
L 3
fame

150 A TREATISE on
fame manner and with the fame
inftruments as in the bubonocele
in men; remembering that as
the hernial fac is in this cafe fel-
dom fo thick as in the fcrotal
rupture of males, more caution
and circumfpection are neceffary
in dividing it.
After the operation is perform-
ed, and the parts returned, it
has been propoſed to pass a liga-
ture round the neck of the fac,
and by that means endeavour to
prevent the future defcent of any
part from the belly. Againft
which it is objected, that by this
means the neceffary diſcharge
which is always made from the
abdomen for fome days after the
operation, would be prevented.
Whe-

RUPTURES. 151
Whether the future advantage
arifing from the ligature is fuffi-
cient to ballance any inconve-
nience from retaining this dif-
charge; or whether this dif-
charge, being freely made, is not
of too much confequence to
run the rifque of ftopping it for
any profpect of future advantage;
I will not take upon me abfolute-
ly to determine: but if any man
has a mind to make the experi-
ment, he muſt carefully attend to
the appearance of the fore and
parts adjacent, and if any pain,
inflammation, or tenfion, either
of the wound or belly, come on,
the part muſt be immediately fet
free by dividing the ligature, and
L 4
an

152
A TREATISE on
an opening made, and preferv-
ed, for this diſcharge, till all
theſe ſymptoms are quite gone
off.
SECT.

RUPTURES. 153
SECT. IX.
HERNIA FEMORALIS OF CRURAL
RUPTURE.
THE
HE crural or femoral rup-
ture receives its name
from its fituation, the tumor
occafioned by it being in the up-
per and fore-part of the thigh.
To underſtand rightly the na-
ture and fituation of a crural her-
nia, it is neceffary to recur to the
anatomical ftructure of the ten-
don of the obliquus defcendens
muſcle of the abdomen, and
what is called the ligamentum
Poupartii, with the parts imme-
diately adjacent.
The

154
A TREATISE on
The lower part or border of
this tendon is not form'd into
an edge as appears in moft diffec-
tions and moſt plates; but hav-
ing conftituted that tendinous
production which runs from the
anterior part of the fpine of the
os ileum to the fymphyfis of the
pubis under the name of Fallo-
pius or Poupart's ligament, fends
off a fine tendinous expanfion
which is loft in the fafcia of the
mufcles of the thigh; under this
expanfion lies a quantity of mem-
brana cellularis, fome fat, and
the inguinal glands; thefe toge-
ther occlude that paffage, which,
by the excavation of the bone,
is left under the ligament into
the cavity of the belly. So that
what

RUPTURES. 155
what is called the ligamentum
Poupartii, is really the lower
border or edge of the tendon of
the oblique muſcle; and the paf-
fage under it, into the belly, is
ftopt merely by fat and glands.
Under this ligament or ten-
don, the hernia in its fac paffes,
and makes a tumor on the fore
and upper part of the thigh.
It is generally defcribed as paf-
fing over the great crural artery
and vein, which are faid to be
immediately behind it; but who-
ever will examine the ftate of
theſe parts in a dead fubject, will
be convinced that this is not
the cafe: the fac lies to one fide
of the veffels nearer to the pu-
bis; the veffels nearer to the os
3
ileum;

156 A TREATISE on
ileum; and the fac, if not very
large, refts immediately upon the
bone.
This fpecies of rupture women
are rather more fubject to than
men, as the rings in their abdo-
minal muſcles are much ſmaller
than thofe of men; but then
it is not fo fubject to ftricture,
there being a large space on each
fide for the hernia to expand it-
felf in.
The general ſymptoms are the
fame as in the inguinal hernia,
and therefore need not be here
repeated; the treatment and re-
duction are alfo the fame, with
only this difference, that in the
inguinal, the contents are to be
preffed

RUPTURES.
157
preffed toward the os ileum, in
this they are to be preffed toward
the linea alba or navel.
When not reducible by the
fimple operation of the hand, it,
like the other, becomes the ob-
ject of a furgical operation; by
which the hernial fac is laid open,
the ftricture taken off, and the
parts returned.
In performing this, the fame
inftruments are required as in
the other; the incifion through
the ſkin and membrana adipofa
is to be made along the upper
part of the tumor, through
its whole length; upon divid-
ing theſe, the tendinous fafcia
or expanfion comes immediately
in

158
A TREATISE 022
in view, ftretched over the her
nial fac; theſe muft both be care-
fully divided in the fame man-
ner as in the other cafe; and as
there is a large space under the
border of the tendon, between
the pubis and ileum, which al-
lows much room to manage the
reduction, it is always worth while
to endeavour at it without dividing
the ligament; for it is not here
quite fo fafe a matter as in the
other cafe: here are two parts to
be avoided, both which lie very
little out of the way of the knife;
thefe are the fpermatic chord,
and the epigaftric artery; whofe
'fituation are fuch as to render
them very liable to be divided:
if the ligament be cut directly
up, as the tendon is in the ingui-
nal

RUPTURES.
159
nal hernia, the chord will cer-
tainly be divided; and if, to avoid
that, the knife be carried more
toward the ileum, the epigaftric
artery will be in great danger;
and make your incifion in what
part you pleaſe of the ligament,
if it is made to any length, the
rifque will be the fame, as will
appear to any who will examine
theſe parts in fitu naturali, and
make a proper allowance for the
preffure and diftenfion of the
hernial fac.
The only way to avoid injur-
ing both, is to make the incifion
fmall, which will be fufficient
here, if neceffary at all.
Of

160
A TREATISE ON
Of the two, the fpermatic
chord is certainly the moft to be
regarded; and if the epigaftric ar-
tery fhould happen to be wound-
ed, it muſt be taken up by needle
and ligature; but in fome cafes
this may not prove fo eafy a mat-
ter to execute as to defcribe.
The epigaftric artery is, in
many people, near as large as the
fmaller carpal; departs imme-
diately from the trunk of the cru-
ral artery; its origin lies in a
bed of foft fat and membranes;
the ftream of blood would be
very brifk, and the paffage of
the needle round it, might
prove troubleſome as well as ha-
zardous, on account of the vi-
3
cinity

RUPTURES. 161
cinity of the crural veffels; for
if the epigaftric artery is divided
in this operation, the lower part,
or that next the crural, is what
muſt be taken up firft. This
may undoubtedly be very hap-
pily executed, if neceffary; but
as it muſt be attended with much
trouble and fome rifque, it is
better to avoid it if poffible,
which may generally be done
by making the divifion of the
tendon fmall, and keeping the
probe-point of the knife againft
the end of the fore-finger held up
tight juft behind the fide or bor-
der of the ligament. In moft
other circumftances, this hernia
is fo fimilar to the inguinal and
fcrotal, as to need no particular
defcription.
M
SECT.

