Contents:
no. 1. de Gimbernat, Antonio.
A new method of operating for the femoral
hernia, transl. from the Spanish... 1795.
No. 2. Garnett, T.
Outlines of a
No. 8. Pearsm, George.
course
of lectures on chemistry.
An inquiry emcerning the history of the
One pox,.. 10798.
M. 4. Woodville, William
Reports of a series of invculations for
the variolae vaccinal, or cno pox. 1799.


A
A
No.1.
New Method of Operating
FOR THE
FEMORAL HERNIA,
TRANSLATED FROM THE SPANISH OF
de
DON ANTONIO DE GIMBERNAT,.
m
SURGEON TO THE KING OF SPAIN.
WITH PLATES.
TO WHICH ARE ADDED
By the TRANSLATOR,
QUERIES RESPECTING A SAFER METHOD OF PERFORMING
INOCULATION; AND THE TREATMENT OF
CERTAIN FEVERS.
55A
SOCIETY OF THE COUNTY
AC
OF
DEMY OF MEDICINE OF BROOKLY
MEDICA
AND
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Hernia - Femoral
ADVERTISEMENT.
THE fuperiority of Mr. Gimbernat's
method of operating for the femoral or cru-
ral hernia will not, I believe, be contested.
The difference, indeed, appears to me to be
exactly this; the patient who is treated ac-
cording to Mr. Gimbernat's method will
infallibly recover; whereas former modes
of operating are well known to have been
attended with the utmost danger.
This was a fufficient motive for under-
taking to tranflate the following tract. I
wish my tranflation may raife fome curiofity
in our furgeons with regard to the publica-
tions of their brethren abroad. English-
men in general are difpofed to undervalue
the productions of foreigners; and among
Jurgeons this propenfity has, I think, been
lately

[ i ]
lately ftrengthened by the example of one
ignorant man of fuperior genius.
What I have added, I give as mere con-
jecture; fhould perfons who have the op-
portunity think my conjectures worth put-
ting to trial, fome useful knowledge may
poffibly be acquired, Had I myself had
any fufficient opportunity of trying what
I have propofed on the fubject of the fmall-
pox, 1 fhould not have offered my obferva-
tions to the public in their prefent crude
State.
T. B.
Clifton, June 26, 1795

AN
ACCOUNT
OF
FORMER METHODS OF
OPERATING
FOR THE
CRURAL HERNIA,
AND OF THE
INCONVENIENCES WITH WHICH THEY
WERE ATTENDED.
OF
F all complaints the true hernia is
doubtlefs the most frequent. On
careful calculation it has been found
that one eighth part of the human fpecies
is afflicted with it. (Arnaud in bis
preface p. 100.) The majority of
infants become ruptured; and many
are born fo. Some of thofe that are
* This, it muſt be remembered, was written in Spain,
where the pernicious practice of fwaddling and tight
cloathing is not yet exploded.-T.
B
cured

[ 2 ]
cured in infancy, (as almoft all will be
if properly treated) relapfe, if not in
the prime of life, at leaft in old age,
when original hernias are extremely com-
mon.
The number of thofe that die of this
complaint is not inconfiderable, and moft
of thoſe who have ruptures, are incapable
of performing certain functions of great
importance to the ftate; and they gene-
rally lead a precarious and valetudinary
life. This accident having at all times
been fo common and dangerous, it is
difficult to fay, why the treatment of it
fhould have remained fo long in the hands
of perfons without education, and with-
out the ſmalleſt acquaintance either with
the human body, or the diforder they
attempted to remedy. It is only in the
prefent century, that well-informed prac-
titioners have applied themfelves to this
defpifed part of furgery; hence the abo-
minable herd of Gelders and Rupture Doc-
RANU
tors

[ 3 ]
tors has infenfibly disappeared; and fur-
geons have acquired diftinguished honor
by the difcovery of various new fpecies
of hernia, and of fafe methods of curing
them radically.
Thefe improvements are entitled to
our warmeft approbation. It muft never-
theleſs be acknowledged, that this branch
of furgery has by no means attained the
defirable degree of perfection. The prin-
cipal defect lies in the mode of operation,
and practitioners are ftill embarraffed to
operate with fafety in cafes of the crural
or femoral hernia, which prefents fome of
the most dangerous cafes.
Some, after the herniary fack is opened,
advife to cut the fallopian ligament across
and forwards; others to cut it outwards,
or inwards. Mr. Arnaud, to avoid the
danger of thofe methods, invented a blunt
hook or curved levator, with which he
made an affiftant raiſe the ligament fo as
to dilate it, till there was room to return
B 2
the

[4]
the inteftine into the abdomen; a method
which may have much affifted Mr.
Leblanc in the invention of his famous
dilator, though he himself affures us, that
he borrowed the hint from Lecat's method
of gradually dilating the neck of the
bladder in the operation for the ftone.
The method invented by Leblanc in
1750, and fince eſtabliſhed by much prac-
tice, is doubtless preferable to all others
in the inguinal hernia; at firft view it
appears fo alfo in the crural hernia.
When the ftructure however of the parts
concerned in the crural hernia is carefully
compared with Leblanc's method, it will
be clearly feen that his dilator is not to
be recommended. In the inguinal, the
aperture which affords paffage to the
protruded parts, is formed by two aponeu-
rotic bands, equally dilatable and having
parallel fibres: fo that were it not for an
expanfion of the fafcia lata which unites
firmly

[ 5 ]
firmly with the bands, and ftrengthens
their junction, they would feparate on the
application of the flighteft force, as far as
the fpine of the ilium. This difpofition
without doubt induced Mr. Leblanc to
fuppofe, as others have fuppofed, that
the extremity, which he calls the handle
of the ring, (l'anfe de l'anneau,) re-
fembles in ſhape the handles of baskets,
and that it confifts of fibres, going off
from the bands themfelves and forming
fpirals round the handle. Hence they
have compared this difpofition of parts
with that which they fuppofed to exiſt
in the foramen of the diaphragm that
gives paffage to the vena cava. Anato-
mifts however, who have well examined
thefe apertures, know that there is not
the fmalleft refemblance between them
and the rim of a basket. If therefore the
dilator of Leblanc be introduced into the
inguinal ring, in fuch a manner that when
B 3
its

[6]
its fides are opened, they apply to the
bands of the ring, the one will be parted
from the other, more or lefs, according to
their rigidity and to the force exerted;
and in the fame proportion will be ſtretch-
ed the fibres of the fafcia lata that traverſe
the handle of the ring, whence a dilatation
of the ring will inevitably refult.
But in the crural hernia, the aperture
through which the parts iffue is not
formed by two bands, but it is a foramen
almoft round, proceeding from the inter-
nal margin of the crural arch near its
infertion in the branch of the os pubis,
between this bone and the iliac vein: fo
that in this hernia, the branch of the os
pubis is fituated more internally than the
inteftine and a little behind; the vein ex-
ternally and behind; and the internal
border of the arch before. Now it is this
border which always forms the ftrangula-
tion, and this is the only part contributing
to

[ 7 ]
to form the foramen, that can be extend-
ed without danger to the patient; the
vein cannot; it might eafily be ruptured;
whence would arife an hæmorrhage, that
would probably foon terminate with life.
In cafe of ftrangulation it would be very
dangerous to introduce into this foramen
the dilator of Leblanc, on account of the
preffure that must be made, on opening it,
upon the great iliac veffels, notwithſtand-
ing the aponeurotic feptum dividing the
foramen from the paffage for thofe veffels;
neither could this inftrument at all extend
the internal margin of the arch, becauſe
it will be cloſe to its infertion, and alfo
becauſe all its force is applied, not to its
edge as would be neceffary to its extenfion,
but along it, fince Leblanc always opens
it with the canal of the gorget towards
the inteftine: in no other pofition indeed
could it be opened, without facrificing the
ftrangulated inteftine.
B 4
I fhall

