SWARD WITHERS Coll Nor 6X LIBRIS *** 102 ALFRED HEACOCK:WHITTAKER- UD A DISSERTATION ON H E R NIAS, OR RU P T U R E S. Taub. Rare Bus РЬ • А-76 А. И О. І Т А ТЯ 21 СЕ ТА . И О 2 А 1 И Я Б 2-аят П sili klip epit отреба 973 і різні авіт Poid bna a.to cart Cod о docume iri ole obr НА aligtolsti el 13bno no night of oil the се за 10 повора 3dsed loo Tyx5V till od bo be дар A por Buminio DISSERTATION ON Son H E R N I A S, I , Surgeontor Newbury R'U P T U R E 'S. In TWO PARTS. 1709. a 1. Familiar and eaſy Inſtructions for Perſons afflicted with thoſe Diſeaſes, by which they may learn to diſtinguiſh their own Caſes, palliate the Symptoms, and promote the Cure. II. Two Memoirs for the Uſe of Surgeons. One concer- ning a Strangulation of the Inteſtine by the Hernial Sac, the other concerning the Adheſion of the Inteſtine in Hernias. To which a Preface concerning the Improvements made by mo- dern Surgery, in the Cure of Hernias, is prefixed ; and a Dic- tionary of Terms of Art uſed in the Differtation, is fubjoined. a By GEORGE A RN AUD, Maſter of Arts and Surgery, Member of the Royal Academy of Surgery at Paris, Demonftrator in the School of St. Come, Surgeon for Ruptures, of the Hoſpitals of Hôtel-Dieu, the In- valids and Incurables, of the City of Paris, and of all the mi- litary Hoſpitals in France. Tranſlated from the Original Manufcript, under the Inſpection of the Author. LONDON: Printed for A. MILLAR, oppoſite to Catherine-Street in the Strand, and fold by him; and alſo by the AUTHOR, at his Houſe betwixt the two Slaughters Coffee-houſes in St. Martin's-Lane, MDCCXLVIII. so 18 TH 515 To solo 2 Hd bas tad olevia GDCD lustra adband um ELITES Bolgado qqe jon I am JE Isranog zal do 9169 vm los bancorida xo 3198 logo VATE Cavabot pysugnis TO THE P U B L I C K. I T is the duty of every man to cultivate thoſe talents, which it has pleaſed God to beſtow upon him, and the duty of thoſe, to whom the cultivation of his talents has made him uſeful, to recompenſe his labours. Such is the reciprocal obligation im- mutably eſtabliſhed between ſocieties, and the individuals that compoſe them. That I may not appear to neglect my part of this general contract, I here exhibit, in a popular and eaſy language, ſuch as every reader may under- (vi) underſtand, a DISSERTATION upon HERNIAS, or RUPTURES, in which is compriſed what appears to me moſt neceſſary for their cure or palliation. COLAS To the particular conſideration of theſe diſorders, which, though the moſt frequent and moſt afflictive of all habitual Maladies, have hitherto been treated with the greateſt negli- gence, I was led by the favour and patronage of the * Royal Academy of Surgeons of Paris, who, as an en- couragement to the endeavours, which I was uſing to diſcover a clearer and more certain method, depoſited with me from the beginning of their inftitution, ſuch Memoirs and Obfer- vations, as the greateſt Maſters of Eu- rope crowded into their hands upon this ſubject, and from theſe ſparks of Science thus collected and united ſuch Light has been received as is fufficient * A fociety of the principal furgeons, efta- bliſhed in 1732. to ( vii ) to guide us through the darkeſt intri- cacies of their dіforders, ALИЯН Thus furniſhed with obſervations, which I have digeſted by long confi- deration, and aſcertained by exten- five practice, I preſume in the fol lowing diſcourſe to offer my ſervice to the Engliſh Nation, and hope that all thofe, who ſhall perufe it, will look upon the care and fidelity, with which the methods are laid down, and the eaſineſs and fimpli- city, with which they are expreſſed, as proofs of reſpect and accuracy and tenderneſs; and conſider me as a man, not indeed wholly without regard to the emoluments of his profeſſion, but as one, who defires no other recompence from the public, than ſuch as his integrity and dili- gence ſhall be found to deſerve.aids now bab Balloonia robottel outoaded adgid siis cogista THE thom barbie E R R A T A. AGE 13, at the bottom read Sect. I. Of Part II. Obf. III. p. 20. fifth laſt line, for ſumma, r. fummam. p. 23. 1. 16. for demarel, r. Demarets. p. 26. 1. 17, 18, 19, 20, and 21. ſhould not be pipped in the margin. ibid. the 6 laſt lines, and the firſt of p. 25. 1. 16. preface, r. eſſay. p. 27. in Ita- lic character, ſhould be by way of remark at the bottom of the page. p. 33. 1. 10. for diſlocation, r. diſorder. ibid. 1. 24. r. a young Lady of 35 years. ibid. 1. 25. for Moraval, r. Mala- val . p. 34. 1. 1. for diſlocation, r. diſplacement. ibid. 1. 5. for pouperti, r. Pouparti, ibid. 1. 22. r. Pouparti. p. 40. 1. 27. for ignorati, r. ignoti. P. 42. 1. 10. fabric hild, is one name. At the remark p. 48. r. the remark at p. 324. Ch. III. p. 65. T. of the diviſion of the human body. p. 222. for care, in the mar- gin, r. cure. p. 321. I. 13. 1. Mr. Lafite. p. 394. 1. 15. in the year, &c. r. Obſ. II. p. 404. for Obſ. XIII. r. Obf. XII. p. 408. for Obf. XV. r. Obl. XIII. de ne to THE 9 CONT ENTS. PRE FACE. A N enquiry into the earlieſt epocha of rup- tures, page 1.Hippocrates is the firſt author that wrote upon ruptures, p. 2.- Who were ancient authors, that wrote beſt from Hippocrates's time to the end of the laſt century, p. 3.-The ignorance of the an- cients in the knowledge of theſe diſeaſes, p. 4. The cruelty of the methods they propoſed for the cure of theſe diſeaſes, p. 5.The uſelefs and dangerous operations that were prac- tiſed in the time of Celſus, ibid. ---Thoſe that were practiſed in the time of Paulus Ægi- nita, p. 6. . Thoſe of Albiccaſis's time, ibid. -In Rogerius of Parma's time, ibid.- Lanfrancus's time, p. 7.- Thoſe of Guy de Chauliaco, ibid. - Obſervation I. p. 8. . A deſcription of the operation called Punc- tum aureum, ibid.--Different method made uſe of in this laſt manner of operating, p. 9. -The The CONTENTS mabnu The method of the Albanians, p. 10.- Obſervation II. ibid. --The advantage of modern ſurgery in the treatment of theſe dif- eaſes, p. 13. The reſources of modern fur- gery in the operation of the Bubonocele, p. 14. The deſign of the author to write a compleat treatiſe on theſe diſtempers, p. 24. The advantage of obſervations, p. 26.—The knowledge of pathological anatomy abſolutely neceffary, p. 29, &c. - -Obſervation III. p. 31.- Obſervation IV. Upon a rupture in the foramen ovale, operated on by the au- thor, p. 33. Obſervation V. p. 35.- There are no diſtempers that require more at- tention; becauſe one tenth of mankind labour under this diſorder, p. 39.—There are no diſtempers that have more medicines appro- priated for their cure than ruptures, p. 40. The treatment of theſe diſeaſes have been abandoned to Mechanicks, why? p. 42, 43, &c. -Very eminent Phyſicians have not been afhamed to make it their chief buſineſs, ibid. PART 1. SECTION I. Inſtructions to Perſons afflicted with ruptures, of hernias page 45 The INTRODUCTION, ibid.---The advantage of wax anatomies, p. 48.—The publick en- tirely ignorant of hernias, and why, p. 50 -Means to make theſe diſorders known, p. 53.-This work the more uſeful, as it is adapted to the capacity of every body, p. 57; IO An anatomical explanation of the ſeveral parts The CONTENTS. parts of the abdomen, neceſſary for the under- ſtanding of hernias, or ruptures, p. 60. oldd CHAP. I. The author's deſign in bis anatomical expoſition. ibid. CHAP. II. Compoſition of the human Body, &c. 62 CHAP. III. Of the diviſion of the human Body 65 CHAP. IV. Of the diviſion of the Abdomen 66 CHAP. V. Of the parts contained in the abdo- men, &c. 72 CHAP. VI. Of the Stomach, &c. 73 CHAP. VII. Of the Guts, &c. 74 CHAP. VIII. Of the Meſentery 77 CHAP. IX. Of the Pancreas, or Sweetbread, &c. 78 CHAP. X. Of the Liver ibid. CHAP. XI. Of the Spleen, &c. 80 CHAP. XII. Of the Kidnies, &c. ibid. CHAP. XIII. Of the Urinary Bladder 81 CHAP. XIV. Of the Parts fubfervient to genera- tion in men, &c. 82 CHAP. XV. Of the Parts ſubſervient to genera- tion in women, &c. 87 CHAP. XVI. Internal parts ſubſervient to gene- ration in women 89 CHAP. XVII. Of the Fluids, &c. 93 CHAP. XVIII. Of Chylification and Sanguifica- tion 95 CHAP. XIX. Of the Blood and its circulation 98 CHAP. XX. Of the nutritive Juice CHAP. XXI. Of nurſes Milk CHAP. XXII. Of the Spirits sub PART Іоо IOI 102 The CONTENT S. II2 121 PART. I. SECT. II. Of Hernias, &c. CHAP. I. What is mean't by a rupture or her. nia 103 CHAP. II. Of the diviſion of hernias 104 CHAP. III. Of the differences of true her. nias 105 CHAP. IV. Of the general Cauſes of hernias 107 CHAP. V. Of the ſigns of true hernias in gene- ral Chap. VI. Of the fymptoms of bernias in ge- neral 115 Chap. VII. Of the Strangulation of the inte- ſtine 117 CHAP. VIII. Of hernias of the Navel in parti- cular Chap. IX. Of Ventral Hernias 125 CHAP. X. Of the hernia of the groin, p. 128- Immediate cauſe of a compleat hernia 130 CHAP. XI. Of the Crural Hernia 133 Chap. XII. Of the means of remedying a ſtran- gulation of the inteſtine, p. 136. —A ſpeci- fic remedy for the ſtrangulation, p. 139.- The manner of preparing it, ibid. Repel- lents when proper, p. 140. When danger- ous, p. 141. -Proper remedies in the in- creaſe of the diſorder, p. 143. Mercurial ointment prejudicial, p. 145. -Proper re- medies in the decline of the diſeaſe, p. 146. Chap. XIII. Of the reduction of the parts, p. 147.-Reduction of the crural hernia, p. 153. CHAP. XIV. Of the radical cure of hernias 154 CHAP. XV. Of remedies proper for hernias 160 Chap. XVI. Of the cauſes which may oppoſe the cure of Hernias 174 WAS laostao L CHAP, XVII 2 XXX 2 т. и ТИО - All 187 ment The CONTENT S. CHAP. XVII. Of Truſſes for hernias 178 CHAP. XVIII. Of precautions patients ought to take during the uſe of truſſes CHAP. XIX. Of the inconveniences, which may happen in truſſes, with reſpect to their diſplace- 189 CHAP. XX. Of the inconveniences, which may ariſe from the diſorder with reſpect to the pa- tient, and the precautions we ought to take to remedy them 191 CHAP. XXI. Of the inconveniences which may ariſe from truſſes, and the precautions neceſſary to prevent and correct them 195 CHAP. XXII. Of the method of taking the meaſures and proportions of the body, for per- fons who want truſſes 197 CHAP. XXIII. Of the method of applying truf- ses CHAP. XXIV. Of hernias of the Uterus, p. 207: Means of relief CHAP. XXV. Of a relaxation of the Uterus, of its 20L 212 falling down properly ſo called; and of the re- laxation of the Vaging 217 CHAP. XXVI. Of thoſe diſorders which oppoſe the cure of Hernias of the Uterus 228 CHAP. XXVII. Of the palliative cure of relaxa- tions and defcents of the Uterus, and Vagina, and of Piſſaries, p. 235.Faults peculiar to Piſaries 237 CHAP. XXVIII. Of the falling down of the fun- dament 239 CHAP. XXIX. Of Falſe Hernias in general 245 CHAP. XXX. Of the general caules of Falſe Hernias 247 CHAP. XXXI. Of the Hydrocele 248 CHAP. XXXII. Of the Sarcocele 260 CHAP. XXXIII. sh The CONTENTS. On_Cure Chap. XXXIII. Of the Spermatocele, p. 263. STOJ DOG 264 CHAP. XXXIV. Of the Kirſokele 265 Of the Pneumatocele I do SI de PART IÍ. SECT. I. Of Hernias o arromoka with Adherencés. 269 What is underſtood by adherences, p. 270. The mechaniſm of nature in the formation of adherences, p. 271. -Four kinds of adhe. rences : by agglutination, fibrous adherences, fleshy adherences, and Spungy adherences, P. 274. Cauſes of adherences, ibid. &c. Symptoms of adherences, p. 276. Symptoms of adherences in ruptures reduced into the abdomen, p. 277.- -Symptoms of adherences when the parts cannot be reduced, p. 282.-The irritations which they cauſe require a ſpeedy ſuccour, p. 281.-Means to prevent them, p. 282.-A method of cure, p. 284.--Obfervation I. Wherein the dan- ger of mercurials inconſiderately uſed is ex- plained, p. 288.Obf. II. Tumors in the 2 meſentery hinder the reduction of the inteſtine, p. 290.- Obf. III. A radical cure of a rup- 3 ture which had about thirty-two inches adhe- verence in its circumference, p. 292.--- -Obſ. IV. The radical cure of an old rupture in a perſon feventy-eight years of age, p. 298.-How ors to perform the radical cure of the largeſt her- nias, p. 296, 297, 298.-A method of re- medying the ſymptoms of adherences, p. 301, Adherences by agglutination known by Franco, and Pareus, p. 304,--Obf. V. On an The CONTENT S. an adherent rupture by agglutination, p. 305. -The author's method to ſeparate this kind of adherence, p. 306. Obf. VI. Proving that the opening of an inteſtine to ſeparate an adherence is not mortal, p. 308.- -Obſ. VII. On the ſame ſubject, p. 311.-Obſ. VIII. Wherein it is ſhewn that one muſt not ſeparate adherences that join ſeveral circumvolutions of the inteſtine, if they are not prejudicial, p. 312. -Obf. IX. This obſervation ſhews the dan- ger of reducing adherences into the abdomen, when there is a ſtrangulation of the inteſtine, p. 313. - Fibrous Adherences deſcribed by Graaf, and Drelincurtius, p. 314. Obf. X. Further proofs of fibrous adherences, p. 315. Obf. XI. which fupports the preceding bobſervation, p. 319.-- Obf. XII. That e- ftabliſhes the two foregoing, p. 320.- -Fleſhy Adherences deſcribed by Bonetus, p. 321. Obf. XIII. A rupture of the navel with fleſhy o adherences ſeparated with ſucceſs, p. 323.- What method muſt be uſed when adherences cannot be ſeparated, p. 326.--Obf. XIV. Proofs of this method, p. 328. Obſ. XV. The author's new method of ſeparating fleſhy adherences, p. 331.----Obf. XVI. Confirms the foregoing, p. 334. Obf, XVII. On the cutting away of fix feet of an inteſtine, p. 341. Spungy Adherences deſcribed by Hildanus, p. 348. Obf. XVIII. On a w ſpungy adherence, p. 349.- Obſ. XIX. On -19 an extraneous body which ſeemed to be of the - nature of a ſpungy Adherence, P: 351. Yo wo no da PART The CONTENTS. PART II. SECT. II. Of the Strangulation of the Inteſtines by the Hernial Sac, or by the Peritoneum. An expoſition of the diſeaſe, p. 353.Diffe- rences in ſtrangulation by the Hernial Sac, p. 354. Obſervation I. This proves that the hernial fac may form a ftrangulation, p. 356. -Obf. II. Confirms the preceding, p. 364. Obf. III. To the ſame purpoſe, p. 366. Obſ. IV. On a crural hernia ftrangulated by the Hernial Sac, p. 370.--Obf. V. On a rupture ftrangulated by the Hernial Sac reduced into the abdomen, and cured, p. 371.- Obf. VI. On a rupture ſtrangulated by the Her- nial Sac, whereof the patient died, p. 382.- Obf. VII. On the ſame ſubject, its cauſe not being known, proves the death of the patient, by the bad fucceſs of the operation, p. 384.- Obſ. VIII. On the ſame fubject, the patient died for having the orifice of the hernial ſac not dilated, p. 386.-Obf. IX. To the ſame pur- poſe, the patient died after the reduction of the parts by the operation Taxis, p. 387.-- Obf. X. On the ſame ſubject, a hernia reduced by operation, the ſymptoms fubfifted, removed by a ſecond operation performed by the au- thor, p. 391.-Obf. XI. Compared with the preceding, p. 394.-The author's opinion on the preceding obſervations, p. 395:--Symp- toms of ftrangulation cauſed by the Hernial Sac, p. 399.--Signs, ibid. ---Obf. XII. On a her- nia with a triple ſtrângulation by the Hernial Sac, partly miſtaken for a hydrocele, 404.- Obf. XIII. On a ſtrangulation by the hernial fac, which obliged the author to dilate within the cavity of the abdomen. a si THE PREFACE. O 3 F all the diſeaſes within the ſphere of ſurgery, there are few in our days more common than ruptures or hernias, and it is probable that they were equally frequent from the earlieſt times * ; but as in the firſt age of medicine, which took its date from the twenty-eighth century after the general deluge, the world had but confuſed notions of diſeaſes in gene- ral, when every man pretended to the art of curing, and only thoſe diſeaſes were at- tempted which diſcover themſelves to the eye, as wounds and fractures, it is likely that ruptures were not known diſtinctly. About the ſixtieth Olympiad, which agrees with the tenth year of the thirty-fifth cen- * The firſt epocha of ruptures, as far as we can find, is but of the twenty-third age of the world, as appears by Leviticus, chap. iii. v. 17, 18, 19, 20, where the Lord ſays to Moſes, " Speak to the prieſts, children of Aaron, " and ſay unto them, If any of your offspring has a rupture, a (fi hernioſus) he muſt not offer bread to his God, neither fhall he approach the miniſtry of his altar." B. turya 66 11 The PREF A CE. . tury, the philoſophers attempted to treat diſtem- pers; but it appears that they did not diſtinctly underſtand ruptures, or at leaſt their know- ledge of them has not been tranſmitted to us. Within the ſpace of a hundred and ten years, which happened between the time of Pytha- goras and the beginning of the Peloponenſian war, philoſophy and phyfic having made a very great progreſs, it was then judged necef- ſary to diſtinguiſh the two profeffions, and make them two different ſtudies, each of which might afford fufficient employment for the powers of man. Afterwards phyſical knowledge being greatly advanced, it was re- quiſite to divide phyfic and furgery into two diſtinct profefſions. This diviſion was made in Egypt in the thirty-eighth age, where ſur- gery firſt began to have its particular profef- ſors. Every one knows, that Hippocrates firſt began theſe diviſions ; for he quitted phi- loſophy, or, to ſpeak better, retained only fo much as enabled him to reaſon juſtly upon the art of healing, which he then made his principal ſtudy. He was the firſt who gave juſt notions of the diſeaſes known in his time, among which ruptures are to be numbered: He diſtinguiſhed them, and obſerved that ſome were of the groin, and others of the fcrotum and teſticles. He faid, theſe tu- mours were cauſed by the falling of the omen- tum and the inteſtine, and by the varices of the teſticles, or by water collected in the ſcrotum. 2 The PRE F A C E. 111 P R E FACE ſcrotum. It is eaſy to ſee by this account, fo well ſpecified for Hippocrates's age, that it is more than two thouſand years ſince rup- tures were treated *. After Hippocrates we find Meges, Softratus, Gorgias, and Heron, who have given pretty exactly the diffe- rences of ruptures incident to the navel. Celfus, who lived in the time of the empe- rors Auguſtus and Tiberius, has written with more exactnefs upon ruptures of the groin and the ſcrotum. Galen, who lived in the time of Antoninus, and ſome of his ſucceſſors down to Severus, has ſtill more accurately obſerved theſe diſeaſes. Since Galen, ſeveral other authors have ſpoke of them, as Oriba- fius, Ætius, and particularly Paulus Ægi- neta, who lived in the ſeventh century of the Chriſtian æra. This laſt author has mul- tiplied the different forts of ruptures beyond all thoſe who preceded him, and omitted nothing which regarded the method of treat- ing them in his time. A great number of authors who have lived ſince Paulus, even to the end of the laſt century, of which the principal are Albucaſis, Roger de Parma, Lanfranc, Guy de Chauliac, Gentilisfulgi- nas, Franco, Scophius, Malachias, Geyge- rus, Megerus, the Fabricii, and ſeveral others, have ſpoken of theſe diſeaſes. We fee, * And above 3000 years ſince their exiſtence was known, as appears by the above cited paſſage of Leviticus. B 2. there- iv The P R E F À CE. a therefore, that the cure of ruptuřes was at- tempted in every age fince Hippocrates; nor is there reaſon to doubt but they were treated before him. But what is ſurprizing is, that notwithſtanding theſe diſeaſes have been fo frequent in all times, and under the eyes of ſo many obſervers, yet they have had a harder fate than other infirmities; for the induſtry of good practitioners, and ſometimes the temerity of quacks, have produced ſucceſs- ful methods of treating other diſeaſes, which methods have been tranſmitted to us; but with regard to ruptures, neither the dogmatiſts nor the empirics have been ſo happy as to diſcover any rational methods of treatment. On the contrary, whether they undertook the radi- cal or the palliative cure, they made uſe of ineffectual, barbarous, and deſtructive me- thods; and when the fymptoms were exaf- perated to a certain degree, they gave up their patients to their cruel fate. The authors whom I have quoted, pro- poſe or approve in their works, for the radi- cal cure of ruptures, different operations not leſs cruel than dangerous and uſeleſs. To make a compariſon between antient and mo- dern furgery, I ſhall lay down, in a few words, the operations which the antients made uſe of in compleat ruptures, their me- thods of treating others being nearly the fame. Celfus The PRE FACE, V Celſus gives us the manner of operating uſed for hernias in his time. He ſays the furgeon opened the ſcrotum with a ſharp in- ſtrument; that he took hold of the fac; that he cut it, after he had put back the inteſtine ; that he tied the ſpermatic cord, and took off the teſticle: He cut part of the ſcrotum, and re-united the lips, to form a ſolid ci- catrice that might prevent the falling-down of the parts. Every one muſt ſee the danger of this operation, by which the patient was not always cured, and by which many were immediately deſtroy'd. This operation has given Mr. Heiſter occaſion to exclaim againſt ſtrolling ſurgeons, whom Roſſetus calls Ēmaſ- culatores * ; and, in full conviction of the miſ- chief which caſtration may do to the moſt flouriſhing ſtate, he ſays they ought to be put to death for ſuch practices. Conſtantine, the firſt Chriſtian emperor, who knew of what ill conſequence this ope- ration was to the empire, made a law to in- flict baniſhment on thoſe who practiſed it, and enforced the obligation of the law with death. He decreed likewiſe the confiſcation of the houſe in which the operation of caſtra- tion ſhould be performed. “ Si quis poſt « hanc ſanctionem in orbe Romano eunuchos "es fecerit, capite puniatur, mancipio tali nec- 5* non etiam loco ubi hoc commiffum fuerit, * See the theſis he fuſtained at Helmſtadt in 1728, De Kelotomia abuſu tollenda. B 3 Domi- m vi The P R E FACE. " « Domino fciente & diffimulante confiſcan- a do. This law, which, properly ſpeak- ing, was only levell’d at thoſe who made eu- nuchs, was put in force by the States General of Holland againſt thoſe who performed this operation in ruptures. France has made the ſame law within theſe fifteen years, on ac- count of a woman born at Rheims in Chain- paign, who had caſtrated more than five hundred children in and about that city. We, then, ſee how dangerous this operation is, what miſchief it may do to a ſtate, and with how much reaſon the rigour of the law ſhould be put in execution againſt ſuch as avarice induces to practiſe it. Paulus Ægineta introduces no other change in the operation of Celſus, but the tying the fac, and the cutting it below the ligature : This method ſeemed to him the beſt and ſureft, and in the reſt of the operation he followed the directions of Celſus. CH Albucaſis gives another method of ope- rating, in which it appears that the teſticle is not treated with any more regard. After a great many uſeleſs precautions, he applies the actual cautery upon the part where the in- teſtine comes out, and lets it penetrate to the bone, ſo that the ſcrotum and the os pubis may unite themſelves more cloſely together. Roger de Parma does not ſpare the teſticle more than his predeceſſors. He takes a needle, threadled with twiſted thread, and paſſes The PREFA CE. vii paſſes it through the thickeſt part of the ſcrotum below the ſpermatic veſſels : He puts a ſmall piece of wood upon the ſuperior and fore-part of the ſcrotum, and ſo ftreightens the thread every day gradually upon this piece of wood. Roffetus ſeems to eſteem this method very much; but in this more en- lighten’d age, its abſurdity is become ap- parent. Lanfranc, ſtill more cruel, takes a large pair of pincers, in the gripes of which there are flits lengthwiſe. He runs a red-hot ſharp knife through the ſlits, when he has taken hold of the part with the pincers, and cauterizes the os pubis: He pretends by this means to join the fleſh and the bone ſo well together, that the rupture cannot return. We are not much ſurprized at cruelty in this au- thor's operations; but can hardly forbear wondering that he ſhould imagine this a cer- tain method of preſerving the teſticle. Guy de Chauliac very much recommends his method, on account of its ſucceſs, of which it will be difficult to convince us. He made uſe of the potential cautery, which he ap- plied to the ringlet, till by different applications he had penetrated even to the herniary fac, which he pretended to conſume without in- juring the ſpermatic cord, and ſo dreſsid the wound. In the year 1725, a foreigner came to Paris, to practiſe after this method, of which B 4 viii The PRE FA CE. which he pretended to be the inventor, and ſaid that he had cured the whole English nation. The Parifians, generally fond of what ſeems new, delivered them- ſelves up to him blindly in prodigious numbers. I was an eye-witneſs of nine pa- tients which he treated without a ſingle cure, of whom one was particularly unhappy: He bore the application of the cautery three dif- ferent times. In the firſt application this in- fallible reſtorer had an opportunity of attri- buting his bad fucceſs to the ſtubbornneſs of the patient ; with his ſecond miſcarriage he charged the inclemency of the air ; and his third he imputed to a defluxion which fell upon the teſticle, and which was followed by a mortification. Then this boaſter of pre- tended cures fell into diſgrace and oblivion, from which he roſe no more. He failed the two firſt times, becauſe his cauſtic (the oil of vitriol) did not penetrate into the ringlet; and the third time, when it penetrated ſufficiently, it cauterized at the ſame time the ſpermatic cord, which cauſed a mortification of the teſticle. How is it poſſible that any man can, without horror, hazard this operation, when the art of the moſt ſkilful ſurgeon cannot be certain of obviating this fatal accident. The punctum aureum is the laſt method that has been practiſed, and appears to have been invented by one Berault, who did not leave any account of it in writing. Tho’ this olyan The P R E FACE. ix this method is as dangerous and ineffectual as the others, it is at leaſt more ingenious. He firſt reduces the rupture, then lays the fac open, and takes hold of it with pincers; then he paſſes a gold wire * through it, as near the ringlet as poflible, four different times backward and forward, ſo as that the two ends of the wire may come together, which he twiſts with ſmall pincers, files off the ends, and fo dreſſes the wound. Franco made uſe of the fame method, but was more faving; for he uſed only common wire; and others made uſe of lead. This method was ſeemingly leſs dangerous and more certain than the others; it was highly recom- mended, and even adopted by regular ſur- geons; however, it was ſoon abandoned, on account of ſeveral inconveniences which at- tended it. The membrane which contained the rupture was ſometimes ſo thin that it was lacerated, being unable to ſupport the wire ; ſometimes there happened incurable fiftulas; fometimes the gut ſlipt between the mem- brane and the wire, ſo as to cauſe very tor- menting ſtrangulations; ſometimes alſo the viſcera protruded the tied portion of the fac, ſo that the hernia became complete as before. But what certainly happened was, that the rupture, from being complete, at leaſt re- mained incomplete ; that is to ſay, there al- ways continued a tumor at the part of the * Whence the operation takes the name of punctum au- ringlet reum. X The PRE FACE. ringlet which did not paſs the os pubis; and this accident attends all the methods which I have hitherto mentioned. “Fit mali non «s finis ſed mutatio,” ſays Celſus ; “ The evil « does not ceaſe, it only changes place.” This is, however, the leaſt misfortune which can happen from theſe dangerous methods. The fame author recommends this method in ſmall ruptures only, and in thoſe of chil- dren: “ Fere tamen hanc curationem pueri- “ lis ætas, & modicum malum recipit." Demetrius de Cantimir, prince of Molda- via, relates in the Hiſtory of the Ottoman Empire, tranſlated by Mr. de Joncquieres, vol. II. p. 397. that the inhabitants of Al- bania and Epirus, otherwiſe called by the Turks Arnaut, excel in the cure of ruptures; and after he has ſpoken of their ſkill in many reſpects, he relates a proceſs which he ob- ſerved himſelf. " As to the cure of ruptures, ſays he, they « undertake it upon all ſorts of people, and at all ages: Their method is coarſe, but yet « ſucceſsful. When I was at Conſtantinople « I had the operation performed upon my ſecretary, who was an elderly man, in my own palace. Having agreed as to the ex- pence, they tied the patient down upon a • broad plank, and ſecured him from his << breaſt to his feet with proper bandages ; es then the operator made an incifion in the s inferior part of the Abdomen with a kind " of < a The P R E FACE. xi 66 CC CC ti of razor, or biſtory. The peritoneum « being opened, he pulled out about the 6 bulk of a hand of the internal ſubſtance « under the ſkin, and drew up the inteſtine, " which was fallen into the ſcrotum, into its proper place. Afterwards he few'd up the peritoneum with ſtrong thread, and a knot « at the end to hinder it from flipping ; and 5 the lips which hung over were cut off with " the ſame razor. Then the wound was < rubb'd with hog’s-lard, and cauteriz'd with a red-hot iron. Before the dreſſing was applied, they lifted up a little the legs of " the patient, who was almoſt dead, and pour'd the whites of nine new-laid eggs « into the wound; and if that liquor fer- " mented and bubbled within the ſpace of an “ hour or two, it was a certain ſign of a cure : On the contrary, if there was no appearance of that kind in three hours, " they made no favourable prognoſtic. They "s attribute ill ſucceſs to the age or weakneſs “ of the patient, which obſtruct the cure, “ for they never doubt of the efficacy of their " method ; and indeed there ſeldom die two “ out of an hundred of thoſe whom they es undertake. After two or three days they repeat the uſe of the whites of eggs; and « all this time the patient is kept extended upon his back, without giving any figns “ of life, or having any great fenſibility. " The operators did not ſuffer him to take any و 0 thing; The PREFACE. a > formed when neceſſity obliged me to omit that precaution. " Here are we to ſeek for the 6 true cauſes of diſeaſes, their generation, « their different characters, their effects, the proper means to prevent or to cure them, «c and the real power of medicines either per- « nicious or falutary: From theſe obſerva- « tions we are to form juſt principles, and a « folid judgment upon the events of diſeaſes : They have alſo the advantage of over- te throwing and deſtroying, falfe fpeculations, “ contradictory hypotheſes, unfupported opi- “ nions, fictions, and errors. It is ſurely the intereſt of furgery to reap be- nefit by theſe truths, ſince its evidence, its per- ſpicuity, and the final object of its labours, all demand the completion of this ſcheme, which is already advanced to fome degree of perfection. That nothing might be wanting on my part to this important end, I have, with great diligence, communicated to the public what- ever my particular application has enabled me to diſcover. “ Whatever tends to the pre- « fervation of the life of man cannot be put « in too clear a light ; and to conceal from " the world any learning, which may be s uſeful to ſociety, is the ſame treafon againſt " the public as to bury a treaſure. Let us " therefore avoid imitating ſuch as are ava- « ricious of their knowledge, and whoſe de- (picable jealouſy would rejoice to ſee the world xxviii The PREFA CE. CC « world in the darkeſt ignorance, for the “ fake of ingroffing to themſelves the con- « fidence of the public. They are even « « afraid that others ſhould be inſtructed by « ſeeing their operations, without remem- bering that they themſelves once wanted to “ ſee, and to be taught." Le Dran, Præfat. ad Obſerv. As I have never yet learned the art of preparing noftrums, the remedies and means which I make uſe of, are all expoſed to ſale in the ſhops of apothecaries, and are con- cealed only from thoſe that will not learn them. I deſcribe every thing that regards the manual operation with the utmoſt ac- curacy and clearneſs : I enter into particular details, perhaps, more than men of experience will think neceſſary; but it is not always for them that ſuch treatiſes are written; and I hope they will excuſe me, ſince others leſs learned mult neceſſarily be carried on ſtep by ſtep. For their fake therefore, like a pilot who is educating young failors, I fhew, with- out reſerve, the rocks on which I was in danger of being loſt, and teach my ſucceſſors how to fhun them. I am not aſhamed to make particular remarks on my own mil- takes, that others may profit by them: My opinion is, that ill ſucceſs affords more in- ſtruction than ſurprizing cures, in which -nature has always a greater ſhare than we, and often hides from us its ſecret methods. Unhap- 2 The PREFACE. xxix Unhappy accidents give unerring lectures, eſpecially in caſes new or uncommon, where reflection comes to the affiſtance of our firſt peruſal of the book of nature. We then ſcarcely fail to make diſcoveries, which ſome diſorder of the parts had before kept in ob- ſcurity, and which are of an ineſtimable va- lue, when we know how to apply them to practice with certainty. If there appears anyſharpneſs in my criticiſm, I declare that it is not with a view to offend any one. It is my duty to oppoſe bad practice, and I always do it with- out paſſion. I mortify my own ſelf-love whenever I have it in my power to ſubſtitute in the place of my own obſervations thoſe of my contemporaries, or of authors of fuffi- cient credit, to ſupport my poſitions ; for many facts of the ſame kind would cer- tainly produce tediouſneſs and confuſion. The conſequences which I draw from each obfervation, are ſo many arguments founded upon the obſervations themſelves, and dem monſtrated by the mechaniſm of the diſeaſed parts. But to render theſe reaſonings juſt and conſequential, let me, in this place, lay down a precept of great importance. In my opinion it is not ſufficient for us to have a perfect knowledge of the parts, of their ſtructure, their dependencies, their true ſituation, their order, and their uſe; hrwe XXX The PREFACE. a we muſt alſo have all the knowledge poſ- ſible of the pathological part of anatomy, that is, of the diforders or diſlocations which happen to the parts affected in ruptures, whether as active or paffive. We muſt therefore ftudy, with great application, the cauſes and effects of theſe diſorders, and make a collection of remarks, if not in all reſpects ſufficient, yet ſuch as may enable us to give a reaſon to ourfelves of the concomi- tant fymptoms, by comparing the natural and found ftate of the parts with the irregu- larities cauſed by the diſorder. The hypogaftrium, or lower belly, in its natural ſtate, has fo admirable a harmony and order, that if other parts perform their functions, it produces a perfect chylification, which conſtitutes a good habit of body: But if the ſtomach is pinched in the triangular ſpaces, which are on both ſides of the carti- lago xyphoides, or by the muſculi recti; or if it is drawn down by the diſplacing of the epiploon, fallen into the ſcrotum; if the arch of the colon, which is ſituated in the epigaſ- tric region, ſhould be drawn out of the ab- domen; if the cæcum, which is ſituated in the right ilium, ſhould form a rupture on the left fide; if any of the inteſtines ſhould en- ter into the oval holes of the os iſchium, &c. what diſaſters and calamities muſt reſult from thence? How can we account for theſe accidents, or remedy them, if we are not thorough- The P R E FACE. xxxi thoroughly inſtructed in the phyſiological and pathological parts of furgery? The knowledge of theſe irregularities is not uſeful merely in the treatment of rup- turés, fince phyſicians, who have the greateſt ſkill in internal diſtempers, are often per- plexed in their prognoſtics, and deceived in their curative intentions, when they are not familiar with theſe diſorders. The late Dr. Hecquet, the Hippocrates of France, never treated any diſtemper, whether chronic or acute, which had its ſeat in the abdomen, without conſulting the celebrated anatomiſt Mr. Winſlow, or my father ; or he took my advice in their abfence, to be aſſured if there was no diſplacing of parts, which might cauſe the diſeaſe; and accordingly acted always in conſequence of the deciſions of others. He was, ſince his retreat, conſulted for Made- moiſelle Delaire, one of the women of the bedchamber to the queen, who kept her bed for fix months with a colic in her ſtomach, and had taken all the remedies which phyſic affords in ſuch caſes. ſult of the conſultation was, that the colic was cauſed by an obſtruction in the pylorus ; and what gave occaſion to this opinion was, that the patient could not take any thing but liquid nouriſhment: Whenever ſhe eat any thing folid, it threw her into great pains and vomitings. Dr. Hecquet adviſed to ſend for me, to have my advice concerning The re- 2 the xxxii The P R E FA CÉ. the ſtate of the viſcera. Mr. De la Peyro- nie, the king's firſt furgeon, gave me an exact account of all that had occurred for fix months before, and of all the remedies that had been preſcribed, and told me particu- larly that the patient had fallen into ema- ciation. They had diligently examined all the parts where ruptures can be formed , but to no purpoſe, becauſe they examined her only as the lay on the bed. Í cauſed her to get up and cough, at which time I preſſed upon the region of the ſtomach, where I felt on one ſide of the cartilago xyphoides, a very ſmall tumour of the bigneſs of a cherry-ſtone, of which the patient complained very much; then I ordered her to lie down, upon which the tumour diſappeared ; ſo that this tumour was juſtly concluded to be the real cauſe of the diſeaſe, and the colic of the ſtomach was only its effect. The emaciation of the pa- tient was eaſily accounted for, fince ſhe was re- duced to live wholly upon liquids, being tor- mented with colics on every attempt to take folid nouriſhment, which did not proceed from any fault in the ſtomach, but from its infinuating itſelf into the triangular aperture , which gives paſſage to fome veſſels that are diſtributed among the pectoral muſcles. This only happened when the patient was ſtanding or fitting down; and as of courſe the fat down when ſhe was about to eat, her fto- mach was pinched by the inſinuation which ; The P R E FACE. Xxxil I have mentioned, being then in the contrary ſituation to that in which ſhe could take broths and liquids. There was, therefore, no place for any other remedy than a truſs me- thodically made, which I applied to the part : By theſe means the patient found herſelf in a condition to eat the fame day, her colic ceaſed, and in a very little time ſhe recover'd her fleſh. By examining with care the diſlocation of the parts, we diſcover eaſily the reaſon of certain truths that were heretofore conſidered only as paradoxes. Ruptures of the oval foramina of the pelvis, which my father ori- ginally diſcovered, were at firſt rejected as impoſible by Mr. Duverney, a celebrated anatomiſt; but ten years after he found two of that nature in the ſame perſon: He was, however, then paid in his own coin by thoſe who ſeem to think the rejection of novelties a point of honour. There were ſome who maintained the fame error till 1742, when I performed the operation, for a rupture of that kind* in a young lady of quality, which Meff . Mataval and Grammont, furgeons, declared to be neceſſary. Who could have given me courage to have performed the firſt operation of this nature, had I not been minutely ac- quainted with every ſtep which ruptures take in their progreſs * Vide Mem, of the Acad. of Surg. vol. 1. P: 715. D How xxxiv The P.RE FACE. How can we judge of the diſlocation of the epigaſtric artery, when a conſiderable portion of the inteſtine has made its way through the ringlet of the great oblique muſcle, or under the ligamentum pouperti, unleſs we know by analogy the different po- fitions in which it then lies; for we may ea- ſily conceive it has now changed its di- rection? be In common ruptures of the ſcrotum, the inteſtine paſſes under the ſpermatic cord; and on the contrary, in certain caſes, this cord paſſes under the inteſtine *, or on one ſide of it. How, then, can we avoid hurting it in the dilatation of the ringlet, if we are not pre- cautioned of this phænomenon ; and if we have not compared the natural with the dil eafed ftate of thoſe parts ? The fame veſſels which, in a natural ſtate, paſs along the laſt fibres of the tranſverſal muſcle, cannot but be confounded with the ligainentum pouperti; when a rupture, be it ever ſo finall, draws the ligament into the form of an arch, what method can be taken to avoid cutting theſe veſſels f, if we are not well acquainted with theſe irregularities , and an infinite number of others, of which the knowledge appears to me not leſs eſſen- tial than that of the moſt perfect anatomy. See Le Dran's Operat. Chirurg. p. 127. See Garengeot in his treatiſe de Splanchnolo, vol. This 099 lelley be guo P. 5. edit. 1742 The P'RE FA C E. XXXV 3 This laſt affertion is too important to be paſſed over in this place without proof. Mr De la Faye diſputed this matter with me one day in the preſence of Meff. Soumain, Cour- tois, Tavernier, Belloc, and others. I under- took to prove it; and we choſe for judges three celebrated anatomiſts, Meff. Verdier, Ruffel, and Bafſuel. The Hotel Dieu was the place appointed for this inquiry, where it happened that amongſt the number which then lay in the chamber of the dead, the firſt that came to hand was a man about fifty years old, who died the fame day of a crural rupture with ftrangula- tion. The rupture continued intire after his death, and was about the bigneſs of a pigeon's egg Mr. Boudon, furgeon-major of the ſaid hoſpital, was preſent, to whom I paid the reſpect of defiring him to perform the operation. He performed it with the ſame care as if the perſon had been living. Mr. Ruffel afterwards diſſected the parts with great pre- caution; but the ſpermatic veſſels were found cut through, for which many reaſons were alleged that were immediately owned to have no weight; for when Mr. Ruffel, who was one of the greateſt oppofers of this truth, performed the operation on the other ſide, every circumſtance was in his favour, ſince as there was no rupture there, the veſſels could not but be at a diſtance from the ligament: Nevertheleſs he cut the veſſels as perfectly through D 2 XXXVI The PREFACE. a through as Mr. Boudon had done the inſtant before, as appeared in the diſſection of the muſcles, which he performed himſelf. To how many reflections, neceſſary to practice, does this pathological remark give occaſion? I have ſhewn Mr. Hunter, an eminent anatomiſt, and his ſcholars, the in- ftrument which I invented to avoid the cut- ting of theſe veſſels in the operation. To how many variations do we find the epiploon ſubject, by comparing its natural with its preternatural ſtate? Lazarus Rive rius found it of a fleſhy ſubſtance, and four fingers thick. Peyerus ſaw it of the bignels of a child's head. Veſalius, on the contrary, found it fo thin that it was taken for a vari- cocele; and the fame author obſerved one that weighed five pounds. Gregorius Hol- tius proves,, by an inſtance of one which he faw, that it may grow to the weight of 56 pounds. According to the obſervation of Bonetus, it becomes of a fleſhy ſubſtance in fome; in others it is found of an offified of ftony conſiſtence, as may be ſeen by the cu- rious diſſertation of the late Dr. Mongin, of the faculty of Paris. It alſo varies in its form and length, according to circumſtances, which lay a foundation for theſe variations. I have ſometimes found it in the ſhape of a cord : 1 have known it likewiſe three feet long, whilft in ſome bodies we ſcarce find any, or elſe its vaſcular cawl is totally deprived of its fat , and The PREFACE XXXVII and ſcarcely to be diſtinguiſhed. Its difpofi- tion is ſometimes ſo confuſed, that it is im- poſſible to unfold it, or find its circumference, It is ſometimes ſo wound up as to loſe intire- ly