162
A TREATISE on
SECT. X.
THE
HE parts compofing an
hernia being replaced in
the belly, while found and un-
hurt, either by inflammation or
gangrene, it had always been
thought that the furgeon had
done all in his power at this
time; and that if a proper ban-
dage was immediately applied
to keep the parts from falling
down again, the patient had no-
thing to fear.
This has always been fuppofed,
and generally been found to be
true; all the beft practitioners
have acted upon this fuppofition,
and have regarded a hernia re-
duced

RUPTURES.
163
duced in thefe circumftances no
farther than to uſe all proper cau-
tion to prevent a new deſcent.
But within theſe few years
it is faid to have been diſcovered
that it is poffible for a hernial
fac to be abfolutely loofe and free
from all connection with the tu-
nica vaginalis and fpermatic
chord that this fac may
turned into the belly while a
portion of inteftine, included
within it, is ftrangulated by a
ftricture made on it by its neck
or entrance.
be re-
This ftraightness of the neck
of the fac is fuppofed to be pro-
duced by the preffure of the bol-
fter
M 2

164 A TREATISE on
fter of a trufs, worn to keep the
parts from defcending.
The preffure of a trufs will un-
doubtedly produce fuch ftraight-
nefs, if the hernial fac be not
very tough; and the more fuch
ftraightneſs is produced, the
nearer the cure comes to being
radical.
The only doubt arifing upon
this reprefentation is, that the
hernial fac is, in general, found
to be fo connected with the tu-
nic and chord, as to be abfolute-
ly incapable of fuch return.
That the ftraightnefs of the
neck of the fac does fometimes
make

RUPTURES.
165
make a part of the ftricture, is
beyond all doubt: This happens
moft frequently in old ruptures,
for which a trufs has been long
wore: but then the fame circum-
ftance of antiquity is generally
found to be productive of fuch ad-
hefion of the fac to the tunic and
chord, as to render the return
of it into the abdomen very
highly improbable.
Mr. Le Dran has given a hiftory
or two of this cafe. In one, the
hernia, after having given fome
trouble, was returned by the
hand perfectly and compleatly;
but all the ſymptoms of ftric-
ture continuing, the patient died,
M3
C
• Upon

166 A TREATISE on
C
C
Upon opening the body, he
fays, he found a large portion of
' inteftine included in the hernial
'fac, which was returned into
'the belly intire: That the ftric-
(
C
<
C
ture made by the neck of the
fac was fuch, that he could
not with all his force difen-
gage the inteftine, and was
obliged to divide the fac to
get a view of the gut.'
There can be no doubt that
Mr. Le Dran found the cafe as he
has reprefented it; it muft there-
fore be looked on as poffible;
but very happily for mankind,
as well as the furgeons, it can-
not be very frequent. It is a
cir-

RUPTURES. 167
circumftance which can neither
be foreſeen nor prevented; and
therefore would add confiderably
to the difficulty and danger of
ruptures.
It is faid, that by very care-
fully attending to the manner in
which the inteftine returns, we
may diſtinguiſh whether this
happens or not; that if the fac
returns with the gut included,
a hard body will be perceived
to pafs under the finger; and
that the inteftine, in its paffage
through the abdominal ring, will
not make that guggling noife it
ufually is found to make. Thefe,
inftead of being characteristical
marks of the return of the fac,
will almoſt always be found
M 4 where

168 A TREATISE on
where a portion of omentum,
that has been much compreffed,
afcends at the fame time with
the gut; and therefore however
ingenious this may feem, con-
fidered theoretically, it will prove
very fallacious in practice.
But fuppofe theſe marks were
clear and diftinguiſhable, (which
I am far from allowing) I do not
fee how we are to avail ourſelves
of this knowledge, or what be-
nefit will be derived from it to
our practice.
The inteftine muſt be return-
ed before we can have this in-
formation; and if inftead of thefe
very doubtful marks we had the
cleareft proofs that this was the
cafe,
2

RUPTURES. 169
cafe, we have no remedy, but
a very perplexing, tedious, and
painful operation; which I be-
lieve, as few furgeons would
chooſe to perform (in fuch un-
certain circumftances) as patients
fubmit to.
I call thefe marks doubtful,
becauſe we have no certain indi-
cation, that the continuance of
the fymptoms after reduction are
owing to this accident. They
may much more probably be ow-
ing to that degree of inflamma-
tion under which the inteftine
laboured from being too long
confined in the ftricture, and
which no furgical operation can
relieve.
This

170
A TREATISE on
This appears to me to be the
ftate of the cafe, as far as it re-
gards the operation of the taxis
or reduction by the hand mere-
ly. And,
When the operation by the
knife is neceffary, it can be of
little or no confequence.
It is faid, that till this was
known, the ftricture, from the
abdominal ring and adhefion of
the contents to the fac, were fup-
pofed to be the only hindrances
to a return of the gut. And
that when fuch a cafe occurred,
if the tendinous rings only were
dilated, and the fac not opened;
the patient might be loft, not-
idT
with-

RUPTURES.
171
withſtanding the operation had
been performed.
But every operator is now fo
perfectly fatisfied of the great
impropriety of not dividing the
fac (to fay nothing of the general
impoffibility of returning it en-
tire) that no inconvenience can
arife from hence.
One very uſeful piece of know-
ledge may however be enforced
from thefe confiderations, viz.
That of making a pretty free di-
vifion of the upper part of the
fac and of the ring in the opera-
tion, and paffing the finger up
within the abdomen all round,
to examine if there are any ftric-
tures

172 A TREATISE on
tures or adhefions remaining,
which will admit of being freed.
M. La Peyronie has related an
extraordinary cafe of an entero-
epiplocele, in which all the fymp-
toms continued after a fuccefs-
ful reduction of the parts by the
hand. Upon diffection it ap-
peared that a portion of the
omentum had, in its return, fo
entangled the inteftine as to caufe
the death of the patient.
SECT.