[ 8 ]
I fhall be told perhaps, that Leblanc
with his dilator raifes the inteftine a little
upwards. But who does not perceive
that this elevation is infufficient; befides,
the inftrument is very unfit for this pur-
pofe; to which it may be added, that if
the edge or border, that produces the
ftrangulation, were not prevented by its
tenfion from being elevated fufficiently,
the tenaculum of Arnaud would then be
preferable. I will venture to affert, that
in the cafes of crural hernia, in which
the dilator of Leblanc has been employed,
fortunately for the patient, it never was
introduced into the foramen; for the
foramen was unknown, as alfo the dupli-
cature of the crural arch that forms it.
Hence Leblanc believed that the fallopian
ligament, and cellular fubftance below,
formed the ftrangulation of the inteftine.
(vide his Operations of Surgery, T.11, p.
141. Paris, 1782.) "The fimple anato-
"mical

[ 9 ]
"mical defcription," fays he, "of the
" crural arch, beneath which pafs the
66
parts that form the crural hernia,
"fhews that the dilatation may be effec-
"ted there, ftill more eafily than in the in-
66
guinal ring. This arch is principally
"formed by a ligamentous and aponeu-
"rotic band, which is ftretched between
"the anterior fuperior fpine of the ilium
" and the fpine of the os pubis, in which
"it is inferted, becoming narrower to
" its infertion: it is called the fallopian
or inguinal ligament: beneath it is
"cellular fubftance of confiderable width,
" which may be preffed fideways by the
flighteft force. There are not, as
"in the ring, any collateral fibres
"which ftrengthen the aperture,
66
66
through which pafs the parts that
"form this hernia, hence this paffage is
66
more eafy. If we lift a little the nar-
"roweft part of this band, with the
"" round

[ 10 ]
"round part of the dilator, and make a
"little preffure on the fides, the aperture
" will be opened fufficiently to allow the
difplaced parts to re-enter, as experi-
ence has fhewn.
66
"Experience and theory concur to
" evince, that the dilatation propofed is
"juft as poffible in the crural as in the
" inguinal hernia; and although Mr.
"Arnaud confiders the operation for the
" latter as much more difficult and dan-
66
gerous; obfervation has convinced me,
"that according to my method, it does
"not retain this character." Such an im-
perfect defcription of the crural arch be-
trays the want of anatomical knowledge
of this part: and from the defcription it-
felf we may deduce the inutility of the
dilator of Leblanc, in the laft mentioned
operation; for he himself confeffes that if
the fallopian ligament be raiſed a little,
and flight lateral preffure be made on the
cellular

[ 11 ]
II
cellular texture below, the parts may be
eafily replaced. Can there be a ftronger
proof, that the dilator of Leblanc has
never been introduced, in operations for
the crural hernia, into the foramen, where
the ftrangulation takes place? I am per-
fectly perfuaded, that in all fuch cafes,
after the herniary fack has been opened,
the parts could have been introduced by
the hand alone; fo that the introduction
ought not to be attributed to the dila-
tor.
Leblanc fell into a great miftake, in
fuppofing that the cellular texture, and
fallopian ligament, form the ftrangula-
tion. That he entertained this opinion,
appears from his being content with raif-
ing the fallopian ligament a little, and
making a flight preffure on the cellular
fubftance of the fides, parts which never
occafion the ftrangulation; for this al-
ways depends on the inner edge of the
crural

[ 12 ]
crural arch, of which Leblanc had no
knowledge.
Leblanc was alfo miftaken in fuppo-
fing that the gradual dilatation was more
eafily effected there, than in the inguinal
ring, and in afferting in confequence, that
the operation for the crural hernia was
not more difficult, or dangerous, accord-
ing to his method, than for the inguinal.
Is it not evident from this, that Leblanc
was unacquainted with the ftructure of
the crural arch, and with the part that
forms the ftrangulation? From what I
have faid, it follows that all the methods
hitherto propofed, are either unneceffary,
as that of Leblanc, (in which there is alfo
great danger if the dilator be introduced,
as was intended, into the foramen of
ftrangulation) or elfe attended with great
riik, as the best practitioners confefs;
fince, if the fallopian ligament be cut
acrofs, the pofterior pillar of the inguinal
ring

[ 13 ]
ring is deftroyed without remedy in both
fexes, and in the male an important artery
will always be cut.
This has been clearly fhewn by Ar-
naud, who relates that, in confequence of
a difpute on this point, an experiment
was made in the Hotel Dieu, at Paris, in
prefence of three able anatomifts, Ver-
dier, Ruffel, and Baffeul. The firft fubject
they choſe had a ftrangulated crural her-
nia, ftill fubfifting, of which the patient
had died. On this fubject Mr. Baudou,
firft furgeon to the hofpital, performed
the operation in prefence of the reft, with
as much caution and dexterity as it is per-
formed on the living fubject. He cut the
fallopian ligament acrofs and forwards, and
eafily reduced the rupture. Mr. Ruffel,
who could not believe that the fperma-
tic artery would be divided in this me-
thod, diffected the part with the utmoſt
care, and found the artery really divided.
That

[ 14 ]
That he might not be obliged to give up
his opinion, he imputed this to fome ac-
cident; he was, however, foon unde-
ceived, when he repeated the operation in
the fame way on the other fide of the
fubject. He found, notwithstanding the
precaution with which he operated, that
the fpermatic artery was equally divided,
though he performed the diffection with
his own hand. This artery, when di-
vided within the abdomen, occafions an
hæmorrhage very difficult to ftop; and
even when we fucceed in ftopping it,
the miſchief in regard to the propagation
of the fpecies fhould be confidered, if the
vas deferens be divided, as is frequently
the cafe.
Laftly, the patient is more than ever
liable to relapfes, becauſe when the pof-
terior pillar of the inguinal ring is cut,
this forms with the crural ring a common
aperture, large enough to give paffage to
a con-

[ 15 ]
a confiderable portion of inteftine; the
confequence therefore is a much larger
hernia than before the operation, as ac-
tually happened to a woman on whom
Mr. Arnaud operated in this way in
1727. He was profecuted in confe-
quence; and he himself confeffes that if
the judges had not been very intelligent,
he muft have been caft in damages and
cofts.
Cutting the fallopian ligament oblique-
ly outwards, endangers ftill more the life
of the patient, for the epigaftric artery
will be infallibly divided at its origin.
An hæmorrhage extremely difficult, or ra-
ther impoffible to ftop, will be produced,
yet no external figns of it will be ſeen,
and the patient will die in a few minutes,
to the furpriſe of the operator, till the
cauſe of the unfufpected death, and at the
fame time the imperfection of this method,
be detected by diffection. If the fallo-
pian

[ 16 ]
pian ligament, as fome have propofed, be
cut obliquely inwards, the epigaftric ar-
tery will be equally divided, though a
little farther from its origin. The risk is
the fame; the only difference is that the
death of the patient is not quite fo immedi-
ate, and the chance of tying the artery is
fomewhat greater. Moreover, in all theſe
methods the fallopian is cut, which is
perfectly uſeleſs, unless the incifion be
carried on to the internal edge of the cru-
ral arch.
Arnaud, with a view to avoid all theſe
dangers, invented, as I have mentioned, a
blunt tenaculum, which I remember Dr.
Hunter fhewed to fome of his pupils, and
of which he spoke in his lectures with
fmall recommendation. This tenaculum
can only raiſe the external edge of the
crural arch; it is not however, this, but
the internal edge, which forms the ftran-
gulation and the inftruments in queftion
2
can