its form, and appears to be rather any thing than what it really is : And, to conclude, there are ſome caſes where it becomes capa- ble of frangulating the inteſtine. If any man thinks the knowledge of all theſe varia- tions needleſs in the treatment of ruptures, he is unqueſtionably miſtaken. How can we remedy the putrefaction of the inteſtines, or of the epiploon in ruptures, if dead bodies are not diffected, and the cauſes, effects, and progreſs are not traced to their original ? If we content ourſelves to commit theſe diſeaſes to the care of nature, after the manner of the antients, ſome indeed may recover ; but by rational aſſiſtance the greater number may be ſaved; and it is only by reaſoning analogically from known caſes, that we are enabled to cure ſuch as reſemble them. How could we have a right to open the inteſtine in theſe caſes of diſtreſs, if we had not ſeen, examined and compared the diſ- orders which produce the neceflity of opera- tion, or give hope of ſucceſs? How could we dilate the ſtrangulations cauſed by the peritoneum, the epiploon, or thoſe which proceed from the inteſtine itſelf? How could we ſucceed in ſeparating adhe- fions, thoſe dreadful concomitants of rup- D 3 tures, Xxxviii The PRE FACE. a tures, if we had not ſtudied exactly the order and regularity of nature in diſtempers of this kind? For let no man run haftily into error; let my treatiſe be read with a little attention, and it will appear that there is a ſort of uni- formity always ſteady, always - conſiſtent in theſe diſorders, but of which different ſpecies are found, and of which juſt diſtinctions much conduces to an exact knowledge. Nature does not always deſign to hide from us what has appeared as myſtery for ſo many ages but, on the contrary, has made herſelf diſco- verable by the regularity which ſhe keeps up. Examples always ſtrike with more force than arguments. It will appear in ruptures with adheſion, and in ſtrangulations of the peri toneum, which are the ſubject of the ſecond part of this eſſay, that the different ſpecies, cauſes, and fymptoms of theſe diſorders are now diſcovered, and means invented to cure them by different manual operations, quite new, to which the way has been ſhewn by analogy, accurate diffections, and practical obfervations. Hence we conclude, there no diſtemper which requires more aſſiſtance from pathologic anatomy than ruptures; and if all thoſe who have opportunities to make obſervations upon dead bodies, would give themſelves a little trouble for this purpoſe, theſe diſtempers would foon extricate them- ſelves from the obfcurity in which they have lain hid by the negligence of paſt ages. This The PREFACE. XXXIX 9 This deſign, already begun by a pathologic anatomy, which I have drawn up for myſelf, would ſoon be in a condition to appear in public, if the learned profeffors of ſurgery, to whoſe protection I think myſelf. intitled, would procure me the means of confirming ſome remarks, which I am afraid are hitherto only ſet down at hazard; of extending ſome obfervations which are better eſtabliſhed, and of ſtudying ſome queſtions which are yet undecided. If they would affiſt my at- tempts with their own obſervations, the pub- lic would be indebted to them for the moſt uſeful work that ſurgery can offer it; for it is certain there are no habitual diſeaſes more common or more dangerous than hernias, or in which there is generally to be found fo little relief. I have clearly demonſtrated, in a particular eſſay, that at leaſt an eighth part of the human race is troubled with hernias, which is ſtill ſtrengthened by a remark of the right revd. Dr. Pearce, now lord biſhop of Bangor, who told me, that of a thouſand men which were raiſed ſome time ago in St. Martin's pariſh, to recruit his majeſty's regiments, there were found more than ninety incommoded with hernias ; yet theſe were men from the age of fixteen to forty; and were we to take an equal number from their infancy to three- ſcore, we ſhould find thoſe affected with rup- n D 4 XI The P R E FACE. ruptures would amount to at leaſt an eighth part; and if we go on to the age of eighty, we might probably find them a ſeventh part. So The want of relief in theſe diſeaſes does not proceed from a ſcarcity of medicines, but from a neglect of the art, from bad choice, or bad application. There are few antient authors who have not diſcovered ſome, and thofe perhaps efficacious methods, according to the ideas which they had of theſe dif- eaſes. JESTE The curative indications are drawn from different confiderations. The antients ſeem to have had regard only to certain particular cauſes, certain circumſtances of place, of conſtitution, of age, of the difference of fex, which ſkill they concealed as a myſtery, and perhaps imagined to be of more uſe in the cure of diſeaſes than the knowledge of the remedies themſelves : And, indeed, the diffi- culty is not to find the proper remedies for theſe diſeaſes, but to know the true cauſes from whence they proceed ; ſo that the rea- ſon why we fee fo few perform cures in theſe caſes is, that there are few who know the cauſes. Ignorati nulla eft curatio morbi, The learned Ferrarius, profeffor of phyſic at Modena, wrote to the illuſtrious Franciſcus Tortus, alſo profeſſor of the ſame faculty, to compliment him upon his differtation on the nature and uſe of the bark. * Happy would « it The PREFA CE. xli 0 0 « it be, ſays he, if all the world were pof- « feffed of your method of preſcribing this « remedy, and if we knew as well as you « in what caſes it is proper, its true uſe, and " its juſt proportion ; if we could diſtin- “ guilh, with your exactneſs, fevers from fe- « vers, with their fymptoms and periods. Although you have put theſe things in the « cleareſt light, yet every body is not capa- “ble, like you, of underſtanding them; and • there will happen, from time to time, a great deal of bad practice, notwithſtand- "ing all our care and attention.” The neglect of theſe attainments among practitioners in ſurgery, who have not given themſelves the trouble of diſtinguiſhing the true indications, for the application of reme- dies in habitual ruptures has inſenſibly let the treatment of theſe maladies fall into con- tempt; and thus the care of ſuch patients has been committed to common workmen, who pretend to a right of undertaking the palliative cure of ruptures by the application of truffes, fuch as often prove more danger- ous than uſeful. Theſe perſons, not having the leaſt idea of anatomy, nor even of the parts to which they apply theſe machines, and having no knowledge of the diſeaſes for which truſſes are ſo uſeful, when they are well conſtructed, cannot but do a great deal of miſchief; as may be ſeen in the remarks which I have made on the cauſes of a con- ſtriction xli The PREFACE. ſtriction of the peritoneum, and the cauſes likewiſe of adheſion. bo If furgeons had not thought it below them to make truſſes themſelves, theſe diſ- eaſes had not fallen into fo great obſcurity. The great men of the laſt ages, however, did not think themſelves diſgraced by apply- mg theſe machines, of which they employ'd workmen only to make the coarſer part, Geigerus, Scultetus, Fabricius, Hildanus, Fabr. ab Aquapendente, Bellangerus, and Bleg- ny, to whom the world is much indebted, have done very important ſervice to the pub- lic, by leaving to pofterity the models of truffes; with regard to which there is no- thing more to be done, but to perfect them by making ſuch alterations as are required by different kinds of ruptures. The whole art confifts in proportioning them to the body of the patient, ſo that they may preſs every where equally, that the point of ſupport be firm, and that the compreſſion of the bolſter be exact and unvariable. The ſemi-circular piece of ſteel ought to be longer or ſhorter, furonger or weaker, and to have more or leſs elaſticity and ſtiffneſs, according to the di- menſions of the parts, and in proportion to the ſtrength of the patient, on whom it is to be applied. Regard muſt be had to the fize and nature of the rupture, to the length of time that it has exiſted, and to the greater or Ebe P R E FACE. . xlüj or leſs contraction of the muſcles of the ab- domen and breaſt. But yet, to ſucceed in this work, one muſt have a knowledge fuperior to that of com- mon workmen ; a knowledge only to be ac- quired by the ſtudy of anatomy. The bones of the pelvis, upon which truſſes are applied, differ as much as the features of the face. In men the features are large, and ſtrongly marked, becauſe, in proportion to other parts, the frontal bones are large, the orbits more open, the naſal bones more extended, the maxillary bones higher, and thoſe of the lower jaw wider ; their muſcles are more fleſhy, and their fibres groffer : But yet men have the bones of the pelvis leſs, and leſs widened than women, and conſequently their hips leſs raiſed, their poſterior parts more flat towards the waiſt, and the os pubis leſs arched. This general knowledge of the whole, leads to a particular acquaintance with ſingle parts, from which may be learned the natural eminencies and cavities of the bones; and we may be enabled to diſtinguiſh thoſe that are out of the regular courſe, or ſuch as deviate from their juſt proportion. He that has not an exact idea of all the different con- figurations of the bones, muſt neceflarily be deceived in the conſtruction of his truffes, which will therefore compreſs in improper parts, incommode the patient, and reſtrain the hernia imperfectly, or perhaps not at all. Theſe xliv The PRE FACE. Theſe circumſtances cannot be well obſerved but by a furgeon, who makes this diſeaſe his principal buſineſs. To this part of ſurgery, therefore, I have chiefly applied myſelf, and in this am able to do more than common ſervice to mankind; for by means of truffes, formed with care and judgment, the patients are ſecured againſt the miſchievous conſe- quences of theſe diſorders, which it is more prudent to prevent than to remedy. Nobis verò præſtantior videtur, qui mela avertere & præcavere noverit, quam qui fimpliciter fanare, ſays Reneaume. That my experience may produce ſome benefit to the public, I have begun this work by general inſtructions for thoſe who are af- flicted with ruptures, in which I have ſhewn their cauſes, their ſigns, and the rules which the patient ſhould obſerve, with precepts for the application and uſe of truffes, with which I hope thoſe who want them will have reaſon to be pleaſed. 2010 ON Top Top 100 bayar letom od 219b Tons A DIS- 50 Mbonitapon at andatin din Watoto agione di bismong 318 firal od to move soha nens amet colo ovisi mənts onivig tartalostih naruto 191 vad madi vbril al videont italiered od -1103 vlist mod sponou alls bas enoishi 0 AT val ( 45 ) bevaldo Ilow to contrario stadt til lo Tiido Joud Isaioan A isid su giotstarb 0105 trobo cho Com DISSERTATION) most or iON O RaoneyP troba HERNIAS, &c. PART I. Sect. I. odon INSTRUCTIONS to Perſons af- flięted with RUPTURES or Hernias. INTRODUCTION. . T HOUGH ruptures or hernias are far more frequent than is com- monly believed, yet there is no fpecies of diſorders with which the public is hitherto lefs acquainted. Moſt per- fons are prompted by a principle of curioſity to form fome general idea, even of the leaſt common diſeaſes, without giving themſelves the ſmalleſt trouble to ſtudy them. They rea- fon and talk concerning them, in daily con- verſations, 4 46 Inſtructions to Perfons POSSI of medi- ful to eve- 10 ob verſations, form a judgment of the capacita s of various phyſicians, extol the ſkill of on bodnom a s10 and as much depreciate that of another: Na bei what is ſtill more, they think they have right to criticiſe on the moſt abſtruſe medi cinal productions. The ſtudy All theſe things are far from being incoi . cine uſe fiſtent with the general welfare of the huma ſpecies, when they do not tend to obſtrud ry perſon and fruſtrate phyſicians and ſurgeons in the rational and methodical treatment of diſeaſes If phyſic and ſurgery were made an eaſy an amuſing ſtudy, it would be in the power d every one to reaſon with exactneſs, to judg with diſcernment of the capacity of phyſ cians and ſurgeons, and to read their work with ſufficient knowledge. Every man has, na doubt, an uncontroverted right to be his own phyſician ; but no one can have any pri vilege to practiſe in that capacity on others without having acquired a competent know ledge of diſeaſes. Why, then, do not peo ple take more pains ? Men, from ſome caule or other, often form tedious and laborious rules for acquiring particular branches of knowledge, intirely foreign to their ſtate and condition in life; but every one pretends to be a phyſician, without taking the ſmallelt care to obtain a due acquaintance with dif- eaſes. Nothing, however, ought to be thought of ſuch importance as the ſtudy of medicine , ſince all men are, more or leſs, ſubject to 10 ز dif- afflicted with Ruptures or Hernias. 47 the hu- st diſeaſes. Beſides, no branch of knowledge Know- ledge of affords a more noble and exalted pleaſure to the human mind than the ſtudy of the ani-man body mal economy, without which no acquain-more fa- tance with diſeaſes can poſſibly be obtained. than any This is, among all other parts of human li-other. terature, at once the moſt curious and the moſt neceſſary. Man, who is the principal a to object of its reſearches and diſcoveries, is to bleſſed with a degree of excellence ſuperior to that of all the other works of nature, how perfect foever in their reſpective kinds. Why, therefore, do we not make it our buſineſs to know the ſtructure, order, and ſeveral uſes of the various parts of which he is com- poſed ? If it ſhould be ſaid, that the mind is pleaſed with making problems, and ſatisfied with the force of its own powers in reſolving them; I anſwer, that no fcience preſents us with more problems than anatomy, the re- ſolution of which furniſhes us with advan- tages as great, and univerſally uſeful, as thoſe obtained from any other liberal art whatever. Others may perhaps remonſtrate, that the ftudy of anatomy is diſguſting; but, on ſup- poſition that this was true, yet the obliga- tions we lie under from felf-intereſt, to know our own frame and make, ought to fur- mount and counterballance all the offences to humanity and delicacy with which the ſtudy of this ſcience can be accompanied. Of this we have a memorable inſtance of a sid prin- I 48 Inltructions to Perſons princeſs of the blood in France, a perſong no leſs illuſtrious for her birth, than venerab for the great and noble difpofitions and fer timents of her foul *. Beſides, every perſo is not obliged to operate with his own ħand The draughts of all the parts, engraved from the greateſt maſters, and every where tob found in their productions, ſet thoſe ideas i a clear light, which a ſimple reading mig have left obſcure and perplexed. Befide Wax ana- wax anatomies, carefully and accurately pm their ad. pared, would be almoft fufficient to for vantage. maſters in anatomy; but they are neglect becauſe we have them in our poffeffio When they were at Paris, ſome perſons taſte and genius thought it worth their whi to take a journey thither, in order to fatist their curioſity; and ſince they have been London, Frenchmen have come on purpol to ſee them there. It is an unaccountab failing in the human mind to deſire only fuo things as it has not, for the preſent, with its reach. But if it ſhould be objected, th we could not live, if we were acquainto with the delicacy and fineneſs of the parts o which life and health depend, but ſhould b continually forming the hateful idea of quick-approaching death ; I anſwer, that thi I would by no means happen, ſince we rather learn, on the contrary, to ſpare preſerve theſe parts, and avoid the mea ز fhou an * See the chap, on adherences. whid afflitted with Ruptures or Hernias. 8849 anatomy which, without being fenfible of our folly, we continually employ to deſtroy them; or, to ſpeak in the ſtrain of a chriſtian philofo- pher, we ſhould at leaft learn how to die. How many great and ingenious men have, notwithſtanding the weakneſs of their con- ſtitutions, arrived at extreme old age, who, without this fo neceſſary knowledge of ana- tomy, would have died in the very flower of Happy ef- **youth? By means of this knowledge of the fes of animal economy, every man would be in a condition to ſtudy his own conſtitution, to obſerve the changes which happen in it, to guard againſt every thing that might prejudiſe 1 it, to diſcover the cauſes of diſeaſes, to know al their principal differences, fymptoms, and y figns; and, in a word, when he was ſeized 1 with any diſorder, he would be able to give la juſt account of it to his phyſician, who could therefore proceed upon the narrative of the patient; whereas he is often obliged to tu ſpend the firſt days of the diſeaſe in inveſti- gating its nature and ſpecies, ſtudying the conſtitution of the patient, and forming the momoft proper plan for his proceeding in the u courſe of the cure. 1 Medicine and ſurgery would be fo far from Advan- fuſtaining any loſs by theſe means, that they cruing to bi would reap conſiderable advantages from them. ſurgery and phy. The public becoming more knowing, would 3 perhaps be in a condition to make ſome hap- the univer- py diſcoveries : They would form judgments fal know- E tages ac. fic from of ledge of anatomy, 150 Inſtructions to Perſons of the dangerous and intricate complication of diſeaſes: They would be witneſſes of the contraſt or contrariety between the indic tions and contra-indications : They would no ſo raſhly impute, to the moſt ſkilful and ju dicious practitioners, fuppofed faults and er rors, of which they are by no means guilty They would be forced to do theſe men tice, by admiring their maſterly ſtrokes of pra tice, which are often highly laudable: The would be able to judge of the true cauſes o death, which are ſometimes inſurmountabk If a ſhip founders in fight of a harbom whence a numerous crowd are ſpectators. her imminent danger, and if good judes have ſeen all the ſteps taken, that were neck ſary to preſerve her againſt the impetuo fhocks of an adverſe wind, which hindera her from regaining the open ſea, the pilot i not the leſs eſteemed for this misfortune; bu if he has the good luck to ſave himſelf from Shipwreck, he is the more careſſed an courted, and every one is fond to intruſt him with his ſubſtance and fortune. Hernias It is quite otherwiſe with reſpect to ru intirely unknown tures than with regard to other diſeaſes ; to the pub- tho' we have fome ſuperficial ideas of the la lic, and ter, yet the name of the former is hard fons why, known among the vulgar, and more eſpecia . ly among perſons of note and diſtinction, wh ought to have a more extenfive knowledg and comprehenſion of things. the rea- TE I afflicted with Ruptures or Herniás. 51 و The moſt general cauſe of the ſmall ac- quaintance we have with diſorders of this kind, ariſes from their having this circum- ſtance peculiar to theinſelves; that by attack- ing either the parts of generation, or thoſe adjacent to them, they give a harſh and un- grateful ſhock to that vanity and ſelf-love which prevails but too much in the human breaſt. This is the reaſon why the fair fex fooliſhly imagine, that theſe diſorders carry with them a certain character of obſcenity, which too grofly offends againſt the modeſty of their ſex; ſince women, afflicted with misfortunes of this nature, concèive a certain degree of infamy neceſſarily connected with them. This is alſo the particular reaſon which hinders ſome from being inſtructed, with reſpect to the true character of theſe diſorders; and which, by making others de- cline the aſſiſtance neceſſary for their relief, forces them to conceal their infirmities within their own breaft. With reſpect to men, a great number of theſe imagine that ſuch of their own ſex as labour under thefe diſorders are incapable of performing the moſt com- mon duties of life; ſo that moſt men avoid ſpeaking of them, for fear of being ſuſpected to labour under them: Whereas thoſe who are really afflicted with them, not daring to conſult able ſurgeons, who deſerve to have an intire confidence repoſed in them, remain ig- norant of the diſorder, and inactive with reſpect E 2 52 Infiructions to Perſons а reſpect to its cure. The more vulgar and in digent people, being incapable of reaſonin on theſe diſeaſes, and not in a condition procuring the neceſſary means of relief, ftru gle thro' the remains cf a languiſhing an miſerable life, under the weight of their a lamties, The diſorder is augmented, a thus rendered perpetual, for want of ad gree of knowledge fufficient to ſtop its p greſs. Families, cities, and even kingdom are ſometimes almoſt univerſally afflid with ruptures, without ever ſo much thinking on the means of curing them. I patients fall deplorable victims to that negli and contempt, into which the maſters of art have ſuffered theſe diſorders to fall. Su geons only make it their buſineſs to repti thoſe fymptoms, which it would have be far more prudent to have prevented. T tedious reſearches, and indefatigable appli tion, requiſite for knowing the vaſt extent ſurgery, have forced them to leave the ord nary treatment of patients afflicted with ru tures to common and vulgar operators," whi meaſures prove mortalto incredible numbers their fellow-creatures, as we have ſhewn int Preface. Theſe being incapable of making! ſmalleſt diſcoveries in the nature, or impro ments in the cure of theſe diſorders, ha greatly injured and depreciated, in the eſter of others, thoſe from whoſe ſkill real rel might be expected; ſo that this part of 1 aflicted with Ruptures or Hernias. 53 a gery is fallen into ſo great diſcredit, that every one who profeſſes himſelf a herniary ſurgeon is looked upon as a quack: But this preju- dice would be diffipated, if all thoſe who aſſume this character were able and ſkilful furgeons. On account of the great confidence with means to which the public has honoured me, I maketheſe diſorders think it my duty, in point of gratitude, to fupply them, by way of inſtructions, with a general knowledge of theſe diſeaſes, and of the means of preventing their ſymptoms. It often happens, that a patient is in the greateſt agonies when ſurgeons come to his relief, and that he dies by a neglect to employ the firſt remedies ſeaſonably. I have ſeen numbers die, fome thro' an ignorance of their own ſtate, others from a delicacy inſpired by mo- deſty *, others for particular reaſons which hindered them from confeſſing their misfor- tune, others for having been in country- places, far diſtant from the towns where the neceſſary means of relief were to be had, known. * This reaſon induced me, ten years ago, to make Mrs. Guiton my pupil, in order to treat theſe diſeaſes in women, on account of the reluctance with which they intruſt them. ſelves to men. The parliament, which approved both of my generoſity, and of the gentlewoman's zeal for the good of her own ſex, granted in her favour an arrét, by which it was ordained that the furgeons of Sr. Come ſhould admit her among them, provided ſhe ſhould be judged capable by the examinations which ſhe underwent for that purpoſe, and which have procured her the honour of being the only female ope- rator for hernias in Paris, where ſhe refides in the ſtreet Da- four in the pariſh of St. Euftachius. D3 and 54 Inſtructions to Perfors and by far the greateſt number, for want d having due care taken of them. As ever one has it in his power, from this part of the work, to know theſe diſorders, together with their fymptoms, and the methods removing them, ſo no perſon can allege hi ignorance as an excuſe for his negligenc When it is known that theſe diſorders ar common to every body, that a fagacious and ſkilful ſurgeon can remove them without di fending againſt the ſtricteſt laws of modely and that it is his intereſt to keep the fecret people will become leſs fcrupulous in ſeekin for the means of relief, and with an intim confidence commit themſelves to his care Thoſe who are too far diſtant to have the ne ceſſary affiſtance foon enough, will know what remedies are to be uſed, while they wil for the arrival of a ſkilful furgeon, whom w ſometimes cannot find but at a great diſtance This interval of time, which is always pre cious, will be employed in uſing the prope remedies, which I ſhall carefully fpecity when it is known that the whole fucceſs the laſt methods, which the moſt ſkilful fut- geon can put in practice, depends on the god uſe which has been made of the remedies in dicated in the beginning of the diſorder. The patient may even be cured by the ſole uſe d theſe remedies, without having any occaſion for manual operation. I have frequently found patients cured, when I arrived at their habi tations afliated with Ruptures or Hernias. 55 tations in diſtant provinces, whither I was called to afford them relief. The prince of Talmont, then in his own territories, about 300 miles from Paris, ſent for me about ten years ago. I being in the country, Mr. Le Dran went in my ſtead, and with ſatisfaction found the prince cured, without any other means than the uſe of the method I had pre- ſcribed to him, in caſe he ſhould be ſurprized by any diſcouraging fymptom, or accident. A great many charitable perſons, who, in country places, employ themſelves in re- lieving poor patients, have reſcued from death, numbers of thoſe who would have died, without the means which I ordered them to employ on ſuch occaſions, when theſe diſ- orders call for a ſpeedy aſſiſtance. Theſe benevolent perſons deſired that I would give them a courſe of connected and rational rules for the treatment of their patients. They perceived how dangerous it was to fubject themſelves to fimple formulas, which are al- ways no leſs trifling than fallacious, when ap- plied without judgment. They had often remarked, that ſuch remedies as in particular caſes had been efficacious, in others proved very prejudicial, and even mortal. The inſtructions with which I now preſent the public, are the ſame I had begun to com- pofe for the benefit of the poor. Having in my Preface, given the reaſons which always devoted me to their ſervice, I ſhall have E 4 56 fons Instructions to Per « The poor, for here add the reflections in their behalf, whid the firft editor of the late Mr. Hecquet's me dicine of the poor, ſuggeſted in his prefa to that work; fince theſe reflections CONTO borate and ſtrengthen the deſire I always he to fulfill my engagement, $c he, are in a ſtate almoſt the fame as ſhade " in a picture : They form a neceſſary con " traſt, under which humanity ſometim groans, but which does honour to di es views of providence. No doubt, the na nity, the ambition, and the caprice of me « firſt eſtabliſhed the diſtinction betwe “ them and the rich; but in the preſent fu « and condition of things, it is proper a « expedient to ſupport and preſerve this c tinction. 'Tis therefore requiſite the “ ſhould be poor people, but it is by means neceſſary that any ſhould be mit « rable. The latter are a deplorable reproad « to humanity; whereas the former enter a fo ſo many uſeful members into the politic « order and economy of the beſt governo “ ſtates, in which, by the labour and in duſtry of the poor, abundance reigns, “ conveniencies are found, and the mechani « and more ſervile arts are improved, « made to flouriſh.-------Do not," cont nues the ſame author, " ſo many conſider « ble advantages ariſing from the poor, ly call upon us to ſupply them at lea ff with what is neceſſary, to enable themp 1 66 a an loud tient affiliated with Ruptures or Hernias. 57 ( (0 e tiently to ſupport the pinching hardſhips « of their condition. The public intereſt , “ and even humanity itſelf, dictate lefions on " this ſubject fo moving, that a perſon of but moderately good diſpoſitions of foul, can never withſtand their irrefiftable force and • energy." This work, being adapted to the capaci- This work ties of charitable perſons, and conſequently the capa- the more uſeful. adapted to advantagious to the poor, is for that very reaſon city of ſo much the more beneficial to every body, every per I have made it my principal buſineſs to ren- confe- der it clear and diſtinct. I firſt give the true quently character of theſe diſorders, their different fpecies, their diſtinguiſhing figns, and the various fymptoms which appear in them. I divide the whole work into chapters, in or- der to render the reading of it leſs irkſome and fatiguing. I avoid the barbarous and uncouth terms which the profeſſors of the art too often uſe. The firſt principles of the healing art having been delivered by the Greeks and Arabians, all the hard-ſound- ing terms, borrowed from theſe dead lan- guages, would prove grating and inſupport- able to a delicate ear. Bubonocelle, oſchcocele, enterocele, epiplocele, exompbalos, entero-epi- plomphalos, &c. are words more capable of diſcouraging people than of exciting in them a deſire of knowing the diſorders, whoſe names they are. I uſe common terms, and ſuch as every body can eaſily underſtand. Thus 58 Inſtructions to Perfons Thus, inſtead of bubonocele, I ſay, delo into the groin, inſtead of ocbcocele, delu into the ſcrotum, inſtead of enterocele, d ſcent of the inteſtine; inftead of epiplom deſcent of the epiploon ; inſtead of exomplo los, deſcent at the navel; and inſtead entero-epilomphalos, deſcent at the navel po duced by the inteſtine and the epiploon bol together. However, as there are certi words which cannot poſſibly be tranſlati into the Engliſh language, I give an explic tion of ſuch at the end of the work, in fon of a dictionary. Thus, if the reader wani to know the meaning of the word anatom he will find its true ſignification under th letter A. In a word, I have done all I coul to render this work uſeful, and executed m deſign in ſuch a manner, as that the moſt i norant may reap from it, all the advantage and aſſiſtances requiſite for the cure and te moval of their infirmities. But as it is not poſfible to obtain a luft cient knowledge of theſe diſeaſes, withou having previouſly a general idea of the parti affected, I thought it proper to give a a fimpl account and deſcription of the parts of the abdomen, which is the ſeat of theſe diſor- ders ; taking care, at the ſame time, to moſt full and particular with reſpect to which have the greateſt connection with, and relation to, theſe diſorders. be thole Thole afflicted with Ruptures or Hernias. 59 Thoſe who deſire a fuller account, may ſa- tisfy themſelves by reading anatomical au- thors. But as in theſe they cannot find a ra- tional anatomy laid down on purpoſe for theſe diſorders, and as there is not on ruptures any treatiſe, which is either ſatisfactory to patients labouring under them, or inſtructive to fur- geons, I propoſe to give a complete treatiſe on this ſubject, together with a rational ana- tomy of the parts affected, both in their na- tural and diſordered ſtate, the uſe of which I have ſhewn in my Preface. a AN (60) AN Anatomical EXPLANATION OF THE Several Parts of the ABDOMEN Neceffary for underſtanding Her NIAS or RUPTURES. CH A P. I. T HE principal deſign of this an tomical explanation, is no mo than to afford the curious an 0 portunity of forming a genen idea of the parts which concur to form he nias or ruptures : Without this knowledge would be impoſſible to comprehend theſe di eaſes, a perfect underſtanding of the natur of which is perhaps of as great importan to thoſe afflicted with them, as any of the en ternal methods of relief. I An Anatomical EXPLANATION, &c. 61 In order to prevent all obſcurity and con- fuſion, I ſhall firſt give a definition of all the parts which enter the compoſition of the human body, that I may not be forced to make repetitions each time I have occafion to fyeak of any of theſe parts. I ſhall afterwards proceed to a deſcription of thoſe parts which compoſe the abdomen ; and in the execution of this part of my de- fign, I ſhall lay down the moſt clear defini- tions, ſpecify the moſt general compoſition, and enumerate the moſt ordinary uſes. By following this order every where, it will be eaſy for the meaneſt reader to apply to the ſtudy of hernias as an agreeable amuſement. If the ſubject had been handled in a more intricate manner, it would have required too much application, and the underſtanding would have been leſs ſatisfied. I ſhall ſometimes ſpeak of the figure, bulk, and adherences of certain parts; but ſhall only enter into ſuch details when they are ab- ſolutely neceſſary to the illuſtration of the ſubject. When I treat of the muſcles, veffels, liga- ments, &c. I ſhall ſay no more than what is effentially requiſite to underſtand them. Some of my friends, after having carefully read my manuſcript, deſired that I ſhould give ſome account of the circulation of the blood, which, in compliance with their re- queſt, n 62 ගල An Anatomical EXPLANATION, &c. queft, I have done in a manner ſo fimple an plain as to be underſtood by every body. CHA P. II. TI Compofi- HE human body is made up tion of the compoſed both of ſolid and of fil human body parts. Of the The fluids confiſt of the blood, and of fluids. the ſeveral liquors of which it is compoſed of the The ſolids are thoſe parts which ferve folids. contain the fluids, ſuch as the arteries, t veins, the nerves, the lymphatic veffels , lacteal vefſels, the excretory ducts, the men branes, the aponeuroſes, the ligaments, muſcles, the tendons, the glands, the bott the cartilages, the nails, and the hairs, all which are compofed of fibres. A fibre is the moſt fimple and fine par which ſerves to form the compoſition of the other parts. The arteries are thoſe canals which com vey the blood from the heart to all the pat of the body. The veins are thoſe canals which retum back the blood from all the parts the heart. The nerves are canals which convey we call the animal ſpirits to all the parts the body. They ariſe from the brain and t A fibre. The ar- teries. The veins. or carry wh The nerves. ſpio An Anatomical EXPLANATION, &c. 63 vefſels. teal ver- fels. ſpinal marrow, which runs between the head and the os facrum or rump. The lymphatic veſſels are very minute The lym- ducts, which return a fine clear liquor called phatic lymph, from all the parts of the body to the heart. The lacteal veſſels are very fine ducts, The lac- which convey from the inteſtines into a par- ticular receptacle, that liquor which is com- monly called the chyle, and which is gene- rated by the aliments. The excretory ducts are canals which con- The ex- vey from the glands the liquors which have cretory been fecern'd in them, ſuch as thoſe which ferve to convey the faliva into the mouth, &c. The membranes are a ſort of very thin, but Themen- at the ſame time very ſtrong ſubſtances, of branes. themſelves capable of a very great extenſion; and their principal uſe is to cover and fur- round the other parts. The aponeuroſes are membranes of a ſtrong conſiſtence, and thicker than com- mon membranes. They are of the fame nature with tendons, of which they are ge- nerally no more than expanfions: They an- ſwer the ſame purpoſes, and ſerve to cover a The apo- neuroſes. other parts. ments. The ligaments are ſubſtances of the ſame. The liga- kind with the membranes, but of a ſtronger texture, and thicker than an apaneuroſis. They ſerve to keep the bones joined together. The 64 An Anatomical EXPLANATION, &c, cles. The ten- dons. The The bones The muſ The muſcles are thofe red ſubſtances com- monly called the flesh, and are ſubſervient to the ſeveral motions of all the parts of the body. The tendons are whitiſh ſubſtances found at the extremities of the muſcles, of which they are only productions. They are com- monly, tho' very improperly, called finews. The glands are cluſters or congeries of vel glands. fels of all kinds, ſuch as arteries, veins, nerves lymphatic veſſels, and excretory ducts. They ſerve to ſeparate certain liquors from the mal of blood. The bones are the hardeſt and moſt folk parts of all the body, and ſerve as a common bafis or ſupport for all the other parts. The cartilages are parts leſs hard than the tilages. bones, but more folid than the fleſh: The are fupple, pliant, and the ſame with what commonly called griſtle in beef or veal. The are deſtined, as well as the bones, to fuppa and maintain the ſofter parts. The nails are ſmall, thin laminæ or plate reſembling horn, and fixed to the extremite of the fingers. They ſerve to facilitate the means of laying hold of minute objects, thoſe of the toes are of uſe in walking. The hairs are very ſmall and fine filaments growing in various parts of the body for ferent uſes. The vil Beſides theſe, there are other parts calli viſcera, ſome of which are included in tb The car- The nails. an The haiis. Cera. head An Anatomical ExPLANATION, &c. 65 head, as the brain; others in the breaſt, as the lungs; and others in the abdomen, ſuch as the ſtomach and guts, of which I ſhall af- terwards ſpeak. There are other parts called organs, which The ora are, as it were, the inſtruments of ſome fa- gans, culties. Thus the ſtomach is the principal organ of digeſtion, and the guts that of chy- lification, &c. Theſe are, properly ſpeaking, Organs of the body. organs of the body. There are others which are the organs of the ſoul, ſuch as the five Organs of , ſenſes, ſeeing, hearing, ſmelling, taſting, and the foul. touching, becauſe theſe convey the impreſ- fions of objects to the ſoul. The eyes are the organs of fight, the noſe that of ſmell, &c. CH A P. III. Р. T of the and hard parts. parts. HE human body is divided into ſoft iſ diviſion body. The ſoft parts are all thoſe already men- Soft parts. tioned, except the bones and cartilages. The hard parts are the bones and carti- Hard lages The body is alſo divided into the trunk and the extremities. body. The trunk comprehends the head, or ſupe- Thetrunk, rior ventricle ; the breaſt, or the middle ven- tricle ; and the belly, or inferior ventricle. The extremities are the arms and legs. F 2d divi- fion of the The ex- Each tremities. 66 An Anatomical EXPLANATION, &c. Each of theſe parts is ſubdivided into others, in order to give clearer notions of them; but inſtead of mentioning theſe, I ſhall proceed to the diviſion of the abdomen, which is our principal ſubject. CHA P. IV. Definition of the abdomen. T Divifion of the ab. External HE abdomen, or lower belly, is a ca- vity including the viſcera, which are ſubſervient to digeſtion and fanguification, and ſome of thoſe which ſerve the purpoſes generation. The abdomen is by anatomiſts divided into domen. regions, and into parts; but to render this matter more clear and eaſy, I ſhall divide it into the anterior or fore-part, the poſterior or back-part, and the lateral or ſide-parts. The anterior part of the abdomen extends the abdo. forwards, by preſenting itſelf to the firſt glance of the eye, from a ſmall depreffion commonly called the pit of the ſtomach, five or fix finger breadths above the navel, as far as the pudenda. Behind, the abdomen reaches from the middle of the back to the fiffure between the buttocks. On the ſides, the ab- domen reaches from about the fifth or rib, counting from below upwards, to about four finger-breadths below the top of the hip-bone. men. fixth Below 1 An Anatomical ExPLANATION, &c. 67 fion. Below the abdomen are the external parts of the pubes; of generation. The moſt prominent part what it is above theſe is called the pubes, which is co- its divi- vered with hair, and has on each ſide what is called the groin. The abdomen is bounded internally above Internal by the diaphragm, which is a partition di- ries of the viding the cavity of the breaſt from that of abdomen. the abdomen. It is bounded below by a membranous partition which covers the bladder, the uterus in women, the internal parts of generation, and the large inteſtines. It is bounded on the ſides by the five or fix laſt ribs, by the fleſh, and the bones of the haunches. Behind it is bounded by a part of the ſpine, and the fleſh of the rump. That part of the abdomen which is below Internal the membranous partition, which bounds it ries of the below, is called the pelvis, which is com- pelvis. poſed of ſeveral bones. Thoſe in the fore- part, under the hair, are called the offa pubis ; that behind is called the os facrum ; and thoſe on the fides, the offa ilea, or the hip- bones . They are more wide, and form a larger cavity in the pelvis of women than in The pelvis contains the blad- der , the large inteſtines, the uterus, the other internal parts of generation in women, and bounda- that of men. thoſe in men. The abdomen is alſo divided into containing and contained. ad diviſion parts of the aba domen. The F 2 68 An Anatomical ExPLANATION, &c. Contain- Contained parts. Of the skin. The parts containing, ſo called becauſe ing parts. they ſerve to contain the parts included in . the cavity of the belly, are the ſkin, the fat ; the muſcles, and the peritoneum. The parts contained, ſo called becauſe they are included in the cavity of the abdomen, are the epiploon, the ſtomach, the liver, the ſpleen, the pancreas, the guts, and the me- fentery ; to which may be added the kidneys, the bladder, and the internal parts of gene- ration: The ſkin is a conſiderably thick mem- brane, compoſed of tendinous fibres mutual- ly interwoven with each other. Its principal uſe is to defend the parts it covers from the injury of the air. of the The fat is an oleous ſubſtance, of a con- fiſtence almoſt fimilar to that of butter. It is contained under the ſkin by very fine mem- branes, which form ſmall cells, almoſt re- ſembling thoſe found in the cakes of wax in which bees depoſite their honey. Its uſe is to render the parts, encompaſſed with it, fupple and pliant. The muſcles of the abdomen are flat, and muſcles. lie upon each other. There are five of them on each ſide: The firſt of theſe is called the obliquus major, or greater oblique mufcle and the ſecond the obliquus minor, or ſmaller oblique muſcle; becauſe the fibres of the former run obliquely from above downwards ; whereas thoſe of the latter run fat. The ab- dominal obliquely from An Anatomical EXPLANATION, &c. 69 from below upwards. The third is the tranſverſalis, or tranſverſe muſcle, be- cauſe its fibres croſs the abdomen. The fourth is called the muſculus rectus, or ftrait muſcle, becauſe its fibres run in ftrait lines from the ſuperior to the inferior parts of the abdomen. The fifth muſcle is called pyramidalis, becauſe it has the form of a py- ramid: Its fibres compoſe a large baſis, and terminate above in one point. The five muſcles on each ſide are joined and united in the middle of the abdomen by a ſtrait line, commonly called the linea alba, or white line. Theſe muſcles ſerve to bend the body The uſe forwards, or bring the breaſt towards the of thele muſcles. thighs ; but their principal uſe is to act upon the parts contained in the abdomen, as the guts, in order to facilitate the motion of their contents, and procure a diſcharge of the fæces; on the bladder, in order to promote the dif- charge of the urine; and on the uterus or womb, in order to aſſiſt in deliveries. With reſpect to ruptures, it is particularly Natural to be obſerved, that theſe muſcles have five apertures , natural apertures, one at the navel, one on muſcles. each ſide of the pubes, and one at each bend- ing of the thighs. Beſides theſe natural apertures, there may, Preter- by ſome accident, be others formed all along the linea alba, or white line, in conſequence of the abs of the diviſion of its parts. The fleſhy and domen, F 3 natural a- pertures ten ਇੱਕ An Anatomical ExPLANATION, &c. Natural apertures ; their names. Hole of the navel. Of the rings. tendinous fibres of the muſcles may alſo be feparated from each other in various parts. All theſe apertures, whether natural or preternatural, may permit the contained parts of the abdomen to fall out and form rup- tures, as I ſhall afterwards explain. The natural apertures have different names and uſes. That at the navel is called the hole of the navel: Its uſe is to afford a paſſage for the navel-ſtring, thro' which the blood and nouriſhment are conveyed from the mother to the fætus, ſo long as the latter remains in the womb of the former. The apertures on the ſides of the pubes are called rings. There is only one on each fide. They afford a paſſage for the vaſa præparan- tia & deferentia, or veſſels deſtined for the preparation and ejection of the ſemen in men, and to the ligamenta rotunda, or round liga- ments of the womb, in women. There is, in the bending of each thigh, an aperture, formed by a part of the obliquus major, or greater oblique muſcle, which part is commonly called the ligament of Poupart, This aperture is called the crural arch, and affords a paſſage for the veffels which convey the blood to the thigh, leg, and foot for their nouriſhment, and return that which has not been uſed in the nouriſhment of thoſe parts. The peritoneum is a thin but ſtrong mem- what it i brane, lining all the internal part of the ab- Crural arches. The peri- tonem , domen, An Anatomical ExPLANATION, &c. 72 domen, where it ſerves as a fac, which im- mediately includes all the parts contained in that cavity. It alſo includes each of theſe parts in particular. This membrane has a great deal of ſpring or elaſticity; and, tho’ thin , extends itſelf ſurprizingly, without be- ing torn, when there is occafion for it, as in geſtations and dropfies ; after both of which it returns to its natural ſtate. Its outward ſurface is compoſed of a texture of fibres and veſſels, which are looſely interwoven one with another. Anatomiſts call this part the cellu- lar texture. Its inner ſurface is very ſtrong, ſmooth, and cloſely interwoven. It has this peculiar quality, with reſpect to What it ruptures, that in the inſide of the abdomen has pecu- liar, with it lines the natural apertures I have mentioned, regard to and cloſes them up in the ſame manner as ruptures. the pellicule of an egg does the hole made in its ſhell , when we want to know whether it is fufficiently boiled. There are a great many other particulars relating to the peritoneum, which I ſhall omit; for they would carry me too far from the ſubject. CHAPA 73 An Anatomical EXPLANATION, &c. CHA P. V. Of the parts contained in the abdomen : And firſt of the epiploon. . I Of the N opening the abdomen, the firſt part epiploon. which preſents is the epiploon, which is a membranous part, generally loaded with a great deal of fat, and which in animals is generally called the leaf. The epiploon covers the guts either total- ly or in part, according to its extent ; for it is not of equal dimenſions in all bodies, When in its ordinary ſtate, it only ſeems in carcaſſes to deſcend two or three finger- breadths below the navel. Its com The epiploon is compoſed of two mem- poſition, branes, as thin as the fineſt ſpiders web. Theſe two membranes include between them, as it were, ſmall pinguious cords, which, by croſſing each other in different directions, Its figure. form a kind of lozenges. It has the figure of a fac, or of an huntſman's bag. This ſac contains nothing; for which reaſon its parts are applied over each other, and this circum- ítance renders the ſubſtance of the epiploon thicker than it would otherwiſe be. As this part is of the figure of a ſac, we may eaſily conceive that it has a mouth or aperture, which is at its fuperior part. It is united before all along the ſtomach, and a behind An Anatomical EXPLANATION, &c. 73 behind all along a portion of the colon, which is ſituated below the ſtomach. It has alſo ſome other adherences on the ſides, with the liver, the ſpleen, and fome other parts. It is fufficient to obſerve, that having only its fuperior parts thus attach'd, all the reſt of its ſubſtance floats on the guts. Its uſe is to Its uſe, communicate heat to the inteſtines, CH A P. VI. of the ſtomach, ments. THE *HE ftomach is a ſort of membranous of the fac, in figure reſembling a bag-pipe, ftomach, and deſigned to contain and digeſt the ali- It has two apertures, a mouth, and a vent Its aper- or iſſue. The former is on the left fide, and cures. Its mouth, communicates with the mouth by a canal called the æſophagus, which ſerves to con- vey the aliments into it. vent, called the pylorus, is ſituated on Its vent, the right fide, and joined to the firſt of the It is compoſed of four membranes, applied Its com- over each other, and joined like the leaves of pofition. playing card, of which it has pretty near the thickneſs. It is the principal organ of digeſtion, CHAP Its inteſtines. 