RUPTURES.
173
SECT. XI.
ATTEMPTS TOWARD A RADICAL
CURE.
IN
'N the firft fection of this trea-
tife I have faid, that the
means uſed to produce a radical
cure, were exactly the fame as
thoſe uſed to produce a palliative
one, viz. reduction and bandage;
and that the event was dependent
on circumftances which a fur-
geon can neither alter nor direct;
fuch as the age of the patient,
the date of the rupture, the
thickneſs of the hernial fac, the
fize of the abdominal rings, &c.
Thofe

174 A TREATISE 072
Thoſe who are acquainted
with the hiftory of this diſeaſe,
may poffibly be furprized at this
affertion, when fo many differ-
ent methods have been propofed
for obtaining a radical cure, and
fuch fuccefs has been faid to have
attended fome of them.n
If any of theſe means deferved
the character that has been given
of them, or had proved gene-
rally fuccefsful, I fhould cer-
tainly have spoke of them in
their proper place.
But all thefe different me-
thods, however applauded by a
few individuals, have upon re-
peated experiment been found
to

RUPTURES. 175
to be unfit for practice: they
have, in general, proved mif-
chievous and inefficacious; the
majority of thoſe who have fub-
mitted to them, have remained
uncured of their rupture; many
have been mutilated, and fome
abfolutely deftroyed.
Theſe were my reafons for not
defcribing them in the firft fec-
tion, and thereby breaking the
thread of my purpofe; and for
referring them to be fpoke of all
together in this place.
They all have the fanction of
antiquity; have been defcribed
or practifed by feveral of the
antient furgical writers; and are
all calculated for the fame pur-
pofe,
2

176 A TREATISE on
poſe, viz. to deſtroy the ſkin and
common cellular membrane about
the abdominal rings, a part of
the tunica vaginalis and hernial
fac, and thereby to procure fo
firm an union of the parts inter
fe, or fuch an attachment of
them to the bone, as to prevent
the defcent of any thing (but
eſpecially the inteftine) from the
belly into the groin or fcro-
tum.
This is the ultimate intention
of them all; but the means
whereby it is propofed to ac-
complish this end are different.
The principal, or thoſe moſt
worth notice are, the cure by
cautery; by cauftic; by caftra-
tion;

RUPTURES. 177
tion; the punctum aureum;
the royal ftitch or future; and
the cure by incifion.
The method by cautery is
mentioned by Avicenna, Albu-
cafis, Paulus Ægineta, Fab. ab
Aquapendente, Guido de Cau-
liaco, Severinus, Theodoric, Ro-
landus, Lanfranc, ferjeant Wife-
man, and others, and is to be
performed as follows:
The inteftines being emptied
by fafting and purging, the pa-
tient is to ftand upright, and
by coughing, ftraining, or any
other means, to make the gut
protrude in the groin; and the
circumference of this protrufion
is to be marked with ink: then
N
the

178 A TREATISE ON
the patient being laid on his
back, and the portion of in-
teftine returned into the belly,
a red hot cautery is to be ap-
plied according to the extent
of the line marked out by the
ink: for this purpofe cauteries
of very different ſhapes have
been propofed, triangular, el-
liptical, circular, and in the form
of the Greek letter gamma;
which difference of form in the
cautery can be of little or no
confequence, (if the fize be pro-
per) either with regard to the
fore or the intended cure.
rab so opdizi
ga
The writers who have defcrib-
ed this method, have differed
from each other with regard to
the depth which the cautery
is
to

RUPTURES.
179
to penetrate: by fome it is or-
dered to be carried down to the
os pubis, the periosteum cover-
ing which is to be deftroyed and
the bone fo laid bare, as to make
an exfoliation neceffary. By
others it is directed to deftroy
only the fkin and membrana
adipofa with the iron, and to
go through the membranes to
the bone with efcharotic medi-
cines.or
The exfoliation of the bone is
by both made a neceffary part of
the proceſs, a caufa fine qua non
of the cure. Albucafis fays,
C
6
Et fcias quod quando tu non
confequeris os cum cauterio non
'confert operatio tua;' Rolan-
dus orders the application of the
N 2
cautery

180 A TREATISE on
cautery in the fame manner; fo
do Guido, Theodoric, &c.
Brunus fays, Si non fueris
os confecutus in prima vice,
'tunc itera cauterium vice alia
'donec confequaris; quia fi non
'confecutus fuerit os cum cau-
terio parum confert operatio
tua.'
C
The efchar and floughs being
feparated, and the exfoliation caft
off from the bone, the fore is to
be incarned as firmly as poffi-
ble; the patient is to obferve an
extremely ftrict regimen; is to
lie on his back during the cure;
and to wear a bandage forty
days after, to prevent a new de-
fcent.
The

RUPTURES.
181
The cure by cauftic is de-
fcribed by many, and among the
reft by Guido de Cauliaco, Se-
verinus, Lanfranc, Theodoric,
Parey, Scultetus, &c.
The patient being laid on his
back, and the hernia returned,
a piece of cauftic is to be applied
on the ſkin covering the ring of
the abdominal muſcle. This
cauftic is to be fo large as to pro-
duce an efchar the fize of half a
crown. By the repeated appli-
cation of efcharotic medicines,
the ſkin and membrana adipofa
are to be deftroyed, and as much
of the tunica vaginalis, and her-
nial fac (if down) as can be done
N 3
with-