[ 17 ]
can never reach the internal edge. We
may therefore prefume that in all the cafes
where Arnaud ufed his tenaculum, the
reduction might have been effected by
the hand alone after opening the her-
niary fack.
All practitioners have acknowledged
the danger of this operation, although
fome writers very flightly obferve by the
by, that it is to be performed as for the
inguinal hernia, an erroneous and moft
dangerous direction, which may be found
in Garangeot and Sharp. Arnaud, Pott,
and Bertrandi, however, exprefsly avow
the difficulty and rifk attending all the
methods propofed to their time, and
without venturing to decide which de-
ferves the preference, they only recom-
mend extreme caution to the operator.
Dr. Hunter did the fame in 1777, when
'I attended his lectures, without determin-
C
ing

[ 18 ]
ing any thing as to the merit of the re-
fpective methods.
Laftly, Mr. Bell has fpoken of the
operation in the following terms.
66
"The membrana adipofa, tendinous.
expanfion of the fafcia lata, and her-
"nial fack, being all cautiously divided,
"if the protruded parts are found in a
"fituation proper for reduction, we
"fhould immediately attempt to replace
"them; and as the fpace below the li-
"gament through which they have paf-
"fed is confiderable, this may frequent-
ly be done without dividing the liga-
"ment, merely by preffure properly ap-
66
plied with the hand, while the pa-
"tient's body is placed in the pofture we
"have already directed in the bubono-
"cele, as being beft fuited for favour-
*ing a return of the bowels.
"When in this manner the contents
" of the tumor can be reduced without
"the

[ 19 ]
"the neceffity of dividing the ligament,
"the patient is thereby faved from a
"great deal of hazard, as from the par-
"ticular fituation of the fpermatic vef-
"fels, and epigastric artery, with refpect
" to this ligament, any cut made into the
"fubftance of the latter runs a very
66
great risk of dividing one or other of
"them.
*
"The fpermatic veffels, as they go
" along to pafs out at the opening in the
external oblique mufcle, run nearly
66
upon the very edge or border of Pou-
part's ligament, almoft through its
"whole length, fo that I confider it as
66
impoffible to make a free divifion of
"the ligament without cutting them
"acrofs.†
* The fpermatic veffels run more than an inch along
the canal formed by the duplicature of the crural arch, be-
fore they pafs out at the inguinal ring, and in this courfe
they are joined by the vas deferens. G.
+ The experiment in the Hotel Dieu is a proof of the
utter impoffibility of doing this. G.
C 2
<< We

[ 20 ]
"We have been adviſed indeed by
"fome, in order to avoid wounding the
"fpermatic veffels, which they acknow-
<<
ledge would certainly happen if the
"incifion fhould be carried directly up-
"wards, to cut in an oblique direction
"outwards. In this method they allow
"that the epigaftric artery, from the
"courfe it ufually takes, may very pro-
66
66
bably be divided. But the risk attend-
ing the divifion of that artery they do
"not confider as of much importance;
" and if the diſcharge of blood, occa-
"fioned by any wound that may be
"made in it, fhould happen to be con-
"fiderable, they fpeak of it as a very
(6
eafy matter to take it up with a needle
"and ligature, and needles of various
fhapes have been invented for this pur-
"pofe. Even in emaciated people,
" however, it is a matter of much dif-
ficulty to reach the epigastric artery,
" and
66

[ 21 ]
"and in corpulent patients it will be
"found altogether impoffible to furround
"it with a ligature; fo that the younger
"6
part of the profeffion ought to be very
"cautious in receiving the directions
ufually given upon this fubject.
"On reading the remarks of the late
"Mr. Sharp upon this point, to fe-
66
66
cure the epigaſtric artery by means of
a ligature, one would expect to be the
"eafieft of all operations; but the dif-
"ficulty which in reality attends it is
ઃઃ
fuch, as muft convince every one who
" has tried it, that Mr. Sharp himfelf
"had never put it in practice.
66
"But even, although this accident of
wounding the epigaftric artery could
"be guarded againft in the moft eafy
" and effectual manner, yet I will ven-
ec
ture to fay, when a femoral hernia is
"of any confiderable fize, the diftention
"of the ligament thereby produced muft
C 3
SO
ACADEM
MEDICAL
AND
UNTY
OF MEDICINE OF
66
bring
KLYN
KINGS
LIBRARY

[ 22 ]
66
bring the fpermatic veffels fo nearly on
"a line with the under border of the
66
46
ligament, as to render it altogether im-
poffible to divide the one without the
"other; and whoever will examine
"theſe parts in the ftate we have now
"defcribed, will fee that this cannot be
"avoided, whether the incifion be car-
"ried directly upwards, or even oblique-
"ly outwards or inwards.
"Some authors, from being fenfible of
"the danger attending this part of the
operation, have propofed merely to di-
"late the paffage, inftead of dividing the
66
ligament; and Mr. Arnaud, a French
"writer on this fubject, delineates a curved
"levator for the purpofe of fupporting the
66
ligament till the protruded parts are re-
"duced. But as we are to fuppofe in
every cafe of ftrangulated hernia, that
"the paffage through which the parts
"have fallen down, is already dilated to
nearly

[ 23 ]
Ce
nearly its utmoft poffible extent; in
"fuch a fituation to attempt a farther
" dilatation without the affiftance of the
"knife, would feldom, it is probable,
"be productive of any advantage.
"A confiderable time ago it occurred
"to me, that in this part of the opera-
"tion fome affiftance might be derived
"from performing it in the following
66
manner, and having fince had occafion
" to make trial of it in one cafe where
"it anſwered moft effectually, I can
now therefore recommend it with fome
"certainty. Instead of dividing the
66
ligament in the ordinary way, I only
"made an incifion into part of its thick-
"nefs. In order to protect the parts
" below, I first infinuated the fore-finger
" of my left hand * between the gut and
* An evident proof that the fallopian ligament, or ex-
ternal border of the crural arch, does not occafion the
ftrangulation, as all writers have hitherto fuppofed. G.
C4
"the

[ 24 ]
"the ligament; and then with a com-
CC
mon fcalpel made a cut of about an
" inch in length, beginning above, and
66
proceeding to the under border of the
"ligament.
66
"The firft fcratch with the fcalpel
was very flight; but by repeated
"touches it was made to penetrate al-
"moft through the whole thickneſs of
"the ligament, till at laft a very thin
"lamella only of it remained. The
66
finger being now withdrawn, the pro-
"truded parts were returned with great
"eafe, the ligament at its weakened part,
66
", yielding gradually as the neceffary pref-
"fure was applied for the reduction of
"the inteftines.
"As in this manner the opening
"may be enlarged to any neceffary ex-
"tent, and as the fpermatic veffels, and
66
epigaftric artery, are thus effectually
"avoided, the operation for this fpecies
" of

[ 25 ]
"of hernia may not only be done with
equal certainty, but with the fame de-
66
gree of fafety as for any other kind of
rupture. For by not penetrating with
"the fcalpel through the whole thick-
"nefs of the ligament, under which thefe
"blood-veffels lie; they are thereby
66
*
kept free from all kind of danger du-
"ring this part of the operation; and
"the preffure to be afterwards ufed for
"the reduction of the protruded parts,
"if done in an eafy, gradual manner, as
"it ought always to be, can never in-
"jure them materially; as blood-veffels
" of the fize and ftrength of which theſe
are eafily admit of a degree of exten-
"fion, much more confiderable than can
"be here required."
66
This author was perfectly well ac-
quainted with the danger of dividing the
* The crural veffels, not the fpermatic and epigastric,
lie below the ligament, as will be feen in the fequel. G.
fallopian