2 Its uſe. 74 An Anatomical EXPLANATION, &c. CH A P. VII. Of the bowels, Of the guts. THE guts confift of a large round on ca. nal, membranous like the ſtomach, from whence it extends to the fundament . They are fix or ſeven times as long as the whole body. They make many windings or meanders in the abdomen. In order to hin- der them from being twiſted with each other , they are maintained in their proper place by means of the meſentery, to which they are attached like a ruffle to the wriſtband of a ſhirt. They only form, properly ſpeaking, fingle canal; but this canal is divided into fix parts, the whole of which, taken together , are called the bowels or guts. We call fome of theſe ſmall bowels, or inteſtines, and theſe are next to the ſtomach. The firſt of theſe is called duodenum. The ſecond jejunum. And, The third ileum. Large in- The three others are diſtinguiſhed by the teſtines. the name of groſs or large inteſtines. The firſt of theſe is called cæcum. The ſecond colon. And, The third the re&tum, which is vulgarly called the great inteſtine, and terminates in the fundament, The ſmall bowels. The An Anatomical ExPLANATION, &c. 75 The duodenum is ſo called becauſe it is about twelve finger-breadths in length. It communicates with the ſtomach. The jejunum is ſo called becauſe it is al- moſt always empty. It begins where the duodenum ends. It is fituated below the na- vel, where it poffeffes a ſpace about ſix inches in diameter. The ileum, which commences where the jejunum ends, is ſo called becauſe the greateſt part of it is ſituated from right to left near the hip-bones, which anatomiſts call the oſa ilea. The coecum, which begins where the ileum ends, is ſo called becauſe it forms a kind of blind bag, or fac, three or four finger- breadths in length. It is ſituated near the right ileum, or hip-bone. The colon begins where the cæcum ends. It is ſo called becauſe it is the ſeat of colics. It ariſes all along the right ſide, and paſſing in form of an arch in the upper part of the abdomen, from the right to the left ſide, it croſſes the abdomen above the navel. After having paſſed under a part of the liver and the ſtomach, it paffes under the ſpleen, and deſcends all along the left ſide. It forms, towards the hip-bones, a fort of Roman S, and is at laſt terminated a little above the It appears, from this courſe, that the colon ſerves as a kind of circle or circum- ference to all the other bowels, which may be rump 76 An Anatomical EXPLANATION, &c. ز a 3 be conſidered as its center. It adheres, in particular places, to almoſt all the parts thro which it paſſes. It is the longeſt of all the inteſtines, and wideſt next to the cæcum. The laſt of the inteſtines is the rectum, which begins where the colon ends. It de ſcends almoſt perpendicularly to the funda- ment; for which reaſon it is called the rec- tum. It is the receptacle of the fæces, which it retains for ſome time. It terminates by an aperture, which is of a ſtructure almoſt fimi- lar to that of a purſe; that is, it has a facul- ty of opening and ſhutting itſelf, almoſt vo- luntarily, by means of ſeveral muſcles ; which being, as we have ſeen, the principles of the motions of the body, make the funda- ment or anus act for the expulſion of wind and the excrements. Compoſi. The bowels or guts are, like the ſtomach , of which they are only a continuation, com- poſed of four membranes, applied over each other. The uſe of the ſmall guts is to convey matter or liquor generated from the aliments when digeſted in the ſtomach, and to elabo- rate and ſecrete it. The uſe of the large guts is to contain the the large groſs matter of the aliments, called fæces , to convey it to the fundament, and to give vent to it, when nature calls. The bowels or guts have a motion called bowels. vermicular, or reſembling that of worms tion of the bowels. Of the uſe of the ſmall bowels. Uſe of Motion of the a which An Anatomical EXPLANATION, &c. 77 which enables them to lengthen and ſhorten themſelves. This almoſt imperceptible mo- tion is, however, fufficient to force the mat- ter they contain thro' their long courſe. This motion is called periſtaltic; but it is called antiperiſtaltic, when it is performed in a con- trary direction, in which the fæces being forced to aſcend, are diſcharg'd by the mouth, as it happens in neglected ruptures. CH A P. VIII. Of the meſentery. TF the bowels or guts had not been ſecured in their proper place, they would have been twiſted and knotted with each other, which would have continually expoſed us to the danger of death. To prevent this incon- veniency, the wiſe author of nature choſe that this large inteſtinal canal ſhould be art- fully fixed; but in ſuch a manner, however, that it might enjoy a gentle motion, which permits the bowels to float on each other, without being confounded and intermixed. The meſentery is a fort of membranous The me- expanſion, which keeps the bowels or guts, which are attached to it, in their proper It is compoſed of two membranes, between Is com- which are ſituated all thoſe veliels which poſition. ſentery what it is places. con- 78 An Anatomical EXPLANATION, &C. convey the blood to the bowels or guts for their nouriſhment, thoſe veſſels which return the ſame blood, and thoſe which convey the chyle from the guts to be mixed with the blood. There is alſo a great number of glands in the meſentery. Its uſe is to ſuſtain all the veſſels and gland which compoſe it, and to preſerve the in . teſtines in their proper places. Its uſe. CH A P. IX. Of the pancreas, or ſweetbread. Of the pancreas. a TH HE pancreas is a gland of about eight or ten finger-breadths in length, re ſembling a dog's tongue. It is of a fleſh co- Its uſe. lour, and fituated under the ſtomach. I ufe is to filtrate a liquor convey'd into the firk of the ſmall inteſtines or duodenum. C H A P. X. Of the liver. of The liver. ΤΗ HE liver is a very large organ browniſh colour, ſituated in the rigo ſide of the abdomen below the ribs. Its up per ſurface is convex, to fit itſelf to the form of the ribs. Its inferior ſurface is concave the "An Anatomical ExPLANATION, &c. 79 that it may not conſtrain that part of the ſtomach and guts which it covers . Its ſub-Its com- ſtance is coarſe, compact, and full of a pro- pofition. digious quantity of ſmall veſſels, which enter its compofition, tho' we can only perceive ſuch as are of a conſiderable bulk. The uſe of the liver is to change the great- Its uſe. eſt part of the blood, which it receives, into bile. We can obſerve, under the liver, a ſmall bag , of a greeniſh colour, which is called the gall-bladder. It has the figure of a ſmall Gall- pear, and is deſtined to preſerve a part of the bladder. bile which has been filtrated in the liver, in order to furniſh fome to the duodenum. It ferves to perfect and elaborate the chyle. This bladder is what is called the gall in animals. Beſides this, the bile is alſo convey'd im- mediately from the liver to the duodenum by a particular duct, which meeting with the canal that carries the bile from the gall-blad- der into the ſame canal, forms with it a kind of Y, whoſe two ramifications repreſent the two particular canals, and the tail the com- mon duct, which they form by uniting them- felves thus together. This is called ductus a cholodocus СНА Р. 80 An Anatomical EXPLANATION, 686 Of the ſpleen. C H A P. XI. Of the ſpleen. THI HE ſpleen is an organ of a dark-red colour, fituated on the left fide of the ſtomach under the ribs. Its figure almof reſembles that of an ox's tongue. It is round on the ſide of the ribs, and hollow or con cave on the ſide of the ſtomach. It is abou five or fix inches in length, and three or for in breadth. The ſubſtance of the fpleen is glandulou, and full of cellules, tho' a very great number of veſſels alſo enter its compoſition. Its uſe can hardly be comprehended perſons who are not perfectly acquainted will anatomy. Its com poſition. CH A P. XII. Of the kidneys. *HE kidneys and parts of generation are not properly in the abdomen, be cauſe we place the peritoneum among number of containing parts : Now, as kidneys and theſe other parts are not in peritoneum, we may look upon of the abdomen, becauſe they are beyond i peritoneum. the th them as ou Th 1 An Anatomical ExPLANATION, &c. 81 neys. tion. The kidneys are two organs of a rediſh The kid- colour, whoſe figure reſembles that of a white bean, commonly called a kidney-bean. There is one of them fituated on each ſide of the ſmall of the back. They are five or fix finger-breadths in length, and about an inch thick. They are compoſed of fibres, ſtrongly ap- Their plied to each other, which renders their ſub-compoſi- ſtance more firm than that of any of the reſt of the viſcera. Their uſe is to filtrate the urine, and de-Their ufe. poſite it in ducts which convey it into the bladder, and are called ureters. The ureters are round, membranous ca- The ure nals , almoſt as large as a quill, which ariſe ters. from that part of the kidneys, where the de- preffion gives them the form of a bean. In ariſing from the kidneys they form a ſort of funnel. Theſe ducts terminate in the blad- der , to which they convey the urine filtrated Their uſe. a from the kidneys. TH CH A P. XIII. of the urinary bladder. HE urinary bladder is a membranous, of the hollow organ, of the figure of an in- bladder. pear or bottle, whoſe bottom is turn'd to the abdomen, whilft its neck is joined to the urethra, or duct which conveys the urine G verted out 82 An Anatomical EXPLANATION, &c. Its uſe. Its com- out of the bladder. Its uſe is to contain the urine. It is compoſed of three membranes, and poſition. has three apertures, two of which are the mouths of the ureters ariſing from the kid- neys; but the third is larger than thoſe two, and ſerves as a paſſage to convey the urine Of the' into the urethra, which is a nearly round membranous canal, which conveys the urine Its com- out of the bladder. This duct is much poſition. longer in men than in women. urethra. CHA P. XIV. of the parts fubfervient to generation is men, of the femen. Its uſe. a A MONG the parts of generation fome ſerve to prepare, others to preſerve, and others to convey the femen out of the body. The ſemen is a thick and glutinous fub- ſtance, of a whitiſh colour, and poffeſs’d of a particular virtue, by which men, and all other animals, generate beings of their re- ſpective ſpecies. It is prepared by the teſticles, preſerved in a proper receptacle for uſe, and convey'd out of this receptable by the urethra, which is common to it and the urine. The teſticles are generally two in number, and contained in a kind of purſe or bag call'd the ſcrotum. Of the teſticles. a 2 They An Anatomical EXPLANATION, &C. 83 tion. ſemen is They are compoſed of veſſels, which are Their an artery, a vein, and a nerve. Theſe veſſels Theſe veſſels compofi- are wound up on each other, like a thread which compoſes what we call a bottom or ball of thread. They are called ſpermatic veſſels. The blood brought to the teſticles is con- veyed to them by arteries, ariſing from the neighbourhood of the kidneys. This blood, by paſſing thro' all the meanders and wind- ings of an artery thus wound up, there ac- How the , quires a degree of perfection, which gives it generated. the colour, conſiſtence, and virtue by which the ſemen is characterized. The femen, when thus prepared, is conveyed from the teſticle into its receptacle, by a duct called the vas deferens. The blood, which could neither be fubfervient to the nutrition of the teſticle, nor to the preparation of the femen, is returned to the heart by the vein which ac- companies the artery. All theſe veſſels, namely the ſpermatic ar- tery, vein, and nerve, and the vas deferens, united together, form a fort of cord, which Spermatis anatomiſts call the ſpermatic cord. This cord cord paſſes thro' the hole which is in the lis courſe. obliquus major, and is called its ring. When the vas deferens has entered the abdomen, it quits the other veſſels which compoſe the fpermatic cord, and joins the receptacle of the femen, in which it depo- fites , ; what it is. G 2 84 An Anatomical EXPLANATION, &c. tum; what. a ſites that which has been filtrated in the teſticles. The ſcro- The teſticles are included, as I have before obſerved, in that bag called the ſcrotum, which is no more than an elongation, or lengthening of the ſkin deſtined for contain- Its com- ing them. It is compoſed of the ſkin pro- poſition perly ſo called, and of a muſcle, which ren- ders this ſkin ſuſceptible of a motion, by which it lengthens and ſhortens, or ſhrivels This muſcle is called dartos. Within the ſcrotum we obſerve a kind of partition, or diviſion, which hinders the tef- ticles from rubbing on each other. This di- vifion is mark'd externally by a kind of ſeam in the middle of the ſcrotum, which runs as far as the fundament. This feam is called up itſelf. raphé. mon to the veſſels teſticles. Covers of Beſides the ſcrotum, which is deſtined to the ter- ticles, cover and include the teſticles, there are three Two com- other parts in which they are contained. The two firſt are common to the fperma- and the tic cord and the teſticles. The firſt of the common coverings Cremaſter called the cremaſter muſcle, one of which Its uſe. belongs to each teſticle. It is by means theſe muſcles that the teſticles are, on cular occaſions, drawn up to the penis, which denotes a perfect ſtate of health. The ſecond of theſe common coverings is a membrane called the tunica vaginalis This membrane is detach'd from the peri- of parti- The tuni- ca vage- nalis. toneum An Anatomical ExPLANATION, &c. 85 & toneum which we have mentioned, and ſerves Its uſe, as it were, for a ſheath to the cord compoſed of the ſpermatic vefſels, and to the teſticle, for which reaſon it is called the tunica vagi- nalis. It is a continuation of the cellular texture of the peritoneum. The coat, which is peculiar to the teſticle, Tunica is called tunica albuginea, or the white coat, albuginea. becauſe it is really of that colour. It is very Strong, and thicker than the other coats. It ſerves to retain the teſticle in its natural form and bulk. The receptacles of the ſemen are called of the the veſiculæ feminales, or feminal bladders. cles of Theſe are two membranous bags, compoſed the ſemen. of different little cells, almoſt reſembling compoli- thoſe of a ſponge. They are of a triangular tion. form, of about three inches in length, and about one in breadth at their wideft parts. They are ſituated under the neck of the blad- der, and each of them has a ſmall duct, Their which, accompanying it , diſgorges itſelf into external the urethra, in order to expel or eject the Their femen. The li- There are alſo two glands ſituated before of the the veſiculæ ſeminales, whoſe uſe is to filtrate proftate. a clear and glutinous liquor, which is dif- quor they charged from the penis in coition. Theſe contain. glands are called proſtate. The uſe of the Uſe of liquor they furniſh in the urethra, in which they diſcharge themſelves, is to lubricate that paſſage, and ſerve as a vehicle to the femen, which this quor. G 3 86 An Anatomical EXPLANATION, &c. which would otherwiſe be too thick. This is the liquor which eunuchs diſcharge in co- pulation The penis, fo well known, is compoſed of two principal parts, the urethra, and the poſition. corpora cavernoſa. The urethra is a membranous duct, which ſerves to convey the urine and femen out Of the penis. Its com- Of the urethra. Its uſe. the body. Of the . Their uſe. The corpora cavernoſa are two fpongeous corpora ſubſtances, which lie on the two ſides of the urethra, and which, by uniting, form the glans or head of the penis. Their uſe is to render the penis hard and ſtiff, in order to facilitate its entry into the vagina of the woman. The ſtiffneſs or erection of the penis is &tion is cauſed by the blood, convey'd to the corpora produced. cavernofá, in a greater quantity than uſual , during copulation. This blood is retained there by muſcles, which hinder its return till the erection ceaſes, by the relaxation of theſe muſcles, which moſt generally happens after the evacuation of the femen. How ere- CH A P. An Anatomical EXPLANATION, &c. 87 CH A P. XV. of the parts ſubfervient to generation in women. THE parts of generation in dum mu- dum, women are either internal or external. Method re- quires that we ſhould begin with a deſcrip- tion of the latter. The part which preſents itſelf firſt is the of the pudendum muliebre. puden- Above the pudendum lies the mons vene- liebre. ris , which is an eminence or riſing covered Its com- with hair. poſition. Below this eminence are the two lips of of the the pudendum, which are ſeparated by what lips of the puden- we call the great chink or fiffure. In ſeparating the lips, we obſerve between their fuperior parts the clitoris, or penis of a woman. Below the clitoris is the orifice of the urethra, and below the urethra is the entry of the vagina The clitoris is of a ſubſtance, figure, and of the compoſition ſimilar to that of a man's penis, Its com- except that it is not perforated; but it is fuf- poſition. ceptible of erection and elongation. There are particular women in whom it is as large as the penis of ſome men; but it is generally Its uſe. of the bulk of a quill, and the ſeat of vene- real pleaſure in moſt women. The urethra, ſituated between the clitoris of the and the vagina, is of a compoſition ſimilar urethra, a G4 to 88 An Anatomical EXPLANATION, &c. neſs. Of the ſtance. Its com- to that of a man, but it is ſhorter, being poſition only two finger-breadths in length at moſt: Its large. It is alſo larger, which is the reaſon why wo- men are leſs fubject to the ſtone than men, and why the extraction of it is more eaſy in Its uſe. fuch of them as are afflicted with it. Its uſe is to convey the urine out of the body, On the two ſides of the aperture of the nymphæ. Their ſuc, urethra we obſerve two ſmall fleſhy portions, by ſome called the little lips. The anato- miſts call them nymphæ, becaufe they ſerve Their uſe. to direct the urine in its courſe outwards, . . They reſemble the gills which hang from the throat of a cock, and, ariſing from the ſkin which covers the clitoris, extend themſelves to the entry of the vagina, and end in the plys or foldings which the ſkin forms in that part. The entry of the vagina is the aperture found under the urethra. This aperture vagina. compoſed of a ſpongious fleſh, which is in- flated during coition. It is larger in women than in girls. Opinions Some anatomiſts pretend to find infallible of anato marks of virginity in this place. It is indeed cerning certain, that theſe are ſometimes to be met the marks with, but are far more frequently wanting nity. In both caſes we can neither poſitively affert virginity, nor deny it, without running a riſque of falling into egregious errors. I in- tend in my pathological anatomy to fhew, that there is neither any ſtreſs to be laid on Of the en- try of the is of virgi- the An Anatomical ExPLANATION, &c. 89. the pretended marks of virginity, nor any conſequences to be drawn from their non- exiſtence. The vagina is a canal about fix or ſeven of the inches deep, and more or leſs large, accord- vagina, ing as it has been more or leſs uſed. It is compoſed of a very thick membrane, capa- ble of enlarging or contracting itſelf by means of the muſcular fibres which enter its com- poſition. It is full of veſſels and glands, which furniſh a liquor with which it is con- tinually moiſtened. The uſe of the vagina is to receive the Its uſe. penis , and ſerve as a conveyance for the fluids diſcharged from the uterus, women. CH A P. XVI, Internal parts fubfervient to generation in 5 THE HE internal parts fubfervient to gene- ration, are the uterus, the ovaries, and the fallopian tubes. The uterus is the principal organ of gene- of the ration. It is placed between the urinary blad- uterus, der and the rectum, The figure of the uterus reſembles that of a pear made flat, or that of a bottle uſual , It is divided into its bottom and its neck. Its neck is the part which correſponds to the þottom of the vagina. This neck terminates in a ly carried in the pocket. 90 An Anatomical EXPLANATION, &c. Of the in the vagina by an aperture called its orifice This orifice, in a natural ſtate, is ſo narrow, that it will hardly admit the head of a large pin. Its bottom is its wideſt part. It is alſo of a firm ſubſtance, and hollow within. The uterus is principally maintained in its ligaments place by four ligaments, two called the liga . menta lata, or broad ligaments; and other two called the ligamenta rotunda, or round ligaments. We muſt, above all other things attend to theſe ligaments, in order to forma juſt idea of deſcents, or fallings-down of the uterus. uterus. The liga- menta la- ta. Theſe ligaments are a continuation of the peritoneum, and for that reaſon membranous that is to ſay, they are capable of a very con- fiderable extenfion, otherwiſe the uterus could not be fituated in the abdomen during gefta . tion, but would remain in its natural place , where it would be too much confined. The broad ligaments cover all the exterio bottom of the uterus, juſt as a cap covers a woman's head. They are ſtrongly attached to it: They ſurround about a third part the uterus, and they raiſe and extend them ſelves by enlarging themſelves at their extro mities, in order to be attach'd to the olſa ilea or hip-bones. Ligamen- The ligamenta rotunda, ſo called becaule they are round, are of a ſubſtance in fom meaſure fimilar to that of the broad liga . ments, ſince they are only parts ſeparatel a ta rotun- da. from An Anatomical ExPLANATION, &c. 97 uterus. ries. from them, in order to cover a congeries of veſſels. Theſe two ligaments, that is, one on each ſide, paſs thro' the ring of the obliquus major, or externus, already mentioned; after which they loſe themſelves in the ſuperior part of the thigh. Thus the uterus is retain'd in its place by theſe four ligaments. The uſe of the uterus is to receive the Uſe of the femen of the man, in order to tranſmit it to the ovary and retain the infant, till it has ac- quired that perfection which is neceſſary to its birth. The ovaries, or teſticles of women, are The ova- two round whitiſh bodies, attach'd on each fide to the bottom of the uterus. They in- clude ſmall and very clear veſicles, which are upon as the ova, or eggs of women. They are united on the broad ligaments of the uterus, which keep them in their natural The falopian tubes, or trumpets of the The falo- uterus, are two canals ſo named by Falopius, becauſe they have ſome reſemblance to trum- figure. pets ; that is, they have one extremity nar- row, and the other large. They enter the uterus at the fides of its bottom. It is the narroweſt part of them which enters the fub- ſtance of this organ; and the aperture it forms in the uterus is ſo narrow, that a hog's briſtle can hardly be introduced into it. The tube, being thus inſerted in the ute- pus, is maintained in its place thro' its whole length, looked ſituation. pian tubes Their 92 An Anatomical EXPLANATION, &c. it Their compofi- tion. Their uſe. length, which is about fix or ſeven finge it breadths. It is thus fixed by the broad lig ra ment of the uterus, to which it adheres. The largeſt extremity of the tube or trum it pet contracts or ſhrivels itſelf up, in order t form an aperture of about three or fou inches in diameter. It afterwards enlarg itſelf, in order to terminate by a kind fringe. This fringed or interſected extremit ty is near to the ovarium, d The falopian tubes are membranous, glas dular, ſoft, and ſpongious bodies. Their uſe is to convey the moſt volati and ſpirituous part of the femen to th ovaria. How con- At the moment the moſt ſpirituous parta çeption the femen is in the tube, it produces in the happens. part an agreeable irritation, which occafion its contraction. At this time two cauſes com cur to fecundate the egg, or render it fru du ful: Firſt, all the glands of the ſubſtance w the tube being compreſſed, the liquor ti contain is diſcharged, and mixed with fpirituous femen of the man, which effe tually renders that ſpirituous matter prolik to no. Secondly, the fringe at the extremity of th tube, by contracting itſelf, clofely embra um the ovary; ſo that the ſpirituous ſemen, m ; being able to eſcape, fecundates the egg is at the aperture of the tube. There has the pens in this egg a certain motion, which to larges it. The ſmall pellicle which retain са W! OLE an whiu An Anatomical EXPLANATION, && c. 93 it in its place, is neceſſarily torn or dilace- rated. Then the extremity of the fringe, by its contraction embracing it on all fides, forces it to quit its place, and infinuate itſelf into the aperture of the tube. This tube conveys it into the uterus, by means of a vermicular motion, of which it is naturally poffeffed. When the egg is in the uterus it is attach'd to it , and is nouriſhed and augmented in it during the nine months of geſtation. a all uta under- call the humours. the fluids. CON humours are. CH A P. XVII. of the fluids. THE HE fluids which enter the compoſi- What we tion of the human body, are what we ſtand by The humours are liquid fubftances, pro- What the u duced by the folid as well as fluid aliments with which the animal is nouriſhed. The humours are divided into alimentary and excrementitious. The alimentary humours are thoſe deſtin'd Alimen- to repair the continual loſs of ſubſtance which tary hu- the body fuſtains, and which reduces the ani- mal to a neceſſity of ſupplying it by nouriſh- There are three kinds of them, namely, the chyle, the blood, and the nutritive juice; to which we may add the milk of nurſes. The Diviſion of the humours, lifi mours, what. 201 ment. hid el 94 An Anatomical EXPLANATION, &C. Beneficial excre- mentitious Excre. The excrementitious juices are liquids, fe mentitious juices, parated from the maſs of blood as incapable what. of nouriſhing the body. Theſe are divided into beneficial and uſeleſs. The beneficial excrementitious humour are thoſe which, having been feparated from humours. the maſs of blood, return into it for ſom uſe. Theſe are called recrements, and an the ſaliva, the ſtomachic juice, the humor ſeparated from the glands of the inteſtine, the bile, the pancratic juice, the humour le parated from the renes ſuccinturiati, ſeroſity in which the heart floats, that found in the ventricles of the brain, that include in the eyes, the ſemen, and the waters com tained in the membranes of the fætus whil it is in the uterus. Uſeleſs The uſeleſs excrementitious humours af excremen- thoſe which, being ſeparated from the malt of blood, do not again return into it, excel te by accident; in which caſe they produce de pl orders. Theſe humours are the matter of extern tranſpiration, the ſweat, the fpits, tears, la fnot, the gum diſcharged from the eyes, el cerumen of the ears, the humour ſeparated from bi the ſkin of the pudenda both in men an women, the menſtrual and hæmorrhoid blood, and the humours diſcharged from the TI uterus after labour. All theſe excrementitious humours, who ther beneficial or uſeleſs, are produced by titious hu- mours. pa th the of ne this the An Anatomical ExPLANATION, &c. 95 blood from which they are ſeparated. We ſhould enter into too long details, if we ſhould attempt to explain how all theſe ſepa- rations are made. I ſhall always be willing to ſatisfy thoſe whoſe curioſity prompts them to a farther knowledge of theſe particulars, if this Effay can merit their approbation : But it is , at preſent, fufficient to give an idea of the alimentary humours, by explications the moſt conciſe I can poſſibly give. 1 lol led 31 an CH A P. XVIII. Of chylification and fanguification. ALI LL the parts of the body are nouriſhed All the and ſupported by the blood, without parts of which they would be extenuated and de- nouriſhed froy'd by the continual waltes and loffes of by blood. their ſubſtance. The blood, for this very reaſon, has occafion for new recruits and fup- plies , in proportion to the diffipation of its parts. The action by which the blood is gene- thy rated is called fanguification, which is the effect of a mixture of the chyle with the blood. It is therefore expedient to examine what the chyle is, and how it is generated. The chyle is a milky or lacteal liquor, ge- of the nerated by the digeſtion of the aliments. chyle. The action by which the chyle is produced be called chylification, which is performed in the following manner : The a ani this 100 96 An Anatomical EXPLANATION, &c. How the The aliments receive their firſt prepara chyle is formed. tion in the mouth by means of maſtication , which converts them into a kind of groſs ( coarſe pulp or paſte. This paſte or pulpl convey'd into the ſtomach by means of the canal called the æſophagus. The aliments being convey'd into the ſto mach, there receive a ſecond preparation by their admixture with a liquor, which is ſepa. Firft di- rated from its glands. This ſecond prepar- geſtion. tion is what we call the firſt digeſtion, h which all the aliments, capable of being geſted, are reduced into a very liquid kindd paſte, which aſſumes a greyiſh colour. Th paſte paſſes into the inteſtines thro' the of fice we have before defcribed under the nam of pylorus, or that orifice of the ſtomac which communicates with the inteſtines, The bile convey'd from the liver, and the geſtion. pancreatic juice from the pancreas into the duodenum, mixing with this paſte as ſoon it is diſcharged from the ſtomach, produs another change in it, by refining and elab rating it, in proportion as it paffes thro' thi inteſtinal canal. This is what we call to fecond digeſtion. This pafte, being thus fined, is changed into a whitiſh liquor ſembling milk, and enters the orifices of te lacteal veins, whilſt the groffer parts are ch ried off by ſtool; and theſe laſt are what w call fæces, or excrements. Second di- TO An Anatomical ExPLANATION, &c. 97 cle of The chyle, after paffing from the inteſtines into the lacteal veins, is conveyed into the glands which enter the compoſition of the meſentery. It is alſo refined in paſſing thro' theſe glands, whence it is diſcharged thro' veſſels ſimilar to the firſt, in order to be con- vey'd into glands of the ſame nature. It paſſes thus frequently from glands to glands, in which it is purified more and more. It is afterwards depoſited in that receptacle which receives its name from Pecquet. The receptacle of Pecquet is, properly Recepra- ſpeaking, no more than a membranous fac, , Pecquet. deſtined to receive the whole of the chyle. It is ſituated in the abdomen on the left ſide of the ſpine, oppoſite to the kidney. u It aſcends in the breaſt, by paſſing thro? the diaphragm. When it quits the abdomen it aſſumes the Thoracic figure of a round canal, as large as a quill, in duct. which ſtate it is calld the thoracic duct, which diſcharges its contents into the left ſubclavian vein, ſituated in the ſuperior part of the breaſt. 9 Its uſe is, therefore, to convey the chyle Its uſe. into the blood, with which it mixes, in or- der to circulate with it, and this mixture of the chyle with the blood is called fanguifi- cation, ſo that we muſt next inquire how the blood circulates in all the parts of the body, H СНАР. 98 An Anatomical EXPLANATION, &c. de fruid vood hocu CH A P. XIX. aida bre Of the blood, and its circulation. What the THE blood is a red viſcid humour, of a blood is. THE 1 ſomewhat urinous ſmell, and of a more folid conſiſtence than the chyle, by which is produced. This humour ſerves as the ori- gin of all the others, the whole of which are ſecreted from the blood. ad The blood is compoſed of globules, which continually float and ſlide over each other and alſo make the rays of light whirle, as is evident from the red colour obfervable in its Compoſi- whole mafs. Beſides theſe red globules there enters another liquid, of a white colour, into the mafs of blood. This whitiſh part is compofed of two ſubſtances; the one called the feroſity, and the other the lymph of the blood. Theſe three kinds of fluids are eafi- ly diſtinguiſhed, tho they are but little adu verted to. It will be eaſy for every one to obferve forts of them, by viewing the blood in porringers , enter the two or three hours after it has been taken compofi, from a patient's arm. We there perceive a . red fubſtance in the middle of the porringer, and this is the globular part. This red ſub- ſtance is ſurrounded by another ſubſtance , which is of a greyiſh colour, thick, folid and tranſparent like a jelly. This is the lymph, which is eaſily infpiffated in the air tion of the blood. a erol Three blood. and An Anatomical EXPLANATION, $C. 99 and frequently in the body. The third ſub ſtance is a water which covers the two others, and is more or leſs copious in the veſſel. This is the ſerum of the blood. The blood has three forts of motions. The firſt is that of fluidity, which it has in common with all the other fluids. The fe- cond is a progreſſive or circular motion, by which it is continually propell’d from the heart to all the parts of the body, and re- turned from theſe parts to the heart. The third is the motion of fermentation, or ex- panſion, by which its conſtituent parts al- ways endeavour to recede from the center of their gyrations to the circumference. This motion reſembles that of fermenting liquors. ei The heart is that large hollow muſcle What the which is the principal organ of the circulation heart is. of the blood, and conſequently the cauſe of life. It is ſituated in the middle of the breaſt, in- clining a little to the left ſide. It is fix inches long, four broad, and twelve or thirteen in circumference. The cavity of the heart is divided into two Its cavi- parts by a very ſtrong partition. Each of ties. theſe parts is call'd a ventricle, one of which is on the right, and the other on the left fide. 5. The left ventricle ſends the blood to all the Alternate parts of the body, by means of a large rami- the blood fication or veffél called the arteria aorta: with re- This artery runs both above and below the fpect to heart, S motion of the parts, bo H 2 100 An Anatomical EXPLANATION, &c. and of heart, in order to furniſh veſſels to all the the parts parts of the body. Theſe veſſels are divided fpect to and fubdivided in infinitum, or to infinity the blood. The blood, which could not be ſubſervient to the nutrition of the parts, and other pur- poſes for which it was originally deſigned, is reforbed by veins as fine and delicate as the ſmalleſt arterial ramifications ariſing from the aorta. Theſe veins are gradually enlarged in proportion as they approach the heart, and in proportion as they are enlarged they diminifh in number ; ſo that they are all reduced into one fingle vein called the vena cava, which afterwards depoſites into the right ventricle of the heart all the blood which it returns from the parts : This blood is afterwards propell’d from the ſaid ventricle to the lungs , thro' a large ramification called the pulmo- nary artery. This fame blood is returned from the lungs by the pulmonary vein into the left ventricle, in order to be thence con- veyed into all the parts of the body, have before obſerved. This motion never ceaſes but with life, which conſiſts in the circulation of the blood. as GO CH A P. XX. Aho Of the nutritive juice. TH *HE nutritive juice is an humour which partakes of the nature of the lymph, but is more thick, and of a whitiſh colour What the nutritive juice is. It An Anatomical EXPLANATION; &c. ΤΟΙ. milated to the ſub- It is fupplied to all the parts, and affimilated to them, in order to repair their continual It is aſſi- loſſes. It is convey'd to the parts by the ex- tremities of the lymphatic arteries, which ſtance of ſhews that it is a part of the lymph, or that the parts. the lymph is proper vehicle. This nutri- It is con- tinually tive juice is continually deſtroy'd by the fric- ditipated, tion of the parts, by motion, and by tranſ- and re- piration ; for which reaſon it requires to be newed by renew'd by the blood, which is itſelf renew'd by the chyle. its the : ΤΗ T milk is. ooinney CH A P. XXI. of the milk of nurſes HE milk is an alimentary fluid, de- What the ſtined by the author of nature to nou- riſh men and quadrupeds. The antients be- lieved that the milk was formed by the blood, and ſeparated from it in the breaſts; but the diſcovery of the receptacle of the chyle, and of the canal which conveys it into the blood, has fufficiently evinced, that it proceeds im- Whence mediately from the chyle, of which it is the the chyle proper matter; for which reaſon it is look'd upon as an alimentary humour. is pro- 3 duced. sto daarom H 3 vin CHAP. domyl to a to sto za oloa diistw e 3o Enabidt som ud o lo 102 An Anatomical ExPLANATION, &c. CHA P. XXII. Of the ſpirits. Of the fpirits ; their De- , Their Their uſe. Y the ſpirits phyſicians underſtand an imperceptable ſubſtance, very fluid, finition. ſubtile, pure, elaſtic, and active, ſeparated from the blood, in the ſubſtance of the brain, Origin. cerebellum, and ſpinal marrow, propelld in- to the fibres of the nerves, and diſtributed to all the parts of the body, to be ſubfervient to their motions and functions. The ſpirits are, therefore, the firſt ſprings of the motion and functions of the body, and the nerves are the organs which convey theſe fluids into the different parts. There is ſome reaſon to think, that the ſpirits flowing from the brain are deſtin'd for the voluntary motions, and all the animal functions which depend on the ſoul and body; and that the fpirits ſeparated in the cerebel. lum, and ſpinal marrow, are employ'd in the natural and involuntary motions, and in the functions in which the ſoul is not imme diately concern'd. bodo bob nila to 1970s and od aliad bad Α Ν et ad you wong 10 MAN do based on 1 metr Batto una vols fonts podran om VOIT ( 103 ). OF H E R NI A S, &C. SECTION II. C Η Α Ρ. Ι. 22 WHILE theſe parts What is meant by a rupture or hernia, HILE the parts of the abdomen remain in that order which I have deſcribed, there ariſe from it (every other cir- cumſtance being equal) the effects of regular digeſtions, and of a perfect fanguification, which conſtitute good health: But if any of fuffer the leaſt alteration, whether with reſpect to their diſplacement, or the obſtructions which often happen in their ſub- ſtances, their functions muſt neceſſarily be changed, and conſequently produce depraved effects; and this is what conſtitutes a ſtate of Ruptures or hernias may be placed in the Hernias firſt rank of theſe diſplacements and ob-moſt com- fructions : They are almoſt always the effects mon ef- bad health. H4 offects of 104 Of HERNIA S, &c. 0 S parts nias. diſplace of them, fince, according to the beſt definie ments of tion, we underſtand no more by an hernia of the ab- than a preternatural tumor of the ſurface of domen. the abdomen, formed by the coming out of Definition of her- ſome of its contained parts, or by the accu- mulation of ſome humour. We therefore ſee that the word hernia is a general term, under which we comprehend all forts of diſplacements, with prolapfion of the parts, and fome kinds of collections of humours, which happen in the ſurface of the abdomen. Etymolo Tho' the etimology of the word bernia is word her- pretty obſcure, yet uſe has given it the pre- nia ob- ference to that of rupture, for reaſons I shall ſpecify in the fourth chapter, when ſpeaking of their cauſes. However, I ſhall ſometimet make uſe of the word rupture, on account of its being moſt univerſally known. gy of the {cure. bom doo SOLO C Η Α Ρ. ΙΙ, of the diviſion of bernias. JERNIAS, according to the general definition have given, are divided genuine into genuine and ſpurious. Genuine or true hernias, are thoſe formed hernias. by the prolapfion of the parts contained in the abdomen. wol Diviſion of her- nias into H , True belle i magar tarlac silicone og rode Isning ballsa 2 a 16 bocor muito gabad ass piquant a Spurious zod od Of HERNIAS, &c. mort 10 105 Spurious or-falſe hernias, are thoſe formed Falſe hermen by a