182 A TREATISE on
without injuring the spermatic
veffels.
de
For this purpofe different kinds
of corrofive applications have
been uſed. Paftes loaded with
fublimate; arfenical medicines;
the ftirpes brafficæ burnt; the
tithymallus; the lapis infernalis
alone, or with fuet and opium;
oil of vitriol; with many others
according to the whim of the
operator, but all defigned for
the fame purpoſe, viz. to de-
ftroy the common membrane and
part of the tunica vaginalis, fo
as to procure an union of thefe
parts, and produce fuch a cica-
trix as ſhall refift any future de-
fcent.
The

RUPTURES. 183
The mere relation of two of
thefe methods is fufficient to
fhock any ingenious or humane
man.
The horror of the cautery muft
be very great; the apprehenfion
from the cauftic will indeed be
lefs, but the pain full as great, and
of much longer duration.
The parts to be deftroyed, are
the fkin, the membrana adipofa,
part of the tunica vaginalis, a
portion of the hernial fac, and
the periosteum covering part of
the os pubis; and this is to be
done without injuring the fper-
matic veffels, or the tendon of
the abdominal muſcle.
Whe-
N 4

184 A TREATISE on
Whether this be attempted by
actual or potential fire, by cau-
tery or cauftic, the precife limits
of the effect of either will be
out of the power of the opera-
tor to determine, and confe-
quently fome parts will frequent-
ly be injured which were not in-
tended, nor ought to be hurt.
abod
If the fpermatic veffels are
hurt, an inflamed or difeafed
tefticle will be the confequence;
if they are deſtroyed the teſticle
will be rendered ufelefs; if the
tendon of the abdominal mufcle
is injured either by the iron or
the falts of the cauftic, terrible
floughs, a large ill-natured pain-
ful fore, and a high fymptoma-
tic fever muſt be expected; which
3
in

RUPTURES. 185
in fome habits must be produc-
tive of much mischief; to fay
nothing of the confequence of de-
ftroying this part of the tendon,
and of the neceffary confinement
which fuch a fore fo circumftan-
ced muft occafion.
That the evils attending thefe
methods are not ideal, and the
fuggeftions of my own imagina-
tion and prejudice, the writers
themſelves who propofe them
may teſtify.
C
Guido, fpeaking of the cauftic
cure fays, In quo fumme ca-
vendum eft quod homo domi-
nus fit de corrofivo; fi indocte
applicatur febris commovet et
'accidentia mala.' fum
C
C
aft
That

186 A TREATISE on
That great pain, defluxion on
the hæmorrhoidal veffels, inflam-
mation and tumor of the fcro-
tum, were the frequent confe-
quence of theſe attempts, may be
learned from the fame author,
who directs the repetition of the
cauftic applications thus ; Et ita
'continue fiat, quo ufque caro mi-
'racis tota fit corrupta ufque ad
C
C
didymum, quod cognofcitur per
'inflationem burfæ tefticulorum,
et per dolorem partium pofte-
'riorum.' And as a proof that
the cauftic has penetrated deep
enough fays, Quod cognofcetur
'per majorem tumorem tefticuli;
' et per majorem dolorem dorfi et
'partium pofteriorum.'
C
The

RUPTURES. 187
The confequence of fuch pain
and fuch defluxions on thefe
parts is too obvious to every
practitioner to need pointing out,
and indeed the precautions taken
by the fame writers to guard
againſt and remedy theſe incon-
veniences, fufficiently prove their
great probability : hence the di-
rections for anodynes; emollient
poultices; embrocations, for the
letting out matter, ftopping hæ-
morrhages, &c.
Brunus fays,
C
Et cave fumma
diligentia ne in hora cauteriza-
⚫tionis exeat inteftinum et com-
buratur.'
Lan-

188 A TREATISE on
C
<
081
UT LUM
Lanfranc, after having de-
fcribed a mixed method, very
operofe and painful, which he
calls his own, adds, Omnes
C autem alii modi funt fallaces,
quia aliquando poft multos la-
bores iterum crepati remanent,
aut funt valde periculofi; et
fuper omnes modos pejor eft
ille qui fit cum cauftica medi-
cina: nam medicina cauftica
'propter ejus magnam malitiam
⚫ et venenofitatem dolores multos
facit, qui funt caufa attrahendi
apoftema; et raro fit quin per
ea apoftema maximum genera-
tur; et quod pejus eft, adeo
per eam inflatur didymus et
contrahitur quod aliquando
per vulnus exit;' and, from what
C
C
<
C
(
C
6
follows,

RUPTURES.
189
88
follows, it is plain that fatal con-
vulfions were no infrequent con-
fequence, Et fic multi fpafman-
tur et fpafmati fubito moriun-
' tur.'
C
Hence it is not to be wonder-
ed at, that Fab. ab Aquapen-
dente, fpeaking of the cures by
cautery and incifion, fays, ' Quæ
C
tamen chirurgiæ uti videtis dif-
'ficiles admodum funt, et inter
'fubtiliffimas haberi poffunt;
quo fit ut plerique patientes
'affectus perpetuo geftare quam
' his chirurgiis fe fubmittere vel-
'lent.'
C
If the os pubis be laid bare,
whether by cautery or cauftic,
fome of the forementioned hazards
muft

190 A TREATISE on
must be incurred; and if they do
not penetrate to the bone, the
intention will frequently be fru-
ftrated; that is, the inteftine will
flip down behind the fcar, and
put the patient under the fame
neceffity of wearing a bandage,
which he lay under before he
fubmitted to fo tedious, fo pain-
ful, and fo hazardous an experi-
ment.
It is of fome confequence to
obferve here, that thefe means
are not propoſed to preferve life;
not as an anceps remedium to
refcue the patient from death;
but merely to rid him of the
inconvenience of wearing a trufs:
which end they frequently prove
incapable to accomplish; for all
4
the

RUPTURES. 191
the beft writers who have de-
fcribed thefe methods of cure,
have directed the wearing a ban-
dage afterward, from a fear, and
(I fuppofe) a knowledge of their
infufficiency: fo that all the be-
nefit that can be derived from
having undergone fo much, will
frequently amount only, to be-
ing rather lefs liable to a new
defcent if the patient goes with-
out a trufs.
If theſe methods prove ineffec-
tual, and the gut flips down be-
hind the fear, the patient is in a
worfe, in a more perilous fitua-
tion than he was before this at-
tempt. For though the parts
behind which the inteftine paffes
in its defcent are not fufficiently
united