[ 26 ]
fallopian ligament in any direction what-
ever, and with the difficulty of dilatation
without incifion. He was not, however,
well acquainted with the duplicature of
the crural arch, or with its attachment
along the creft of the os pubis; neither
had he any exact acquaintance with the
foramen, which gives paffage to the parts
forming the crural hernia; confequently
he could ill underftand what part forms
the ftrangulation. Had he known it,
he would not have meddled with the fal-
lopian ligament, not even with its edge,
as he did, doubtlefs fuppofing, that this
ligament forms the ftrangulation.
This able practitioner nevertheleſs dif-
covered a method of operating without
dividing the fpermatic or epigaftric veffels.
He introduced his finger below the fal-
lopian ligament, between this ligament
and the inteftine; an evident proof that
there was no ftrangulation there: he then
made

[ 27 ]
made a very fuperficial incifion from
above downwards into the thickeft part of
the ligament to its lower edge; and with-
out cutting quite through it, he continued
his incifion about an inch. He would
naturally reft the back of the fcalpel
upon his finger, which ferved as a guide
to the inftrument, and at the fame time,
as a defence to the inteftine. The inci-
fion being continued for an inch, the
operator would inevitably cut the internal
edge of the crural arch. Now cutting
this but for a few lines, gives fufficient
room for the eafy reduction of the parts,
and there is no neceffity to touch the
ligament, as it never occafions the ftrangu-
lation:
Confidering the place and direction in
which the internal edge is divided, we
fhall perceive that the epigaftric veffels
are much expofed in both fexes, and the
fpermatic veffels and vas deferens in the
male.

[ 28 ]
male. I am perfuaded, that an hand lefs
dexterous and lefs in practice than Mr.
Bell's, could not have avoided dividing
them; and as there is left only a thin
lamina between the edge of the inftru-
ment and the veffels above mentioned,
I will venture to affirm, that he will not
be equally fuccefsful in all the cafes in
which he fhall follow this method. Al-
though, therefore, the internal edge of the
crural arch will be cut, I would earneſtly
diffuade from this mode of operating, on
account of the imminent danger attend-
ing it.
Evidence in favour of the Author's method.
I ſhould not propofe my new method
with fo much confidence, if I had not in its
favour the fuccefsful event of two cafes,
in which I practifed it in Barcelona in
1772 and 1773- My patients were
female. I regret that my travels have
prevented

[ 29 ]
prevented me from accumulating more
facts. Profeffor Torner, however, of Bar-
celona, who was prefent at both my
operations, has communicated to me two
other cafes, in which he followed the
fame method. One of his patients was a
male, aged 54. The operation was per-
formed on the 5th of June 1786, and by
the 16th of the next month, compleat
recovery had taken place. The other
was a nun 68 years of age; the operation
was performed on the 23d of Auguft 1788,
and the patient was well by the 4th of
October. Both theſe perfons are ſtill
living. The nun has not been troubled
with any hernia fince, though the has
worn no trufs. The man wanted no-
thing of this kind for a twelvemonth;
he then met with a violent accident, and
had an hernia in the fame place. Befides
thefe four fuccefsful cafes, I am encou-
raged to make my method public, by the
decided

[ 30 ]
decided approbation it received from Dr.
Hunter, to whom I explained it on a
preparation in 1777. As it is, in my
opinion, free from all the dangers that
have been pointed out, and perfectly
eafy to practice, I cannot but flatter my-
felf, that every furgeon who puts it to
trial, will find it preferable to any hi-
therto propofed.
Its fafety and fuccefs entirely depend-
ing on a perfect knowledge of the part
where the accident takes place, I am
under the neceffity of premifing an ex-
act defcription of the crural arch.
This part, although it is fo remark-
able, had been little examined, and lefs
underſtood by anatomifts, till I demon-
ftrated it for the first time in 1768. The
ignorance of its true ftructure has occa-
fioned fuch a variety of dangerous me-
thods; and this is in reality, the reafon
why furgery has not made the fmalleft
progress
2

[ 31 ]
progrefs in the treatment of this acci-
dent.
Defeription of the Crural Arch.
In the lower part of the abdomen,
the external oblique mufcle forms a
ſtrong and broad aponeurofis. The fibres
are parallel; they defcend obliquely from
without inwards; and the lower extend
from the fuperior anterior fpine of the
ilium, to the os pubis, at a little dif-
tance from which they open into two
bands, or pillars, to form the inguinal
ring. In all this tract, the aponeurofis
forms a duplicature inwards. This du-
plicature, which is more manifeft towards
the os pubis, conftitutes a ſtrong whitish
cord, which Fallopius fuppofed to be
a ligament; and fo it was called, till
of late, when it received the name of
crural arch, becaufe at the top of the
thigh, it has fome diftant refemblance
to an arch or vault. This aponeurotic
dupli-

[ 32 ]
duplicature in its infide forms a canal,
which is larger towards the os pubis, and
lodges the fpermatic veffels. Thefe vef-
fels run for a certain fpace through the
canal, before they traverfe the inguinal
ring, where the canal terminates.
Between the ilium and os pubis, the
arch is kept fufficiently tenfe by an ex-
panfion of the fafcia lata, which unites
intimately with it in its whole length, in
fuch a manner, that if the expanſion be
cut, the arch is confiderably relaxed. In
the natural ftate, the tendons of the pfoas
and iliac muſcles pafs beneath it, as alfo
the great crural veffels, and the lympha-
tic coming from the lower extremity.
In the difeafed ftate, fome of the parts
contained in the abdomen alfo país, and
form a tumor at the lower part of the
groin. This is what is called a crural
hernia.
This

[ 33 ]
This arch offers to our confideration
fome peculiar contrivances, little or not
at all underſtood, though the knowledge
be abfolutely neceffary to a perfect idea of
the crural hernia, and to the fafe opera-
tion for its cure. When the inferior band
feparates from the fuperior to form the
inguinal ring, it goes to infert itself in a
tubercle of the os pubis, which has been
denominated its fpine, and which gives
origin to the creft of the fuperior branch of
this bone, and is a continuation of the linea
ileo-pectinea; moreover this pillar is not
only inferted into the fpine by a confidera-
ble union of aponeurotical fibres, but the
duplicature of the arch being much
greater there, it is continued inwards along
the creft of the pubis, by means of a re-
markable plait or duplicature, confifting
of a portion of the aponeurofis. The par-
ticular difpofition of this duplicature, ex-
tending from below upwards, and its infer-
D
tion

[34]
tion from the ſpine to the end of the creft,
which makes more than an inch in fome
fubjects, is highly worthy of our confide-
ration; for without it, we fhould all proba-
bly fuffer large and dangerous protrufions
of the contents of the abdomen. In con-
fequence of this ftructure, the crural arch
has two edges; one external, rounded like
a cord, thicker towards the pubis, and re-
fembling a ligament, as Fallopius actually
denominated it; to this adheres the ex-
panfion of the fafcia lata: in emaciated
perfons, the direction and tenfion of this
cord may be felt through the integu-
ments. The other edge, which I have cal-
led internal, is the termination of the
edge of the aponeurofis; it is very thin,
and from its origin unites intimately with
the aponeurofis that covers the iliac
mufcle. This ftrict union, and that of
the fafcia lata with the external edge, are
moft perceptible from the anterior fupe-
rior