collection of blood, lymph, ſemen and wind. do no gremo bomotomobda od nias. mo 21 RIMA T ces of her- nias with of which fift. omo CHA P. III. Sw Of the differences of true bernias. HE differences of true hernias are drawn from the parts prolapſed, and in the places they poffefs. They differ from each other on account of Differen- the parts prolapſed, fince ſome conſiſt of the inteſtine, others of the epiploon, and others reſpect to the parts of the epiploon and inteſtine. Some others, which happen leſs frequently, are form'd by they con- the ſtomach and the bladder. There are others which happen very rarely, ſuch as thoſe form'd by the liver, the ſpleen, the ovaria, and the uterus, thro' the ſeparation of the muſcles of the abdomen, or under the aper- ture at the folding of the upper end of the thigh. But I ſhall only here ſpeak of ſuch as are form’d by the inteſtine and epiploon, and of the defcents of the uterus and inteſti- num rectum. bog od 19 True hernias differ from each other, with Differen- reſpect to the parts they poſſeſs , fince fome ces of true happen at the navel, and are for that reaſon with re- called umbilical hernias. Others happen in fpect to the groins, and are therefore called inguinal they pof- hernias . Others happen at the bending of fefs. the hernias, parts 106 of HERNI AS, &c. the fuperior part of the thigh, and are on that account ftiled crural hernias : And others are formed in different parts of the ſurface di the abdomen, and are from that circumſtanc no denominated ventral hernias. There are alſo hernias which appear i other parts, and which, for this reaſon, ar different from the other ſpecies, ſuch as thol which are in the back, in the region of the kidneys, and in the vagina. Others ar formed thro' the holes at the bottom of the bones of the pelvis. But I ſhall not conſider all theſe differences, fince, inſtead of inſtrud ing thoſe for whom I write, they would sa ther hinder them from acquiring true notion of common hernias, which is the only I propoſe for the good of the public. a I have placed hernias of the uterus and P large inteſtine among the number of tru hernias, tho' authors do not follow this mel thod, becauſe, properly ſpeaking, theſe parti A are not contained in the abdomen, being be yond the peritoneum; but I have comprare hended them in this diviſion, in order to avow of a confuſion of ideas. end q a زا M toon also ad ນະວັນທີ່ 001 ដែលខ្ញុំបាន bol to Ener CHAP th solibet Of HERNIAS, &C. 107 of the cauſes of no o bom stanitoba CH A P. IV. Toto Of the general cauſes of hernias. SH N medicine we call the cauſe of a diforder Diviſion a preternatural affection or difpofition, which produces a diſeaſe, or which concurs hernias. to make it appear. I divide the cauſes of hernias into remote or primary, into proxi- mate or conjoint, and into determining cauſes. The remote cauſes are ſuch as proceed from the natural conſtitutions of patients, or from the difpofition which they acquire by their method of living. is certain, tho' the thing is hard to be Remote accounted for, that children very frequently hernias poffeſs the good or bad mental and corporal may be qualities of their progenitors: Neither is it leſs certain, that robuſt parents procreate ſtrong and vigorous children; whereas ſuch as are weak and delicate, have children who reſemble them in the delicacy and weakneſs their conſtitution; that arthritic parents beget arthritic children; phthifical parents, phthifical children; and parents afflicted with ruptures, children for the moſt part ſubject to the ſame diſorders; ſo that the moſt re- mote cauſes of hernias may be fought for in e diſpoſition communicated to the embryo, at the very moment of its conception. cauſes of tary. 3 The 108 Of HERN I AS, &c. Remote The diſpoſition acquired by the meth cauſes a- riſing from of living is much more common. In ord the man. to be convinced of this, it is fufficient tor ner of flect on what has been ſaid in the anatomic living. account of the parts which concur to the mation of hernias. The epiploon, the teſtines, and the other parts, are maintain in their ſituation by fimple membrane which, as I have obſerved in their definitio are ſuſceptible of a ſurprizing extenſion. T peritoneum itſelf, which covers all the parti osebe may be extended to double or triple its i i tural dimenſions. Thus all things capable too greatly mollifying or relaxing theſe parti become principal, but remote, cauſes of he nias. Too moiſt an air, marſhy places, y relaxing aliments, ſuch as the too ferous m of a fickly nurſe, oil, butter, too great a que tity of water, ſmall-beer, weak fyder, other ſimilar liquors, are evident caules ruptures; for a moiſt air, &c. diſpoſes parts to a relaxation. Butter and oil, by thi natures, render the membranous parts flexible, and ought therefore to be look upon as remote cauſes. Others furniſh blood with a redundance of ferofities, wb conſtitute the proximate or conjoint cauſes hernias. Theſe redundant ſerofities, by n. . , Conjoint ſtening the parts, make their adherences causes of into a relaxation, and facilitate their elon, tion; while thoſe which cover them and are extended and enlarged to ſuch a che a hernias. ye OF HERNIAS, 8c 109 190 gree, that, by the reiterated efforts which is conſtitute the immediate or determining cauſes, the parts infinuate themſelves, by little and little, into ſome of the five natural aper- tures mentioned in the anatomical expoſition of the parts. Sometimes alſo they enter theſe apertures ſuddenly, without the previous ap- pearance of any diſpoſition to ſuch a dif- order. The immediate cauſes are, therefore, all the true things capable of determining the parts alrea- dy relaxed to fall thro' theſe apertures : Thus mediate in fucking children, their cries determine the cauſes. inteſtines, or the epiploon, or both together, in a larger quantity, and with a greater ef- fort, towards the ringlets, in order to form character of the im- hernias. a bozu For the ſame reaſon, the fame cauſes pro- duce a ſimilar effect in a more advanced ſtate of infancy; and in children fomewhat far- ther advanced, leaping, efforts of all kinds, and fits of anger, are determining cauſes of ruptures. In that ſtate commonly called youth, im- moderate exerciſe, ſuch as fencing, riding, high dances, and other fimilar diverſions, young people daily carry to exceſs, require efforts which contract all the muſcles of the abdomen and diaphragm, and thoſe into qe muſcles force the inteſtines and epiploon, which they compreſs on all ſides, to flip thro' ſome of the natural apertures of the abdo- which IIO of HERNIAS, &c. TOL 2900 abdomen, or thro' ſome other apertures forma there, contrary to the order of nature. In a ſtate of manhood, three things pris cipally concur to the production of hernis namely, conſtipation, immoderate venen and the carrying heavy burdens, In women, geſtations are very proxima cauſes of theſe diſorders, by means of the great extenſion of the peritoneum and mu cles, whoſe apertures are forced far beyon their natural fize. The efforts of wome in labour are the moſt ordinary, immediat or determining cauſes of ruptures. The ligaments which, in a natural fiz retain the uterus in its place, are extended a elongated, in proportion as that organ from the pelvis, to place itſelf in the abdo men, which is a proximate cauſe of deſcent and relaxation of its ligaments. the little care of ſome women after deliver becomes the immediate and moſt determi ing cauſe of this diſorder. In old perſons, all whoſe parts are na rally weak, violent and reiterated coughin , and, often, the difficult diſcharges of uri to which ſuch perſons are ſubject, neceffari determine to ruptures; for which reaſon pa ple at this period of life are fo generally flicted by them. How her In all theſe, and a great many other, nias are which I ſhall relate, in treating of each ! cies of hernia in particular, all the conta cale co2 2 Of HERNIAS, &c. III ing parts of the abdomen, act at once with efforts on the epiploon and inteſtines. The ſtrong and reiterated preſſures of the muſcles, and of the diaphragm, paſs particularly to the center, ſo that the parts are conveyed in a greater quantity to the circumference; and as the natural apertures are only ſhut up by the peritoneum, which lines them internally, and as the peritoneum itſelf is already relaxed, or very much difpofed to a relaxation, the parts finding leſs refiftance in theſe places, infinuate themſelves in one, two, and ſome- times almoſt the whole, of theſe apertures at once. In proportion as the parts make efforts to deſcend, they puſh before them the peri- toneum, which always ſerves as an imme- diate covering for them. This part of the peritoneum thus elongated, is called the her niary fack. The more ſtrong and the oft- ener reiterated the efforts are, the more the parts are lengthened internally, and form her-- nias more or leſs long and large, becauſe the apertures which give a paſſage to them, yield infenfibly, and by little and little, to their impulſes, which renders them much larger than in a natural ſtate. This enlargement is called a dilatation. The greater the dilata- tion of the navel, the ringlets , and other parts , is, the more conſiderable the hernia muft of courſe be. Hernias of all kinds are formed in this manner; that is, by the ſimple dilatation of the containing parts, and by the relaxation II 2 Of HERN I AS, &c. relaxation and elongation of the contained parts This is the reaſon why, as I obſerved firſt, the term rupture is by no means propi for theſe diſorders, fince they only happen Hernias relaxation, and not by ruption; or if this la almoft al- cafe happens ſometimes, the proportion ways hap- pen by re- moft, as that of one to a thouſand. The an laxation. tients, who gave the name rupture to herni. imagined that all theſe diſorders were forma by the dilaceration of the peritoneum: Bu tho' in theſe diſorders the peritoneum fhou be dilacerated, yet ſtill the word ruptur , would be improperly uſed, and the wa deſcent better applied, becauſe it is the actiu by which theſe parts deſcend, which chara terizes theſe diſorders, and not the breaki of the peritoneum; for there might rupture in this part, without a deſcent thoſe contained in the abdomen thro' aperture, which would be produced by fun a dilaceration. What a fign is. difti CHA P. V. ad of the ſigns of true hernias in general THE HE ſigns of diſeaſes are ſenſible mar which make them known and din guiſh'd from each other. of figns .. Signs are divided into thoſe of the diagn tic, and thoſe of the prognoſtic kind. -10 96 Diviſion 970 OF HERNIAS, &c. 113 bord of hernias. Boo The diagnoſtic ſigns are ſuch as enable us What the to know the preſent ſtate, the character, and diagnoftic ſpecies of a diforder. The prognoſtic ſigns are ſuch as qualify us What the for judging what may happen, whether good prognoſtic or bad, in the courſe of a diſorder. The diagnoſtic figns common to all true Diagnoſ- tic ſigns hernias are different, according to the times of the hernias ; for which reaſon it is neceſ-- ſary to conſider theſe diſorders, before their appearance, during their progreſs, and in their ftate or height When an hernia is about to be formed, the patient feels a pain like that perceived upon having any part pretty violently exco- riated. This is the effect of the elongation and ſtretching of the aponeurotic filaments, which unite the pillars of the ringlet. The other natural apertures of the abdomen have allo ſimilar apertures, which ſuffer the fame elongation and extenſion in the hernias which happen in theſe parts. In the progreſs of the diſorder, that is, when it manifeſts itſelf and augments, the patient , putting his hand to the part where he feels the pain, perceives a ſmall protuberance, which diſappears when he preſſes it with his hand, or lies on his back. This protuberance . appears to him to augment daily. In its ſtate or height, the protuberance may be greater or ſmaller, from the bulk of a pi- egg to that of a man's head, and even I more, geon's egg 114 OF HER NIAS, &C. more, if its progreſs is not ſtopp'd. In this caſe the pain is different, ſince it is no longer felt in the part thro' which the hernia de ſcended, but has its feat in the hernia itſelf This pain is a ſpecies of colic, which is per- ceived but very gently below and about: Be- fides, this protuberance has, or has at its be- ginning had, the liberty of re-entering. The diagnoſtic ſigns common to all her- nias, alſo diſcover of what parts they are formed; whether, for inſtance of the epi- ploon, or of the inteſtine, or of both toge- ther. Thoſe hernias formed by the epiploon make a kind of clammy reſiſtance; ſuch as that we perceive in feeling a piece of double tripe, or the ſtomach of an ox when boild. Thoſe hernias formed by the inteſtine are known to the touch by their flexibility, their ſpring, and the noiſe they make when we handle them, which is cauſed by the mo- tion of the wind and fluid matter they tain. This noiſe is called rumbling. In hernias formed of the epiploon and in teſtines theſe figns áre mixed; that is to fay they meet together, as in the other caſes they appear ſeparate and diſtinct. Prognoſtic With reſpect to the prognoſtic ſigns hernias hernias in general, it may juftly be faid, that theſe are very terrible diſorders when they are neglected, and accompanied with fymptoms but thoſe without fymptoms are leaſt danger CON- of . STRO S ous. OF HERNIAS, &c. 115 düs. Thoſe form’d of the inteſtine are more dangerous than thoſe formed of the epiploon, Thoſe which happen in children, are far more eaſily cured than thoſe which happen in adults. Thoſe of the navel and abdomen are more difficultly cured, than thoſe of the groins; and thoſe which happen in the flex- ure of the upper end of the thigh, are very difficultly cured. Hernias of the uterus are much more troubleſome than dangerous. And laſtly, that of the large inteſtine, commonly called a de- ſcent of the fundament, is the leaſt danger- ous, but the moſt troubleſome and difficult to be cured. adAll of them are ſo much the more diffi- cultly cured as they are of longer continuance. 9 3W LONS CH A P. VI. Of the ſymptoms of bernias in general. a ſymptom we mean every thing What a troubleſome which ſupervenes in a dif- fympton order ; ſuch as a delirium in a fever, and ſo BY of others. The fymptoms of hernias are affections Symptoms which ſupervene in hernias, and from which of hernias they derive their troubleſome confequences. chronical Theſe affections are either chronical or or acute bisa sa losko The D acute. I 2 ol 200 116 Of HERNIAS, &c. toms. Acute a toms. 10 Chronical The chronical ſymptoms are ſuch as may fymp- be looked upon as habitual, and to which the patient is accuſtomed, becauſe they ſeem but ſlightly and momentaneouſly to injure the functions; ſuch as the irritations commonly ſuffered by the ſtomach and inteſtines, bad digeſtions, faintings, and windy colics, which frequently happen, eſpecially in changes of weather, &c. The acute ſymptoms are principally two, fymp- which conſtitute different ſpecies of a ſubor- dinate kind, which ſucceed each other, and become more and more violent and dan- gerous. Theſe ſymptoms are adherences and ſtran gulations. Adherences are unions which join the prox lapſed parts of the abdomen with the exter- nal parts, and which by that means hinde them from re-entering their natural place This fymptom, much more neceſſary to known by ſurgeons than by the public, is fubject of a particular part of this work. I is here ſufficient to obſerve, for the ſake of thoſe whofe buſineſs it is to guard again this fymptom, that it only proceeds from the badneſs, or total want of truſſes. The part being, in theſe caſes, habituated to remain without the abdomen, fuſtain all the trou bleſome impreſſions of external agents. any produce in them irritations, excoriations, and su inflammations ; whence ariſes the union of Of adhe. fences. agents. They the Of HERNIA S, &c. 117 HO the parts within with thoſe without the ab- domen, to which they adhere fo firmly. Bad truſſes, which continually comprefs with- out containing theſe parts, are therefore caufes moſt capable of producing this terrible ſymptom; but this fymptom, bad as it is, is not near fo dangerous as the ſtrangulation of the inteſtine, which is of the laſt importance to the public, both that they may know how to guard againſt it, and remedy it when it happens. The principal end of this work is to make the public ſo well acquainted with this fymp- tom, that every one may be able to prevent it, and afford relief both to himſelf and others when it happens. But, as I have ob- ferved in my Preface, the only method of remedying this diſorder, when it happens, is feaſonably to employ the proper remedies in the very firſt inſtants of the fymptoms; for if the firſt moments are not employ'd in uſing the proper remedies, it is hardly poffible for the moſt ſkilful furgeon to cure the patient. But let us proceed to inquire what this fymp- tom is. big BMS 160 CHA P. VII. gree nuo of the frangulation of the inteſtinesti Trangulation is a very ſignificant term, by What a which we eaſily comprehend that the frangula- inteftine is clofely contracted or ſhut up. This I 3 118 Of HERNIAS, &c. Gravid This contraction is made by the ſtrong com preffion of the parts thro' which it paſſes and which neither permit it to go forwards nor backwards. doider The epiploon may alſo fuffer a ſtrangula , tion; but the conſequences of it are not 10 troubleſome as thoſe of the ſtrangulation of the inteſtine ; for which reaſon I ſhall not here ſpeak of it. There are different ſpecies of ftrangulas tions of the inteſtine; for ſome happen in ternally, and others externally. Both of thele have ſeveral ſubdiviſions, a detail of which would lead us too far from our purpoſe. In the firſt chapter of the ſecond part of this work, the reader will ſee how far the ſtrangulation formed by the peritoneum alone may be extended. But the mot frequent ſpecies is the ſtrangulation made by the apertures, which give paffage to the parts which form hernias; ſuch as the opening of the navel, the ringlets, the apertures found at the flexure of every thigh, which I have called crural arches, and thoſe which are ex- traordinarily formed by the ſeparation of the linea alba, or white line, and by that of the fibres of the abdominal muſcles. A know- ledge of theſe ftrangulations will be ſufficient to preſerve the patient, incommoded with hernias, from all the other ſpecies of fran- gulations. riboral y The OF HERNI A S, &c. 119 fuch The manner which nature follows in form- ing a ſtrangulation, is the ſame in all circum- ſtances. The differences only ariſe from the parts which concur to form them. By ex- plaining how an ordinary ſtrangulation hap- pens, we may conceive in what manner all the others are formed. do If the parts which have infinuated them- How a felves into the natural or preternatural apertures tionis ſtrangula- of the abdomen, exactly fill all the cavity ; formed. and if, by a new effort, ſome other portions of the inteſtine, or of the epiploon, are forced into the fame aperture, as it often happens, parts are neceſſarily conftricted in theſe apertures. If a proper remedy is not forth- with ufed, the veſſels of theſe parts are com- prefs'd, the blood can no longer circulate freely in them, they are inflated; and, by this inflation, augment the bulk of the parts, and conſequently the degree of the obſtruction. When this obſtruction is at its perfect ftate or height, it is called ftrangulation, becauſe the parts are really ſtrangulated. The preſfing neceſſity of remedying this fymptom ariſes from the effects which very foon fucceed it. Theſe effects, which I call confecutive fymptoms, or accidents, appear by little and little, and ſtill continue aug- menting till the ninth day, and ſometimes longer. But it alſo fometimes happens, that they continue only thirty-fix or twenty-four hours. When they laſt only ſo ſhort a time, they I 4 are 120 Of HERNIAS, &C.0 The con- fecutive are much more violent, and ſucceed each other more quickly. I have ſeen a great many inſtances of patients who have died in the firſt twelve or fifteen hours; and I have even ſeen fome cut off in five or fix.nl Theſe ſymptoms are to be conſidered in fymptoms their beginning, in their augmention, in their of a ftran- ſtate, and in their decline, gulation In the beginning the patient inſtantaneouſly feels an intenſe pain in the part of the abdom men where the inteſtine is ſtrangulated.al In the augmentation this pain ſpreads by little and little, but by intervals, thro' all the extent of the abdomen. When the hernia is in the groin, the ſcrotum, or the flexure of the ſuperior end of the thigh, the pains bo gin at theſe places, and terminate about the navel ; and in hernias of the navel, and fur- face of the abdomen, the pains extend as far as the ſtomach. In proportion as theſe pains augment, they are called gripes : The patient has a deſire to vomit, which terminates in a copious diſcharge of thick and glarous ſaliva. Vomitings ſucceed the nauſeas and the diſa charge of ſaliva. The firſt ſubſtance the pa- tient vomits is his food, if he has any in his ſtomach; and ſometime after he vomits pure bile. The excrements are then diſcharged by the mouth, and nothing can paſs by the anus, not even the wind, which regurgitates from the inteſtines to the ſtomach, and is with great pain diſcharged by the mouth; OF HERNIAS, &c. 122 SH ſo that the patient ſeems continually ready to be ſuffocated by it. Then the abdomen is inflated, and extended to the laſt degree, and a fever ſupervenes radio . vo In the ſtate of the diſorder the fymptonas are more confiderable, and fucceed each other fooner. An hiccup and convulfive ſpaſms migrant fupervene. In the decline, the pulſe becomes concen- trated and intermittent. The patient vomits without efforts ; the wind is ſometimes dif- charged by the anus, the abdomen becomes flat, and the extremities turn cold. The noſe is pinched, and the eyes are fixed and ſtaring. Then death approaching, the parts fall total- ly into a mortification. The gripes, the vo- mitings, and the hiccup ceaſe; the hernia becomes ſoft, the abdomen collapſes, and the patient dies in a miſerable condition, without any poſſibility of affording him the ſmalleſt a a relief. gu es CH A P. VIII. o V sr sto Of bernias of the navel in particular. Anar STA H ERNIAS of the navel are tumors, Differen- or elevations of this part, formed by ces of the deſcent of the inteſtine, of the epiploon, the navel. or of both together. brous bolib aing Hernias hernias of 122 OF HERNIAS, &C. Cauſes. Hernias of the navel differ one from an other ; for ſome happen in the middle of this part; whereas others are formed in dif ferent places of its circumference; as in its fuperior, inferior, and lateral parts. They alſo differ with reſpect to their bulky for ſome are ſmall, others of a middle fize, and others of ſo large a bulk as to include the greater part of the epiploon, and almoſt al the inteſtines, The particular cauſes of hernias of the navel ariſe from the ſtructure of the part , and from the diſorders which happen to it. The nouriſhment is communicated from the mother to the foetus, by the veſſels which make up the navel-ſtring. Theſe vefiels ar covered by the peritoneum. When the in fant is brought into the world, this ftring tied with a thread about an inch from the navel, in order to prevent a diſcharge of the blood of the infant. What remains of the ſtring between the ligature and the abdomen is dried up; and the peritoneum, which ca vers it, is joined to it in all the circumference of the part where it has been tied. Befides the peritoneum is very thin, both in this play and all round the circumference of the navel. In geſtations and dropfies, the peritoneur, the muſcles, and the ſkin are extremely Tendad. The peritoneum, already more than tendəd in this place than elſewhere, becomes more ex- Of HERNIAS, &c. 123 fo at the circumference of the navel, when it is forcibly ſtretched. It even ſometimes hap- pens, that it is divided at the part where it was united by the ligature of the navel-ftring. This is the reaſon why there is almoſt always a rupture accompanying thoſe hernias which happen in the middle of the navel, and ſome- times alſo in thoſe about its circumference, when they are of a conſiderable bulk. If the peritoneum is divided during geſta- tion or a dropſy, hernias are ſuddenly form’d; but if it is not divided, it is extremely relaxed after geſtation or a dropſy. In this caſe, upon the ſmalleſt effort of the patients in coughing and going to ſtool, the epiploon and inteſtines which correſpond to this part, are determined to deſcend ſo much the more eafily, becauſe the peritoneum and muſcles, in conſequence of their great relaxation, are not in a condi- tion to make any reſiſtance. The figns which diſtinguiſh hernias of Diagnoſ- the navel, are thoſe I have related in tic igns. chap. v. The prognoſtic figns are drawn from the Prognoſis character of the hernia, from its ſpecies, from ligas. its duration, from its bulk, and from its fymptoms. Hernias form’d by rupture are incurable, and more dangerous than thoſe formed by di- latation. Thoſe of the inteſtine are more dangerous and incommodious than thoſe of the re or 124. of HERNIAS, &c. The Symp- toms. the epiploon. Such as are ſmall and recent are more dangerous than thoſe of a middle ſize, but they are more eaſily cured. Thoſe which are of long ſtanding, and very large, produce continual colics, eſpecially when they are of the adherent kind, which circum- ſtance renders them generally mortal, when a ftrangulation fupervenes . This diſorder i very dangerous in children, but may be eafily cur’d. The ſymptoms of hernias of the navel, are the ſame in general, with thoſe of other her nias. The fymptom which is particular and habitual to them, is a kind of flight colick leſs painful than troubleſome, fince the pati- ents are continually afflicted with it when they ſtand upright, and it is augmented after meals. Hernias of the navel are ſuſceptible of three different cures. The firſt is called palliative, and the ſecond radical, whereas the third con- fiſts in remedying the ſymptoms. The palliative cure, is that by means which we only ſtudy to prevent the ſymptoms by containing the parts within the abdomen It is obtain'd by means of truſies which ex- actly ſhut up the hole thro' which the parts deſcend, and which hinder them from coming out, when they are reduc'd into the abdomen, This cure is proper in hernias accompanied with obſtacles which oppoſe the radical cure, as in thoſe formed by the rupture Cure. of the peri- Of HERNIAS, &c. 125 peritoneum, thoſe of long ſtanding, thoſe of too conſiderable a bulk, and thoſe incident to women who have born many childrena The radical cure is that by means of which we cure the hernia either by the application of truſſes, or the uſe of remedies proper for theſe diſorders, of theſe I ſhall aferwards treat. The cure of the ſymptoms ſhall be related in the 12th chapter, ſo that I ſhall not ſpeak of it here. bre V CHA P. IX. - 380 Of ventral Hernias. ENTRAL hernias are thofe form'd Ventral hernias, on all the ſurface of the abdomen, ex- where cept at its natural apertures. they hap Some happen all along the linea alba, from pen. the under-part of the navel to the very low- eſt part of the abdomen. Others happen on the ſides. Of thoſe forne are pretty often form'd above the ringlets, and others above the apertures found in the flexures of the thighs, which difference make the various ſpecies of They alſo differ from each other in this, that ſome of them are form’d by the dilata- tion of the peritoneum and others by its dogo bide dw ad anotado The theſe hernias. rupture. pris -1790 126 Of HERNIAS, c. Cauſes. The great extenſion of the peritoneum and muſcles, during geſtation, or a dropfy is the moſt ordinary proximate cauſe of ventral hernias form’d by dilatation. The determin ing cauſes, are the violent efforts which the patient makes in coughing and going to ſtool The blows receiv'd in thoſe parts, become the the moſt immediate cauſes of hernias form'd by a rupture of the peritoneum by dividing it, ſuch as wounds inflicted by fire-arms and cutting inſtruments, becauſe when the perito neum is divided it can never be united, and conſequently cannot oppoſe the ſmalleſt effort which the internal parts make to ſeparate the fibres of the muſcles. It alſo fometimes happens that the perito neum is lacerated by blows of bruiſing in ſtruments, without any wound in the ſkin Caſes of this kind are indeed very rare, ſome inſtances of them are to be found. The continual twitchings which the liga ments of the ſtomach and inteſtines fuffer in this ſpecies of hernia, when a large quantity of the epiploon deſcends, put the patients out of a condition either to make laudable digeſtions, or to ſupport the weight of the abdomen. The wind which is accumulated in the hernia, ſubjects them to continual co licks . They are incapable of any action, and it is often impoflible for them to walk or in dertake a journey in a coach, the joltings e which augment the pain of the abdomen. I tho Symp- toms. this OF HERNI A S, &c. 127 this ſtate the patients are never better than when in bed, unleſs they have recourſe to well made truſſes, which render theſe fymp- toins a little more ſupportable. We know ventral hernias by their ſoft- Diagne- ſtic ſigns. neſs, their elaſticity, and the facility with which they deſcend and re-enter, eſpecially in their beginning. The figns which denote that theſe hernias are formed by rupture, are to be drawn from the relation of the patient, when interrogated with reſpect to the cauſes which might have produced the diſorders. It may be ſaid in general, that theſe forts Prognoſtic ſigns. of hernias are incurable, whether they are form'd by dilatation, or by a rupture of the peritoneum. Tho they are not ſo much fub- ject to ftrangulation as hernias of the other parts, yet when this fymptom happens, 'tis very difficult to return the parts, and the con- lequences of the operation are very dangerous, fince it is rarely performed at a proper time, becauſe the fymptoms are not generally fo violent as in other ſtrangulations. The moſt advantageous cure of thoſe her- Cure. bias, is that of the palliative kind, which is obtain’d by means of truffes, which either hinder the deſcent of the parts, or fuſtain them when the hernia does not enter the ab- domen, by which means they ſecure the pa- tient against ſtrangulation labai С НА Р. 128 OF HERNI A S, &c to obd SHI Of a her- nia of the groin. H Differen- ces. С НА Р. Х. Of a hernia of the groin. ERNIAS of the groin are thoſe whid happen in the flexure of the groine deſcend by the aperture, call'd the ringleto the muſculus obliquus externus. This fpeos ſpeci of hernia may be double; that is to ſay, the may be one on each fide, which happer very frequently, fince, of twelve perſons bouring under inguinal hernias, there are a leaſt two who have one on each fide. Hernias of the groin differ, with reſpecto the places they poſſeſs: Some remain in the flexure of the groin, and theſe are called in complete. Others deſcend into the ſcrotun in men, and into the labia pudendi in wo men, and theſe are called complete. Bet ſpecies may be formed of the inteſtine, oro the epiploon, or of both together, Obſervations convince us, that theſe ha nias are form’d by the dilatation of the pas toneum alone, and never by ruptures, they are produced by blows, ſuch as the ; mentioned under ventral hernias. The particular cauſes of theſe hernias men, as well as in women, ariſe from thi hernias. that the ringlets are ſituated in the loweſt of the abdomen. In this low poſition continually receive the matter of the intero perſpiration, which is by little and little 200 с General cauſes. unle Particular cauſes of ingainal End mulat OF HERNIAS, &c. 129 و 03 hi mulated upon the diviſion which ſeparates the abdomen from the pelvis. The tranſpired matter, which, like an inſenſible vapour, is inceſſantly diſcharged from the parts contain'd in the abdomen, is indeed again received by the reſorbent pores; but it is alſo ſometimes diſcharged in a greater quantity, than that it can be received by theſe parts. In this caſe it muft neceffarily be accumulated, and re- * main in the loweſt part of the abdomen. The peritoneum forms in this place, oppoſite to the ringlets, angular foldings, like ſmall boats, proper for retaining and preſerving this amaſs’d humidity. In conſequence of this, the peritoneum and ringlets of the abdominal muſcles muſt neceſſarily be relax’d, extend themſelves, and yield to the efforts which the inteſtines make to deſcend, when the deter- mining cauſes begin to act. A great many other cauſes, peculiar to hernias of the groin, contribute to their formation, but it is ſuffi- cient to have explain'd this, which is the principal, in order to diſcover the others , a detail of which would be too tedious. "Tis, however, neceſſary to explain how the dif- ference happens between the complete and incomplete hernia. If the ringlet does not yield with too much cafe, and if the peritoneum is but moderate- y elongated, the hernia is incomplete; that ſay, it only forms a ſmall eminence in form of an hemiſphere, whoſe baſe is towards K the DUL Rich Is to D a CM brinis 130 Of HERNIAS, &c. so Different hernias. the abdomen, and its ſurface round. It re- mains in the flexure of the groin for a cer- tain time, till by ſome new effort the parts are determined to deſcend farther. Then it tingid becomes a complete hernia, becauſe the parts dub eis finding no reſiſtance, it has the liberty of de- fcending into the ſcrotum, or the labia pu: dendi. It changes its figure, and, from round, becomes more and more long, in proportion to the progreſs of its deſcent. This progreſs makes theſe hernias be dif- fizes of tinguiſh'd into thoſe of the ſmall, the middle- fiz'd, and the large kind. Some of them are ſo ſmall, that they cannot be diſcern'd the eye, nor hardly felt by the touch ; fuch as thoſe form’d by a very ſmall quantity the epiploon. Some of them are middle fiz’d, being two, four, or fix inches in cir- cumference. Others are large, having eight , ten, or even twelve inches in circumference . In a word, ſome are 20, 25, or 30 inches in circumference. They are all more or tolong, and ſome ſo long as to deſcend to the w knees. Immediate The immediate cauſe of a complete her . complete nia conſiſts in neglecting to contain thol that are ſimply incomplete; fince, if the are either not at all or imperfectly contain by means of a truſs, the parts eaſily follow road they had begun to make for themſelve They are inſenfibly elongated in men to ſcrotum, and in women to the labia pudende , os lacur lels a cauſe of a hernia. where Of HERNIAS, &c. 131 ons orders. . where they may be accumulated to ſuch a degree that almoſt the whole inteſtines, the epiploon, and even ſometimes the ſtomach are found included in theſe parts. 19 In theſe diſorders and diſplacements of the Digeftia parts the functions muſt neceſſarily be altered, cult in ſo that the ſtomach very imperfectly digeſts theſe dif- the lighteſt aliments. Provided the patients eat but a little more than their ordinary, they have dangerous and mortal indigeſtions. The inteſtines, whoſe diameters are changed, with difficulty permit the paſſage of the faces. The wind ſtops in them, and pro- duces violent cholic pains. The meſenteric glands being obſtructed and inflated hinder the chyle from paffing into the blood. The weight of the prolapſed parts produces in the ſtomach the ligaments of the liver, the Ipleen and the mefentery, twitchings which prove fatiguing and uneaſy by the laſſitudes, inclinations to vomit, and almoſt continual weakneſs they produce. are almoſt al. Chroni- Ways accompanied with adherences which join all the parts contained in the hernia, to each other, and to thofe which contain them, and this is a very powerful obſtacle to the cal ſymp toms. relief of the patient. 90 Strangulation indeed rarely ſupervenes in this caſe, but when it happens, it is always accompanied with imminent danger. brobo sido del nostrow K 2 Incomplete 132 Of HERNIAS, &c. nias moſt tion. Incom Incomplete hernias are rarely ſubject to plete her theſe accidents, but they are more ſubje& fubject to than the others, to ftrangulation, becauſe ftrangula- the ringlet has a great deal of more ſpring than incomplete hernias. It is true that we can more eaſily preſerve them from ſtrangu- lation, becauſe they are more eaſily contained , but ſuch as are neglected ſoon become ſtran- gulated. Diagno An incomplete hernia of the groin is ei- fily known, by the eaſineſs of its deſcent and reduction, when it is not adherent When it does not re-enter, we may know of the patient, whether it returned eaſily in the beginning, for an hernia muſt neceffarily fub- fift ſome time before it can contract adhe ftic Signs. rences. Progno- ftic. all A complete hernia in both ſexes, is allo known by the fame figns, and by the other figns common to all the ſpecies of hernias I have mentioned in chap V, but particularly by the incomplete hernia which alway precedes it. The judgment we are to form of hernias in the groin is common in general to ſpecies, but in particular, it may be faid that an incomplete hernia is more eaſily than a complete one, every other circum- ſtance being equal, becauſe it is more contained. A complete hernia on the contrary is more generally complicated with fymptoms, ſuch cured eaſily as Of HERNI ASc. A S, &, & 133 as adherences, diſorders of the teſticules and ſpermatic cord in men, and ſometimes with ſeveral falſe hernias. The complete hernias are more difficult to be contained and conſe- quently worfe to be cured: It may alſo be faid that they are leſs dangerous in women, becauſe in them, they cannot be accompa- nied with ſo many other diſorders as in men. The fymptoms of hernias in the groin, Symp- whether complete or incomplete, are the toms, ſame with thoſe mentioned in chap VI and VII, fo that I ſhall not ſpeak of them here. Hernias of the groin admit of three diffe- Cure. rent cures namely the palliative, the radical, and that which confifts in remedying their fymptoms, of which I thall ſpeak hereafter. COLT Ti C H A P. XI. Of the crural hernia. HE crural hernia is fo called becauſe it is formed by the aperture at the flexure of the thigh, which gives a paſſage to the crural veſſels. It happens much more commonly to women who have born children than to men and girls. I have always ob- ferved, that among twenty women who had hernias in the inferiour part of the abdomen, there were nineteen in whom they were cru- ral. This does not hold true in girls in whom this ſpecies of hernia, is as rare as. in men, K3 among 134 Of HERNIAS, &c. among whom this diſorder hardly happens to one in an hundred. The reaſon of this diffe- Particular rence conſiſts in the diſplacement of the parts Cauſes. mentioned when treating of the particular cauſes of inguinal hernias in chap. X. In an hernia of the groin, the ſeroſities extravaſated in the abdomen, immediately on thoſe parts of the peritoneum which correſponds to the ringlet , relax them and facilitate the deſcent of the parts through their apertures. The like quantity of ſerofities, extravaſated in pregnant women, produces the ſame effect ou the cru- ral arch, by the diſplacing which happens in the foldings of the peritoneum, which re- tained theſe ſerofities, at the part of the ring lets, like ſo many ręceptacles. It is eaſy to comprehend how this happens, if we refled that the peritoneum forms a partition, which ſeparates the abdomen from the pelvis, and that the uterus is below this partition. Now during geſtation, this partition is elevated and extended in proportion to the enlargement to the foetus in the uterus. The foldings of the peritoneum which ſerved as receptacles to the ſerofities extravaſated on the partition, faced. The ferofities are forced elſewhere towards the fides of the pelvis. The parts which correſpond to the apertures, whic give paſſage to the crural veffels, are the on- oly parts where theſe ferofities can be lodged In conſequence of this, theſe ferofities act in theſe parts on this place of the peritoneum as they did formerly on thoſe which covered of are ef the Of HERNIAS, &c. 135 , a the apertures of the ringlets : The peritone- um and muſcles are ſo much the more dif- poſed to relaxation, becauſe they are extraor- dinarily extended by the bulk of the uterus. Thus in the efforts a woman makes during or after labour, it frequently happens that the parts eſcape through one or other of theſe apertures, and even ſometimes through them both together. Crural hernias do not differ very conſidera- Differen- bly, except with reſpect to their bulk. The ces: largeſt do not exceed the bulk of a hens Egg, but generally they are much ſmaller. - Their fymptoms are the ſame with thoſe of Symp- other hernias. They are very ſubject to ad_toms, herences on account of the continual fricti- ons they ſuffer, by the motion of the thigh : The uſe of truffes alſo contributes a great deal to this, becauſe the trufs-makers are ignorant of this ſpecies of hernia. Hernias of this kind are for the ſame reaſon very ſubject to ftrangulations. su The diagnoſtic Signs of this ſpecies of Diagno- ſtic Signs. hernia, are almoſt the fame with thoſe of the incomplete hernia of the groin, only we muſt sobſerve, that without a great deal of atten- tion, we may miſtake it for a venereal bubo. The obſervations of authors with reſpect to this miſtake, do not prevent daily blunders of this kind : On the contrary they ſerve to nthrow practioners into a double error, ſince real bubo’s are frequently taken for hernias of bonyos ribin won K 4. mut bis vor this orb 136 Of HERNIAS, &c. this part: Hernias of the epiploon princi pally produce this difficulty of diſtinguiſhing) I have ſeveral remarks and obſervations which contribute to remove theſe doubts, but this is not the proper place for them.hr Progno- A great deal of trouble is requiſite to rea fic Signs. duce a crural hernia with ſtrangulation, which renders the operation much more difficult and dangerous. It is alſo very difficult to contain it well; neither is it leſs hard to obtain the radi- cal cure of it; ſo that we may fay in general , that this ſpecies of hernia is very dangerous. of CHA P. XII. of the means of remedying the ſtrangulation of the inteſtine. THE moſt troubleſome fymptoms ruptures are thoſe which I have called acute, and which, as I have ſaid, are adhen rences and ſtrangulation. The means of re- medying adherences almoſt always depend on an operation performed by a cutting inſtru- ment; but as in this work, I only intend to inſtruct the public who neither can nor to undertake this ſpecies of cure, I ſhall here make no mention of it. Thoſe who defire to know more about it, may have their cutie ofity ſatisfied in the ſecond part of this work sabidont como vidinis be vedled bantogoot Bat Just ought TOM Of H ERNIAS, &C. 137 But ftrangulation is a fymptom much more common, and for which the patients may find conſiderable relief, before they have re- courſe to the operation performed by the cut-ou ting inſtrument. Befides, it is the laſt method, which is only to be employed when the other means have not ſucceeded, I ſhall therefore make it my buſineſs to relate the means which I think moſt efficacious, and beſt accommo- dated to the comprehenſions of all thoſe who have an opportunity of relieving either them- felves or others, when furgeons are either wanting, or too long in coming. If we conſider the effeets of ſtrangulation, mentioned in chap. VII. of this ſecond ſec- tion, we will eaſily comprehend of what importance it is to remedy this diſorder with all expedition It is remedied by three means, the firſt of Three which conſiſts in the ſituation in which the remedy- patient ought to keep, the ſecond in the uſe ing a of proper remedies, and the third in the re- ftrangula duction of the inteſtine into the abdomen. In hernias of the inferiour part of the ab- Situation. domen, the fituation ought to be ſuch, that, the patient being laid upon his back, his but- tocks and thighs may be conſiderably ele- vated, as well to determine the parts more eaſily into the cavity of the abdomen, as to keep the muſcles in a kind of general relaxa- tion. If the hernia is in the ſcrotum it ought to be supported below, and raiſed by ſome- thing means of a tion. I 138 Of HERNI A S, &C. for a lation. thing of a ſoft nature, ſuch as a pillow. This ſituation ought to be the ſame during the ſtrangulation, but this poſture is of in do great importance in the firſt moments of this ſymptom, that a great many perſons have preſerved their lives by lying down even in the fields and applying to their hernias, the remedy pomatum I generally give my patients. T4 pomatum is a remedy, which though peculine frangu- to myſelf, I ſhall not be ſo mercenary as to keep a ſecret. The effects of it are fo fpe- dy, that the moſt conſiderable ſtrangulations are either reduced ſpontaneouſly, or may be very eaſily reduced, when it has been applied an hour to the hernia, unleſs it is accompa- nied with adheſions to the parts. The efi . cacy of this remedy, which on account of its ſpeedy effects, ſurpaſſes all others the bel adapted to this fymptom, cannot be better evinc'd, than by the relief it affords, the ve ry moment it is applied to the moſt painful hemorrhoids. Improper. It is prepard in the following manner. Diffolve an ounce of the gold of african du cats, or of the pureſt gold in aqua rega precipitate the diffolution, and let it fub lide, and then pour off the menftruumbi inclination, waſh the precipitated fubftanc ſeveral times in fountain water, in order to diffolve the falts of nitre, which will be . ell OF HERNIAS, &c. 139 entangled in the divided parts of the gold. Put the precipitated ſubſtance into a glaſs omortar, and triturate it for two or three hours. Then pour upon it by little and little, four pints of highly rectified fpirit of wine, and ſtir the powder with a glaſs peſtle, in order to make its parts riſe ; pour off the liquor by inclination, into a - china veſſel, taking great care not to mix with it, what of the powder remains at the bottom of the mortar. Put ſome of the ſpirit into the mortar again, and conti- cnue to move and pour the mixture into the bchina baſon. Repeat this operation till the whole of the powder is entirely carried off. Set fire to the ſpirit of wine, and allow it foto confume till there only remains a ſmall degree of moiſture in the powder. Then quench the flame, in order to avoid the sfulmination of the gold. The remaining humidity is to be dried by the fun. Take this powder and put it again into the glaſs mortar. Add to it two ounces of the ſeeds of oriental pearl reduc'd to an impalpable powder on a marble. Pour upon it four ounces of white and very clear vinegar : Stir theſe powders together with the vinegar, for three hợurs at leaſt, let the whole fubfide for twenty four hours ; filter the vinegar, and put the powders into a glazed earthen veffel. Pour upon that a a 2 pint 140 OF HERNÍ A S, &C. art. 9 pint of the oil of piftachie's, and to ounces of orange flower water, then add four ounces of virgin wax. Boil the whole, to make a pomatum according t When it is cold waſh it by little and little, for twelve or fifteen hours, with w ter of butter-milk diſtill'd in balneo maria in which is macerated a fufficient quantit of the leaves of burdock and nightſhade After it is waſhed, mix exactly with pomatum an ounce of ſedative ſalt and hal an ounce of Saffron reduc'd to powder. N. B. It is of importance to boil it to a propa conſiſtence, and to waſh it carefully, in or: der to preſerve it from corruption. tubet Borbet This does not hold true with reſpect to a ther remedies, which muſt be applied fucce. fively at different times of the diſorder; ant their good or bad effects always depende the good or bad uſe which has been maded them. But for the want of my remed with which every perſon cannot be provide I ſhall lay down in order, a fufficient numbe of thoſe I think the moſt efficacious remedio for the different times and ſtates of a fran gulation Repel- In the firſt inſtants of a ſtrangulation , lents pro- the parts have deſcended with effort, and SZWE a larger quantity than uſually; and if they a ftrangu has given paflage to them, that they cand itants of exactly fill up the cavity of the hole whic per in the firft in. lation. Of HERNI A S, &C. be return'd into the abdomen, then all the veſſels of the parts are compreſs'd by the cir- cumference of the aperture, and reciprocally the veſſels of the aperture compreſs’d and conſtricted on each other, by the parts it con- tains. In this caſe, repellents which force back the blood into the veſſels, by irritating them, and forcing them to contract them- felves, are very efficacious ; for the veſſels cannot contract themſelves till they are thri- veld up; and the fluids cannot return into the ſtrangulated veſſels, till the collection of the parts loſes fome of its bulk, and till thoſe parts , which permitted their paſſage, make no longer too powerful a reſiſtance to their reduction. By this means it will be very eaſy to return the hernia, by ſafe and efficacious motions, which nature teaches to the patient, and experience to the furgeon. Of all the repellents, the beſt are the coldeſt water, ſuch as ice-water, pump-water in cold ſea- or water and vinegar. The beſt way of uſing theſe is to throw two or three pot-- fuls at once on the tumor, the patient being laid on the ground. This practice is moſt efficacious, when it is uſed before the patient 1$ aware. Linnen cloths, foak'd in cold wa- ter, may alſo be applied; but no longer than quarter of an hour. But theſe remedies Danger of ought not to be continued, if they do not at frift produce the deſign’d effect. They would become too prejudicial to the patients, by giving fons, 2 chefe re- medies. 