192 A TREATISE on
united to keep it up within
the belly, yet they will be fo
ftiffen'd and hardened, and ren-
dered fo little capable of di-
latation, that a ftricture with
all its fymptoms will be more
likely to happen now, than it
would have been in the fame
perfon before fuch operation had
been performed.
Some of the antients have pro-
pofed caftration as a radical cure
This they did
for a hernia.
openly and avowedly, and not
with intention to conceal it, as
fome of their fucceffors have,
who, under a pretence of a new
operation, have caftrated num-
bers.
Celfus

RUPTURES. 193
Celfus propoſes it as the beſt
method in children, but forbids
it in adults, Paulus and Fab. ab.
Aquapendente both ſpeak of it
in the fame manner.
C
Van Horne, in his Michro-
techne fays, fæpe etiam tanta
'eft proceffus peritonei in alteru-
tro latere diftentio et hinc pro-
lapfus inteftini in fcrotum, ut
'eidem alia ratione occurri non
<
'poffit quam per ablationem di-
'dymi.'
Munnicks, fpeaking of the pal-
liative methods fays, hifce qui
'contentus non eft chirurgia
femetipfum tradat quæ per ab-
O
latio-

194
A TREATISE on
lationem didymi herniam peni-
'tus curare potis eft.'
The cure of a rupture by ca-
ftration needs no comment, as
I take it for granted, that there
are few people who would not
prefer wearing a trufs to being
caftrated.
audit aar
The punctum aureum is per-
formed thus:
The inteftines being emptied
and the hernia reduced, an in-
cifion is to be made through
the ſkin and membrana adipofa,
quite down to the upper part
the fpermatic veffels. This in-
cifion must be of fuch length as
to permit the operator to take
of
up

RUPTURES.
195
up the procefs either with his
fingers or with a hook, and when
it is thus lifted up, a golden
wire is to be paffed under it.
This wire is to be fo twiſted as
to prevent the defcent of any
thing down the tunica vaginalis,
but not fo tight as to reftrain
the circulation of the blood to
the teſticle.
Some have directed a leaden
wire inftead of a golden one, and
others a filken ligature; but the
great uncertainty of them all is
obvious. If the wire or what-
ever is paffed round the proceſs
does not bind pretty tight, it
will not prevent a defcent; if it
binds too tight, it will reftrain
or ftop the circulation of the
blood
O 2

196 A TREATISE on
blood through the fpermatic vef-
fels to the teſticle, and either in-
jure or deftroy it.
d
This operation had at one
time a kind of vogue, and is de-
fcribed by feveral as practifed by
them, Guido, Parey, Scultetus,
Franco, Smaltfius, Purmannus,
Nuck, &c.
The royal-ftitch or future is
performed thus:
The inteftine being emptied
and the hernia replaced, an in-
cifion is to be made in fuch
manner as to lay bare the fper-
matic procefs about two inches
in length from the abdominal
ring downward. When the pro-
cefs

RUPTURES.
197
cefs is laid bare and freed from
the membranes about it, it must
be properly held up by an affift-
ant, while the furgeon with a
needle and ligature makes a con-
tinued future, beginning at the
lower part of the incifion and
ending at the upper. This fu-
ture must comprehend fo much
of the membranes as to fhut
up
the paffage from the abdomen
without injuring the fpermatic
veffels, and what remains above
the future may be removed with
a knife, or be left to flough off.
This is defcribed by many of
the old writers, with fome little
variation from each other, both
in the manner and in the inftru-
ments,
03

198 A TREATISE on
ments, but all tending to the
fame purpoſe.
Paulus, Albucafis, Fab. ab
Aquapendente, Guido, Rolan-
dus, &c. have all defcribed an
operation of this kind; and
Parey and ferjeant Wifeman,
whether from themſelves or any
other, I know not, have offered
an emendation in it, by directing
the fkin on the fide next the
pubis to be comprehended in the
future, by which it is fuppofed
that the future will be ftronger
and the union firmer.
The fatigue to the patient in
this operation must be greater
than that of the punctum au-
reum,

RUPTURES. 199
reum, as the incifion is larger,
and the future muft give fome
additional pain.
In fome habits an incifion of
fuch membranous parts will al-
ways be hazardous: the fcro-
tum will fometimes inflame, and
the cellular membrane becoming
floughy will produce very pain-
ful and troubleſome abfceffes.
Thefe are indeed difagreeable
circumftances, but yet might be
fubmitted to, if the cure proved
always radical; which is far from
being the cafe; this, like all
others, frequently proving in-
fufficient, permitting the in-
teftine to paſs down behind the
cicatrix,
04

200 A TREATISE on
cicatrix, and making a trufs
full as neceffary afterward as be-
fore.
bbst
Some who have thought that
the ftitch added unneceffarily
to the pain and hazard, have
directed the incifion to be made
in the fame manner as for the
future, the membranes to be dif-
fected out, and the fore to be
firmly filled up and healed; and
have thought that by this means
they could prevent any new de-
fcent.
This is fo like to the opera-
tion for a bubonocele, both in
the manner of performing great
part of it, and in its confequence
as a radical cure, that it may
2
be
looked

RUPTURES.
201
looked upon as the fame: and
how very fallacious and uncer-
tain that operation proves in an-
fwering this end, every prac-
tioner knows too well to depend
upon it (in general) without a
bandage.
The punctum aureum and
royal future frequently proved
deftructive of the teſticle, even in
the moft judicious hands; and
when it got into thofe of ignorant
pretenders, it became generally
fo: for they not knowing how
to perform properly what they
had undertaken, being afraid of
the confequence of too ftrict a
ligature, and finding it very eafy
after the incifion was made to
flip out the tefticle, frequently
did