1 35 ]
rior fpine of the ilium to the neighbour-
hood of the crural veffels; hence the crural
arch is more flattened and fixed down in
all this courfe on the iliac muſcle, ferving
it as a band to keep it in its place during
its contractions; confequently it is impof-
fible that a crural hernia can ever take
place in this tract, as fome have fup-
pofed.
As foon as this intertexture of aponeu-
rofis reaches the great fecondary external
iliac artery, there is detached from the
internal edge of the crural arch a mem-
branous expanfion (which is ftrengthened
by the tendon of the fmall pfoas muf-
cle, when this mufcle exifts,) and in-
finuates itſelf behind the great fecondary
external iliac artery and vein. This ex-
panfion goes to be inferted cloſe to the ex-
ternal edge of the pectineus mufcle: more-
over, one lamina from it paffes over that
mufcle, and is attached to the creft of
the
D 2

[ 36 ]
the branch of the os pubis, where it is
united with the duplicature of the arch
which terminates in the fame creft. By
this union is formed a fpecies of ligament
which paffes along the creft, below which
the fuperior extremity of the pectineus
mufcle is inferted.
From this divifion of the crural arch
there arifes an aponeurotic fheath at the
top of the thigh; it begins at the crural
arch itſelf, clofe to the os pubis; fo that
the expanfion, which has been defcribed
as fent from the internal edge of the
arch, and paffing behind the iliac veffels,
forms the pofterior part of the fheath,
while the anterior is formed by the exter-
nal edge of the fafcia lata.
The iliac veffels, enveloped in the cellu-
lar fubftance of the peritonæum, enter into
this fheath in their paffage out of the abdo-
men; there are likewife fome glands and
lymphatics in it; but the crural nerve
always

[ 37 ]
always paffes without the fheath towards
its external and pofterior part.
The iliac artery and vein, before they
enter into the fheath, fend off the epi-
gaftric veffels by its anterior part: theſe
veffels "pafs obliquely inwards, between
the crural arch and fpermatic veffels,
which they appear to embrace on their
entrance into the canal of the arch. From
the external lateral parts of the iliac vef-
fels, after their entrance into the fheath,
are fent off the fmall inferior iliac
branches, which take their courfe to-
wards the fpine of the ilium, clofe to the
infertion of the oblique internal and tranf-
verfe muſcles, in the bottom of the dupli-
cature of the crural arch.
In the internal lateral parts of the
fheath cloſe to the branch of the os pubis,
precifely where the infertion of the dupli-
cature of the arch ends, and on the infide
of the great fecondary iliac vein, there is
D 3
left

[ 38 ]
left a foramen fufficiently diftinct, almoſt
round, at which many lymphatics enter.
A lymphatic gland is fometimes fitted
into this foramen, and the parts which
form the crural hernia always pafs through
it, confequently we may properly call it
the crural ring. A fingle gland placed
in this ring would prevent the iffue of the
parts contained in the abdomen; but if a
portion of the inteftine fhould flide be-
hind, fo as to get out of the cavity, it
would be very difficult to diftinguish the
hernia at firft. A furgeon not acquainted
with the ftructure would be much embar-
raffed if he were to attempt the opera-
tion.
The great iliac veffels occupy the prin-
cipal portion of the orifice of the ſheath;
the fpermatic veffels clofe a little of the
external fide before they enter the canal of
the arch. The epigaftric veffels, in their
way to the mufculus rectus, cover it fuffi-
ciently

[ 39 ]
ciently in its anterior and internal part.
Laftly, fome aponeurotic fibres turn in
from the internal edge of the arch; and
a few lymphatic glands affift in ftop-
ping it compleatly, fo that it is very diffi-
cult for the parts contained in the abdo-
men to make their way out, except
through the crural ring.
If the particular ftructure of the crural
arch and its tenfion as kept up by the ex-
panfion of the fafcia lata be confidered,
we fhall clearly fee the reafon why the
crural feldom obtains fo great a bulk as
the inguinal hernia. We fhall likewife
fee why the tumor is regularly round,
hard, and flippery; a circumftance that
caufes much heſitation and even miſtakes
in practitioners of fmall experience. We
fhall alſo perceive why the operation is
more dangerous, and reduction without
operation more difficult. This difficulty
has laid practitioners of the greateft credit
D 4
under

[ 40 ]
under the neceffity of performing an ope-
ration which they dreaded, becauſe they
did not know how to fteer befide the dan-
gers that threatened the patient's life. To
underſtand the preceding defcription ful-
ly, fee the two plates at the end of this
tract.
Before I proceed to explain the new
method of operating without danger, it
will be proper to remark that the fymp-
toms of ftrangulation are the fame in
this hernia as in others, and that they are
to be mitigated by the fame means
Thefe means belong rather to a compleat
treatife on hernias than to the prefent
differtation.
Nevertheleſs as the reduction ought to
be repeatedly attempted before the opera-
tion is refolved upon, I fhall lay down a
few ufeful rules for effecting the reduc-
tion by the hand alone: from my expe-
rience and the particular ftructure of the
parts,

[ 4 ]
parts, I think that this fhould not be at-
temped in the fame manner as in other
cafes of hernia.
Method of Reduction without Operation.
The patient ſhould be laid on the fide
oppofite the hernia, with his body a
little bent and fomewhat lower than the
pelvis; the head fhould be inclined to-
wards the breaft; the thigh on which the
hernia is fhould be in a ftate of half
flexion, ſo as not to be at all in the way of
the operator. The operator fhould ftand
clofe by the bed, on the fame fide with
the hernia: with the hand next the pa-
tient's abdomen, he fhould grafp the
tumor at its bafe and upper part, and
compreffing it moderately on the fide by
his three foremoſt fingers, he fhould, at
the fame time, with the other hand puſh
the lower end of the tumor upwards and
inwards, to direct it towards the crural
ring,

[ 42 ]
ring, for it cannot poffibly be re-
duced by any other means. This at-
tempt ought to be continued for a long
time without intermiffion, provided the
tumor is not inflamed; the force, in
cafe it be neceffary, fhould be gradually
increaſed. But when the patient is fa-
tigued, the compreffion and puſhing
fhould be difcontinued, without lofing
hold of the tumor; which, on the con-
trary, fhould be firmly grafped, until the
patient is refreſhed and the reduction can
be attempted anew. I have fometimes
found above an hour neceffary to effect
this purpofe; and I have reafon to believe
that I have been more fuccefsful than
others, who, without attending to the
above rules, have contented themſelves
with a flight attempt at reduction, for
fear of injuring the inteftine.
I can aver, that of numerous ruptures
which I have treated in this manner, there
have

[ 43 ]
have been very few which I have not
been able to reduce; and among theſe
are fome which have baffled other prac-
titioners; in none of theſe cafes has any
bad confequence followed. For although
the compreffion and pufhing have been
long continued, and great force has fome-
times been applied, it has always been
gradually increafed. The operator's nails
put the patient to great inconvenience if
he does not keep them cut cloſe.. I ought
to add, that this method will be very in-
jurious, if the tumor be inflamed and
confiderably painful; and it will be ftill
worfe, if the violence of the fymptoms
announce inflammation in the inteftine.
In thefe circumftances the judicious prac-
titioner will not harrafs the patient with
ineffectual and perhaps fatal attempts at
reduction by the hand, but will proceed
directly to the operation.
Method