10 be 142 Of HERNIAS, &c. a с giving too great a ſpring to the veſſels, which would have no longer pliantneſs enough yield to the column of blood, which the ought to receive: The tumor would confe quently foon fall into a mortification. This Veneſec- when theſe remedies have not acted accord comes ab- ing to the intention propoſed, we muſt forth ſolutely with blood the patient as copiouſly as neceſſáry. ſtrength will admit of. The beſt pradi. tioners do not meaſure the blood, but orde it to be taken away, till the patient becom extremely weak. Then all the parts being relax’d, we lay hold of this opportunity d returning the hernia; and it is always mo favourable when we fet about it in a proper manner. Every time I have uſed this method of reducing the parts without ſucceſs, I hart not heſitated to perform the operation, bei perſuaded that the hernia can never be in more favourable diſpoſition to return, and the all the remedies which can be uſed after the are inſufficient and ſuperfluous. It is to e with'd, that the public and ſurgeons wa convinced of this truth : If they were, fue a number of perſons would not die, becaux people always in vain imagine that they w be cured by gaining time. But if, for any reaſon whatever, we are tion to be obliged to defer the operation, tho' venele the feet, tion has not had all the ſucceſs expected, y during we are to perform it in the arm every hour, for twenty-four hours, except when werd soul Veneſec- fourth menftrua. tion. the Of H E R NI A S, &c. 143 the ſtate of the menſes forbids it; in which caſe we are to be more ſparing, and make the venefections in the feet. If the repeated venefections do not promote the relaxation intended, they at leaſt prevent new obſtruc- tions of the blood-vefſels, or hinder theſe obſtructions from becoming too conſiderable; and at laſt diſpoſe the patient to reap all the advantages from the operation, which could not be expected when one is forced to defer If veneſections are to be continued in theſe Remedies circumſtances, much more are they to be ſo, if they have not been uſed at firſt. During the venefections the following ca- diſorder, 23 , taplaſm is to be applied to the hernia : iteoogd segar proper in the aug. mentation Take four ounces of the crumb of bread; eight ounces of new milk; two yolks of ds eggs; one dram of faffron, reduced to z powder ; and one ounce of the oil of ca- od momile : Crumble the bread, mix it with so the milk, and boil them till they have ac- to quired a thick conſiſtence, ſtirring them su conſtantly · Then take them off the fire, , li and mix with them the yolks of the eggs, the ſaffron, and the oil of camomile, ſtirring the whole ſtrongly with a ſpoon. Shave the part, and apply the cataplaſm to the hernia, between two fine linnen cloths. si doo briw 1993 This 144 Of HERNIAS, &. the This cataplaſm muſt be continued as long as the diſorder augments; that is, for about twenty-four hours, taking care to renew i every three hours. We may alſo very advantageoufly uſe a hogg's bladder, fill'd with half a pint of te pid milk, and renew'd every three hours. In thoſe parts where milk is ſcarce, oil, generally very common ; ſo that we may we a cataplaſm moderately, boil'd with oild nuts, which is beſt when recent. During this time it is proper to give patient two or three ſmall clyſters, prepared of a pugil of fena, boild with a fufficient quantity of water; to which a dram of com mon ſalt may be added. We are by no means to put oil into it, for the reaſons I ſhall af terwards give. We may try to return hernia every time we renew the cataplaim provided we do it without violence, and will the precautions I ſhall mention in the endd the following chapter. Regimen We ought to give no food to the patien during the whole of the diſorder, for 470 reafons: Firſt, becauſe he diſcharges thing he takes, which is conſequently le And ſecondly, becauſe the ſmalleſt quantity of food would but augment the vomiting which is too frequent and violent in the caſes. We muſt only give him ſome ſpoor fuls of the water of dogs-graſs, at great inte vals, to moiſten his mouth; or make his eyer lot holl OF HERNIAS, &c. 145 dies , hold in his mouth fome ſlices of lemon to quench his thirſt. The ſtate or height of the diſorder is State or known by the violence and frequency of the height of vomiting, the pains of the abdomen, which der, and augment, the hiccup, and the fever. In this the reme- ſtage of the diſeaſe, the blood being diſpoſed per for it, to ſtagnation in the veſſels, and the veſſels themſelves being ready to fall into too great a relaxation, we muſt uſe remedies capable of acting both on the veſſels and fluids, and of re-eſtabliſhing the equilibrium between them. Theſe intentions are anſwer'd by emollient, reſolvent, and attenuating cataplaſms. Some practitioners uſe mercurial ointment; Mercurial but I muſt here appriſe the reader, that this ointment remedy is prejudicial and dangerous ; for it prejudi- throws the blood into too violent a circula- tion, and augments its expanfive motion, by rarifying its globules. By this means the diameters of the veſſels being augmented, the ſtrangulation muſt of courſe become more confiderable. We muſt only attempt to fa- cilitate the progreſſive motion of the blood, for which purpoſe the following cataplaſm cial. is very proper : Take of the leaves of mallows, marſhmal- dud lows, violets, pellitory of the wall, camo- too mile, and melilot, each a large pugil ; of con the meals of barley, beans, bitter vetch, mil and fenugreek, each four onces; and of L gum 14.6 Of HERNIAS, &c. a gum ammoniac, two ounces : Boil the herbs in four pints of water, reduced to an half. If they are freſh, paſs the pulp thro' a ſearce; but if they are dry, it is fufficient to paſs the water only. Put the water, or the pulp mix'd with the water, on the fire ; add the meals, diluting them by little and little : Boil the whole till the meals have no longer any ſmell. During the boiling, diſſolve the gum ammoniac in ſtrong vinegar, and mix it with the cataw plaſm, after having taken it off the fire. Toto This, wrapt up in a fine linnen cloth, is to be applied warm to the tumor, and feu new'd every third hour. Every time we te- new the dreſſing, we are to moiſten the quantity we uſe with oil of nuts, or oil of dill. If this cataplaſm cannot be had, we may advantageouſly apply cows-dung, boild with hogs-lard. When the ſtrangulation does not yield of the diſ- theſe remedies, after having uſed them eight eaſe, and the reme- or ten hours, we are not to flatter ourſelves dies pro- with the hopes of ſucceeding without the operation, the only remaining method of re- lief; without which the diſorder grows worſe, the parts fall into a mortification, and the patient dies. Nature, 'tis true, ſometimes c gains the aſcendant, and ſome patients have recover'd, contrary to the judgment of the Decline per in it. mot OF HERNI A S, &c. 147 moſt ſkilful furgeons; but this happens fo rarely, that we have hardly one example of it in an hundred If we are obliged to defer the operation, we muſt give over the uſe of cataplaſms, and foment the tumor with ſome corrobo- rating and ſpirituous liquor, in order to ſtop, if it is poſſible, the progreſs of the gangrene, which quickly ſeizes the parts. The moſt proper remedy for this purpoſe is common wine, moderately warm'd, and mix'd with a little ſpirit of wine. As I do not intend to ſpeak of the opera- tion, which in this caſe is to be perform'd by a cutting inftrument, I ſhall deſcribe that which depends ſimply on the operation of the hand, and which is call'd taxis, or re- duction. VNEGA R ; it is. CH . C Η Α Ρ. ΧΙΙΙ. of the reduction of the parts. Eduction is an operation of the hand, Redu&i- which conſiſts in making the prolapſed on what parts - enter the abdomen, and which the It is very difficult to lay down particular fules , with reſpect to the manner of per- forming this operation, becauſe theſe rules fances, which the moſt ſkilful practitioner on an infinite number of circum- Greeks call taxis. depend Som L 2 can 148 OF HERNIAS, &c. Method tion. cannot always foreſee, and which the diſpo . ſition of the diſorder determines him to em ploy. But, in general, this operation is pe: form'd by different motions, which are termined according to the place the hero poſſeſſes, and the parts which compoſe it. It is, firſt of all, requiſite to make the of making tient diſcharge his urine; then we are to pa him in a favourable ſituation to relax muſcles of the abdomen, and thoſe of the thigh, when the hernia is in the inferior of the belly : But in hernias of the nare and other parts, it is ſufficient to facilitate relaxation of the abdominal muſcles. The moſt proper ſituation for reducin hernias of the lower part of the abdomen, the ſame with that ordered in the beginni of the preceding chapter ; only with this d ference, that in the reduction we muſt mak the patient lean a little to the fide oppofiter the hernia. The perſon who makes the reduction ought to chuſe the moſt commodious fit tion, and always endeavour to make the pa return in the ſame direction they had wide stand they came out. În the hernia of the navel, and in the rules to be calld ventral, the direction we are to follu in reducing the parts, ought to be perpendio duction. lar to the tumor. In inguinal hernias, the direction ought be towards the hips. ; General obſerved for the re Of HERNIAS, &c. 149 1 In thoſe at the bending of the thigh call’d crural hernias, the direction which we muſt give to the parts in order to return them ought to be in a right line. TO If the hernia is compos'd of the epiploon and inteſtine, the operation is much more difficult , becauſe the epiploon on account of its ſoftneſs hinders the inteſtine to flip eaſily back. It is neceſſary, if there is a great deal of the epiploon, to be well aſſurd of that part of the tumor which the inteſtine poffeſfes. If there is but little of the epip- loon, which we may know, when we do not diſtinguiſh it by the touch, we muſt act as if there was none of it at all. If there is a great deal of the epiploon, our only buſineſs is to reduce the inteſtine. All theſe circum- ſtances are very difficult to be diſtinguiſh'd, sand the moſt ſkilful ſurgeon has ſometimes oa great deal of trouble to make all theſe di- ſtinctions as difficult as important. But be this as it will, we are to take the following method. atys To reduce an incomplete hernia, we take Reduction nit with the extremities of the fingers and of the in- thumbs of both hands. We handle it gent- hernia. olyas if we were handling a bladder full of wwind, by which motion we make the fluid matter it contains re-enter. We afterwards puſh it fucceffively with the fingers of one hand, whilſt with the other we collect all the parts which remain without the abdomen. L 3 As 150 OF HERNI A 3, &c. of the in- nia. Reduction As for a complete hernia, we with the teftine in fingers and thumbs of both hands lay hold an ingni- of the tumor if it is poſſible, preſſing nal her- with the flat parts of our fingers and never with their ends on which are the nails. We compreſs it gently giving it the fame motion we give to a bladder full of air when we compreſs it with our hands. By this moti. on repeated ſeveral times and in different di rections, we facilitate the return of the wind and fluid matter the inteſtine contains. As foon as we perceive that theſe are totally dr in part returned, we muſt without changing the fituation of the hands, act only on one part of the hernia when it is larger than a that is to ſay, we muſt only act on one of the parts of the fame circumvolution of the inteſtine, becauſe if we ſhould attempt to reduce one whole circumvolution 6 more, at a time, we ſhould never make the reduction of any. The fingers of the hal which is at the ſuperior part of the tume, ought to direct and ſuſtain that part of the inteftine which is next to the ringlet, in pro portion as it enters, whilſt the other hand puſhes and collects the remaining part of the inteſtine towards the ringlet, by compreffing and puſhing it fucceffively. When the in teſtine is returned, the tumor diſappears alti -gether when it is only compos'd of the i hens egg; teftine; fometimes when it is compos de the inteſtine and epiploon, this laſt remains Soto with Of HERNIAS, c. 151 3 1 without the abdomen, but the patient is in ftantly relieved. We muſt not obſtinately attempt to return the epiploon, ſince we ſhould do a great deal of harm, by the irri- tation which handling would produce. It is fufficient to be aſſured of the return of the inteſtine, and to apply warm wine to the re- maining tumor. The epiploon enters of its own accord, after a few days, if there are no adherences. On the contrary when we perlift in making it return, an abſceſs is ſome- times form'd in it. It is therefore fufficient to be affurd of the reduction of the inteſtine. That the inteſtine is reduc'd, may be known by the diminution of the tumor, the ceffa- rtion of the ſymptoms, and the eaſe which the patient feels immediately after the operation, It ſometimes happens however, that the fymptoms continue one or even two days af- ter the reduction, becauſe the inteſtines are greatly inflam'd, and do not reſume their na- tural motion till that inflammation is over. In theſe circumſtances we are at a great loſs to know whether the inteſtine is totally re- turn'd or not. In order to be ſure in this par- we make the patient take two ounces of the oil of fweet almonds. If the inteſtine . is reduc'd, the oil is foon diſcharg’d from the anus. This is the reaſon why in the pre- ceeding chapter, I ſaid we muſt not put oil in the clyſters, becauſe then we ſhould be at a loſs to know whether the oil found in the L 4 baſon ticular 152 Of HERNIAS, &0.0 bafon was not a part of that given in the cly- fters, which might have poſſibly remained in the inteſtines. It is not without reaſon that I make this remark, ſince it is of ſuch im- portance that it has often been the cauſe of life or death by the ambiguity it ſometimes produces. சம் There is an objection to this reaſoning which ſeems to be too well founded not to require an anſwer. one It is ſaid that the paſſage of the oil can ona ly ſerve as an equivocal ſign of the perfect to duction of the inteſtine, becauſe it may not be totally reduc'd, but a portion of its diam- eter being pinch’d, it is always the cauſe of the fymptoms which ſubſift after the fallero duction, tho' the oil paſſes freely thro' that portion of its orifice which is free. To this I anſwer, that we cannot be deceiv'd in this reſpect, when we are ſure of the ſigns of this pinching. The moſt certain fign of this pinching is the pain the patient feels in the pinch'd part of the inteſtine. This pain is very intenſe, and produces the gripes of which the patient complains. But in this caſe there is no particular pain at the part where the reduction has been made, and conſequently there is no pinching to be ſuſpected, ſo that the paſſage of the oil denotes the perfect redu&tion of the inteſtine. The continuation therefore of the ſymptoms, only proceeds from the inflammation of the inteſtine, and its in- ob verted Of HERNIAS, &C. 153 ; 10 verted motion which ſtill fubfiſts. Without any remedies, this diſorder is cur’d by a little patience, and an exact regimen ; the cauſe not ſubſiſting any more, the effect muſt néceſſa- rily ceaſe. But if we make the patient take medicines of any kind, they augment and keep up the vomiting. The beſt thing we can order the patient to do is to take ſmall clyſters every three hours, capable of corro- borating the inteſtines, cooling them, reſtor- ing their proper tone, and recalling their na- tural motion. The following clyfter is a ſpecific in theſe caſes. Take of the beſt old red wine three ounces, of fine white ſugar two drams, and of recent oil of nuts two ounces, for each clyſter to be injected tepid. When the hernia is in the flexure of the Reduction thigh, the reduction is obtain'd in a different of a cru- manner. Theſe kinds of hernias are gene- rally very ſmall and only require to be handled in the ſame manner as the complete hernias. is ſufficient to return the wind and matter contained in them by compreſſing the tumor in all its circumference, if poflible, gently and at intervals. In proportion as we com- preſs it in order to return the wind, we muſt draw it outwards as little as poſſible. By theſe motions we facilitate the return of the wind and fluid matter contain'd in the inte- fine, which follows very ſoon after, if we de ral hernia, borts 154 OF HERNIAS, &c. zoba Reduction of umbi. hernias. determine it to return, by puſhing it by de grees into the abdomen. In hernias of the navel, and ventral her lical and nias, when we have made the wind retur ventral by treating them in the manner I have recom- mended in the crural hernias we make hall to as low circular motions to the right and left, at the TIBA ſame time compreſſing the tumor perpend. y cularly. When the parts are reduc'd, and the ſymp- toms have ceas'd, the patient ought to remain in bed, till a proper truſs is applied by a akil- ful ſurgeon. T! In hernias accompa- nied with fymp- toms, peo- but cor- CHA P. XIV. gnose of the radical cure of bernias. Of HE neceſſity of remedying the fympu toms of hernias is ſo preſſing, that i the different treatments of them, our princ ple think pal care ought to be to return the parts into of nothing the abdomen. Thus whether we redua recting them by the taxis, or by the operation with a cutting inſtrument, we never have the radici fymp- cure in view. On the contrary, it often haq. pens that we are oblig'd to facrifiſe it to the preffing neceffity of ſaving the patient's lif by making inciſions in parts the foundnes of which is abſolutely neceſſary to a barev Jobwa theſe toms. radic cure, Si bato 1 SOLO Of HERNI A S, &c. 155 undertake which have been lated, as have not. cure of But when the parts have been reduc'd by We may the taxis, after a ſtrangulation, we may un- the cure dertake the radical cure of theſe hernias, as of hernias well as of thoſe habitual hernias which have never been ftrangulated, provided they have frangu the requiſite qualities, that is, if nothing op well as of poſes their cure. It is the ſame with theſe as thoſe with all other diſeaſes which are not ſuſcepti- which ble of a cure, when we cannot eradicate their cauſes. ni The reaſons which have made theſe dif- Why the orders be thought incurable among moſt au- theſe dif. thors, and the common ſort of practitioners, orders is are not founded on the ſcarcity of remedies, look'd fince a greater quantity of theſe have not impoffi- been invented for any diſorder whatever. ble, The reaſons proceed from this, that among thoſe who have underſtood theſe diſorders well , none have been willing to inſtruct others with reſpect to their true cauſes, and diſtin- guiſh the ſpecies of hernias which were cu- rable, from fuch as admitted of no cure, This diſtinction was not eaſily made. It re- quired (a circumſtance wanting to all the said authors who have written on theſe diſorders) an incredible number of patients on whom they might with care make theſe effential di- ftinctions; which would have been infinitely more uſeful than the confus'd collection of remedies, which each of theſe authors has given us, without any juſt and reaſonable in- 3 dications, In 156 Of HERNIAS, &C. sota sa od In effect, what advantage can we reap from the prodigious number of remedies with which books abound, if we do not know how to apply them to the true cauſes of here nias and their various ſpecies ; if they are not ſuited to the conſtitutions of patients, to their si baih age, their fex, and the climates in which they live; and if we do not know how to to diſtinguiſh thoſe hernias which are curable from thoſe which not admitting of a cure , totally ruin the patient's conſtitution ; for its eaſy to conceive, that by the abuſe of aftrin gents with which the patients are overloaded without order or method in aliments, and ptiſans, in powders, in electuaries in bolus, in pills, in plaiſters, in caſaplaſms, in fomen- tations in baths, &c. we muſt deſtroy the con- ſtitution, and that theſe remedies are the four- ces of an infinite number of acute and chro- nical diſorders, moſt terrible in themſelves and obſtinate to the beſt remedies indicated If we reflect on the ſtructure of the parts both internal and external, which concurfi form theſe diſorders, and if we conſider the general cauſes I have mention'd in chap. IV of this ſection, it will be eaſy to concen all the myſtery of their cure by the diſtinct on of incurable hernias, from thoſe whic may be cured by the due application of pe per remedies. soti apib 10191 Sbodu so od 168 The true character of hernias confiftsi the relaxation of the ligaments, which ku the epiploon, inteſtines, and other parts COR taine Of HERNI A S, &c. 157 ons to be diſorders, tain'd in the abdomen, in their place; in the elongation or rupture of the peritoneum, and in the enlargement of the natural or pre- ternatural apertures of the containing parts of the abdomen. The only intention to be purſued in the Intenti- cure of all hernias, is to reſtore all the parts purſued in to their natural powers, to ſhrivel up ſuch as the courſe are enlarg’d, and to ſhorten ſuch as are elon- of theſe gated. The following reaſoning will in a few words unveil the myſtery of the true cure of theſe diſorders, which has hitherto been either conceald or not known. be It is an eſtabliſhed principle, that by de ſtroying the cauſes of diſeaſes, the effects of them muſt ceaſe of courſe. Now we have ſeen that the conjoint or proximate cauſes of hernias, are a redun- dance of ſerofities which moiſten the parts and keep up their relaxation ; every thing therefore capable of evacuating theſe redun- dant feroſities, ought to be employ'd for the cure of theſe diſeaſes. Thus all remedies capable of evacuating a too ferous and copi- ous lymph, thoſe proper to remove obftruc- tions, to divide, and attenuate the too thick humours, and to thin the too viſcid lymph, fuch as diuretic attenuating, aperient, and inciding medicines are proper. But that theſe remedies may become truly cuſeful , it is not ſufficient to attempt the eva- acuation of theſe ſerofities; we muſt alſo con- nos ating marido bonhom moolai efider D'nin 758 Of HERNI A S, &c. fider whether it ariſes from the too copios tranſpiration of the internal parts, or whethe they ariſe from lymphatic concretions, which block up and obſtruct all the glands in genes olaral, and particularly thoſe of the meſenter and the ſmall glands ſpread in the men branous texture of the peritoneum. All the glands of the body ſerve as filtres for the lymph. As ſoon as there is an obſtruction in the glands, the lymphatic veſſels, which terminate in them, muſt neceſſarily be choak up: Then they are diſtended far beyond ther natural diameter. If the glands are only ſtructed in a ſmall degree, the lymphatic ve ſels are flaccid, without ſpring, and diſpola to the greateſt relaxation; in conſequenced which all the parts, into whoſe compofition they enter, will alſo be relax'd. But if the glands are more obſtructed, the veſſels which terminate in them are diſtended beyond their natural tone, their texture becomes much more lax, their orifices are dilated, and allow a part of the liquor they contain to eſcape With this liquor all the parts are more on moiſten'd. This is known by the pale and 1 livid colour of the countenance, by the foll: and moiſt conſiſtence of the fleſh, by the diſtenſion of the inferior eye-lids, and by the palpable hardneſs of the glands of the neck armpits and groins ; by the ſweats and ſpon- taneous laſſitudes; and laſtly, by the fad and melancholy diſpoſition of the patient ; lel a ſtate which OF HERNIAS, &c. 159 gents. which differs from that ſpecies of dropſy call'd anafarca only in this, that the infiltra- tion of the feroſity of the blood is not ſo ge- neral, nor fo copious. Aldo Sold The cauſes of theſe diſeaſes being thus Abuſe of known, nothing ought ſo much to be avoided by practitioners as the indiſcreet uſe of aſtrin- gents , given without principles, without rea- ſonings, without method, and contrary to all the laws of the animal economy, conſider'd either in a natural or diſorder'd ſtate ; for it is eaſy to conceive that thefe remedies, whoſe quality is to contract, crifpate, and harden the parts, can neither be taken internally, nor applied externally, without acting equally on a the glands. . a Now if the glands are already obſtructed, 'tis not to be doubted but that the degrees of their obſtructions muſt be augmented by the action theſe remedies; and that the cauſes of theſe diſeaſes , far from being remov'd muſt be augmented more and more. The patients conſequently fall into a ſtate worſe than that in which they were before. Thus without faying any more of the indiſcreet and deſtruc- tive uſe of theſe remedies, we ſhall proceed to the order and method which ought to be obſerv'd in the cure of theſe diſorders, ac- cording to the principles we have eſtablished. nogle BO quants hos bord de She sisile min motto CHA P. поіnileg - doid conto 160 OF HERNIAS, &c. cure of W hernias, ous an internal Ever tion. CHA P. XV. , Р. Of the remedies proper for bernias, Proper THEN an hernia is maintain'd the matter of a too copious inter cauſed by tranſpiration, the cure of it is more eaſily too copi- tain’d: For this purpoſe it is ſufficient to a vert the tranſpiration another way. tranſpira- one knows, that, in order to diminiſh certa ſecretions, we muſt augment others. It certain, from experience, that thoſe who po ſpire a great deal are coſtive, and have a fim diſcharge of urine; whereas, on the contrar when we diſcharge a great deal of urine , u when the evacuations by ſtool are very au fiderable, we tranſpire much leſs. In orde therefore, to diminiſh the too copious in nal tranſpiration, we muſt render the ben foluble, and facilitate the diſcharge of urine. The firſt means of fucceeding ind depend on the method of living : Thus muſt order a regimen, which tends rathe dry than moiſten. But we are, above things, to make it our buſineſs to contain parts in the abdomen, in ſuch a manner , they may not have the leaſt facility fcending. This would be a proper place! ſpeaking of the ſure means of containing chapter. parts; but I ſhall refer this taſk to the in the a of Of HERNIAS, &C. 161 The parts being well contain'd, the patient Regimen, is to eat roaſt meat, ſuch as beef, mutton, pigeons, rabbits, partridges, and other ſuch- like aliments. He muſt avoid all aqueous and flatulent food, ſuch as pulſes, herbs, milk, fruits, and other things of a ſimilar nature. By this regimen alone, and the application a truſs which contains the parts well, we obtain at leaſt a third part of the cures of this kind; but we may cure a great many more, if the patients uſe the following ptiſan : Take of the roots of dogs-graſs, one ounce ; Ptiſan. of rupture-wort, two ounces; and of the root of madder, two ounces : Boil the whole in fix pints of water, reduced to four. At meals the patient may drink wine, mix'd with this ptiſan. As a copious dif- charge of urine is of great importance, the patient ought every day to drink at leaſt two pints of this ptiſan. He may drink tea in the mornings and afternoons. If the patient is coſtive, he may uſe every Means of day, or every other day, half an ounce or fix keeping drams of the pulp of caflia boild. Poor perſons will find the ſame advantage, at a ſmaller charge, by now and then taking an ounce of the ſyrup of buckthorn in a glaſs of water; or by ſwallowing, every other day, fourteen or fifteen buckthorn-berries, drink- the body foluble, M ing 162 Of HERNIAS, &c. and con- Method of reme- children. C ing water-gruel after them. The uſe of theſe ought to be perſiſted in a longer or ſhorten time, according to the greatneſs or conti- nuance of the diſeaſe, and the age ſtitution of the patient: For this reaſon we muſt diminiſh or augment the doſe of thele ingredients, or uſe them as often as prudence fhall direct. In fucking-children the uſe of ſteel-truffes dying the made with juſtneſs and proportion, is alone hernias of ſufficient to produce a cure, unleſs the child was born with the hernia ; or unleſs this diſ- order is kept up by the moiſt conſtitution of the infant. In theſe caſes, where it is ne- ceſſary to procure the evacuation of the noxi- cous humidity, the uſe of remedies would become difficult and diſagreeable ; ſo that the whole treatment ought to conſiſt in the re- gimen. If the nurſe has a good conftitution to the laudable quality of her milk will greatly a contribute to change the conſtitution of them infant; but ſhe ought to avoid giving it papeh eſpecially if there is any fufpicion of obstructie tion in the glands: But if there is no appears ch ance of ſuch obſtruction, we muſt take great w care to have the meal well dried in the oven fo putting it in after the bread is taken out. W Bu reap a double advantage from pap made of all meal thus prepar’d; for it cauſes leſs gripe fra and is more eaſily digeſted. It is true, renders them ſomewhat more coſtive; bulth this inconvenience is removed by mixing 1 W me very Of HERNIAS, 8c. 163 very ſmall quantity of freſh butter with it: Four or five grains of fal prunella may be commodiouſly added. In countries where pap is not given to children, they are generally fed on panadas, which ought to be made without oil. Thus in Italy, and the ſouthern parts of France, it is much better to prepare them with water in which parſnips, carrots, turnips or parſley roots have been boild, or with rice-water. The bread ought to be well bak'd and much boild in the panada. The nurſe ought alſo to follow the ſame regimen, and eat theſe roots without ex- cels, leſt part of her milk ſhould be car- ried off by the urinary paſſages. When children have naturally moiſt con- The man fitations, the poor women whoſe circum- ner in fances oblige them to fuckle them them- felves , ought to uſe aliments capable of re- ought to moving the ferofities of their blood; for if live, when the infant continually receives ferous milk, their chils temperament will be ſo far from being dren. chang'd, that it will become daily worſe and worſe , and the hernia will become incurable for the reaſons I ſhall afterwards ſpecify. as I have ſaid, diuretic and aperient aliments are capable of removing the milk from the breaſts, the mothers muſt uſe ali- ments capable of generating more milk than they have, for which purpoſe they muſt add lentils to thoſe roots, and uſe ſeeds and M 2 leaves which mothers they nurſe its But if, 164 Of HERNIAS, &c. t Cure of leaves of fennel in their drink. Theſe things procure plenty of milk, and fupply its difi- pation by the uſe of the aperients. The whole cure of hernias in ſucking children , ought to be reduc'd to this method, whole efficacy conſiſts in its fimplicity. We ought to employ no other method till the children are four or five years old ; we ought to uſe no other expedients, than the truſs and medic nal aliments. When children are paſt this . age, we may uſe the firſt remedies propost for adults, proportioning the doſes, to the different ages and conſtitutions of the pati.lt ents. There are few diſorders more eaſily cur'd hernias in than thoſe hernias of adults which ariſe from 1 a ſimple relaxation of the peritoneum and is obftrućti . abdominal muſcles. By the methodical ap the tepp. plication of the truſs alone, we cure at leat ſupply two thirds of hernias, provided they are not of long ſtanding. But we cannot fail to curea them all by means of the following remedies provided none of the things mentioned i chap. XVI. oppoſes their cure, Take of the meal of black beans half pound, of the powder of well bak'd til four ounces; of cumin reduc'd to powder Gold of goats dung, of the flowers of pomla granate-tree and bark, of red roſes, od each two ounces. Reduce the whole powder, and boil in a fufficient quanti e M adults when no V fities. Doll Of HERNIAS, &c. 165 of red wine, till it has acquir'd a pretty thick conſiſtence. 32 This is to be applied warm twice a day to the whole abdomen from the navel to the groins, and eſpecially to the part of the her- nia, where it ought to be thickeſt . A ſteel truſs muſt be applied on the place of the hernia, and ſecured in the moſt exact pofi- tion. b. The uſe of this cataplaſm is to be conti- nued for fifteen days, during which time the patient ought to keep his bed. He is to live on roaſted food, and avoid all aliments which have a tendency to relax the parts. He may at his meals drink a ptiſan made of guaiacum and fafafras, an ounce of each of which is to be boild in four pints of water reduc'd to three. He is alſo, every morning las foon as he awakes, an hour before dinner, every night before going to bed, to drink half a pint of the following liquor. Take of mouſe-ear, fanicle, ladies mantle, golden road, and root of the greater com- frey, each an ounce; boil all in fix pints of genuine white wine, till they are reduc'd to four. Man When a redundance of ferofities capable The cure of relaxing the parts ariſes from an obſtruc-of hernias cauſed by tion of the glands, the method ought to be different both with reſpect to the regimen, on of the and а obftructi- M M 3 and glands, 166 Of HERNIAS, &c. and the order of exhibiting the medicines , In order to deſtroy the redundance of fero- fities, we muſt remove the cauſes which produce it. The lymph, which as I have ſaid in the beginning of this chapter, has ac- quir'd ſuch a degree of inſpiffation as hinders it from paffing freely into the glands, form obſtructions, which force the ſerofities of the blood to regurgitate into the veſſels, or to be filtrated thro’ their pores. We muſt therefore attempt to remove theſe obſtructions of the glands ; for we ſhould in vain endea- vour to evacuate theſe ſerofities without re- moving the cauſes which produce them. This can only be obtain'd by obſerving a proper order in the exhibition of the reme- dies, which ſucceeding each other properly , convey their falutary virtues much better than when otherwiſe us'd. We ought therefore to begin, with difpof- ing the infpiffated blood and lymph to flow freely, and with reſtoring the fýſtaltic motion to the veſſels. Among all other remedies bitters are moſt capable of anſwering the intention, fince they attenuate the inſpiflated lymph, and by their gentle aſtringency the relaxed veſſels to their patient muſt uſe them for fifteen days or weeks, and muſt at the ſame time be confin'd to a moiſtening regimen. This regimen any theſe remedies, tho' ſeemingly improper hernias, are yet very beneficial, provided the reſtore proper tone. The three her- pogo OF HERNIA S, &c. 167 hernias are well contain'd in the abdomen. The cure will be more efficacious by being ſomewhat flow. tin The regimen conſiſts in the uſe of moiſt- ening aliments, ſuch as veal, lamb, and wild- fowł boil'd in broth, to which we may add lettuce, purſlain, white ſuccory, chervil and white onion. 3 For ordinary drink a weak water of dogs- graſs , barley, or rice is ſufficient. The patient is every morning and evening to eat broth prepar’d of lean veal boil'd in a quantity of water fufficient for two meſſes, Towards the end of the boiling we are to add, Of wormwood, of wild fuccory, and of fumitory, each half a handfull; of the tops the leſſer centaury, and of camomile flowers, each as much as you can hold be- tween your fingers. Theſe herbs and flowers are to be boil'd only for four or five minutes. Then the whole is to be pafs'd thro' a fierce or a linen When the patient has us’d theſe broths during the time appointed, he is forthwith to make uſe of aperients, which will then be better diſpos'd to penetrate into the glands, becauſe the lymph has loſt a little of its viſcidity. Theſe remedies ought to be of the hot diuretic kind, as the following herbs, flowers cloth. a 0 M 4 168 Of HERNIAS, &c. V O TOME 100 flowers, roots, and feeds, of which we may make choice according as they can be found Take of the leaves of wormwood, burdock, baſilicon, ſcurvy-graſs, the roots of fil- que pendula, aſparagus, china, of madder, gen- tian, fern, and parſley ; the flowers, leaves , ſeeds and roots of broom and rupture- wort: Having collected half a pound theſe plants, leaves, flowers, feeds, or roots they are to be boil'd in fix pints of water reduced to four, fixteen or twenty ounces of which are to be drank daily by the pa- tient, dividing them into three parts, one for morning, another for noon, and the third for night. ba When the patient has uſed this ptiſan thret or four days, we muſt add to it fix or eight grains of the ſalt of tamariſk, that of the twiggs of the vine, that of the ſtalks of fat : beans, or falt of tartar. The uſe of this remedy is to be continued for eight days. Some lay a great ſtreſs on the ſpirits of fall the ſpirit whoſe virtues are more generally extolld than miſtaken. underſtood. Moſt of thoſe who preſcribe them look upon them as aſtringent, for ng other reaſon than that they have been recom- mended in hernias, and that people have fooliſhly imagined that aftringents alone went acapable of curing theſe diſeaſes. any influence in the cure, it is only on 2 Virtues of count of its aperient quality; for which boog If it has reaſon Of HÉRNI AS, &c. 166 the 1291 reaſon we may equally uſe fpirits of nitre, vitriol, or fulphur dulcified, all of which, as well as the rectified ſpirits of ſugar, of paper, Their ac- of gum ammoniac, and of amber, the acid tion on fpirit of fal ammoniac, and others, have the lymph. fame aperient and diuretic qualities ; but they do not operate by dividing the infpiffated lymph, but by forcing its ramified and fibrous parts into a kind of coagulum, and by ſepa- rating the moſt fluid part of the blood which is its ſerum, from the other parts, in the fame manner as the whey of milk is ſeparated from the caſeous part by means of any acid. In caſes therefore where the lymph is already too much infpiffated, this infpiffation muſt be augmented by the uſe of acid ſpirits. Some however, are rafh enough to preſcribe them to ſucking children, notwithſtanding Proofs of the great incompatibility between the milk the bad and theſe acids ; for I have ſeen a great many children fall victims to theſe remedies for want of nouriſhment, becauſe they continu- ally threw up the milk they ſwallowed, in portions as folid as cheeſe. 