202
A TREATISE on
did fo and went off undifco-
vered.
Thefe are the principal me-
thods which have been propofed
for the radical cure of a hernia.
Infants, young children, and
fuch whofe ruptures have de-
fcended no lower than the groin,
cannot ftand in need of
them.
any of
The pain, the hazard, and
the frequent difappointment from
their inefficacy, have been the
reafons why the furgeons have
difufed them in adults.
That thefe, and thefe only,
have been their motives, may be
bu
proved

RUPTURES.
203
proved to the fatisfaction of every
candid inquirer.
The general charge brought
againſt them is, that either they
are not acquainted with the
proper means, or that through
obftinacy they will not make ufe
of them: a charge both falfe and
unjuft. They always have been
acquainted with them, many have
tried them, and found them in-
efficacious.
ind
The prefent practitioners have
therefore difufed them all: for
which, inftead of incurring cen-
fure, they ought to be reward-
ed with praife. They have can-
didly acknowledged the infuffi-
ciency of their art in fome ftates
4
of

204 A TREATISE on
4
of this diſeaſe; and have freed
mankind from a furgical procefs,
which, though painful and ha-
zardous to the patient, muft
have been very lucrative to the
operator.
If on the other hand they had
continued to practiſe theſe me-
thods, notwithſtanding their ha-
zard and infufficiency, they would
then have been highly blameable,
and would have incurred the cen-
fure of being obftinate, inhuman,
and mercenary; imputations
which cannot now, with any
kind of justice, be thrown on
them, with regard to this fubject.
oliang drive ho
Nor is this the only inftance
of the great lenity of the mo-
dern

RUPTURES.
205
dern furgery, compared with that
of the antients; many more might
be produced if neceffary.
If this is doubted by any one;
let him obferve the efcharotic
medicines among the old writers.
There he will find fuch unma-
nageable and deleterious applica-
tions, as fublimate and arfenic;
fuch painful vegetable cauftics,
as the tithymalus, in frequent ufe.
Let him examine the antient
manner of treating ftrumous
glandular tumors, and old ulcers
attended with caries, callus, or
fungus.
Let him take a view of the old
armamentaria chirurgica, and fee
(with-

206 A TREATISE ON
(without horror if he can) the
almoft infinite variety of cau-
teries which were fo freely ap-
plied.
Let him look over their tracts
de laqueis et machimentis, where
he will find fuch ligatures and
bandages as muſt be productive
of pain and fever at beft, and
fuch complex pieces of machi-
nery for fimple fractures and
luxations, as feem much more
calculated to pull a man to pieces
than to fet him to rights.
And when he has done this,
I would ask him what diſeaſes
or deformities were cured or re-
lieved by thefe painful complex
me-

RUPTURES. 207
methods, which we leave un-
cured, now they are laid afide?
No diſeaſe has furniſhed and
fupported a more conftant fuc-
ceffion of pretenders than her-
nias.
The methods ufed by thefe
people to obtain reputation and
bread, have been different ac-
cording to the abilities of the pre-
tender. They who have had
fome fmattering of anatomy or
furgery, have adopted the cau-
ftic, the future, or the incifion.
They have been more ignorant
have pretended to ſpecific reme-
dies.
The

208 A TREATISE on
The methods by cauftic and
incifion have been already de-
fcribed; and fpecific remedies
and applications have been fo of-
ten tried, and fo conftantly found
unfuccefsful, that to ſay any
thing about them would be waft-
ing time.
I cannot conclude this fection
better than by a quotation from
an old and much efteemed practi-
tioner on this fubject; 'Neceffa-
rium eft tibi fcire locorum ana-
tomiam, ut in cura non incidas
' in errorem ; nam multi de hac
cura fe cum audacia intromit-
(
C
tunt, qui nec loca noverunt,
'nec ægritudinis differentiam;
quare quotidie cadunt in fuis
( ope-

RUPTURES. 209
C
<
operationibus in errorem nec
propter ab eorum infania fe
divertunt; fed quanto minus
'fciunt tanto magis de curis fe
' talibus intromittunt.
O mifer medice qui pro pe-
'cunia ponis corpus humanum in
periculo mortis.'
C
P
SECT.

210
A TREATISE on
SECT. XII.
EXOMPHALOS, OR HERNIA UMBI-
LICALIS,
S fo called from its fituation;
Isaf
and, like the other fpecies of
hernia, has for its general con-
tents a portion of inteftine, or
caul, or both: in old ones the
quantity of omentum is fome-
times very large.
Mr. Ranby found two ells and
half of inteftine in one of theſe
and about a third part of the
ftomach; and all connected to-
gether.
3
Mr.

RUPTURES.
211
Mr. Gay and Mr. Nourfe found
the liver in the fac of an umbili-
cal hernia.
Whatever are the contents,
they are originally contained in a
fac formed by the protrufion of
the peritoneum.
In recent and ſmall ruptures,
this fac is very vifible; but in
old and large ones, it is broke
through at the knot of the navel
by the weight and preffure of
the contents, and is not always
to be diftinguifhed; which is the
reafon of its being difputed whe-
ther this hernia has a fac or not.
P 2
In-

212
A TREATISE ON
Infants and young children
are very ſubject to this in a ſmall
degree, from the feparation of
the funiculus; but they either
get rid of it as they grow up
and gather ftrength, or are eaſily
cured by a proper bandage. It
is of more confequence to get
this diſorder cured in female
children than in male, that its re-
turn when they are become adult
and pregnant, may be prevented
as much as is poffible. At this
time it often happens, from the
too great diftenfion of the belly,
or from fome unguarded motion
while the parts are upon the
ftretch. During geftation it is
very troubleſome, but after de-
livery, if the contents have con-
3
tracted

RUPTURES. 213
tracted no adheſion, they will
return, and are eaſily reftrained
by a proper bandage,
If this bandage was put on in
time, and conftantly wore, this
diſeaſe might generally be kept
within moderate bounds, and
the terrible confequences which
frequently attend it, might often
be prevented. The woman who
has the fmalleft degree of it, and
who from her age and fituation
has reafon to expect children after
its appearance, fhould be parti-
cularly careful to keep it re-
ftrained.
In fome the entrance of the
fac is large, and the parts eafily
reducible; in others they are dif-
P 3
ficult