[ 44 ]
Method of Operating.
The patient being placed as for the
operation of the inguinal hernia, and the
hernial fac being properly laid open, an
attempt fhould be made, if the inteftine
be uninjured, to replace it by the hand.
For this purpofe a little more of the in-
teftine fhould be drawn out, becauſe fome-
times the incarcerated portion is fo ftrong-
ly contracted as not to allow paffage to the
matter contained in the part beyond.
This is frequently the only impediment to
reduction: it is generally to be overcome
by bringing to the ring, if poffible, a
portion of the inteftine that has remained
in the abdomen. This not having fuffer-
ed ftrangulation, will not be contracted
like that which has fuffered it for hours
and days.
If the reduction cannot be effected in
this way, it is abfolutely neceffary to di-
vide

[ 45 ]
vide the part that occafions the ftrangula-
tions. For this purpofe introduce, along
the internal fide of the inteftine, a canu-
lated or grooved found, with a blunt end
and a channel of fufficient depth. This
is to be directed obliquely inwards, till it
enter the crural ring, which will be
known by the increaſed refiftance; as alfo
when its point refts upon the branch of
the os pubis. Then fufpend the intro-
duction; and keeping the found (with
your left hand, if you are operating on
the right fide, and v. v.) firmly refting
upon the branch of the os pubis, fo that
its back fhall be turned towards the in-
teſtine and its canal to the fymphyfis pubis,
introduce gently with your other hand in-
to the groove of the found a biftoury with
a narrow blade and blunt end, till it enter
the ring: its entry will be known as be-
fore by a little increaſe of refiftance.
Cautiously prefs the biftoury to the end of
2
the

[ 46 ]
the canal: and employing your two
hands at once, carry both inftruments
clofe along the branch to the body of
the pubis, drawing them out at the
fame time. By this eafy operation
you will divide the internal edge of the
crural arch at its extremity; and within
four or five lines of its duplicature, the
remainder continuing firmly attached by
the inferior band or pillar, of which it is
the continuation. This fimple incifion be-
ing thus made without the fmalleft danger,
the internal border of the arch, which
forms the ftrangulation, will be confider-
ably relaxed, and the parts will be reduced
with the greateſt eafe.
By this new method, the operation for
the crural hernia, which the moſt cele-
brated furgeons have juftly accounted ex-
tremely dangerous, is rendered the moft
fimple and fafe of all that are practifed in
cafes of ftrangulated hernia.
The

[ 47 ]
The fallopian ligament is not at all
concerned in this operation; neither can
the fpermatic cord or fpermatic artery,
much lefs the epigaftric, be divided, for
all theſe parts are left at the fhoulders of
the found, and far remote from the edge
of the biftoury. The fame may be faid
of the obturatrix artery, when it arifes
from the great fecondary external iliac,
though it paffes over the branch of the
pubis in its way to the foramen obturator.
If by chance any of its fmall branches
extend to the duplicature, they are fo
very minute that they carry with them
no danger. I may fay the fame of ano-
ther fmall anomalous artery, that occa-
fionally ramifies through this part, fince
capillary veffels are never obftacles to ope-
rations of furgery.
The danger moft to be dreaded, is that
of wounding the urinary bladder, which
would certainly be expofed, if it were
full

[ 48 ]
full at the time of operation; but it can-
not poffibly be wounded if empty. The
precaution, therefore, of making the pa-
tient evacuate his urine a little before the
operation, which was obferved by Garan-
geot in fuch cafes, muft by no means be
neglected.
In pregnancy of four months and up-
wards, the uterus may alfo be wounded.
To avoid this injury, a biftoury, blunt at
the end, is to be employed, like that
which Arnaud ufed in the bubonocele.
Befides, we must take care not to intro-
duce it far, and to have the patient
greatly inclined to the oppofite fide.
After the operation, a fimple dreffing
is to be uſed; no extraneous body fhould
be introduced into the incifion; on the
contrary, care fhould be taken to bring the
lips together, and to keep them fo by
means of fome ftrips of adhefive plaifter.
Over this dry future let a fimple com-
prefs

[ 49 ]
Upon
prefs be laid, flightly covered with an
ointment made of white wax and good
common oil, that it may not ftick to the
ftrips of plaifter, or the lips of the
wound. This comprefs fhould extend
two inches beyond the future, to prevent
the introduction of air, or any body ca-
pable of occafioning irritation.
the comprefs lay fome lint, which ſhould
be kept in its place by other compreffes,
and a fimple fupporting bandage like the
inguinal, which is commonly fufficient,
or by the fimple fpica, if neceffary. The
patient is to be kept in the fame pofition,
as after the operation for the inguinal her-
nia; and he is to maintain equal quiet-
nefs, and to obferve the fame diet. The
firft dreffing, if nothing new occurs, is
to be left on five or fix days at leaft.
Another is to be applied exactly like the
former, and to be continued as long as
poffible; the dry future is to be employed,
(unless
E

[ 50 ]
(unless another become abfolutely necef-
fary) in order to procure a ſpeedy union.
Should any thing unufual occur, the
mode of treatment will of courſe be va-
ried according to the circumftances.
742
EXPLA-

( 51 )
EXPLANATION of the PLATES.
PLATE I, fhews the pelvis vertically divided
through its middle, with the two loweft lumbar
vertebræ, one of the nates, and a portion of the
thigh with its integuments. The interior part of
this right half of the pelvis is fhewn for greater dif-
tinctnefs.
1. The inferior ramus, or branch, of the os pubis.
2. The tefticle.
3. Section of the corpus cavernofum.
4. Superior ramus, or branch, of the os pubis.
5. The fymphyfis pubis.
6. The duplicature of the crural arch, and its in-
ſertion in the creft of the os pubis.
7. The crural ring formed by this duplicature.
8. The epigaftric veffels.
9. Part of the rectus muſcle.
10. Aponeurofis of the abdominal mufcles.
II. The vas deferens.
12. The fpermatic veffels, enveloped in cellular
fubftance.
13. Great fecondary iliac vein.
14. Great fecondary iliac artery.
15. Crural arch at its origin.
16. Section of the abdominal muſcles.
17. The iliacus muſcle.
18. The creft of the iliums
19. The primary iliac artery on the left fide.,
20. The primary iliac vein.
21. The fecondary internal iliac, or the epigastric
artery.

[ 52 ]
PLATE II. The fame fide of the pelvis after the
MO
operation.
1. Superior branch of the os pubis.
2. Incifion in the duplicature of the crural arch
cloſe to the creft of the os pubis, by which
the crural ring is widened, and the internal
margin of the arch is relaxed confiderably.
3. Section of the abdominal mufcles.
4. The epigaftric veffels.
5. The crural arch.
6. The vas deferens.
7. The fpermatic veffels.
8. The fecondary iliac artery.
9. The fecondary iliac vein.
10. Section of the primary iliac artery.
QUERIES

QUERIES
CONCERNING
INOCULATION.
BY THE
sift of galgheed
TRANSLATO R.
A
N opinion relative to the beft me-
thod of performing inoculation, of
which it is of great importance to afcer-
tain the validity, has been lately advanced
by Dr. George Fordyce. (See Tranfac-
tions of a Society for the Improvement of
Medical and Chirugical Knowledge. John-
fon, 1793). According to Dr. Fordyce,
the moſt effential circumftance in this
operation, is to make a puncture exceed-
ingly fmall, and fo fuperficial that if no
blood be drawn, the better. This direc-
E3
tion