57 There are, however, caſes in which the patient may ſafely uſe the ſpirit of ſalt; but alt fome- theſe caſes are ſo difficult to be known, that times uſe- none but fkilful practitioners ought to pre- fcribe the uſe of it. Foreſtus, a learned au- thor , made a ſecret of this remedy, perhaps for fear the ignorant ſhould make a bad uſe of it; for nothing is more dangerous than a ofe of them. Spirit of ful a good h 10 170 Of HERN I AS, &c. good remedy ill-applied. Others, and eledy cially Bafile Valentine, have greatly correctaling it, by dulcifying it by good fpirit of win, which, by its ſulphureous parts, ſheaths u its too ſharp points. But no author has bet ter known the advantages of ſalt, as a ſpecific for hernias, than the learned Hartmannus who uſed ſal gemma, which is of the ſame ſpecies with ſea-falt. He did not, however , preſcribe the acid ſpirit of it, which is only obtain’d by diſtillation; that is, by the ſub- tilization of its conſtituent parts by fire , which renders them fo corroſive as to enter the compoſition of aqua regia, which is, o all others, the moſt powerful diffolvent of metals. He only order'd it to be calcina , and reſolved into a liquor, which preſerved that balſamic ſaline quality which renders it friendly to the blood and vital principle . I was to conceal any ſecrets, as did the prior of Cabriares, who impoſed on Lewis XIVch , by ſelling him for a ſecret the ſpirit of fat, a which he had found in Baſile Valentine, ſhould be that of Hartmannus, which is neither known nor uſed by any one, and with which I have perform'd the greateſt number of cures in theſe kinds of diſorders: But as deſign is purely to inſtruct, and to be bene- ficial to the public, I think I cannot give them a greater proof of my diſintereſtedneſs , than by aſſuring them of the efficacy of this reme I CE a no 20 CO dy Of HERNIAS, &c. 171 fal gem- dy, and laying down the method of prepar- ing it. Take of fal gemmæ, what quantity you Balſam of pleaſe; calcine it nine or ten times, and mæ a ſpe- each time diffolve it in diſtill'd rain-water: cific in When it has been diſſolved, filtrate it thro' ruptures. paper, and evaporate the water over a very low fire. When by theſe different calci- nations and diffolutions it has acquir’d ſuch a degree of ſubtilty, that it may be fuſed by the flame of a candle, diſtil it with oil of turpentine, and cohobate it ſeveral times, till it remains at the bottom of the receiver in the conſiſtence of liquid honey : Then preſerve it, to be uſed on proper occaſions. It may be taken to four, fix, ten, or twelve drops in wine, or any other liquor, ſuited to the age and conſtitution of the patient, and the violence and duration of the diſeaſe. Before we uſe this remedy, we ought to be Cautions certain whether there are any acids predomi- to be oba nating in the firſt organs of digeſtion, fince, with re- in this caſe , the remedy would become very ſpect to acids pre- prejudical . If we are certain that there are dominat- we ought, before the uſe of this reme-ing in the dy, to give abſorbents which deſtroy the acid and acrid ſubſtances found in the ſtomach digeftion. and inteſtines. Theſe remedies are crabs- eyes, the ſhells of eggs and oyſters, and the calaminar-ſtone, reduced to a very fine pow- der ; and given every morning fafting for eight acids, firſt or- gans of or 172 OF HERNIAS, &c. per. tic reme- dies or ten days, from the quantity of twelve or fixteen grains to two ſcruples. We may alfo to give coral, powder'd pearls, and other fub- ſtances of the ſame kind in the fame doſe. Purga- We are afterwards to purge the patient with tives pro- twelve or fifteen grains of the arcanum du- plicatum, or with the pulvis cornachini, com- monly call’d the pulvis de tribus, or with the earl of Warwick's powder ; between fifteen and forty or fifty grains of which may be given, according to the age and ſtrength si the patient. We may after this, with greater ſafety, uſe acids; but I always eſteem it bet- phrac- ter to employ ecphractics obtain'd from iron or mercury, according to the cauſes which have produced the obſtruction. If the cauſe proceeds from venery, the pa. ecphrac- tient is to take mercurial ecphractics; ſuch as tics, when dulcified ſublimate, from ſix grains to twenty- five; or the mercurial panacea, from fix of eight grains to fifty. Chaly= When the cauſe does not ariſe from vene- phraćtics , ry, all the preparations of iron are the mat when pro- powerful remedies to remove the obſtructions as ſaffron of ſteel, from fix grains to twenty or twenty-five; falt of vitriol of ſteel, from eight grains to fifty; or tincture of ſteel with tartar, from half a dram to three or drams. All thefe remedies, when well pre stort teen days, are capable of totally removing pared, and continued for ten, twelve, or fit os aigua suudi so 2 med pro- per. Mercurial proper. Stara beate ec per. four the obe 2 Of HERNIAS, &c. 173 deficca- tive re- COM a bir obſtructions of the glands which cauſe the ferofities. V It now remains, that we reſtore the loſt Uſe of ſpring of the parts, in order to anſwer all the intentions we propoſed for the radical cure of medies. theſe diſorders. The patient being purg'd as before, with the pulvis de tribus, or the arcanum duplica- tum, is afterwards to uſe the following ptifan : Take of the roots of china and farſaparilla, of guaiacum raſp'd, and ſhavings of faf- ſafras, each two ounces : Boil the whole together in a cloſe-ſtopt veſſel, over a gen- tle fire, in twelve pints of water, reduced to eight, or thereabouts. When the li- quor is cold ſtrain it, and let the patient drink two pints of it a day, more or leſs, juſt proportions being obſerved. We muſt put in every pint of this liquor fifteen, twenty, or thirty drops of the ſpirit inte of vitriol of Mars. The uſe of this ptifan is to be continued for twelve or fifteen days, during which time the patient ought to be reduced to a dry regimen ; that is to ſay, he is only to eat roaſt beef, mutton, or pigeons. He is to avoid pulſe, herbs, fruits, and milk. He may drink wine at meals, and uſe tea and coffee in the ordinary-manner. If, as I have faid in the beginning, the The truſs truſs is the firſt remedy which can contribute ought to 20 - 30 1 e to 174 Of HERNIAS, 8c. after the cure. n1 nued long to the cure, it is alſo the laſt we ought to ra end with; for which reaſon we cannot too w carefully advertiſe the patients to continue the th uſe of it for three, or even ſix months, after in having laid aſide the other remedies; and even at the end of that time it is improper to lo quit it ſuddenly, ſince it is far better for the re patient to habituate himſelf to the want of it it by little and little, during the night-time, for eight or fifteen days; and afterwards by to remaining two or three hours, after getting out of bed, without applying it, for ſeven om Precau- eight days. The patient may afterwards be be taken, without it for ſome half-days, and fucceffive- in order" ly ſome whole days, in order to reſume it 10 quite ſometimes, and at laſt to quit it altogether I cannot, however, too much recommend the uſe of it in caſes, where the patients are obliged to make great efforts. Reaſon alone in dictates rules in this reſpect, which I think itp fuperfluous to relate. I ſhall, in general, fpecify in the following chapter the cauſes which may oppoſe the cure of theſe diſorders. P tions to the . W 10. CO W C H A P. XVI. Of the cauſes which may oppoſe the cure (9 bernias. TI HO' in general it is very eaſy to culte the hernias of children, and tho' the proper application of the truſs alone is gene- rally 2 OF HERNIAS, &c. 175 down, op rally fufficient for their radical cure, yet it would be dangerous to undertake the cure of them, when the teſticles are not fallen down Tefticles into the ſcrotum. In ſome children the her- not fallen nias remain long in the ringlets, or a little be- poſe the low theſe apertures. They alſo ſometimes cure. re-enter, and fall down, according to the ftronger or weaker contractions of the muf- cles which ſupport them. If, in theſe caſes, there is an hernia, it is hardly allowable to contain it with a truſs, on account of the dificulties of conſtructing it in ſuch a man- ner, as that it may oppoſe the deſcent of the inteſtine, without wounding the teſticle. If the remedies fuppoſed proper for the cure of fuch hernias were applied, we ſhould aug- ment the contraction of the muſcles, which would make the teſticles return all together into the abdomen, or keep them com- prefl'd in the ringlets, whence a double in- convenience would ariſe ; for the teſticles would keep open the apertures of the ringlets, and hinder the cure of the hernias ; and the teſticles themſelves would be painfully com- prefd by the ringlets. Perſons little ſkilld in the cure of theſe diſorders, ought carefully to guard againſt this inconvenience; fince a are frequently miſtaken in this par- In adults, whoſe breaſts are weak and de- Delicacy licate, we cannot, without a great deal of of the danger, preſcribe attenuating medicines drawn adults, an from furgeons ticular. lungs in ylla 176 Of H ERNI A S, &c. to the cure. obſtacle from minerals; fuch as the acid ſpirits and preparations of Mars and Mercury, which have deſcrib'd. Theſe remedies, tho' very falutary in themſelves, may produce ſome ruptures in the pulmonary vefſels, which at too weak to reſiſt their effects; for they open to themſelves a paſſage thro' the hard obſtructions, with which the ſubſtance of the veſſels rarely fails to be ſtuffed, in perſons ſubject to a conſumption or phthiſis ; ſo that ſuch perſons ought to be content with the palliative cure. There are a great many other circum ſtances, to which we ought to have a regard in the treatment of hernias; but of which IT ſhall not here ſpeak, becauſe they would led The pati- us too far from our purpoſe: For this realon ent ought it is of great importance to the patient to a skilful conſult a ſkilful phyſician and ſurgeon, before phyſician he begins to uſe any remedies for the cure d geon, in theſe diſeaſes. We cannot too much attend to the cauſes of theſe diſorders, to the com- choice of ftitution of the patients, and the choice do the remedies. We ought alſo to have a great regard to ing more the inconveniences, which, by oppoſing the capable of cure, become a part of the diſorder : 2 his conici- without this, all the remedies would beo no uſe. In the firſt place, we muſt bed to a the uſe and his me- dicines, none be- g , fured whether the hernia is form'd by rup, ture; and in this caſe there is no curing it. Secondly, we are to conſider wie tution. hope ther OF HERNIAS, &c. 177 a bither the parts can be reduced. Thirdly, whether, when reduced, we can ſurely con- tain them, without the eſcape of the ſmalleſt portion. Fourthly, whether the herniary yifac has not acquired too thick a conſiſtence. Fifthly, whether the herniary fac, tho' in its natural ſtate, is not as exactly contain'd as the epiploon and the inteſtine; for it is princi- pally on the latter that the remedies ought to det, by reſtoring it to its juſt proportion. It si fometimes happens, however, that the her- nia is cured without the peritoneum ever having been reduced ; but this caſe occurs ſo rarely, that it ought by no means to be de- pended upon; and this ſpecies of cure may even prove very dangerous, becauſe, before it can be obtain'd, it is neceſſary that the inter- o'nal ſurface of the fac ſhould be united to each other, which cannot happen without an inflammation of thoſe parts, which may do a great deal of injury to the cord of the ſper- matic vefſels, becauſe it always ariſes from the too great compreffion of the bolſter. Sixthly , the ſymptom which moſtly oppoſes the cure is the adherence of the parts, with- out the abdomen; for if it is abſolutely re- quifite that they ſhould be contained in the abdomen, it is equally neceſſary that it be poſſible to return them into it. Now adhe- rences are generally invincible obſtacles which hinder the reduction; ſo that we muſt not andertake the cure of theſe ſpecies of hernias, N unleſs 278 Of HERNI A S, &c. om unleſs we find the patients tractable enough to ſubmit to the regimen and remedies men- tioned in the third obſervation of the chapter on adherences, which makes the laſt part of this work. Shut Ibibo In theſe circumſtances, the patients not being capable of obtaining a radical cure, ought to content themſelves with the pallia- tive one ; that is to ſay, with the uſe of am truſſes, by the juſt and methodical applica- bittetion of which the parts will be kept in the abdomen, and the patients fecured te againſt the troubleſome ſymptoms of a ſtran- gulation, which they ought always carefully M to guard againſt. I now come to give ſome rules with re- ſpect to the conſtruction of theſe inftruments , that the patients, who are almoſt always the dupes of the ignorance of truſs-makers, may at leaſt know the qualities theſe machines be ought to have, in order to obtain from them the helps neceſſary for theſe diforders. Gondoa ped 1500 CE fi Dow W a ali 01 to Tond by elaide SUR toolbar abil 20 bio CH A P. XVII. Of truſſes for hernias. Idak ada ori ។ What a TRulles are folid bandages, which, by their equal compreffion, exactly clofen up the apertures which give paſſage to the parts, and hinder them from falling down simo did not tool when - trufs is. We 00) sch was enter the 10 OF HERNI A S, &c. 179 dotto, la when they are once returned into the ab- domen. fra bids are botol According to this defcription I only in-n10 tend to ſpeak of methodical truſſes; I meansis freel-truſſes, in which alone we find the qua- lities requiſite for containing the ſmalleſt and d moſt ſimple, as well as the greateſt and moſt o compound hernias. oy Tho' I call them ſteel-truſſes, it is not ne- The mata ceflary that they fhould be of pure ſteel, ter which fince this ſubſtance, being too brittle of itſelf, ought to would not have pliancy enough to be bent compofi- any way, according to the neceſſities of the tion of - patient. Iron, on the contrary, would be too foft, and conſequently incapable of re- taining the figure the truſs ought conſtantly to preſerve, in the different attitudes and mo- tions of the body. It was therefore necef-15 fary to find a ſubſtance which partook of both theſe qualities, which was neither too nor too ſoft. This ſubſtance is a com- poſition of ſteel and ſoft iron join'd, and furged together till they acquire a confiftence which is folid, elaſtic, and incapable of lofing its form. This ſubſtance compofes the half, two thirds , and ſometimes three quarters of the tus, according to the violence of the diſeaſe, Rd the degree of compreffion and reſiſtance heffary to oppoſe the efforts of the parts We intend to contain. The reſt of the truſs wilts of leather-thongs, which conſtitute the brittle N 2 180 Of HERNIAS, &c. Its parts. a the length of the girdle. All the reſt of the truſs is lined with ſome ſoft ſubſtance, ca- pable of preſerving the hips from the rude impreſſions of the ſteel. That portion of the truſs which is com- poſed of iron, conſiſts of three principal parts ; namely, of a body and two extremi- ties. The body is a kind of plate, more or leſs thick, and broad, according to the ſtrength we intend to give the truſs. The extremities are two, one anterior, and the other poſte- rior. The anterior is enlarged in a form and bulk proportion'd to that of the part on which the point of compreffion ought to be made . This extremity is call’d the platine. On the external ſurface of the plate is a hook, to ſecure the leather-girdle. On its internal für- face is a cuſhion, which ought to preſs upon the aperture of the abdomen we want to cloſe. The part immediately following plate is called the neck, or collet. The red of the truſs is call'd the body, and forms the portion of the circle, which conſtitutes the principal part of the whole trufs. The porte rior extremity is called the tail, to which, I have ſaid, is fixed the thong of leather which is to complete the whole circle of the truts It is of great importance to the patients know theſe parts of the truſs , that they maj know how to apply it, in the manner direct in chap. XXII. the I thall This vor Of HERNIA S, &C. 781 to truís. This ſteel ought to be made in ſuch a Properties manner, as to be duly applied to the emi- nences and depreſſions found in the bones of the hips, without which its action would be falſe , it would wound the patient, and the compreſſion, which ought to be on the aper- ture we intend to cloſe, would always be ir- regular. This condition or property of the truſs, which is very ſimple, when we know how to give it the figure it ought to have, is not on- ly the moſt confiderable and neceffary, but alſo that which is generally wanting in all the truffes made by the common workmen in that buſineſs, who are neither acquainted pith anatomy, nor the proportions of the body . They think it fufficient to forge the iron well, and by means of the ſteel to ren- der it fo folid as that it may not break. They think that they have done all that can done, when they have only made the out- lines, as it were, of the work. In order to ren- der it perfect, the ſurgeon who applies it muſt know how to give it the proper bending- Neither can he fucceed in this, unleſs, to a great deal of experience in managing theſe machines, he adds a perfect knowledge of all the different ſpecies of hernias, when he takes meaſure of the hips, and attends to their gures, which vary as much as there are dif- ferent patients. This would be a proper place to give particular rules on this ſubject, but they N3 ?$2 Of HERNI A S, &c. they would render the work too extenſive; and the public, for whom I write, has no pccaſion to learn the method of making theſe machines. It is ſufficient to warn them in general, that they ought not to be deceived , and that the only advantage they can reap from a truſs conſiſts in its perfect ſtability , and in its conſtantly regular compreffion, I ſtability ought to ariſe from its juſt applica- tion to the bones of the hips, As theſe bones are unmoveable, the por.ion of the circle fosse remains fixed, and never changes its place , esitus when it is bent exactly according to the true chas figure of theſe bones. Its regular comprel- 1999 al fion ariſes from the methodical conſtruction of the cuſhion, and from the force of the points of ſupport, which ought to paſs into the iron oppoſite to the part where the com- preffion ought to be made. The conſtruction of the cuſhion, mere or leſs convex or yated, more or leſs flat, more or leſs long silent large, middle-fized, or ſmall, generally de- 1951-19 pends on the fatneſs or leanneſs of the pa- tient, or the elevation or depreſſure of the o pubis, on which it ought to reſt more or les according to circumſtances. It alſo depends on an infinity of other circumſtances, which vary according to the different fpecies of her nias, the parts of which they their duration, their bulk, their figures Bago their cauſes, their fymptoms, and the parts satu blot di golim vd 200mmon som THƯ C ele- are form'd , which OF HERN I AS, &c. 183 29 Slow truſſes a lone pof- ad- which ought to be fpared in the neighbour- Chood of the points of compreſſion. The point of ſupport, which is always in the poſterior part of the iron, ought to be Oppoſite to the cuſhion under which the point lof compreſſion lies; for which reaſon it is neceſſary that the point of ſupport ſhould be fure and folid. Thus, in double hernias, there muſt be two points of ſupport, equal, or at leaſt proportion'd, to the reſiſtance we want to oppoſe in each hernia. Jo The ſteel-truſs is the only one in which Steel- we can find theſe qualities. The moſt ſim- ple are, of all others, the beſt; fince we feſs’d of diminiſh their advantages by attempting to the neceſ compound them. Some have thought that vantages. they augmented the point of compreffion by adding to the cuſhion a ſpring with a nut, and a ſupport which fixes this nut, and makes the inferior part of the cuſhion ſupport bet- ter; without confidering, that if we augment Spring, compreſſion in the inferior part, we di- truffes im- minifh it in the fuperior, and the hernia falls thro ' the fuperior part of the aperture. When a truſs is properly bent, and the cuſhion duly haped, the hernia is perfectly retained, without having recourſe to ſo many expe- dients ; for proper expedients are only to be found in the genius of the furgeon, and not Todos Louis T30 Others have thought to render the fteel- Jointed truſs more commodious, by making it fold fuficient . with 0 the perfect. in the trufs. truffes in- N 4 N 4 184 OF HERNI A S, &c. with hinges, which, tho' a very old in vention, is yet become in great repute, by means of the avarice of ignorant truſ- makers who recommend them, becauſe they ſell them dear, and not becauſe they are be-b neficial to the patient; for if the truſs ought to be fixed and ſtable on the hip-bones and if it ought to preſs equally every where, by adapting itſelf to all the natural or preter natural depreffions of the hip-bones, it is 2010: not poſſible that theſe kinds of bandagesatario be of any benefit. The play of their hinges facilitates their liberty of opening and fhutt ting, according to the different motions of the body. Theſe motions oblige them to form angles at their joints, which make them con: ſtantly compreſs unequally: The joints of the different plates which compoſe the truf hinder us from making in theſe parts the preffures and cavities neceſſary to correſpond to the inequalities of theſe bones. Beſides each branch, which extends from one joint to another, being too ſhort, cannot be made ſtrait when it bends. The uſe of fuchib truſſes is, therefore, inſufficient, Elaſtic Some have thought they found a great ver com- many advantages in certain truffes, to which preſs juft, they have given the name of elaſtic truffesyo ly, of a new invention. This elaftic quality which is their only fault, has feduced fome perfons, who imagine that there is fomething wonderful in them. In order to obtain this great! truffes ne TE CE elaſti Of HERNIAS, &c. 185 without iren vesy elaſticity, the truſs muſt be compoſed of a plate of ſteel, temper'd fo high that it will no longer yield either to the hammer, or the effort of the hand to bend it to the patient's body, without breaking it, which is the reaſon that it every where bears on the parts unjuſtly, that it has no fixed point of ſupport, and conſequently that its compreffion is al- ways unequal and uncertain. Some others, as ignorant of mechanics as Truffes of the treatment of hernias, have imagined that they removed all theſe inconveniences by danger- renewing the antient uſe of bandages, with-ous. out iron. Theſe machines are fo dangerous, that the patient cannot be too much preju- difed againſt them. Their moſt effential faults are two: Firſt, The heat and excoria- tion they cauſe all round the hips, by the tightneſs with which they muſt be ap- plied, a circumſtance which renders them in- fupportable. Secondly, What is ſtill more dangerous is, that the cuſhion of this ſpecies of trufs does not compreſs the aperture of the hernia, except when the patient ſtands up- right , or lies in bed; for when he fits down, the girdle and a band, which paſſes under the thigh, are flacken’d, on account of the relaxation of the muſcles, which raiſes the cufhion of the truſs on the inferior fide, and always permits the parts to go and come; for which reaſon it is abſolutely uſeleſs. But the Sanger of it ariſes from this, that the parts 4 are 186 of HERNIAS, &c. are compreſs'd by it every time the patient riſes up, becauſe the cuſhion, which låt looſe when the patient was ſitting, conſtricts them extremely when he riſes up. Theſe reiterated . compreſſions bruiſe and excoriate them whence troubleſome adheſions enſue, which conſtitute the ſubject of the ſecond chapter of the ſecond part of this work. This truls is fo dangerous, that three fourths of the chil . dren to whom they apply it in their infancy , become incurable by the infpiffation of the herniary fac, occafioned by its continual frie- tions, and its irregular compreſſion. Fu this reaſon they muſt, from their moſt tender infancy, wear ſteel-truſſes, which cure in a very ſhort time, and produce no inconven nience. stborsella The only hernias, for which truffes with out ſteel girdles are permitted are thole d the navel, or ventral hernias, becauſe fuck truſſes, preſs upon the foft parts of the ab domen. But there are alſo caſes in which it is not poſſible to retain theſe kinds of her nias without the advantage of the point at ſupport afforded by the ſpine of the back This is moſt methodically done by means of a double girdle of iron invented by Mis Guiton. This double girdle is the greater ſecurity of women who have born a many children, and whoſe abdomen is very foft. un na synalni -13300 orando V291099 CHAP ye Caſes in which we may uſe truffes, without a ſteel girdle. Of HERNIAS, &c. 187 2 1 $ 2 multko odismi udba Blool in din CHA P. XVIII. Of the precautions patients ought to take du- ring the uſe of truljes. GOD IT is not ſufficient that the patients be provided with proper truffes, but they muſt alſo be at due pains to apply and re- şain them in their proper places. We ſhould deceiye ourſelves if we imagin’d, that theſe | machines were not ſuſceptible of any dif- placement or alteration of poſition, which may render the uſe of them much more pre- judicial than beneficial. If a man wears an habit .with ſome fault he does not ſee, every body elſe perceives it, and tells him that it muſt be remedied, but it is not ſo with ref- pect to a truſs which no body ſees. If it is faulty in any particular, the patient is not al- rways a judge of it, becauſe he can neither know the faults nor the perfections of theſe our kinds of machines. He often thinks him- og felf in the greateſt ſafety, when he is in the igreateſt dạnger, by means of the diſplace- ment of his truſs, or his want of care to make a good uſe of it. Surgeons are the on- ly perſons capable of preventing or correcting the faults they may contract, and of ſetting patients free from their bad habitudes in the uſe of theſe machines. Rich perfons who live in large cities where there are generally herniary furgeons, may obtain all the neceſ- ſary a 188 Of HERNIAS, 8c. ſary ſecurities from the care of thoſe who merit this confidence. But perſons remote from large cities, and people of ſmall for- tunes have not the ſame advantages. The poor decline applying for relief, for fear of the demands of the perſon propoſed to afford them aſſiſtance *. I cannot more perfectly inſtruct the public with reſpećt to thoſe diſorders, than by acquainting them, in the fubſequent chapters, with what hap pens by means of the diſorder itſelf, means of the truſs, and by means of patient's neglect. Every perſon may relieve himſelf by reading this part of the work with a little attention. Every one will learn to act as he ought to do, and to correct the faults which may happen in his trus Parents, nurſes and all perſons who have the care of children, may regulate their condut by theſe inſtructions. Huſbands and wives may mutually affiſt each other. Charitable perſons may inſtruct the poor, and even af ford them the affiſtance neceſſary in theſe di orders, by following the advice of any kil- ful and beneficent furgeon, in concert the inſtructions I ſhall give in the following chapters. Horto * For this reaſon I ſhall, every Wedneſday, from eight to ten in the morning, give my advice gratis to the poor. . tor СНАР, OF HERNIAS, &c. 189 T! Ozon e SJORIST CH A P. XIX. of the inconveniencies which may happen in truffes with reſpect to their diſplacement. HE things which demand our greateſt attention with reſpect to this diſorder, ariſe from the nature and ſpecies of the her- nia . Hernias form'd by a rupture of the peritoneum, are much more difficult to be retain'd than others, ſince they require that the patients ſhould wear their truſſes night and day, and avoid making the very ſmalleſt efforts. Hernias form’d by the epiploon are allo much more difficultly retain'd than thoſe form'd by the inteſtine, ſince if we neglect but for a ſhort time to contain them, they augment ſtill more and more. The patients muſt therefore wear lighter truſſes, than in caſes where the hernia is form’d by the in- teftine. It ſometimes happens that the inteſtine reenters eaſily, whilſt the epiploon does not reenter, notwithſtanding which, the patient is oblig'd to wear a trufs to binder the de- fient of the inteſtine. In this caſe the com- preſſion of the cuſhion ought to be ſo ma- nagd, that the epiploon may not fuffer by it, but in ſuch a manner, as to be ſufficient to hinder the deſcent of the inteftine. Too trong a compreffion of the cuſhion on the epi- 190 , Of HERNIAS10 ЯНdo 2 . , &c. epiploon, might excite an inflammation and troubleſome ſuppuration in it. When there is a falſe hernia with the true one, the compreffion of the truſs may great deal of injury to it, eſpecially when the tumor is in the teſticles, or in the ſperma- tic cord. The veſſels would be com- preſs'd and ſtrangulated by the truſs, and the fluids would with greater difficulty remount againſt their own weight. In this caſe it is tr of great importance to remedy the diſorderob of the teſticles or cord, whether by medi- cines or a chirurgical operation, when it is in its beginning, to hinder two curable difor- ders from becoming mortal, which they would otherwiſe infallibly prove. But if necel fity abſolutely requires the uſe of a truſs, itera muſt be made ſo methodically, and its point of compreſſion muſt be managed in ſuch an manner, that it may defend the hernia from all troubleſome events, without putting the patient to a greater inconvenience from the ith diſorder of the teſticle. If an hernia of water is formed with the sa hernia of the part, we muſt uſe the fame A precautions, eſpecially in children, in whom it is eaſy to cure collections of water formed in the ſcrotum, if we carefully manage point of compreſſion, which the cuſhion may make upon it. а. ba0 Jousy Dotzuotbormoon VOIE stucht is diversitariscose 1960st didw 291dino 3b ots or thell СНАР. Of HERNIAS, &C. 191 G. as buscoCH A P. XX. dgica noolgiqə uggul Smolidwout of the inconveniences which may ariſe from the diſorder with reſpect to the patient, and the precautions we ought to take to remedy them. muut TREAT leanneſs, and exceffive fatneſs, are inconveniences, with reſpect to the diforder, which oppoſe the ſtability of the trufs , and render its uſe always difficult, if both ſurgeon and patient take not uncom- mon pains to the contrary. The hip- bories, which, in a natural ſtate, are ſmaller ad below, in order to render the bottom of the a pelvis more narrow, form depreſſions on their ateral parts. When the patient is mode- rately corpulent, theſe depreſſions are filled by the muſcles and the fat: But in extreme emaciation theſe muſcles are very flender, and uncovered with any fat, which makes thefe bones almoft as much depreſsid as if they were bare ; fo that behind they form unequal eminences. The os pubis , which is at their anterior part, is very much elevated : A certain eminence at the ſuperior part of the Sah-bone, is, in this caſe, alſo deſtitute of st; ſo that it is cover'd almoſt only with bin, which renders the application of the tals very difficult to the ſurgeon, and very sommodious to the patient. It frequently appens, that with theſe natural inconve- liences there are deformities which render the 192 Of HERNÍ AS, &c. the application almoſt impracticable ; and what is ſtill worfe, in theſe extenuated pa tients the abdominal muſcles are ſo poo, flender, and relaxed, that in them herna are more ſlippery than in any other patients A ſurgeon, the beſt acquainted with the making of theſe machines, cannot in fuch caſes ſucceed in bending the truſs juftly without the greateſt care to give it a figure proportioned to that of the bones. The pa tient ought alſo to be at great pains to re- tain it in its proper place. It shall be part- cularly deſcribed in the 23d chapter. When the patient is extremely corpulent, the great quantity of fat gives the hips a deformity ſo contrary to the natural flate , that the bending of the truſs ought to alſo very different from that it ought to have in the natural ſtate. It is alſo very for the truſs to afford the aſſiſtance to be ex- pected from it, notwithftanding all the cart of the furgeon, if the patient himſelf is na at due pains to anſwer the intentions, and ob ſerve the particularities relating to the tru pofition of the truſs, which ſhall be deſcribd in the 23d chapter, The inconveniences which occur to the patients, in hernias of the navel, arife equal ly from the deformity of the abdomen , which is more or leſs large, more or leſs lea) firm, or ſoft, according to the greater of fmaller relaxation which the peritoneum, difficult mud Of HERNIAS, &c 193 105 muſcles and ſkin have ſuffer'd in geſtations or dropſies. Conſequently the truſſes for theſe kinds of hernias ought to be as differently made as the figures of the abdomen are dif- ferent, for if it terminates in a point towards the navel, it is very firm, and the compreſſion varies eaſily. If the navel is lower than the hips , the point of ſupport cannot be op- poſite to the point of compreffion. If the abdomen is more elevated below the navel, than above it, the truſs continually inclines to remount above the hernia. If on the contra- ry the abdomen is larger above than below the navel, the truſs is determin’d to deſcend below the hernia. All theſe differences re- te quire different pieces of care in the conſtruc- htion of truffes, but they demand ſtill more be re attention from the patient. The precautions to be taken by the patients againſt theſe inconveniencies, being common to all ſpecies of hernias, I ſhall comprehend them in the following general directions. The more the truſs is ſubject to varia- utions , the more reſolution the patient ought to have to give it time to fix, and the ſurgeon ought to ſtudy to adapt it gradually and by little and little to the patient's body. In ve- ty lean patients we muſt not at firſt contract it to the laſt degree, fince by ſo doing the uſe of it would become uneaſy and inſupportable It is neceffary that the parts ſhould be infenfi- bly accuſtom'd to its impreſſions. In very ve are 101 he mg 0 cor- 194 OF HERNIAS, &c. corpulent perſons, we muſt uſe the fame precautions, becauſe the fat can only be de- preſs’d by little and little under the girdle and the cuſhion. Thus 'tis neceffary only to con- tract or tighten the truſs in proportion as it fubfides in the thickneſs of the fat, without which it would become too large. Theſe meaſures ought to be divided between the pa- tient and the ſurgeon, till the truſs has ac- quir'd a firm and invariable ſituation. The patients ought not to take away their truſles, either in the night or day, till they are accii- ſtomed to them. When hernias are very flippery, as thoſe of the epiploon, the patients ought to avoid all motions capable of deter- mining the parts to fall out, ſuch as ſtriding or ſeparating the legs with violence, railing the arms too high, and ſneezng with effort. In a word, if the patient is coſtive and oblig'd to make great efforts in going to ſtool, it! expedient to render his body foluble by means of clyfters, or by giving him boil'd pulp caffia. If notwithſtanding this he is obligd to make fome efforts, he muſt, with his hand, preſs the ſuperiour part of the cuſhion , in order to make it approach more to the os pubis. He muſt alſo obſerve the ſame pre- caution, when he fneezes or blows his noſe . By theſe means the parts will, by little and little, be accuſtom'd to remain in the abdo- men, and acquire an habitude of not coming segirl to oro eget to out 992 OF HERNIAS, c. 19$ but in bed, in which caſe the patients may lay aſide their truſſes in the night-time. bacalle CH A P. XXI. Of the inconveniencies which may ariſe from truſſes, and the precautions neceſſary to prevent and correct them. I. HAVE in the preceding chapter ſaid that truſſes can only by little and little be accuſtom'd to the body of the patient. They are therefore of themſelves ſubject to ſome alterations, which we muſt remedy, in order to give them the laſt degree of perfection. This perfection, as I have already obferv'd, con- confifts in bending them to a foree exactly pro- tioned to the parts to which the truſs ought to be applied; for if it compreffes more on one part than another of the circumference, it muſt neceſſarily hurt the patient, and the point of compreffion muſt be faulty and ir regular. Beſides, in this caſe the truſs is apt to break at the part where the vacuity is : We do not ſometimes perceive this fault when we firſt apply truffes, becauſe the fur- niture which is new and rais'd conceals the vacuities : But when a trufs has been worn fome days, the furniture becomes flat, the fat under the girdle fubſides, the leather which compoſes the reſt of tne circle is lagthend, and the trufs no longer compreffes any of the circumference of the hips, ex- O2 cept 796 Of HERNIAS, cept in that part which, as I have faid, com preſſes irregularly. This inconvenience is ea: fily remedied by the hand, when the iron of the truſs is good. The method of rectifying this fault ſhall be deſcrib'd in the ſubſequent chapter À fault common to all truffes applied to the groins and in the foldings of the thighs when they labour under any imperfections, is that they preſs too little on the aperture they ought to cloſe up, when the patient fits.com a low feat, becauſe then the abdomen is de preſs’d towards the back. To remedy this fault, the patients muſt always fit on the higheſt ſeats they can find. They ought el pecially to be in a pretty elevated ſituation, when they go to ſtool, becauſe in the efforts they make for the expulſion of the fæces, the parts find more opportunity to eſcape from under the truſs. The muſcles of the lower belly facilitate this eſcape by determining the parts downwards, and by receding from the point of compreſſion. It is therefore abſo- lutely neceſſary, that in ſuch caſes, the patient ſhould with his hand preſs the cuſhion, as to make it approach nearer to the abdomen. But the leſs neceſſary this precaution is, the more elevated the fituation of the patient is. In lean perſons the abdomen becomes when they lie on their backs, ſo that there neceffarily remains a vacuity between cushion, and the part on which it ought to , flat the prets Of HERNIAS, &c. 197 PASVET preſs. We remedy this fault, when the pa- tient is oblig’d to wear his truſs in the night, by putting a compreſs between the cuſhion and the abdomen, to fill up the vacuity. Or inſtead of the iron truſs, we may ſubſtitute leather girdle, to which we may fix a ſoft and very thick cuſhion ; but the patient muſt not get out of bed till he again applies his truſs of iron. a 16 e T I je 30 CHA P. XXII. Of the method of taking the meaſures and proportions of the body, for perſons who want truſſes. THOSE perſons who have hernias, and live at a diſtance from towns where they could eaſily find truſſes, have often reaſons which hinder them from going to theſe towns for theſe means of relief. They neglect the methods of alleviating or curing theſe diſorders, which augment and often arrive at ſuch a height, as to be incurable, and tven incapable of having any relief afforded them. That theſe perſons may have the truſſes neceffary for them without going to the Towns where they are to be had, I ſhall lay down the rules neceſſary for taking the juſt dimenfions of truſſes and girdles, and make fome obſervations, by which the patient will DO So ar re he TO $50 03 be 198 Of HERNIAS, &c. be able to give proper directions to his trufs- maker. Firſt, The patient ought, if poſſible, to recollect the cauſe of his hernia; whether it was occaſioned by a blow, a fall, or ſome violent effort; of what nature this effort was; whether it was in coughing, going to ftool, or in lying-down: In this laſt caſe he muft dif- tinguiſh whether the hernia appeared in the ly- ing-down, or afterwards : He muſt, if poſſible, carefully ſpecify the cauſe, becauſe, by apply- ing to a ſkilful workman, he may obtain a truſs of great importance, either for his re- lief or cure. 57000 Secondly, In the account he gives of the ſtate of his diſorder, he ought to ſpecify whether it is recent, or of long ſtanding. Thirdly, He ought carefully to diftinguih the part of the hernia, whether it is in the groin, the folding of the thigh, &c. and on what ſide. Fourthly, He ought to mention its bulk and figure, whether it is round or long, Fifthly, He ought to tell whether it re- enters eaſily, or with ſome difficulty, ing or lying, or whether it does not re-enter at all in any of theſe ſituations. Sixthly, When the hernia is at the folding of the groin, he muſt tell whether it de- ſcended into the ſcrotum in men, or into the labia pudendi in women, only 9 Seventh 0 ſtand- T15LIỆC GHz OF HER NIAS, &c. 199 Seventhly, If he has two hernias, he muſt ſpecify which is the largeſt, whether one re- enters with more difficulty than the other, or whether they are both of an equal bulk. Eighthly, He muſt tell whether he is lean of corpulent, and whether his leanneſs and corpulence are exceſſive or not. Ninthly , If he has any deformities in the hip-bones, it is neceſſary to ſpecify what they are, whether they are natural, or whe- ther they happened by accident. A great many perſons, eſpecially among the women, have one hip larger, more elevated, or more depreſs’d than the other. Others have the fuperior part of the thigh larger, and others fatter; and in very fat women this part is not to be felt at all. All theſe differences are neceſſary to be known, for the proper con- ftruction and bending of the truſs . Tenthly, To theſe ordinary deformities there are ſometimes particular ones joined, ſuch as eminences rifing on the furface of theſe bones. If theſe eminences are under the meaſure, of which I ſhall ſpeak in the following paragraph, we muſt with ink mark upon the meaſure the parts where theſe emi- nences are, that, in making the truſs, the iron may be fo bent as not to make too ſtrong a compreſſion on that part, which would ren- der its application inſupportable . tiba2 habna The patient, having given an exact account of all theſe circumſtances, muſt alſo ſend the juſt 04 200 O HERNIAS, &C. 15 juſt meaſure of his girdle, taken at the part of the hernia, with a ſlip of paper about half an inch broad. If the hernia is ſimple or dou- ble, if it is in either of the groins, in either of the foldings of the thigh, or in both to gether, he is to place the middle of the mea ſure behind, immediately above the diviſion of the hips, and make its two ends meet at the root of the penis ; or, in women, imme- diately above the pudendum. If the hernia is in the navel, we muſt alſo take the bulk of the abdomen, by placing the middle of the meaſure on the back, and bringing its two ends to the part of the hernia. In accounts of umbilical hernias, the paar tient ought to ſpecify: I. The part of the navel which the her- nia poſſeſſes; whether it is in the middle, or in the circumference; whether it is in the fu- perior, inferior, or lateral parts. II. Whether it is recent, or of long ſtand- ing III. Whether it is large or ſmall. IV. Of what figure it is. V. Whether it re-enters or not. - VI. Whether the navel is lower than the hip-bones. And, VII. Whether the abdomen is very or ſoft ; and if the truſs is for a woman, the number of children ſhe has born ought to be ſpecified. All theſe particulars are neceſſary ERO 97 pod hard Suo to OF HERNI A S, &c. 201 to be known, in order to make truffes proper for each of theſe circumſtances, and to ren- der them as commodious as uſeful, when the patient's take the trouble neceſſary for their jut application. The method of doing this I hall deſcribe in the following chapter. mortense SI CH A P. XXIII. Of the method of applying truſſes. THE beſt made truffes become abſolutely uſeleſs and dangerous, when they are not well applied and ſecur'd in an invariable manner. It is therefore requiſite, to give particular rules for their application, ſince nothing is of greater importance to the pati- ent, than the neglect or obſervation of theſe The rules to be obſerv'd are the ſame in fucking children, as in thoſe farther advanced directions. and in adults. As the truſs is made in order to fill the