214
A TREATISE on
ficult of reduction; and in others
irreducible; of which laft, many
have for years been fufpended
in a proper bag, without giving
much trouble.
They who are afflicted with
this diforder are fubject to cho-
lics and diarrheas, and, if the
paffage be at all obftructed, to
very troublefome vomitings;
therefore it behoves them to take
care to keep the inteſtinal tube
as clean and free as they can,
and to eat nothing likely to pro-
duce difturbance in that part.
The cure of this, as propofed
by writers, is either radical or
palliative.
Celfus,

RUPTURES. 215
Albucafis,
Celfus, Paulus,
Aquapendens, Guido, Severinus,
Rolandus, and others propofe a
radical cure by ligature; Fab.
ab Aquapendente propoſes alfo
aut medicamentis aut ferro um-
bilicum adurere; but after having
defcribed both methods, he lays
them under fuch reftraint from
age, habit, fize of the tumor, time
of the year, &c. as amounts al-
moft to a prohibition.
The methods by ligature are
two. In one, the ſkin covering
the tumor is to be lifted up by
the finger and thumb, or by a
fmall hook, to free it from the
inteftine underneath; and then a
ligature is to be made round the
P 4
bafis

216 A TREATISE ON
bafis of the tumor fo ftrict as to
procure a mortification of all on
this fide the ligature. In the
other, the fkin is to be elevat-
ed in the fame manner, and a
needle armed with a double li-
gature is to be paffed through
the bafis of the tumor, which
is to be tied above and be-
low, or on each fide, fo tight
as to produce the fame effect.
Previous to drawing the liga-
ture cloſe, it is advifed to make
a fmall incifion in the top of the
tumor large enough to pafs in
the end of the finger, and with
it deprefs the gut or omentum,
and thereby prevent either of
them from being engaged in the
ftricture.
The

RUPTURES. 217
The intention in both thefe
methods is the fame, viz. by de-
ftroying the lax fkin covering
the top of the tumor, to pro-
duce a cicatrix which fhall bind
fo tight as to reftrain the parts
from any future protrufion.
In young fubjects and fmall
tumors, a bandage wore for a
time generally proves fufficient;
and in old perfons and large
tumors, I take it for granted,
that nobody would attempt fuch
a deftruction of parts fo fituated;
the hazard being obvious.
But fuppofe the fubject young,
and the tumor of fuch fize and fuch
ftate as to make it unlikely that
a

218 A TREATISE 022
a bandage fhould do more than
palliate; that the ſkin covering
the tumor is fo lax as to make
it improbable that it fhould ever
recover its former ftate and
lie fmooth; and, when it has
been thus removed, that the
cicatrix fhall bind fo tight as to
prevent the protrufion of any
of the contained parts: yet who
can tell what will be the confe-
quence of this tightnefs, this in-
dilatability of the ſkin, in a ftate
of pregnancy.
I mention this, becauſe I have
feen very terrible confequences
from the burfting of a cicatrix
on the navel during geftation,
though the cicatrix was from an
abfcefs opened by incifion, and
con-

RUPTURES.
219
confequently cannot be fuppofed
to be equal either in fize or re-
fiftance to that produced by the
operation here propofed.
Perhaps lefs objection may lie
againft this method in male fub-
jects: but as the generality of
umbilical hernias in adults are
in female fubjects, and as the ma-
jority of them make their ap-
pearance during geftation, the
circumftance of pregnancy fhould
always be confidered, however
young the patient may be at the
time the operation is propofed.
This, like the other fpecies of
hernia, becomes the fubject of a
furgical operation, when the
inteftine is irreducible by the
hand,

220
A TREATISE on
hand, and the ſymptoms of ftric-
ture run high: but here every
means fhould be tried before
the operation is propofed; for its
fuccefs is fo infrequent as to
make it by no means a defirable
thing.
The operation confifts in di-
viding the fkin and fac either at
one or two incifions, in a longi-
tudinal, crucial, or oval form,
as fhall beft fuit the tumor or pleafe
the operator; and having divided
the ftricture, the inteftine, if found
and not adherent, is to be re-
turned into the belly; if the in-
teftine is gangrenous, the altered
part muſt be removed, and the reft
managed in fuch manner as to de-
rive the focal difcharge through
bred
the

RUPTURES.
221
the wound at the navel, by which
means fome people have pre-
ferved their life, if fuch a ftate
can be called living.
Strangulations of the omen-
tum in this fpecies of hernia
fometimes produce an abfcefs,
which ſhould be opened with
fome caution; and often prove
very troubleſome to manage.
SECT.

222
A TREATISE on
SECT. XIII.
HERNIA VENTRALIS
MAX
AY appear in almoſt any
point of the fore-part of
the belly, but is moft frequently
found between the recti mufcles.
The portion of inteftine is al-
ways contained in a hernial fac,
and when reduced fhould be
kept in its place by bandage; if
engaged in a ftricture which the
hand alone cannot relieve, that
ftricture must be carefully and
properly divided, and the parts
returned.
The

RUPTURES. 223
The hernia foraminis ovalis,
or protrufion through that fora-
men which is formed by the if-
chium and pubis, is mentioned
by one or two of the French
writers; but as I have never feen
it, I can fay nothing about it.
All the parts contained in the
cavity of the abdomen or pelvis
are capable, by the dilatation of
their connecting membranes, of
being fo thruft forth, as to oc-
cafion external fwellings, which
are called herniæ.
The uterus has paffed through
the ring of the abdominal muf-
cle very foon after impregnation
or has been impregnated, and re-
mained

224
A TREATISE on
mained there during the whole
time of geftation.
Sennertus relates one of this
fort which made its first appear-
ance after a blow on the groin.
The uterus remained without
the ring the whole nine months;
and the child was taken out
alive, by incifion.
Ruyfch faw the fame cafe after
an abfcefs in the groin; the tu-
mor increafed gradually, and at
laft reached the knees of the wo-
man, who when fhe fat down
refted it on her thighs; the child
was taken out alive.
The fame author faw an in-
guinal hernia formed by a large
fpleen

RUPTURES.
225
fpleen which had paffed the aper-
ture in the muſcle.
I have myſelf feen the ovaria
hanging without the abdomen,
having paffed the openings of
the oblique mufcles. They were
fo very troubleſome and pain-
ful to the poor woman, that fhe
could not get her bread till they
were removed. Mr. Nourfe took
them away, and the woman did
very well.
Q
SECT.