[ 54 ]
tion is founded upon the fuppofition that
the lefs matter is applied, the more mild
will be the diſeaſe.
The evidence offered by the author in
favour of this opinion, is nearly as fol-
lows. He inoculated three young ladies
belonging to the fame family, by three
punctures each. One puncture fuppurated
before the two others, in one of theſe
cafes; in the two other cafes, the three
punctures fuppurated together. In thefe
laft, the difeafe was much more fevere.
Happening to inoculate a child with five
punctures, he remarked that the diforder
was very unfavourable. From theſe facts
combined with the fuppofition, that when
infection has taken place the fubfequent
application of matter has no effect, he de-
duced the opinion above. The author
adds, that he has fince inoculated a great
number of perfons by a very fmall punc-
ture, and that he has not met with "one
cafe

[ 55 ]
cafe in the ſmalleſt degree unfavourable."
It might have been better perhaps, if Dr.
Fordyce had affigned the number of pa-
tients on whom inoculation had been thus
performed.
From the well-known experiments of
Spallanzani, on artificial fecundation, it
had occurred to me, that if it were advan-
tageous to introduce a fmall quantity of
variolous matter at the time of inocula-
tion, this might be done by diluting the
matter with water; nor did it appear pro-
bable that its power of communicating
the fmall-pox would be deftroyed, even
by a confiderable quantity of water.
The paper of Dr. Fordyce revived this
idea, and I communicated it to various
practitioners, particularly of furgery,
whom I had occafion to meet. I found two
who had actually adopted the practice of
dilution; and both have obligingly per-
mitted
E 4

[ 56 ]
mitted me to communicate the refult of
their experience to the public.
As to sdman, sdi bongile had soybe
Letter from Mr. WATTE, Surgeon,
at Calne, in Wiltshire.moneq
To etnemhogye
at recibe
SIR,
wond-flow or mor
Calne, May 26, 1795-
2014
I had the honour of receiving your let-
ter of the 22d inft. and will faithfully
anfwer your queries refpecting the dilu-
tion of variolous matter, to the best of
my obfervation. About three years ago,
I was defired to inoculate fome patients
in a neighbouring village; I had only a
fmall quantity of moift matter upon a bit
of horn. When I arrived, I found about
thirty people expecting to be inoculated,
and fearing there might not be a fuffi-
ciency of fluid matter, I procured fome
cold water, and mixing it well with the
flat fide of the lancet upon the horn, ino-
culated

[ 57 ]
culated them all. They went through
the difeafe fo regularly and favourably,
that it ftruck me that the diforder might
be rendered milder by this method. An
opportunity has fince offered in our town
to follow the fame practice, viz. in Sep-
tember, 1793, when the poor of the
parish were inoculated. I procured the
matter from a woman at Bradford, near-
ly a goofe-quill full. This matter being
very vifcid, was diluted, and divided be-
tween myſelf and two other gentlemen,
who affifted in inoculating the poor. We
inoculated fix hundred and upwards,
without any preparation; the diluted gave
the diforder with the fame certainty as
pure matter; and all the patients re-
covered: a few had pretty full crops not-
withstanding. Befides the poor, I ino-
culated about two hundred patients, who
all recovered, except one child about five
months old: this child had a red fcor-
butic

[ 58 ]
butic humour all over it, but as it could
not eſcape the diſorder in the natural way,
it was inoculated. When feized with the
eruptive fever, it had a convulfion fit,
after which petechia appeared, and it
died before the eruption was complete.
So that you will pleaſe to obferve, that of
eight hundred patients treated by this
method, all recovered except this child.
Now in inoculating a whole parifh, we
have no choice of patients, all ages, and
the fickly as well as others, were inocu-
lated; but theſe were moftly children, as
I affifted in inoculating the whole parish,
about twelve or thirteen years ago.
In anſwer to the particular heads of
your enquiry. First, average degree of
dilution? Equal parts of water and mat-
ter, fometimes a greater proportion of
water. Secondly, number inoculated in
this manner? At least eight hundred.
Thirdly, deaths? One child of five
months

[ 59 J
]
months old. Fourthly, comparative mild-
nefs? The patients went through the dif
eafe without any irregular, or dangerous
fymptoms; generally a few diftinct puf-
tules appeared, which maturated kindly;
not more than five or fix out of the whole
number had pretty full crops, but thoſe
were diftinct. Fifthly, my own obferva-
tions? I have fometimes known trouble-
fome abfceffes form in the axilla, after
inoculation, but I do not recollect one fuch
inftance after this practice, or any ill con-
fequence to the health of the patients
fince; fo that I cannot help thinking but
the diforder may be rendered milder and
lefs fatal by it.
I am,
Sir,
With great efteem, &c.
ALLEN WAYTE.
To Dr. BEDDOES.
Letter

[ 60 ]
Letter from Mr. ROLPH, Surgeon, at
Thornbury, in Gloucestershire.s
DEAR SIR,
sicAgreeably to your requeft, I fend you
a ftatement of fome facts, which have
occurred in the courfe of my practice,
from the uſe of diluted variolous mat-
ter.
In the year 1793, I was called to ino-
culate feveral perfons: two of the num-
ber had a confluent difeafe, and died; and
fome others had it in a violent degree. In
thefe inftances, recent matter was uſed.t
From theſe unfortunate cafes, I was
led to conceive, that by a confiderable di-
lution of the matter, the violence of the
difeafe might be alleviated. I was not
ignorant of the received opinion on this
point, but convinced how very erroneous
many received opinions are, I was deter-
mined

[ 6 ]
mined to put this to the teft of experi-
ment.
In the month of March, 1794, an op-
portunity offered itfelf. I was called to
vifit J. Price, who at that time was
fickening of the fmall-pox, and on whom
the eruption was juft beginning to make
its appearance. To prevent the conta-
gion from fpreading, the parish officers
had Price removed to the houfe of a poor
perfon, who, together with two children,
was inoculated. The lancet I had by
me was armed with variolous matter,
taken in a very early ftage of the com-
plaint; this I largely diluted in a little
warm water; when, on Sunday, 23d,
(the day Price was removed) I proceeded
to inoculation, making only one flight
fcratch through the fcarf fkin of each
perfon.
On Tuesday, 25th, there was no ap-
pearance of infection; I therefore inocu-
lated

[ 62 ]
lated them a fecond time, with the fame
lancet, and in a fimilar mode. Thurf-
day, 27th, about noon there was no in-
flammation. Apprehenfive now, of their
receiving the difeafe in the natural way,
I took fome matter from Price, and again
inoculated them, but in the other arm.
The Sunday morning immediately follow-
ing, the children having taken a purging
medicine, complained of flight fickness,
and in the evening of that day, the puf-
tules made their appearance, few in num-
ber, and unaccompanied by fever: in the
ufual time they came to maturity.
I must not conceal, that the parts to
which the undiluted matter had been ap-
plied were inflamed a little, the day after
its infertion, which appearance continued
to increaſe in a ſmall degree, but no un-
eafinefs was felt in the axilla at any time.
Is it likely that the undiluted matter,
applied on Thurſday at noon, fhould
produce

[ 63 ]
produce an eruption the Sunday follow-
ing? Or is it probable that two perfons
ſhould take the difeafe in the natural way
at the fame time, and that the eruption
in each fhould make its appearance in
feven days, after expofure to contagion ?
Though there was not the leaft inflamma-
tion from the firft, or fecond inoculation,
yet every circumftance confidered, I am
induced to attribute the diſeaſe to the
firft. It may not be unneceffary to ob-
ferve, that no perfon in the neighbour-
hood was then labouring under the dif-
eafe, or had been for fome time before.
Price caught it whilft out on a journey.
The man and children had not been in
the
This queftion will, I fuppofe, be generally anfwered
in the negative. In Dr. Haygarth's Sketch, there is a ta-
ble, from which it appears, that out of eight hundred and
thirty-three patients, inoculated at Newcaftle and in Lon-
don, not one had any commencement of the eruptive fever
before the fifth day.
T. B.