a- perture, thro' which the parts deſcend, it is neceſſary that theſe parts ſhould be return'd into the abdomen before the truſs is applied. The fureft method of facilitating the reduc- tion is reſt. As the parts generally re-enter of themſelves, when the patient has been en bed all night, it is proper not to apply the tuſs till he awakes; but it muſt be done be- vre he gets out of bed. The patient ought | fore to 202 OF HERNI A S, &c. So. 2 DE 1 0 nE to begin with making water, if he has an inclination to it; but he is to avoid all moti ons capable of making the parts flip down, He muſt apply his hand on the aperture of the hernia. He muſt afterwards lie on his back, paſs the truſs under the lower part of his hips, and make it flip upwards above the diviſion of the hips, with both his hands, a ſupporting himſelf a little on his heels. Bi this means he will avoid the falfe bending of the trufs. He is afterwards with his hands to take the parts prolaps'd during theſe moti. ons, and return them exactly. When he is ſure that there is nothing without the abdom men, he muſt with one hand place the co- fhion on the place of the aperture, whillt with the other hand he draws the end of the girdle, always ſupporting the cuſhion, that t it may not incline too much towards the thigh. By theſe motions he is to make the iron of the truſs apply juſtly to his hip He is afterwards to fix the girdle to the hook on the external ſide of the cuſhion, by puta ting it into one of the holes in the leather at the end of the girdle. He muſt afterwards examine whether the 19 truſs is in its juſt poſition; that is today! whether it is too high or too low. He mul in paſs his hand all round the iron, in order to judge, whether it does not preſs more in ons part, than in another, and whether it door not leave a vacuity in any part. If the vacu 01 ity 29113 OF HERNI AS, 8c. 203 1 by is equal every where, it is a ſign that the girdle is not ſufficiently tight. If the vacuity is only in one place, this ariſes from a fault of the truſs, which muſt be corrected in the manner deſcribed in the following paragraph. When the girdle is not ſufficiently tight, it muſt be made tighter ; but to do this in an advantageous manner, we muſt not be con- tented with drawing it by its extremity, fince this method is almoſt uſeleſs. We muſt therefore draw it together ſucceſſively, by lipping the hand from the part where the girdle is fixed to the iron; whilft, with the other hand, we ſupport the truſs near the cuſhion, at the part I have called its collet or neck, preſſing it at the ſame time on the part of the hernia. We are to obſerve whether the edge of the girdle is immediately above the fiffure of the buttocks. If it is not fo, we muſt carefully place it there, and the cu- thlon will be in the juſt and proper poſition for fapping up the aperture of the hernia. If the truſs compreſſes more in one part than in another, it leaves a vacuity in the part where it does not preſs fufficiently. This fault is corrected by unbending the iron a lit- le at the part where it preffes too much. This fault may proceed from a want of at- sition in taking the meaſure; but it may be sily corrected in the following manner : We lay hold of the truſs, in the part where it falle , with both hands. One of the hands I ferves a OF HERNIAS, &c. SANISMI ſerves as a fix'd point, or fulcrum, at the part of the iron near that which we intend to raiſe, whilſt the other hand ſerves as a move- able point, or lever, to act on the part to be raiſed or made ſtraighter: Thus by the mo- tion of the hand, we determine the iron to the part oppoſite to that in which it prefits too much. The ſame thing is to be done, tho” in a different direction, when the circle, being too wide, is not applied with ſufficient exactnek to fix the point of ſupport. In this caſe we take the iron with our two hands, and bend it inwards towards the cuſhion, from its cen- ter to the extremities. By this means we may render the truſs more wide or tight, accord- ing to the general rule ; which, for all forts of truffes, preſcribes a conſtantly equal com preſſion, and a firm and unvariable point ſupport. In the 21ſt chapter I have ſaid, that the the truſs appears very juſt at the firſt applica tion, yet after a few days it becomes too wide, becauſe its furniture becomes flat. We perceive this by the looſeneſs of the truk and by the want of a ſufficient compreſſion by the trufs. In this caſe we muſt neceſſarily what I have preſcribed; for it would be i vain to contract the leather-girdle, ſince the cuſhion would not more powerfully compras the aperture of the abdomen, and the iron would hurt the fide of the hip. of . a 3 There Of H ERNI A S, &c. 205 There are certain rare caſes in which we are obliged to apply a ſmall flexible bandage, in order to fix the truſs in its place. This bandage is tied behind the girdle of the truſs, and ought to paſs under the hip, and be tied to the ſame hook to which the girdle is fixed. This is to be done with truſſes made in my manner, in order to avoid the multiplicity of hooks. The bandage is deſigned to hinder the trufs from going upwards. When the patient is obliged to lie with his truſs, he muſt take care to put it in a proper fituation before he gets out of bed. It fre- quently happens, that the truſs flips a little lower than it ought, by the motions the pa- tient makes in riſing; or that it aſcends a lit- de higher than it ought when he lies down, or ſtretches himſelf in bed. Thus he muſt faile or depreſs the cuſhion as he has occa- fion, without which, if it was too low, it would not preſs enough forwards; whereas, on the contrary, if it was too far raiſed, it would preſs too much. The weight of the breetches, whoſe head- band is often above the truſs, makes it preſs hard on the bone of the thigh, which ferves $ a ſupport to it, and hinders it from defcend- Ang lower. In this caſe the patient ought to wear ſtrings to ſupport his breeches, unlefs he is accuſtomed to have his breeches reach Od: 20 bild to A 3 far above his hips. e 2 206 Of HERNIAS, &c. A great many people imagine, that the lower the hernia deſcends, the lower they are obliged to bring the truſs: So many in conveniences ariſe from this miſtake, that we cannot be at too great pains to warn the pa tients againſt it. Nothing is more capable of correcting this bad cuſtom, with perſons who allow themſelves to think, than to make them ſenſible, that as the truſs is made to ſtop up the hole which gives a paſſage to the parts ſo it is neceſſary that the cuſhion ſhould be placed directly on the hole, and not under it becauſe then the truſs is ſo far from being ſerviceable, that the hernia is very much in commoded by it. With reſpect to fucking children, or thule ſomewhat farther advanced, we muſt daily change their truffes, in order to avoid the iher conveniencies which might ariſe from the naſtineſs with which they are continually com ver’d: For this purpoſe it is ſufficient to have two truſſes, which are to be alternatelj changed every day. When this change is to be made, we are to ſeize a moment in which they do not cry, and apply the clean truth with as much expedition as we poflibly cam That the truſs in children may be in a poſition, it is neceſſary that the cuſhion ihould be half a finger's breadth above, towards one ſide of the penis in males, and the upper part of the pudendum in females In both, it ought to be a finger-breadth abort a jul and the Hosx OF HERNIAS, 80 207 the diviſion of the hips, when the patients are very fat; whereas when they are lean, it ought to be immediately above this diviſion. Every time we change the child's linnen, we ought carefully to obſerve whether the hernia does not come out, and whether it has the liberty of deſcending totally, or in part. We muſt alſo obſerve, whether the iron is not become too eaſy and wide by the fubfiding of the furniture, or by the finking of the fat. In this caſe we muſt, as I have juſt now ſaid, bend the iron a little inwards with our hands, in order to make it preſs more juſtly. If the ton is not too wide, it is ſufficient to draw the girdle a hole or two tighter.d Theſe are all the directions which relate to perſons afflicted with hernias, as well with reject to the knowledge of theſe diſeaſes, as with reſpect to the remedies proper for them. Perſons who have need of greater inſtructions, ball, by applying to me, be ſatisfied in every telpect, i zi sgrabad bogado vab CHA P. XXIV. pole duis Of bernias of the uterus. THE uterus is fubje&t to different difor- ders, which are comprehended under te kind of hernias, relative to the diſplace- rents which happen to that part and to the egina, and which are the fiets of the re- laxations 208 Of HERNI A S, &c. What an inverſion rus is. Differen- ces of in- rus. laxations of their ligaments, or of their prou per fubſtance, in the ſame manner as in true hernias. Theſe diſorders are the turning the uterus inſide out, its relaxation, its de ſcent, or hernia properly ſo called, and the relaxation of the vagina. In an inverſion or turning of the uterus , or turning its bottom becomes concave externally, and of the ute-forms internally a kind of prominence like that in the bottom of a bottle. Four different ſtates conſtitute the diffe verſions of rences of the inverſions to which the uterus the ute- is ſubject. I. The inverſion is more or les conſiderable, if in the depreffion which is made of the uterus, its bottom approaches more or leſs to the internal orifice. II. The bottom of the uterus may be engaged orifice, without paffing beyond it. III, T: bottom of the uterus may come totally orin part out of this orifice, and be contained in the vagina. And IV. It may come out to tally or in part from the vagina, and forma tumor more or leſs large, in proportion o Cauſes of the bulk of the uterus, The inverſion of the uterus may proceed either from internal or from external cauſes Exceſſive fatneſs in perſons obliged make great efforts, which continually de términe the bulk and weight of the towards the uterus, is the moſt ordinary cauſe of this diſorder. The uterus infenfibi and by little and little falls down, when ata the inver- fion of the uterus. Internal cauſes. certain Of HERNI A S, &C. 209 ES certain critical age; that organ, which is then collapſed, happens to be too weak, either na- turally or thro' accident. 'Tis ſufficiently cer- tain, from modern experience, that this dif- order happens indifferently to girls and wo- men who have never born children. It is becauſe theſe inverſions, ariſing from internal cauſes, have been unknown till now, that we have ſeen them taken for extraneous bodies; that they have been rafhly cut off; and that the patients have died, for not having taken the precautions which a thorough ac- quaintance with this unexpected diſorder would have ſuggeſted. The public has gain'd a great deal by the publication of the ſecond volume of the memoirs of the academy of furgery of Paris, in which is inſerted a learned differtation on this ſubject by Mr. Puzos, a celebrated man-midwife. This does not hold true, with reſpect to External the inverſion of the uterus produced by ex- A furgeon, ſays Mr. Puzos, muſt be intirely deſtitute of experience, if is ignorant of ſuch an inverſion. Labour is the immediate cauſe of it, when a ſurgeon being neceffarily obliged to deliver a woman, extracts the fecundines, ſtill adhering to the uterus , without having previouſly diſengaged them. This error, which has been fome- times committed by great practitioners, ſuch Ruyſch, who is not aſhamed to confeſs it, , produces no fatal conſequences, when we are, P. like DIS cauſes. ternal cauſes. es a un 210 OF HERNIAS, &c. like him, able to remedy it forthwith: But it becomes of infinite conſequence to the life of the patient, when it happens thro' the igno- rance of midwives, incapable of repairing it. The reflections made on that ſubject by Mr. Puzos, induced the King, in behalf of the public, to eſtabliſh a courſe of midwifry for midwives, and one for ſurgeons, which is gone thro' by Mr. Puzos, and Mr. Gervais his ſubſtitute, in the moſt accurate and diſtin- guiſh'd manner. We know the turning of the uterus by inſpection, ſince it appears like a maſs of fleth, of a round figure, larger at its baſe than at its ſuperior part. There is no aper- ture obſerved in it, as I ſhall fhew in ſpeaking of its deſcent. On this occaſion, the veſſels being very open, allow a great deal of blood to flow from all its ſurface. Signs of It is not ſo eaſy to judge of an inverſion an inver- arifing from an internal cauſe, eſpecially in duced by girls, or women who have not born chil- an inter- dren. This is the reaſon why the uterus , nai caute, thus inverted, has been frequently taken for an extraneous body. Nothing is, however , more eaſily diſtinguiſh'd, when we are upon our guard, and conſider that every extraneous body is included in a particular membra- neous and very thick cyftus ; and that the membrane which internally lines the U terus is extremely ſlender, and interſperſed with an infinity of ſmall holes, which are fion pro- when uterus comes out of the vagina. dif OF HERNIAS, &C. 2 II an inver- diſcovered by the naked eye, but are ſtill more perceptible by the affiſtance of a glaſs. Be- fides, extraneous bodies coming from the uterus are generally very ſmall at the part of the orifice, and form, with reſpect to their ſubſtances, a part as much depreſſed as the tail of a pear is, with regard to that fruit. Moreover, an extraneous body, however large, does not deſtroy the orifice of the uterus to ſuch a degree, that it cannot be diſcovered by the fight or the touch; whereas, in an in- verſion, it is totally effaced; neither is it pof- fible to diſtinguiſh it, eſpecially when the in- verfion is complete. We can only be deceived in rare caſes, Signs of when the uterus thus inverted does not come fion, when out of the vagina, and when it fills the whole the uterus ſpace of it. In this caſe we may be eaſily does not miſtaken, becauſe we can neither ſee nor of the touch the affected parts. It is much better vagina. to paſs no judgment upon it than a falſe one, by taking it for a mole, the head of a child, or a body of a quite different kind from what When the bottom of the uterus is engaged Signs of we may be aſſured of this cir- gagement cumſtance by introducing our finger, and re- of the are pelling it, if it is not adherent. As the depreſſion of the uterus, which is the firſt degree of its inverſion, is a diſcovery the de made by Mr. Puzos, it is better to refer the preflion of reader to that author than to give a wrong rus, or its repre- come out a It really is. . in its orifice, the en- rus in its orifice, Signs of the ute- P 2 212 Of HERNI A S, &c. gree of inverſion. of uterus. firſt de repreſentation of his ideas, becauſe the ſigns of it are very equivocal, and becauſe only they who have made many careful obſerva- tions are capable of acquiring the profound and uſeful knowledge of the ſigns of dif- eaſes. Symp- The ſymptoms of an inverfion of the ute- the inver- rus ſoon diſcover themſelves manifeſtly, if fion of the they are not ſpeedily remedied, eſpecially in an inverſion occaſion’d by the extraction of the fecundines. The orifice of the uterus is contracted, and braced up. Its body is com- preſs’d and inflated, and at laſt becomes in- flamed and gangrened. In inverſions arifing from internal cauſes, the uterus is inflated and indurated ; ſo that we cannot be too expedi- tious in ſuccouring patients in this condition. The method of remedying it, is to replace the bottom of the uterus : For this purpoſe we muſt , if time will permit, inject a clyſter, in order to procure an evacuation of the groſs matter which may be lodged in the rectum. We are to cauſe the patient to make water if ſhe can; if ſhe cannot, we are to uſe the cathe- ter, in order to procure a diſcharge of the urine. We then order her to lie on her back, with her buttocks higher than her body. We take the extremity of the turn'd uterus, with the points of the five fingers, and preſs it inwards, When we have re-enter'd all that had fallen out beyond the orifice of the uterus, we gra- dually withdraw the fingers one after another , Means of Relief. a begir Of HERNI A S, &C. 213 beginning with the thumb; then the little finger, and that next to it, and the other two afterwards. This operation, which is moſt ordinary, cannot be perform'd, except the orifice is much dilated; for when it is ex- tremely contracted, we have a good deal of difficulty to obtain the reduction, by intro- ducing a ſingle finger into it: But we ought always to uſe the five fingers in putting the bottom of the uterus back to its orifice, whe- ther it is within the vagina, or hangs out without it; as it happens ſometimes one way, and ſometimes another. When we have ar- rived at the nave of the orifice, we withdraw all the fingers, except the middle one, which is to perform the operation, whilſt with the other hand we ſuſtain the reſt of the uterus. But when the ſurgeon is call’d too late, and finds the body of the uterus very much in- fated and infamed, he muſt uſe the weak afliſtance to be obtain'd from oil of ſweet al- monds, in order to make it ſlip up more ea- fily, If by this means we cannot fucceed, and if the uterus is like to fall into a gan- grene, there is no other expedient left, but to cut it off. It is true, that in this caſe the danger is ſo great, that there is hardly any hope of ſucceſs, on account of the ligature we are obliged to uſe, and which muſt fuppreſs the evacuations which ſucceed the But, on the other hand, death is till more certain, if we permit the patient which delivery P3 to 214 Of HERNI A S, &c. to remain in this ſtate. As authors of credit have inform'd us, that they have perform'd this operation with ſucceſs, I think we ought not to heſitate to perform it, when, after having ſhewn the danger to the patient and her friends, we have the benefit of good ad- vice, and perſons capable of affiſting in an operation of ſo great conſequence. This is not a proper place for deſcribing the method of performing this operation ; I ſhall only ſay, that tho' this fymptom is the moſt dan- gerous of all the diſplacements which happen to the uterus, yet it is, without contradiction, the moſt eaſily cured ; and when it is reduced into its firſt ſituation, the means of cure are very ſimple. The authors and practitioners who are moft converſant in the treatment of theſe diſorders, adviſe the introduction of a peffary to main- tain the uterus in its place. Various ſpecies of peffaries have been invented; but each of them has its particular inconveniences, and all of them have two, which have induced me to reject them, both in my method of ob- taining the radical and the palliative cure. ſhall, in the 26th chapter, ſhew the faults common to all theſe machines. But be this as it will , the uſe of peſſaries is by no means proper for the cure of a turning of the uterus. The intentions we ought to purſue in rus ought treatment of this diſorder, after the uterus is 1 The ute- the re- Of HERNIAS, &c. 215 a fhrinks reduced, are to reſtore it to its juſt propor- ftored to its jaft tion, and give its ligaments their natural propor- ſpring ; ſo that, by ſhortning themſelves, they tion. may maintain it in its proper place. This, indeed, is generally the work of nature, and art ought never to be employ’d, except when nature is inſufficient for the purpoſe. After a natural delivery, the uterus is in a fate of extenſion, proportioned to the dila- tation it has ſuffer'd during the continuance of the fætus, in the whole time of geſtation. Its ligaments are extremely lengthen'd, but How this immediately after the delivery it gradually is brought up and is reduced to its uſual bulk. Its ligaments reſume their natural ſpring, without the ſmalleſt affiſtance from art. As reft alone is fufficient to remedy all theſe dif- orders, why ſhould it not be fo to reſtore the parts to their juft proportion, when by accident the uterus has been turn'd. Peffaries can be of no uſe to reſtore the action of the uterus and its ligaments ; fince, after de- livery, the parts ſhrink up, and are contracted by reſt alone. I cannot therefore conceive, Reſt fuf, any thing is to be added to reſt, except proper ſituation of the patient. This alone is fufficient to maintain the uterus in its place, without the poſſibility of its being diſplaced by any thing; ſo that the peſſary would do more harm than good. Thus, during the whole courſe of the lochial dil P 4 charge ficient. that the 216 Of HERNIAS, &c. charge, the patient muſt lie on her back, with her buttocks raiſed, and her thighs ought to be kept together by a band, tied a little above her knees. If, notwithſtanding theſe meaſures, which are rarely taken ſo carefully as they ought , the uterus ſhould happen to be relax’d, we muſt afford the aſſiſtance recommended in the following chapter, directing our views to the relaxation, and not to the turning, with which we have nothing to do after the ute- rus is reduced; for immediately after a natu- ral delivery, the orifice of the uterus is gra- dually contracted to ſuch a degree, that the point of a quill can hardly be introduced into it, and its body reſumes its uſual thick- neſs: Conſequently the ſame thing mult happen after its perfect reduction, and there can be no turning of it any more, eſpecially when the patient is placed in ſuch a ſituation as determines its bottom to remain at a dili tance from its orifice, a a OCH СНАР, OTO dh bolo JIC นาว 2 คน OF HERNIAS, &c. 217 W a laxion કારyt pod CH A P. XXV. bras of the relaxation of the uterus, of its fall- ing down properly ſo call’d, and of the re- laxation of the vagina. CHAT furgeons call a relaxation of what is the uterus, is very different from meant by the real ſignification which theſe words ſeem on of the to import, ſince this fymptom happens only uterus. when its ligaments are fo lengthen'd as to permit it to defcend more or leſs into the va- gina. When its ligaments are only relax'd to a Of its re- certain degree, the diſorder is properly call’d properly a relaxation. When the uterus falls out at the vagina, of its de- this fymptom characterizes a falling down of ſcent the perly lo uterus, properly ſo call’d. may fall down in part, or in whole. fonly a part of it falls down, it is calld an incomplete hernia of the uterus, and if the incom- whole of it deſcends, it is call’d a complete plete fall- The vagina may be alſo relax'd totally or terus. part. If a part of it is only relax'd, the What a diſorder is call'd a relaxation of the vagina, and falling but if the whole of it is relax’d, the diſorder out of the is call'd a falling out of the vagina. vagina For the production of theſe diſorders, the ame remote and proximate cauſes which in- duce other hernias muſt concur. ſo callid. a pro- But it call'd. a Com - plete and hernia of the uterus. of the u- . relaxation a If the li- gaments are. Cauſes. 218 Of HERN I AS, &c. gaments of the uterus, and the membrane of the vagina have been relax'd by a redun- dance of ſeroſities, when the proximate cauſes, ſuch as efforts of all kinds, come to ac, the uterus will deſcend more or leſs, and Magned form a ſimple relaxation, or an incomplete or complete defcent. The ſame thing happens to the vagina, fince it may be either relaxi, or totally turn'd out. According to theſe principles, unmarried ject to women may be ſubject to diſorders of this orders. kind. 'Tis indeed true, that they are not much expos'd to them as married women , tho' in ſome of the former, the uterus falls down and the vagina is relax'd in a furprizing Girls fub- theſe dif- manner. Married women moft incom- moded During geſtation, the ligaments of the uterus are greatly lengthen'd, and the vagina generally is extraordinarily diſtended when the infants remain long in the paffage. So that mot with theſe generally, married women are incommode diforders, with theſe diſorders, eſpecially when they do not by repoſe and good management give the parts a liberty of reſuming their natural ſpring and elaſticity. General The ſymptoms of theſe diſorders are fymptoms different kinds. When the uterus is fimply relax’d, the patients feel ſome pain in the region of the kidneys, and in the ſuperior and internal parts of the thighs. They walk leſs eaſily than before, and are often obligo to reſt themſelves, becauſe they are never of theſe diſorders. 10 ealy OF HERNIAS, &c. 219 cult dir. eafy as when they fit or lie. Theſe pairs happen becauſe the ligaments are pulled by the weight of the uterus, and are for the time reaſon augmented in proportion as it deſcends. si When the uterus is totally defcended, the Change of ſymptoms fymptoms change their nature, ſince the pa- tient has either a frequent inclination to make water, or a difficulty in diſcharging her u- tine. The difficult diſcharge of urine is owing Cauſe of to this , that the bladder is ſometimes carried the difi- along with the uterus. In this caſe the diffi- charge of culty of making water is greater or leſs, ac- urine. cording as the bladder has deſcended more or leſs, and according as its neck is more or dels compreſs’d by the uterus. The frequent inclinations to make water, Frequent happens , becauſe the bladder is compreſs’d inclination by the parts, which fill the vacuity left by water. the uterus which has quitted its place, fuch a the inteſtines and epiploon, which preſs upon the bottom of the bladder and inſinu- ate themſelves between its body and the rec- tum. In this caſe the bladder can only hold a very ſmall quantity of urine, which muſt conſequently be the more frequently evacu- When the uterus is totally prolaps’d, it is Accidents expos'd to the friction of the thighs, and to happen to the impreſſions of the urine, which flow- the uterus ated. which when it is ad ing totally fallen out, 220 Of HÉRNI A S, &. eroja SO II o 1 coing continually on its ſurface, irritates it and produces intolerable heats, excoriations and pains. Theſe fymptoms are fucceeded by ſuch a attack the uterus itſelf, which becomes in flated and indurated. Its inflation renders it ſometimes as large as a child's head, even in married women. It is very eaſy to account for this inflation, if we conſider that it can- not remain without the body for any confide- rable time, without having its veſſels com- preſs’d, and that the blood continually co- vey'd to it by the arteries, cannot be re- turn'd by the veins in a proportionably large quantity. As long as the veſſels are in a condition to yeild to the effort which the blood makes to accumulate itſelf in them, bulk of the uterus is augmented, but when theſe veſſels are arriv’d at their greateſt ex- tention, and can no longer yield to the efforts of the fluids to accumulate themſelves in them, theſe fluids are collected in them, indurate the uterus to ſuch a degree , that i fometimes becomes as hard as a ſtone. From this circumſtance the following inconvenient cies ariſe. A part of the humours becomes ſtagnant in its veſſels, which breaking, allow a purulent, fetid and cadaverous matter to be continually diſcharg'd from them. There are ulcers form'd both within and without the u- terus, an inflammation of it is brought of and quickly ſucceeded by a gangrene proves mortal. 0 which The OF HERNIAS, &c. 221 mitant laxation and turn- The ſymptoms accompanying a relaxation, Conco- or turning of the vagina are not very confi- fymptoms derable, except when it is totally turn'd out ; of the re- in which caſe it neceffarily draws the uterus after it. In this caſe the patients feel pains ing of the about the region of the kidneys and in the vagina. fuperior parts of the thighs, on account of the vellications of the ligaments. By the touch, we eaſily know the relaxa- Sigos. tion of the uterus, which is perceiv'd by the inger , more or leſs near to the entry of the ragina . But we ought always to examine the patients when they are ſtanding or in the poſition proper for going to ſtool, defiring them to make efforts, by which means the uterus is eaſily determin’d to deſcend. We much more eaſily diſtinguiſh the in- Means of or complete deſcent of the uterus guiſhing by the fight and the touch. By the fight we complete ditinguiſh its orifice. By the touch we find and in- it more or leſs advanc'd externally, and per- deſcents. complete Oive its folidity, which diſtinguiſhes it from a relaxation of the vagina which fometimes mpoſes on the fight. Beſides, by puſhing uterus with the finger, we convey it to the bottom of the vagina, whereas when the gina is relax'd, upon attempting to reduce 4 the finger enters into the vacuity form’d by complete diftin- the ly is cavity. In caſes where the uterus cannot be re- un'd, we may know by asking the patient, whether it re-enter'd in the beginning. In a word 222 OF HERNIAS, &c. ſtic, 1 I a CO ag word we muſt carefully obſerve, whether is not an extraneous body, ſome of which on particular occaſions aſſume figures fo near- ly reſembling that of the uterus, that they de- ceive the fight of perſons little acquainted come with the ſigns of theſe diſorders. Progno- Of theſe three diſorders, the relaxation and turning of the vagina, tho' without dan- ger, are nevertheleſs the moſt difficult to be cur’d. On the contrary the relaxations, or incom- plete deſcents of the uterus are eaſily curd when they are not of too long ſtanding. even ſometimes happens that after a new im- pregnation patients are cur'd of them. Danger of The violent ſymptoms which happen in complete deſcent of the uterus, ſo fully evince the danger of this diſorder, that at preſent we ſhall ſay no more of it. The intentions we ought to purſue in cure of theſe diſorders, are to remove the re- mote cauſes which have produc'd them, and to correct the effects of theſe cauſes. Every thing that tends to evacuate the redundant fe- rofities which continually moiſten and relax theſe parts, and every thing which can con- tribute to reſtore their loft tone, ought to us'd with order and accuracy. But as all re- medies would be uſeleſs without reſtoring thoſe parts to their natural ſituation, the pa tients ought to remain in perfect reſt, as long a time as is requiſite for the cure. The fitu- this diſor- der. Care. the be ation Of HERNIAS, &c. 223 zion is the ſame with that I mention'd, Situation then ſpeaking of the deſcent or burning of of the pa- . But we are not to begin the cure, ill immediately after the menſtrual evacua- the uterus. tion. The patient is to be ſubjected to a deſicca- Regimen. tive regimen, in order to conſume the redun- dant humidities, which keep up the relaxa- ton of the parts. Beef, mutton, pigeons, abbits , partridges, pheaſants and other ali- ments of nutritive qualities are permitted in theſe caſes. Veal, lamb, fowl, water-fowls, have too pinguious, oleous and relaxing qua- ties , which would oppoſe the intentions of ture , and counterbalance the efficacy of the medicines. The uſe of coffee, tea, choco- stand vanelloes may be reaſonably permit- and a little good wine can do no harm. far ordinary drink, the patient may uſe the llowing ptiſan. lake of the roots of china and of ſarſapa- rilla, each two drams, thirty grains of juniper berries bruis’d, and of ſalt of tartar one dram, boil the whole in eight pints of Water, reduc'd to fix; paſs the decoction thro ' a cloth, and add a little lemon juice a to it. The patient ought to be purg'd every fourth % with the following draught. Take 224 Of HERNIAS, &C. Purge in Potion. Take of cleans'd fena two drams, of the roots of mechoacan and jalap in powder each a fcruple, and vitriolated tartar ten grains, boil all gently in half a pint of the water of lettuce, or harts-tongue. We muſt augment or diminiſh the dole according to the conſtitution of the patien . For very delicate perſons, we muſt add two ounces of manna inſtead of the jalap and mechoacan. Perſons who cannot uſe liquid purges, may pills. uſe the following pills, Take of the troches of alhandal three grains of ſcammony fix grains, cf black helle- bore ten grains, and of the aquila alba fifteen grains ; incorporate the whole with fyrup of buck-thorn, into a maſs to be divided into ſeveral pills. Injections During the uſe of theſe remedies, which by parti. cular fy- ought to be continued twelve or fifteen days , ringes. we muſt make injections thrice a day into the vagina, with a fyringe of my invention , which is much more commodious and uſeful, than any of thoſe commonly us’d*. Thein- jection is to be compounded of the following ingredients. Take * They are ſold by George Stafford, Pewterer, at the corner of Hemings Row, facing Shandeis Street, St. Martina Lane, London, Of HERNIAS, &6 225 Take of the lower ſtalk'd plantain, of the greater confound, and of roſemary each a large pugil, thirty acorns; of the roots of biftort an ounce; bruiſe the accorns and the biſtort roots, boil the whole in twelve pints of water reduc'd to nine. Allow the whole to cool, ſtrain the decoction, and filtrate it thro' brown paper. We muſt manage matters, ſo as that the injection may remain in the vagina. For this purpoſe we muſt raiſe the patient's hips as much as we poſſibly can, and keep the labia pudendi fhut with our fingers, that the injection may remain in the vagina for fome time. We muſt alſo put a bafon un- der the hips, in order to receive the injection in proportion as it flows from the vagina. Every time we make theſe injections, we muſt carefully examine, whether the uterus is in its proper place. This precaution is ne- ceffary, that we may not be impos’d upon by the patients, who conſult rather their eaſe than their real intereſt. After twelve or fif teen days we muſt add the following herbs to the ingre- dients, in the injec- Thyme, marjoram, wild thyme and ſage, each a pugil; all theſe are to be boild to- gether, and the decoction filtrated as above. Every time we uſe this preparation we muſt add a ſpoonful of the arquebuſade Q water; Change in theſe injections. tions. 226 Of HERNIAS, 830 water; thefe injections are to be continued for eight days. So trottimo flrl nors aim od dolu o od fuld In this liquor we are to ſoak flanel cloths and apply them warm from the hip-bones to be the loweſt part of the places at the foldings of Lay the thighs. We muſt renew the flanels be- fore they become cold. We need not punc- su tually confine ourſelves to the quantity of the ingredients above mentioned, but retrench and diminiſh fuch of them as are either too ſcarce, or too dear for poor patients . The vulnerary water for inſtance, which is mix'd with the injections, in order by its fpirituous penetrating quality, to open a paſſage to the principles of the aromatic and aftringent herbs of which the decoction is prepard , may be ſupplied by common ſpirits. The roots of farſaparilla, and thoſe of china may be alſo ſupplied by the wood of the juniper tree, and by the root of angelica, augment- ing the doſe to one half more. Theſe all- fwer the ſame intentions, by freeing the parts from theſe redundant ferofities which main- tain their relaxation. Itchings As theſe injections fometimes occaſion in appearin ſupportable itchings in the vagina and its'en- try, by bracing up the orifices of the exteri how to re- our veſſels which are deſtin’d to ſeparate fome medy humour from theſe parts, it is prudent in phyſician or furgeon, who has the manager ment of the patient, either to ſuſpend thele tron jections ; them. I reme- OF HERNIAS, &c. 227 De the cure 00 remedies, or to diminiſh their force in order to mitigate their effects. 27th anders to Whilſt the patient uſes the injection laſt prefcrib'd, he muft drink the following ptiſan.od-i sw modo vlage bas totswol Take of china, ſarſaparilla, guajacum and A deficca- , faſſafraſs, each two ounces; boil the whole ought to over a very gentle fire, in nine pints of terminate water reduc'd to fix. bote We muſt ftrain the decoction thro' a linen cloth, and when it is cold put it up in cloſe ftopt bottles. The patient is every day to drink a pint of it, taking one third in the morning, another at noon, and another at night. To each of theſe doſes, we may add as much of the eſſence of Rabelius, as is fuffi- cient to give it an agreeable acidity. If du ting the cure, the patient is coltive, it is pro- per to give her ſome clyfters of bran-water, Some days before the approach of the tenſes, we muſt defiſt from all medicines, but the patient muſt ſtill retain her proper even during the whole time of her menſtruation. After the uſe of all theſe medi- cines, ſhe may be rais’d, but with great pre-ban cautions for during the firſt day ſhe muſt fitta with her back very much reclin'd, and her thighs fupported on ſomething which maya keep them more elevated than her hips. She muſt avoid all efforts which might occa- fon a new relaxation. There would be no danger, pofition Q2 228 Of HERNIA S, &c. TO DOTTO gailowo be TS tug 1970 io lwol blod Treat- nicht danger, if ſhe was to become pregnant im- mediately after the cure. 063 Vem henta od Don- nel bb C H A P. XXVI. Of thoſe diſorders which oppoſe the cure of hernias of the uterus. TH HE means of cure propôs d in the precedirg chapter, though efficacious , would become uſeleſs, and even very preju- dicial, if the uterus was very hard, tumified and obſtructed; for in this caſe it would fall proper in down again by its proper weight, if it was ons of the poſſible to reduce it to its natural place . The ſtate in which it would be, would be worſe than the former; for the remedies above pre- fcrib'd for corroborating the ligaments of the uterus, cannot fail to act upon its body, be- fore their virtue could be convey'd to them. By this means the ſubſtance of the uterus would be deſtroy'd and become more callous and foon arrive at the ſtate of a ſcirrhus, the fatal conſequence of which is an ulceration , againſt which art is of no advantage. We muſt therefore firſt of all make it our buſineſs to cure the local fault of the uterus ; that is to ſay, we muſt foften it, remove its inflation, and reſtore it to its natural bulk, which ends are obtain’d by internal as well as Regimen. uterus. external remedies. But a proper regimen is of the greateſt importance among all the Sito meurs FoCoU ERN 229 32 Я ЗНО Of HERNI A S, &c. Introdas **199115b means of cure. It ought to be moiſtening and cooling. Thus the patient may cat broths prepar'd with a third of beef and two thirds of veal, to which we may add lettuce, chervil , purſlane and white onions. We may alfo indulge her now and then with a bit of boild fowl or fiſh. Her ordinary drink ought to be water with a toaſt in it, or weak rice- water. arm. ES Three or four days after the uſe of this re- Half- gimen the patient muſt be blooded in the baths. The day after the veneſection, the muſt uſe half-baths, prepared of mallows, marſhmallows, pellitory of the wall, the herbs mercury and mullen. Theſe herbs may be uſed either altogether or ſeparately. One or two of them are even fufficient, if we put five or fix handfuls of them in thirty or forty pints of river-water. When theſe herbs are well boild, we paſs the water thro' a fierce, and forthwith uſe it as a half-bath, in which the patient muſt continue at leaſt four or five hours every other day. Theſe baths are to be continued for eight, ten, and fometimes ſixteen days, obſerving to change the water every time the patient bathes. It is the relaxation of the proper ſubſtance of the uterus, which muſt determine the time and the continuation of the baths. In the intervals between the bathings, we muſt ap- ply to the body of the uterus ſoft and worn Innen-cloths, dipt in tepid milk, or in the Q3 deco&ion 230 Of HERNIAS, &c. terus. Fomenta- decoction for the baths. Theſe cloths muſt tions. be now and then renew'd. If the uterus, when thus deſcended, is cover'd with ulcers, which are not of a malignant kind, we muft reſtore the uterus to its place, becauſe ſuch ulcers will heal of themſelves, when the cauſes which maintain them are removed. If the ulcers are venereal, we muſt employ the remedies proper in ſuch caſes; and if they are of a concerous nature, we muſt, without heſitation proceed to the extirpation of the u- It is not my buſineſs, in this treatiſe to ſpeak of the proper method of treating theſe venereal ulçers, nor of the chirurgical operations, I now proceed to the remedies proper for the cure of deſcents of the uterus, when indurated without ulcers. Situation When we have replac'd the uterus, we pa- muſt maintain it in its place, by the fituation which the patient ought to keep herſelf in, and of which I have ſpoken before. We muſt afterwards make it our buſineſs Grote to render the humours fluid, that they may borside be reſumed into the maſs of blood, and eva. cuated. Attenuants, both internal and external, ought to be employed for this purpoſe. Theke muſt be uſed during the whole interval of the menfes. We muſt begin by giving the patient the following broths ag TOHO of the tient. con . a Braths. Take a fourth part of a fillet of veal, of 2 dozen of the hinder legs of frogs, water crefies , Of HERNIAS, &c. 237 eiro Vola ner. creffes and wild fuccory, each a pugil, and not a white onion; boil the veal or frogs well, in a quantity of water fufficient for two meſſes; then add the herbs, and allow them to boil only for four or five minutes; then ſtrain the whole decoction, one half of which is to be taken by the patient in the morning faſting, and the other in the afternoon, three or four hours after din- To each meſs we muſt add thirty grains of wood-lice reduced to powder, or we muſt order the patient to take this powder in a ſpoonful of the broth. Ini During the uſe of theſe broths, which Plaiffers ought to be continued till the menſtrual eva- the region applied to cuation is over, we muſt, after ſhaving off of the the hairs, apply the hemlock plaiſter to the uterus. region of the uterus, that is, from one groin to the other; and this plaiſter is to be changed every four days. When the menſes are over, it ought to be Pargation our buſineſs to free the uterus from the fordes lodged in it; for this purpoſe, we muſt uſe obtained. the following medicines. bevolen Take of marjoram, favine, galangals and cantharides, each an equal quantity. The whole being reduced to a powder, and in- timately mixed, fill a ſmall fac with them made of a doubled piece of white ſatin, in a round and long figure, proportioned of the u- terus, how bloque quo QA to 232 Of HERNIA S, &C. to the cavity of the vagina. - The powe ders ought to be ſtuffed into this facriu ſuch a manner as to acquire a ſolidity proti per to give it a due figure. The ſoft op filky ſide of the fatin ought to be out, wards, that it may be the more exactly applied to the orifices of the fmail veffels diſperſed through the vagina. A cord is to be fixed to the fac, that it may be drawn out with the greater eaſe. 90 fac for the uterus. с Uſe of the The property of this fac is to excite an irritation in the vagina and uterus, which obliges the fibres to contract themſelves, and expreſs the humours contained in the fub- ſtance of the uterus. Sometimes the uterusi ſuffers a conſiderable pain by this means, and at other times the patient only complains of a certain numbneſs of this part ; but in both caſes this remedy, though very good in it- felf, ought not to be abuſed, becauſe it may occaſion an inflammation, if this fymptom not prevented by drawing it out ſeaſonally . When its action produces intenſe pain, rib ought forthwith to be withdrawn. If there is only a numbneſs in the uterus, we muſt withdraw it, when the pulſe indicates the neceflity of ſuch a conduct, by its elevation and frequence; for theſe are proofs that the acrid, volatile and penetrating parts of this remedy have entered the maſs of blood. but de root of A و OF HERNIAS, &c. 233 in- As ſoon as the fac is withdrawn, the uterus diſcharges a thick, turbid and bloody matter. As long as this diſcharge continues, we have nothing elſe to do but to waſh the pudendum and vagina with chervel water. We ought alſo to inject ſome of this water into the vagina. This diſchargé continues two or three days, and ſometimes more. When the evacuation has ceaſed, we purge the patient with the pulvis cornachini, or the arcanum duplicatum, mentioned in chap. XV. or with the pills recommended in the foregoing chapter. The day after the purging, we may troduce a new fac, if from the quantity of the matter diſcharged from the uterus, or its conſiſtence, which is diſcovered by the touch, we think it neceſſary to purge it more . We introduce one finger into the va- gina, to know the ſtate of the orifice of the uterus, and at the ſame time puſh it as high as poffible, and compreſs it with the other hand above the pubis. If it is of a conſiderable bulk, we feel it with the hand, provided we order the patient to make water or the uterus ſenſible of the com- preffion, gives occafion to the patient to com- plain of iti vo The uterus being thus purged and freed from every thing, which can render its bulk and weight more conſiderable than in a na- tural ſtate, the only thing we have to do is to previouſly, 234 Of HERNIAS, &c. The fluor albus an to the cure. to maintain it in its place, by corroborating its ligaments, and reſtoring their ſpring The patient is to obſerve a proper regimen , and uſe the remedies preſcribed in the fore- going chapter. Theſe remedies would, however, be very indication dangerous, if the patient was ſubject to the contrary fluor albus, which would be ſuppreſſed by them, and throw the patient into a worle ſtate than before. We muſt therefore la bour to remove this diſorder, for two rea- ſons. The firſt of theſe is the neceſſity curing a diſorder, which produces mortal exhauſtions, throws women into conſump , tions, and is the ſource of incurable ulcers . the uterus. I ſhould here ſpeak of this di- order, and the methodical treatment of I but this ſubject would lead me too far from my purpoſe. I ſhall, in the work as I have promiſed, lay before the reader every thing my application and experience have diſco vered moſt effectual for the cure of thele diſorders. The intereſt of ſurgeons to ex tend their knowledge, with reſpect to diſeaſe, gives me reaſon to believe, that they will be pleaſed with the means I ſupply them of curing this diſorder, as obſtinate to the ordinary methods, as it is obſcure in beginnings. baltul 918. ਕਈ ਪਰ doba bobot CHAP me alige folle omo Doqlar diw 36 azador OF HERNIAS, 8C 235 TONTEST THE W berodo 100 vdes gongd CH A P. XXVII. egildi Of the palliative cure of relaxations and de- ſcents of the uterus and vagina, and of effaries. bam 17 THEN all the means mentioned in Palliative the preceeding chapters either could cure, in not be employed, or have not ſucceeded for the radical cure of the diſplacements of the uterus and vagina, we are obliged to be con- tent with the palliative cure, which conſiſts in maintaining the parts in their natural fitu- ation, by means of certain machines called peftaries. Peflaries then are inſtruments invented to Of peffa- keep the uterus and vagina in their natural places. Some of theſe are with force intro- duced into the vagina, whilſt others enter it what caſes proper. . ries. 1 2 eafily' . The former are maintained in their place, Some en- only by the action of the fibres of the vagina, ter the va, which being divided by the peffary, whoſe force. diameter is greater than that of the vagina, muſt contract themſelves every where. Theſe peflaries are of different ſubſtances and fi- gures . Some are of cork covered with wax, others are of wood, and others of ivory. are alſo of ſilver, and others of gold. With reſpect to their figures, fome are round, others are oval, and others triangular, In a word, fome of them are of all other ir- regular Some 236 OF HERNI A S, &c. Others en- into the regular figures, according to the intention d him who employs them. They are almal all flattiſh, being at moſt ſeven or eight line in thickneſs. Their diameter is never de- termined, being greater or leſs in proportion to the largeneſs of the vagina. But of who ever ſubſtance they are made, and whatever figure they are of, they are always perforated in the middle, in order to facilitate the di- charge of the matter from the uterus. Of theſe peffaries which enter into the ter eafily vagina, fome are fupported on ftalks, and by vagina. external cords tied to a girdle; others are made with iron branches, and others with ſprings, which permit them to enter eafily into the vagina, and by their ſeparation from the body of the peffary, maintain it in is place. All theſe kinds of peſſaries have not only common inconveniencies common to them, but each to all paſ- has alſo diſadvantages peculiar to itſelf . . which en- order to be convinced of this, we muſt con- ter with fider, firſt, what their uſes ought to be. The general view propoſed by the uſe of theſe in ſtruments, is to maintain the uterus and va- agina in their place, after they have been dil de placed. This intention is never anſwered by any kind of peffary. Theſe which enter by force, have the following inconveniencies in common. They preſs always in the lowel part of the vagina, in conſequence of which the uterus can never be maintained in its na- Faults force. tural Of HERNI A S, &0. 