226 A TREATISE O
T
SECT. XIV.
HERNIA CYSTICA.
dug
HE vefica urinaria is alfo
liable to be thruft forth
from its proper fituation, either
through the abdominal ring or
under Poupart's ligament.
This is no frequent fpecies of
rupture; but the inftances pro-
duced of it, though but few in
number, are of good authority.
The writers who mention this
as having feen it themſelves, are
J. Dom. Sala, Platerus Bonetus,
Ruyſch, Petit, Mery, and M.
Verdier; the laft of whom has
pub-
5

RUPTURES.
227
publiſhed an account of fome
ſeen by himſelf and others.
In one of theſe cafes, the ura-
chus and impervious umbilical ar-
tery on the left fide were drawn
thro' the ring of the oblique
muſcle into the fcrotum.
எ
In another, four ftones were
found,
Ruyfch gives an account of
one complicated with a bubono-
cele.
M. Petit felt feveral ſmall ſtones
in one, which were afterward dif-
charged by the urethra,
Q 2
Bar-

228 A TREATISE ON
Bartholin fays, that J. Dom.
Sala was the firft difcoverer of
this difeafe; and quotes a cafe
from him in which the patient
had all the ſymptoms of the
ftone in his bladder, which ftone
could never be felt by a catheter,
but was afterward found in that
portion of the bladder which
had paffed the ring and formed
the hernia.
From what thefe gentlemen
have faid, and from confidering
the ftructure, fituation and con-
nections of the bladder, it appears,
that this fpecies of hernia may
be either inguinal or femoral.
2
That

RUPTURES. 229
That as the bladder is only in
part covered by the peritoneum,
and muft infinuate itfelf between
the peritoneum and muſcle in
order to pass the ring, it can
have no hernial fac; and that
when complicated with a bubo-
nocele, that portion of the blad-
der which forms the hernia cyfti-
ca muft lie between the hernia
inteftinalis and fpermatic chord,
i. e. the inteſtinal hernia muft
lie anterior to the cyftic hernia.
When a fmall portion of the
bladder has infinuated itſelf into
the abdominal ring, more will
eafily follow: and when fo much
has paffed as to drag the upper
and

230 A TREATISE on
and hinder part, the perito-
neum which covers that part
of it will follow; and thus a
fac be formed for the reception
of a portion of gut or caul to
form another fpecies of hernia.
Hence the different fituation of the
two hernia in the fame fubject;
for in the hernia cyftica the blad-
der muſt precede the fac, con-
fequently cannot be contained in
it; and hence the hernial fac
with its contents muft lye ante-
terior to the hernia cyftica.
If it arrive to any fize, the
patient cannot diſcharge his urine
without lifting up and compref-
fing the tumor.
While

RUPTURES.
231
While recent it will be free,
eafily reduced, and may be kept
in its proper place by a bandage;
but if it be adherent, the patient
must be contented with fuch re-
lief as a proper fufpenfory can
give him.
In the cafe of complication
with an inteftinal rupture, great
care muſt be taken (if the ope-
ration become neceffary) to
avoid opening the bladder. If
this fhould be done by acci-
dent, the portion forming the
hernia cyftica muft not be re-
turned into the pelvis, where
the fhedding the urine would
be of bad confequence; and to
affift the healing of the wound
in

232 A TREATISE, &c.
in this cafe, a flexible chain ca-
theter, or a hollow bougie, fhould
be kept in the urethra for fome
time.
POST-

POSTSCRIPT.
W preceding papers in or-
HEN I began to put the
der, I had two principal inten-
tions.
One was, to lay before the
young practitioner a plain, practi-
cal account of the nature, fymp-
toms, and method of treating
the three moft frequent fpecies of
ruptures, and to endeavour to
remove fome of that prevailing
fear of the operation, by which
I apprehend many lives may
R
be

POSTSCRIPT.
be preferved: in doing this I
have been very careful not to
omit any thing which appears to
me uſeful or neceffary; and have
defignedly paffed over feveral
minutiæ to be found in writers
on this fubject, which are ra-
ther matter of ingenious fpecu-
lation than inftruction, and are
more likely to mislead than to
inform a reader not verfed in
bufinefs; in fhort, my endea-
vour has been to advance nothing
in the theory but what is fairly
deducible from the anatomical
ftructure of the parts; nor any
thing in the practice, but what
I know from my own experience
to be true.
My

POSTSCRIPT.
My other intention was to
endeavour to remove the pre-
judice against the profeffion
(with regard to this diſeaſe)
which the repeated affertions of
advertifing quacks has raiſed;
and which a perfect ignorance
of the nature of the difeafe and
the parts concerned in it ftill
fupports.
The pains I have taken to ex-
plain this to the unknowing, in
as clear a manner as I can, has I
fear rendered me prolix and te-
dious to thofe who were mafters
of the fubject before; but as the
brevity, fufficient for the latter,
would have been obfcurity to the
former,

POSTSCRIPT.
former, I hope this, the true rea-
fon, will be admitted as my apo-
logy.
FINI S.
CORRIGENDA.
Page 25, line 6, after body add except the fac; p. 27,
fecond line from the bottom, dele of life; p. 57, line
ult. for timely, read early; p. 68, line 3, for tumor
r. hernia; line penult, after or add other; p. 77, line
3, for foreceps r. forceps; p. 79, line 14, for was
7. were; p. 105, line 3, after this add mortified s
p. 111, line 15, for always r. generally; p. 127,
line 3, for by r. with; p. 129, line 1, after with add
the; p. 146, line 1, dele if; p. 161, line 10, dele
much; line 16, for fide r. edge.