[ 64 ]
the way of contagion, till the day of ino-
culation.
I have fince availed myfelf of every con-
venient opportunity of communicating
the complaint in a fimilar mode; par-
ticularly to three of my own children and
one fervant; two of my children and the
fervant had no eruption or fever, and but a
flight inflammation in the arm; my
other child had a mild difeafe; but
neither of them had the leaft uneafinefs in
the axilla.
The advantages of this mode of inocu-
lation have been realized in fo many other
inftances, as not to permit me to afcribe
it wholly to accident. Wherefore, I am
led to conclude, that the more the matter
is diluted, provided it remains in fuf-
ficient force to produce infection, the
better. Should any objection be made
to this mode of practice, it muft arife
from the uncertainty of the infection
taking place in a given time. This ob-
jection

[ 63 ]
jection, I think, except under particu-
lar circumſtances, can be of little confe-
quence.
I have hitherto purpofely omitted faying
any thing of the man I inoculated, becauſe
I have to obferve, he never received the in-
fection, though repeatedly inoculated with
undiluted matter, and for days expofed to
contagion, living in the fame room with
Price, who died of the difeafe.
It is worthy of remark, that this man
had fome years before a complaint in-
cident to cows, and commonly called the
Cow Pox; a malady more unpleaſant
than dangerous. It is generally received
by contact in milking. In the human
Species, the complaint is fometimes local;
at other times abforption takes place, and
the glands in the courfe of the abforbents
become indurated and painful. When this
is the cafe, I have learned from my own
obfervation and the teftimony of fome
old practitioners, that fufceptibility to the
fmall
F

[ 64 ]
fmall-pox is deftroyed. Some advantage
may probably in time be derived from this
fact.
I remain yours,
June 10, 1795.
To Dr. BEDDOES.
With great refpect,
T. ROLPH.
It is pretty generally agreed, that in-
fants, before the time of teething, ought
by no means to be inoculated. Dr. For-
dyce, in the paper already quoted, ob-
ferves, that, "Of the children who have
"died in London of inoculation for
"many years, as far as I have been able
"to collect, more than two thirds have
"been under nine months." The want
of that firm connection between the
trains of motion, which is eftabliſhed by
habit, is I imagine a much more general
caufe of mortality among inoculated in-
fants than the fymptoms arifing from the
protrufion of the teeth; they may and
ought

[ 65 ]
ought to be mitigated by freely lancing
the gums.
In fome fituations, however, inocula-
tion of infants will be preferred as the
fmaller evil; and in fuch emergencies, a
method of performing the operation fo as
to produce a milder difeafe, is of un-
fpeakable importance. For the reafons
already adduced, I propofe a trial of the
following method. I have two objects in
view: 1. To enfure the application of a
fmall quantity of diluted matter; and 2,
to enfure a fuperficial wound. Should
more ample experience fhew neither of
thefe circumftances to influence the de-
gree of feverity of the difeafe, there will
not, I fuppofe, be any advantage in the
method to compenfate the fmall addi-
tional trouble it will occafion.
1. Apply a blifter of an extremely fmall
fize, not more than a very fmall fraction of
an inch in diameter, over the infertion of
the deltoid mfucle. After the fearf kin
F 2
bas

[ 66 ]
has rifen and all pain has fubfided, open the
vefication, and let out the liquid.
2. Mix fome variolous matter with ten
or twenty times its bulk of water; dip the
point of a camel's hair pencil into the di-
luted matter, and touch the expofed fkin as
lightly as you can.
Space and quantity must be determin-
ed by experience. From the analogy of
fome other animal fluids, it is probable
that the addition of feveral hundred
times its bulk of water would not deſtroy
the power of the variolous matter.
I have mentioned the ufual place, but
it is poffible that this may not be the
moft advantageous for the application of
the matter. To fome perfons, the pain
arifing from the blifter may occur as an
objection; but they will be perfons who
have never witneffed the feverity of the
inoculated fmall-pox in young infants,
and the anxiety and injury to the health
of the mother thence arifing.
Query

[ 67 ]
Query concerning Fever.
From a fingular, if not an unexam-
pled concurrence of teftimony from va-
rious quarters of the world, we learn that
the ufe of quickfilver has been attended
by the moft beneficial effects in certain
cafes of fever. According to accounts
publiſhed by Dr. Clark, Dr. Wade, Mr.
Boag, Dr. Rufh, and Dr. Chisholm,
this treatment has been far more fuccefsful
than any other of which we have infor-
mation.
Medical men, who believe that in
fevers of a certain kind, and particularly
of fuch a violence or malignity as thofe
which fell under the care of the authors
above mentioned, there occurs a putrid
diffolution of the blood, will revolt at the
idea of fuch practice. But the greater
number of pyhficians feem at preſent to be
perfuaded that the term putrid was former-
ly uſed at random in medical reaſonings;
and

[ 68 ]
and why in fact ſhould fetid perfpiration or
urine be regarded as the fign of a putrid
ftate of the blood, any more than offen-
five breath?
Such however is the baneful operation
of falfe theory, that it produces an im-
preffion even on the minds of thoſe who
reject it. Hence we fhall not yield our
affent to the fame evidence in behalf of
quickfilver, as would produce full convic-
tion with regard to the power of any
other drug, that had never been fuppofed
to increaſe the fuppofed putrefaction of the
fluids.
Quickfilver would probably be of effen-
tial utility in many fevers, common in
this country; and yet one cannot expect
that it fhould foon have the trial to which
it feems fairly entitled. We fhall perhaps
moft fpeedily obtain the advantage it may
afford, and prevent the facrifice of many
victims to prejudice, if we take pains to
inveſtigate the principle on which it ope-
2
rates.

[ 69 ]
rates. Its operation in fyphilis has been
much the fubject of difpute. By fome it
has been fuppofed to deftroy the fyphilitic
virus, exifting in the body. Enquirers,
more on their guard against first appear-
ances and hafty conclufions, believe that
quickfilver ftimulates to a new mode of
action, and fo fuperfedes the effect of
the contagious matter. May not its be-
neficial effect in fevers depend upon a
principle different from either of theſe?
Since in fevers the fyftem continually
paffes from a ftate of torpor to a ſtate of
excitement, may not the increaſed action
of the falivary glands tend to keep the
whole body in a more equable ftate, and
prevent the formation of fever-fits? Sa-
livation is ftated to be effential to the
cure; and if future obfervation ſhould
eſtabliſh the fact, will not my fuppofition
be confirmed? Will falivation prevent
the return of the fits of intermittents?
To

[ 70 ]
To evince the propriety of attending
to new information on the fubject of fever
no laborious inveftigation is requifite.
Simple infpection of the bills of mortali-
ty is fufficient. I do not expect that any
perfon, acquainted with the uncertain effi-
cacy of the other methods that have been
hitherto recommended, will deny that
the treatment by quickfilver is entitled to
the moſt mature confideration.
The object in cafes of fever being to
excite fpeedy falivation, does not Mr.
Clare's way of applying quickfilver pro-
mife to be the most advantageous?
In hydrocephalus internus, quickfilver
is never, I believe, of fervice, unleſs fali-
vation be brought on. At the period
when phyficians are often called in, this
is a thing very difficult to be accomplish-
ed. Ought not therefore the fame me-
thod of applying quickfilver to be tried
in this diſeaſe?
THE END.

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