237 To Do ovo common tural place; they make compreſſions on the parts of the vagina, which cauſe, in the ver- of its ſubſtance, obſtructions, which gra- dually communicating themſelves to the ute- rus , produce diſcharges of purulent and in- fected matter ; and this diſorder is called the fuor albus. The others, which are eaſily introduced Faults into the vagina, not fitting its cavity, permit to the per the uterus to flip between the vagina and the faries peflary. From this neceſſarily ariſe two in- which en- ter eaſily. conveniencies, the firſt of which is, that the terus flips out as if there was nothing in the vagina; the ſecond is, that the uterus is ndely compreſſed, bruiſed and contuſed by te compreſſion made upon its body by the peflary, which follows all the motions of the body when the patients walk, ſit down, or rife . Beſides, both theſe kinds of peffaries al- ways compreſs the bladder very unequally, and by that means greatly injure it. Suced In a word, none of theſe peffaries are fuf- ficient to retain the ſmalleſt relaxation of the e20 ES TO vagina. culiar to The faults which are peculiar to each Faults pe- pelflary, ariſe from its ſubſtance. Thoſe made each fpe- of wood and cork become rotten, and con- cies of vey ſuch a ſtench wherever the patients go, peffaries. wat people can hardly ſupport the odour which exhales from their bodies. Thoſe of sury are too heavy and flippry, ſo that they a that are 238 OF HERNIAS, &C. free th-fe faults, are continually falling out of the vaginala Thoſe of filver are pierced by the acrimony met of the matter, whoſe diſcharge from the mot uterus and vagina they excite. Hence arik mortal fymptoms, by the introduction of the wat membranes of the vagina, which vegitate into their cavity; for theſe forts of peffaries 10 are hollow, otherwiſe they would be too heavy. Peſſaries of gold, beſides other dile advantages, are ſo expenſive, that few pa tients are able to purchaſe them. Peſſary of Necefſity has induced me to invent a pela my inven- fary of a quite different kind, which, without from all having any of the inconveniencies of the coule thers, has all the advantages neceſſary to hide der the uterus and vagina from falling down to when we are reduced to the laſt means, to which the whole palliative cure is reduced My peffary is a kind of ivory ſtopper, of a round or oval figure, at that part which cor- reſponds to the aperture of the vagina. It is more or leſs elevated towards its fuperior furo b.face, and more or leſs long towards its bale or inferior ſurface, which is always convex and oval. Its higheſt elevation is that of an inch, or fifteen lines, and its greateſt length is three inches. It is maintained without the lips of the pudendum, by four final bands, two of which are tied to its anterior, and other two to its poſterior parts. bands are fixed to a girdle of leather of fiul tain, which bears upon the hips. The AY Thele vagina OF HERNIAS, &c. 239 pagina and uterus are by no means income noded by it, and the patient can eaſily re- e and apply it when the pleaſes. She is mer in ſuch a condition as to repulſe her bulband, to whom the uſe of the ordinary tillaries would prove very troubleſome and hommodious in embracing her.ro ofert It is true, that by means of this peffary, the uterus is never maintained in its proper place , but it is ſo at leaſt as much as by other pellaries; and this has two advantages, which s, that it can ſuffer no alteration, and never all out; beſides, the patients will not be ex- multed by the fluor albus, which is often sduced by other peffaries, of whatever kind they be. BUSCA el is, and its CHA P. XXVIII. of the falling down of the fundament. THE fundament, or anus, is the lower What the part of the inteſtinum rectum, and fundament place where the inteſtinal canal termi- ufe. tes . Its uſe is to open and afford a paſſage the evacuation of the feces and wind, nd to cloſe again, in order to hinder their soluntary diſcharge. Theſe motions are perform'd by the action Iis action. i three muſcles, one call'd the circular or phincter muſcle, becauſe it ſurrounds the ex- smity of the inteftine. The two others are HO cail'd 240 Of HERNI A S, &c. a call'd the levatores ani. Of theſe three mul cles, the firſt ſerves to open and ſhut the anus; and the two others to draw the fur dament inwards, and by that means afſift the action of the ſphincter. When, by any cauſe, theſe muſcles are to much relax'd, the fundament falls down form of a purſe, more or leſs large, form’d by the inteſtine, which is eafly lengthen d externally in returning, as a flock ing does when it is pulld off, without turn- ing it altogether. The inteſtine ſometime deſcends lengthways, and may be ftretch to the length of a foot. This diſorder, which is very common more com-among children, ſometimes happens to adults. In both the remote cauſe of this relaxa- tion conſiſts in the redundant ferofities, which Primitive render the muſcles too moift, and, by weak- ening them, deſtroy that elaſtic force which is neceſſary for their action. In children, the crying to which they are mining ſubject, and the ſituation in which they are put over cloſe-ſtools, on which they are fre quently left for a long time, without think- which determine the rećtum to fall down. ing on the harm it may do, are the caules In adults, violent efforts made in ſtool, aifo determine the inteſtine to this di order. This dif- order mon to infants than a dults, cauſes. Deter- cauſes. going to OF HERNIAS, &c. 241 toms. 1 diſorder. It is rarely accompanied with troubleſome Symp- fymptoms, becauſe it is generally ſpeedily remedied; but if we neglect to return the inteſtine, an inflammation will enſue, and a gangrene may be induced, which would ei- ther prove mortal, or expoſe the patient to the greateſt danger. The figns of this diſorder are fufficiently Signs. manifeſt of themſelves, without recounting them. Beſides, they have nothing of an equi- vocal nature which can lead us into error, with reſpect to them. The means of remedying this diſorder, Means of confift in returning the inteſtine, and in keep- remedy- . ing this ing it return'd. The reduction is very eaſy both in chil- Manner dren and adults, when the inteſtine only of return- forms a kind of thick cuſhion or pad round intelline, We order the patient to lie on his over the edge of the bed, with his feet teſting on the ground: Then, preſſing the two buttocks againſt each other, and making gentle ſemi-circular motions from right to left, and from left to right, on the middle of the pad or cuſhion, it enters very eafily. We put children on ſome body's knee, ſupport their feet, and perform the operation in the man- ner now directed. When the inteſtine forms a kind of pud- ding, which extends itſelf in length, the operation is more difficult, eſpecially in chil- dren when they cry. We muſt therefore R. amuſe ing the the anus. belly a 242 of HERNIAS, &c. amuſe them, and embrace the favourable moment in which they allow us to operate . Then, having our nails cut very ſhort, we in- troduce the fore-finger into the extremity of the inteſtine, puſhing the internal part, which forces that which is external to follow the motion of the finger : With one or two fin- gers of the other hand we ſupport the edge of the aperture of the inteſtine, whilſt we retract the fore-finger, to hinder that which is reduced from coming out again. When the finger, which enter'd firſt, is ready to come out, we thruſt in the other; and in making theſe motions fucceffively, we reduce all that was fallen out, to the very brink of the anus. Then we continue theſe motions, by introducing the fingers into the fundament, one after another, in the ſame manner as fore, in order to puſh it to its brink or edge. We have ſometimes a good deal of difficulty to perform theſe motions in the fundament , becauſe it contracts itſelf, eſpecially in chill dren. In this caſe we muft fuſtain it, and put a little oil or butter in the aperture , and upon the edges of the pad which it forms : Then, with both hands, we perform the fame motions which I before faid were proper compreſſing the pad with the two buttocks but as the pad is too large in this caſe, the compreſſion made by the buttocks would be ineffectual and impracticable.lt rarte DEL 01 set The be 0 Of HERNIAS, &0. 24 а The fame thing is done with more eaſe in adults, who yield to the intentions of the furgeon.rod in no gaivni nad to We muſt, however, have a regard to fome circumſtances which may oppoſe this ope- ration ; fuch as an inflammation and deſic- cation of the inteſtine. In theſe caſes the inteſtine is not ſufficiently flexible to yield to the various motions which are neceſſary to the reduction. If it is only dried, we may moi- ften it with a feather, dipt in recent oil of ſweet almonds, in order to render it more flippery. If it is inflamed, we muſt forth- with blood the patient copiouſly, and reduce the inteſtine immediately after the veneſection. All means muſt be employ'd for its ſpeedy reduction, otherwiſe the inflammation will infallibly be augmented, and a gangrene brought on, which cannot be remedied with- out the greateſt difficulty. If we ſuſpect ſome faeces retain'd above the anus, we muft, above all things, and in oppoſition to all difficul- tes, inject a clyſter of bran-water, mix'd with a third part of oil. sud The reduction being made, we muſt re- tain the inteſtine in its place by a proper fitua- tion of the patient, and by compreſſes and a bandage. This is often fufficient in children, provided we take care every time they want to go to ſtool, to inject a ſmall clyfter, in or- der to foften the hard fæces, which would oblige them to make efforts. We muſt ne- a R2 ver 244 Of HERNIAS, &c. ver ſet them on cloſe-ſtools, when they want to go to ſtool. When they are ſtrong enough to ſtand, it is ſufficient to lean them againſt ſomething which may ſupport them. If, notwithſtanding all this care, the inteſtine falls down, it is of ſervice to preſs the fore and middle-fingers on the two ſides of the anus, in order to retain the inteſtine in the efforts which the infant makes in the expul- fion of the fæces. With reſpect to adults, they may affit themſelves in the ſame manner, by preſſing the two fingers on each fide of the anus, in order to puſh the inteſtine upwards, in pro- portion as the excrements are diſcharged . They ought alſo to take a clyfter every morn- ing, to facilitate the evacuation of the faces, They muſt keep themſelves in an almoſt up- right poſture, when they go to ftool. This attitude is the ſafeſt, and by far preferable to that preſcribed by authors, which confifts in placing the patient on a board with a narrow hole, and ſtuffed at the circumference. Be- fides that this does not hinder the inteſtine from deſcending, the circumference of the hole produces a friction on the inteſtine , which, tho' not very painful, is nevertheleſs diſagreeable. In adults we may cure this diſorder, when recent, by making them remain in a ſtate of reſt for fifteen days, and by applying very thick compreſſes, fecured by a bandage in Cure in adults. a the form Of HERNIA S, &c. 245 form of a capital T; that is, by a bandage which paſſes round the waiſt above the hips, and to which is tied behind another bandage four fingers in breadth, llit in two, which paffing over the compreſſes, and from thence under the buttocks, muſt be tied to the girdle before. The compreſſes muſt be foak’d in fome aſtringent liquor, fuch as the fol- lowing: Take a pint of the tarteſt red wine; boil it for a quarter of an hour ; red roſe-buds, pomegranate-bark, and roch-allum, each a dram; and of dry hogs-dung pulverized, an ounce : Paſs the whole thro' a linnen- cloth, and uſe the preparation warm. The compreffes ought to be kept always moiſt. If theſe remedies are ineffectual, and if the fundament, as it ſometimes happens, falls down habitually when the patient does not go to ſtool, we muſt apply to it a peſſary, like that which I uſe in deſcents of the ute- rus, and which is deſcribed in the end of the preceding chapter. asst CHA P. XXIX. Of falle bernias in general. THERE frequently happen certain pro- Falle herk minences or tumors in the groins, ſcro- nias, tum, and ſometimes in the lips of the puden- dum, R 3 246 OF HERNI A S, &c. Hernias are very common dum, but rarely in the navel, and in the fold- ings of the thighs; and theſe tumors, on ac- count of their ſituation, figures, and confift- ences, have been rank'd among the claſs of hernias. But, in order to diſtinguiſh them from hernias properly ſo call'd, they have diſorders. received the denomination of falſe hernias . The knowledge of theſe diſorders, which are almoſt as frequent as true hernias, is of great importance; both that we may not confound them with true hernias, and that we may able to prevent them, to ſtop their progreſs and to cure them after they are arrived at ſuch a height, as renders ſome of them the moſt terrible of all diſorders. Diviſion Falſe hernias are generally divided into five hernias fpecies ; namely, a bydrocele, a ſarcocele, a kerſokele, a ſpermatocele, and a pneumato- cele. An hydrocele is a tumor produced by a collection of water, which characterizes a particular ſpecies of dropſy of the part where the water is collected. A farcocele is a tumor of the teſticle, which ſeems to give it the conſiſtence of a flethy maſs. A kirſokele is a tumor or prominence , form’d by the dilatation of the veſſels. A ſpermatocele is a tumor of the teſticle, form'd by a retention of the ſemen in it. ST Post GI A of falle . 30 10 Of HERNIAS, &c. 247 BATO eine A pneumatocele, according to authors, is a collection of air in thoſe parts where hernias are form’d. 29000 rad CHA P. XXX. Of the general cauſes of falſe bernias. or TF the reader recollects the general idea I have given in my anatomical expoſition of the human body, it will be eaſy for him to comprehend what the general cauſes of 33 SAS TO falſe hernias are. lids occaſion to falſe The whole body is compos’d of folids and Diſorders fluids, that is to ſay of liquids and veffels. of the fo- Perfect health conſiſts in the agreement and Auids give harmony between the fluid and the folid parts, but if the fluids are too thick, and the vef- hernias . fels either too rigid or weak, there is no longer an equilibrum between the ſolids and the fluids. The veſſels have no longer that proper ſpring which ought to make them act on the fluids; and the liquids, which are al- ready too thick viſcid and glutinous, having loſt their motion for want of a fufficient flui- dity , are more and more infpiffated, become fagnant and block up the veſſels, and occafi- on in the parts, where they are accumulated, inflations which form tumors of different kinds, either by dilating their proper veſſels or burſting them. R 4 Ac- 248 OF HERNIAS, &c. . Divifions According to theſe principles, the general of caules cauſes of falſe hernias, are all things capable of infpiffating the fluids, or of rendering the o folids either too rigid or too much relax’d, အဖြစ် om ſuch as living in a thick air, uſing food whe- "other folid or fluid, which is coarſe, viſcid, and of difficult digeſtion, leading an idle and ſedentary life, labouring too hard, ſleeping or waking too much, giving way to violent pal- fions, fuch as love, wrath and anger, and the hindrance or retention of the neceſſary evacuations, ſuch as thoſe by ſtool and urine, and others of which I ſhall ſpeak in treating particularly of theſe diſeaſes. o a Its charac ter. T 0 The places in which it CHA P. XXXI. of the hydrocele. HE hydrocele is a tumor or prom- nence, cauſed by a certain quantity of water collected in a part. The ſcrotum is the part where this collec tion is moſt generally made. However an happens. hydrocele is ſometimes form'd in the navel, and in the lips of the pudendum in women, I have even ſeen hydroceles in the foldings the thighs of men; and in women in the places where the hernias of theſe parts hap- pen. But theſe caſes are very rare. Their dif. Authors make two kinds of hydroceles ferences. the one call'd hydrocele by filtration, and the a a 0 other Of HERNIAS, &c. 249 are other hydrocele by extravaſation, but to theſe two I add a third, which I call hydrocele by dilatation. To zabront och sticker 10 The hydrocele by infiltration, is that in of the hydrocele which the feroſity of the blood, infinuates by infiltra- itſelf into the texture of the parts. It is of tion. two different kinds, and for the moſt part happens only in the ſcrotum of men, and lips of the pudendum in women. In the firſt ſpecies, the water ſometimes Firſt ſpe. infinuates itſelf only into the ſkin of the cies of hya drocele, fcrotum, and into the muſcle common to both by infil- teticles call'd the dartos. This ſpecies of tration. hydrocele is very frequent in children, ſome of whom are born with it. Perſons who unacquainted with it, take it for wind, when the ſerofity is only infiltrated into the muſcle and not into the ſkin. Sometimes alſo the feroſity is only infiltrat- Second ed into the cellular ſubſtance of the ſheath, ſpecies of hydrocele of the fpermatic veſſels, of which I have by infiltra- poken in the anatomical explication. This tion. infiltration conſtitutes the ſecond ſpecies of hydrocele. On this occaſion the ſeroſity has this in particular , that it may come from the cavity of the abdomen, and inſinuate itſelf from one cellule into another, all along the fheath of the ſpermatic veffels. This fpe- dies of hydrocele is very common to children three or four but adults are more rarely ſubject to it. It ſometimes cauſes uncertainty when it is not well diſtinguiſhed of age, from years of 250 OF HERNIAS, &c. Third from true hernias in this, that it diſappears when the patient lies, or when in com- preffing the ſheath of the ſpermatic veflek like a bladder in which there is a certain quantity of water, we by equal compreffion , force the water from the bottom upwards , This ſpecies of hydrocele, alſo ſometimes happens to women and children three or four years old, which makes it to be taken for a true hernia, becauſe it diſappears when thele children lie, and becauſe it is not generally thought that it can happen in women. But this is not a proper place for examining the mechaniſm of this diſeaſe. fpecies of In the third ſpecies of hydrocele by infiltra hydrocele tion, the ſerofities infinuate themſelves not by infilrra. only into the ſkin of the ſcrotum, but alio into that of all the adjacent parts; fuch as the ſkin which covers the penis , and that of the thighs as far as the fundament. The cauſes of that hydrocele in which the the by, infiltration is only made into the ſcrotum in by infiltrati- men, and the lips of the pudendum in wo- men, are internal and external. The inter- nal cauſes ariſe from a bad ſtate of the whole habit of body, the principles of which are eſtabliſhed in the preceeding chapter. In women, the cauſe of this ſpecies of hy- droceles, is the compreſſion which the infant makes on the veſſels of the inferior parts of the pelvis, which hinders the return of the Huids. For this reaſon women are only VE tion. M Cauſes of on. 10 W ſub- OF HERNIAS, &c. 251 18 uterus. 7 fubject to this ſpecies of hydrocele during geftation, and in fcirrhous diſorders of the Bouton The external cauſes ariſe from too ſtrong compreſſions of the ſcrotum. It ſometimes happens that children of good conſtitutions, begot by healthy parents are born with hy- droceles of this kind, which are occafion'd by the compreſſion of the ſcrotum, between de thighs during the delivery. That hydrocele by infiltration, which ex- tends itſelf to the ſkin of the parts adjacent to the ſcrotum, has for its cauſe a dropſy, whoſe conſequence it always is. Both theſe ſpecies of hydroceles are eaſily signs of known, becauſe the ſkin of the ſcrotum is hydro- cele by very thick and ſhining, and becauſe the pref- infiltra- fire of the finger leaves a mark in it, and we y perceive the light of a candle thro' the krotum. It almoſt always occupies the two lides of the ſcrotum in men, and the two ips of the pudenda in women. The ſecond ſpecies diſcovers itſelf, mani- titly by the inflation of the penis and The firſt ſpecies has nothing troubleſome, Progno- and may be eaſily curd by the application of fic. rituous , corroborating and deficcative me- It is fufficient to apply to the Cure of motum, compreſſes dipt in lime-water, to ſpecies. which we add an eighth part of the ſpirit of mie , taking care to change the compreſſes tion. thighs. ücines. often, the firſt C Ta ON vaſation IS 252 Of HERNI A S, &c. sbb often, and to ſuſtain the ſcrotum in linnen cloths that it may not be compreſs’d by the thighs. But theſe remedies are abſolutely uſeles i the ſecond ſpecies of hydrocele by infiltration if they are not ſeconded by aperients and i hydragogue purgatives, of which I ſhall al terwards ſpeak in treating of the other droceles. Hydrocele The hydrocele form’d by extravaſation, by extra- a collection of water inclos'd in the tunica vaginalis. This ſpecies of hydrocele includes too many circumſtances to recount them all here. I ſhall therefore only ſpecify their differences which ariſe from the places they poſſels, and from their number, bulk, and figures, fince theſe differences will be ſufficient to fix the ideas of curious perſons. Diferen- Some hydroceles are plac'd above the te- fticles, whereas in others the teſticle is con. founded in the middle of the ferofities. Of thoſe above the teſticle, ſome are long, others round, and others of a pyramidal Thoſe in which the teſticle is contain' in the ſeroſity are exactly round. They differ in number, becauſe there my be only one on one fide, and there may two on each ſide. It alſo ſometimes ha- pens that there may be one and even two each ſide of the ſcrotum, and there may 1 ven be more of them. ces. figure HA 2 Of HERNIAS, &c. 253 Hydroceles may be allo ſmall, middle- na nd, or large. 01 ca 00 ce This ſpecies of hydrocele ariſes from this, Cauſes. at the veſſels being too weak are broken by the efforts the patient makes, or the blows e receives on theſe parts. The veſſels being woken, diſcharge the liquid they contain. If hey break in the internal part of the tunica rginalis, which is above the teſticle, the ſe- roity is extravaſated into this part of the coat in heath, and can go no farther, becauſe it s reunited above the teſticle, unleſs it is di- ided by the redundance of ſeroſities, which defroy the points of its reunion. If f any other veſſel breaks in that part of be tunica vaginalis, which covers the teſti- at the internal ſurface of the ſheath, the folity will be diſcharg'd from it between the Sheath and the teſticle, and conſequently te teſticle will be ſurrounded by the water. The hydrocele form’d by dilatation is that Hydrocele which the water is contain'd in a particu- by dilata- This ſpecies is very common, and has its at all along the cellular texture of the tunica inalis . It is ſometimes above, and ſome- times below the teſticle. There are ſome- times ſeveral of them at once, and of diffe- bat bulks. It is often confounded with the Wydrocele by extravaſation. This ſpecies of ydrocele is that to which women are ſub- Mt , and never to that form’d by extravaſa- 30 har fac. IS 07 tion. 254 Of HERNIAS, &c a tion. It is alſo this ſpecies which happens i al the foldings at the groin, and in the navel both in women and men. It comprehende great many particularities, which I ſhall me attempt to explain, becauſe it is ſufficient for the reader to know, that the ſmalleſt veffel are capable of being diſtended to ſuch a gree, as to acquire a diameter more than an hundred times larger than their natural dia- meter ; - ſince a veſſel, no larger than a hair , may become ſo large as to be an inch in cir cumference, as we ſee from daily experience When a veſſel wants ſpring to oppoſe the ef- fort which the fluids make to paſs thro'i, its membranes yield, by little and little, to the conſtantly reiterated impulſions of the fluide, and are enlarged to ſuch a degree as to form round tumors. The reaſon of the round figure which the tumor affumes, proceeds from the ſtructure of the lymphatic vefiek which are divided and interfected in their length, almoſt like a ſtring of beads. Qualities The liquors found in hydroceles are different natures, conſiſtencies, and colours The water they include is generally clear, of form hy- a citron colour, and frothy like urine, tha without its ſmell: Thus, properly ſpeaking it is no more than the lymph of the blood as may be ſhewn by its analyſis . But this liquor is ſometimes very thick and turbid, and in ſome caſes it is found bloody. That which is thick and turbid, acquires of of the fluids which 141 droceles. its CON- Of HERNIAS, &C. 255 mith'd daliſtence by ſome cauſes which are not well underſtood ; tho' ſome authors pretend that ; this fault ariſes from the long continuance of the fluids in the part in which they are in- oluded : But experience thews the contrary, fince I have penetrated hydroceles of twenty- five years ſtanding, whoſe water had con- mcted no bad character. The rediſh colour, and the mixture of blood ſometimes con- tand in the water, ariſe from this, that ſome blood-veſſels, being broken, allow fome of their contents to be diſcharged; whilſt, at the ime time, ſome lymphatic veſſels have fur- a part of their fluid, which makes a e mixture more or leſs red, according to the quantity of the predominating fluid. The ſigns of the hydrocele by extravaſa- Signs of wn, that is, by the rupture of the veſſels, the by- efter but little from thoſe of the hydrocele by extra- by dilatation. In the hydrocele by extrava- vafation. stion, the tunica vaginalis is never fo full, but that we may perceive a kind of undula- ton, which practice renders more fenſible ban all the precepts which can be given. In s hydrocele form'd by a dilatation of the vef- the tumor is always exactly round, hard, ad refifts the touch more. It is of greater mportance to know the differences between be figns of the hydroceles form’d by extra- palation and dilatation, and thoſe of hydro- eles form'd by infiltration. In the hydrocele infiltration, as I have already obſerved, the NO 256 Of HERNIAS, &c. the ſkin is ſmooth, and without wrinkles It is alſo very thick and clammy, and appears tranſparent, like a piece of horn. On the contrary, in hydroceles form’d by extravaa . tion, and the dilatation of the veſſels, the ſkin of the ſcrotum retains its wrinkles, which are indeed leſs deep than in the natural ſtate, but the tumor, however large, always affords a poffibility of laying hold of the ſkin. The tranſparence is by no means ſenſible, except in very young patients, the ſkin of whole ſcrotum is very tender; and when the hydro- cele is recent. Large hydroceles by infiltration render the penis very big. In others the pe- nis is retracted, in proportion as the hydro- cele is enlarged; and in the largeſt hydroceles it is funk as far as the navel. One fingle hydrocele always fills the two fides of the ſcrotum, tho' they are divided by a partition, which is externally mark'd by a thick line or ridge, called rapbé. In this caſe the line is effaced, if the hydrocele very large. This line is continued to the fun- dament, at which place it is generally effaced The direction it takes denotes the ſide of the hydrocele, which is always oppoſite to to which the line is determin’d. When there is an hydrocele in each ſide of the ſcrotum, the line divides them into two very difini parts. The ſigns which diftinguiſh hydroceles in the lips of the pudendum, in the foldings at 3 that the OF HERNIAS, &c. 257 celes and dila- the groin, and in the navel, which are not by infiltration, are hardneſs, elaſticity, round- heſs, and the eaſe with which we lay hold of the ſkin, however tenſe it may be. Tho' it is very difficult to cure theſe kinds Cure of of hydroceles by means of remedies, and hydro- tho' we are almoſt always obliged to have re- formºd by courſe to the operation, in order to obtain ei- rupture ther a palliative or a radical cure, yet a great cation of many of them are cured by the uſe of topics the vef- and hydragogue purgatives, eſpecially when fels. they are not of long ſtanding The intention which ought to be purſued is to procure the reſolution of the hydrocele, by diſlipating a part of the water by tranſpi- ration, and by diſpoſing the other part to re- turn into the ways of the circulation. We may very advantageouſly uſe the following remedies, which with me have ſucceeded in tales where ſucceſs could hardly be expected; but it is alſo certain, that they have fail'd in others where I had juſt reaſon to hope for a cure. The ſucceſs, then, of theſe remedies is uncertain ; but as there is no danger in ting them, it is better to do fo than to ne- glect them. We muſt always begin with blooding the patient, if there is an indication for it; that is, if he is very phlethoric. The day after the venelection he is to be purged with the arcanum duplicatum, or the coun- af of Warwick's powder, as I have directed in the fifteenth chapter. We muſt continue S be he to P2258 Of HERNIAS, &c. to purge the patient every eight days. The 70 day after the firſt purge, we are to apply the following cataplaſm : slə Take of the four refolvent meals, one pound; son of the powders of cumin, roſes, camomile , uns and melilot, each two ounces; a fwallow's el neſt; of the roots of marſh-mallows, and of fat figs, each two ounces; of gum am- moniac and pidgeon's dung, each two ounces : Break the ſwallow's neſt into pieces, and boil it with the marſh-mallow roots and the figs in fix pints of water, Te- duced to four. Paſs the whole thro' a fierce, and with a ſpoon bruiſe all the part which can be reduced, to a pulp: Then put the water on the fire again, after having diluted the meals by little and little in it , and boil all together, ſtirring it conſtantly till it has acquired the conſiſtence of a thick ſoap, or of clear glew. With this we muſt afterwards mix the powders and gun ammoniac, previouſly diffolved in vinegar . When the whole is well mix'd, it is to be taken off the fire. The uſe of this cataplaſm is to be con tinued for a month, taking care to change i twice a day, and to ſecure it with what I have call the ſuſpenſory bandage. In the place of the cataplaſm we may ſubſtitute the following plaifter : a a Take OF HERNIAS, &c. 259 slice a Take of the plaiſter call’d gratia dei, that of al Paracelſus, that of Diabotanum, that of Charas for malignant ulcers, and the mu- bucilage plaiſter, each an ounce; of black pitch, and oil of ſpike, each two ounces : wo Melt the whole in a baſon over a gentle be fire, ſtirring it continually. When the whole is melted, take it off the fire, and continue ſtirring it till it is cold. on A plaiſter of this is to be applied to the hydrocele, ſo as to cover all the parts of it. We muſt continue the plaiſter to the end of the cure, if, in a month's time, we perceive a manifeſt diminution; without which the no continuation of it would be uſeleſs. It is to be changed every four days, and the patient is to be purg'd every eight days, as I have or- der'd above. If , after the uſe of theſe remedies, the hydrocele is totally cured, the patient muft, for eight or even fifteen days, apply to his ſcrotum a compreſs, dipt in the following li- quor. He muſt take care to keep the com- preſs always moiſt. Take two handfuls of the leaves of the cy- preſs tree, and two pints of the coarfeſt red wine : Boil them together to the dimi- si nution of the half. Then ſtrain the liquor thro' a linnen-cloth, and preſerve it in a a bottle. S $ 2 The 260 Of HERNI A S, &c. The patient ought to wear the ſuſpenſory bandage during the whole of the cure, and even a long time after it. If theſe remedies do not ſucceed, we muſt have recourſe either to the palliative or radi- cal cure. As theſe two cures depend on chi- rurgical operations, the one by piercing the ſcrotum, in order to procure a diſcharge of the water ; and the other, by opening into the whole depth of the ſcrotum, to conſume the cyſtus which includes the water, I ſhall not here ſpeak of them, ſince my deſign is not to deſcribe the method of performing ope- rations. mod blanco What it is. 100 Its diffe- fences. CHA P. XXXII. of the farcocele. A Sarcocele is an inflation of the teſticle, cauſed by the obſtruction of the blood in the veſſels of its ſubſtance. The differences of ſarcoceles ariſe from the cauſes which have produced them. The cauſes may be either fimple, and without a bad character, or malignant ; that is to say they may have a venereal, fcorbutic, cerous taint for their principle. It is eaſy, by the ſigns, to know the exil tence of a forcocele, but it is not eaſy to ſtinguiſh the true character of the cauſe which has produced it. The bulk of the teſticle , 3 or can- Signs. a and Of HERNIAS, &c. 261 and the weight and pain felt in it, are certain marks of this diſorder. But whether the cauſe which has produced it be ſimple or malignant, theſe figns are ſtill the ſame, and we cannot know whether the diſorder has a venereal or fome other taint for its principle, except when ſome diſorders of theſe kinds fubfift, or have preceded. It belongs to thofe who have the management of the patients, carefully to diſcover theſe cauſes, that they may treat the patients according to the indi- cations they afford. But as a perſon muſt be extremely ſkilful in the treatment of theſe diſeaſes, to be able to find juſt relations be- tween their caufes, and the methods moſt proper for removing them, the patients, for whom I write, would reap no advantage from the confuſed directions which theory could point out. I ſhall therefore content myſelf with preſcribing the remedies proper in the beginning of this diſorder. If it has not a bad character, it will be very eaſily cured, by a ſpeedy and ſeaſonable applica- tion of proper remedies. Very frequently, though the cauſe is ſimple, it becomes ma- lignant, becauſe it has not at firſt been treated in a proper manner. The following are the moſt accurate and falutary rules we can give to the public. As foon as the patient perceives a pain in Cure. the teſticle, with inflammation and weight, he qught , of his own accord, to ſubject himſelf S3 to 262 Of HERNIAS, &C. to as low a regimen as poſſible, uſing only liquid aliments, as ſoops, and other ſuch things of a ſimilar nature. He ought in twenty-four hours to be blooded twice on thrice in the arm. We muſt, at the ſame time, apply a cataplaſm of crumb of bread and milk, to which we may add a little faf- fron. This cataplaſm ought to be renewed every three hours. By this treatment the pain ought to ceaſe in twenty-four hours, on two days. Then, in the room of this cata. plaſm, we ſubſtitute another made of the crumb of bread with wine, which the pa- tient is to uſe for three or four days. By this method the bulk of the teſticle is dimi- niſhed, and it is ſometimes reduced to juſt proportion. But there are alſo caſes in which it remains diſtended very much be- yond its natural bulk. We muſt, in theſe caſes, apply a plaiſter made of equal parts of that of diabotanum, that of vigo, and the mucalage plaiſter. This plaiſter ou cover the whole teſticle. It is to be made pretty thick, that it may laſt ſeven or eight days, without being changed. The uſe of it is to be continued five or fix months. The plaiſter and ſcrotum ought to be ſupported by the ſuſpenſory bandage, which ſecures them very exactly. If , during the uſe of the plaiſter, the diſ- order is augmented, inſtead of being dimi- niſhed, or if the teſticle is indurated, with- out Of HERNIAS, &c. 263 out having its bulk leffened, the patient mult apply to a furgeon, who may, by the ampu- tation of the teſticle, prevent the inevitable death which neceffarily fucceeds this dange- rous diſorder, braid to do T bow CH A P. XXXIII. no Of the Spermatocele. 10. HE teſticles are organs deſtined to filtrate the matter of the femen, which ſerves for the propagation of mankind. The ſemen being prepared in theſe organs, is depoſited in certain receptacles called veficula femenales, or femenal veſicles, and it is con- veyed from the teſticle into theſe receptacles by a very ſmall duct called vas deferens. But by any cauſe the vas deferens is obſtructed, the matter of the ſemen, inſtead of being de- How a poſited in its receptacle, is forced to return, fperma - and is inſenſibly accumulated in the veſſels of formed. the teſticles, which it inflates, indurates, and renders very painful. Every inflammation of the vas deferens may produce this diſorder ; but the moſt or- dinary cauſe ariſes from gonorrhæas, whoſe inflammation communicates itſelf from the urethra, or from the venereal ulcer, to the vas deferens. This inflammation cauſes an Cauſes, inflation in the texture of this veffel. The was deferens cannot become thick, without being S4 264 of HERNIAS, &c Signs. Cure. being ſhriveld up; fo that the greater the inflammation is, the more narrow and obil ſtructed the vas deferens muſt be, and com: ſequently the reflux of the femen muſt be the more conſiderable and dangerous. The ſigns of this diſorder are ſufficiently known of themſelves, according to the do- fcription I have given of its particular cauſe. I ſhall only add, with reſpect to the prog- noſtic, that this diſorder is very dangerous, when it is not ſpeedily remedied. In order to remedy it efficaciouſly, we muſt, without loſing time, blood the pa- tient in the arm twice or thrice in twenty- four hours, and order him fimple clyſters of bran-water, or ſome other fimilar ſubſtance , We muſt alſo apply to the teſticle, in form of a cataplaſm, that earth which is found at the bottom of cutlers troughs. This remedy adapted as a ſpecific for the ſpermatocele, the moſt efficacious of any that can be em- ployed. This earth is more repellent than aftringent, and, by corroborating the vefléls of the teſticle , reſtores that ſpring which is neceffary to keep them in a ftate capable of reſiſting the redundance of the ſeminal mat- fail to make ſuch apertures as would caule ter, which is there pent up, and would not an extravafation of this matter into the tela ticle. In this caſe, the diſorder could only be cured by dividing the teſticle, or by cute ting it off by the operation called caſtration 18 We OF HERNIAS, &c. 265 We continue the uſe of the cataplafm, till the pain and bulk of the teſticles are re- moved. If an induration remains, we muft apply the plaiſter I have mentioned in the preceeding chapter. The uſe of this plaiſter is to be continued, fecuring it by the fuſpen- fory bandage, as I have directed in the fame chapter. CHA P. XXXIV. ab hos Of the kirſokele. THI HE kirfokele is a diforder in which the What is veins of the ſcrotum, and thoſe which meant by this word. teturn from the teſticles, are dilated and form n theſe veſſels, what we call varix in other parts. This diſorder is called varicocele, when Diviſion the veins of the ſcrotum, and of the muſcle of the which moves it, are dilated, or extraordi- parily large, black, and here and there in- terſperſed with certain nods which render kirfokele. them unequal , The diſorder is called kirſokele when the | dilatation is in the veins which return the blood from the teſticles, commonly called the ſpermatic veins. The figns of the varicocele are ſufficiently Signs. deſcribed in its definition. Beſides, the fight alone is fufficient to diſcover it. The 266 Of HERNIAS, &c. and Lor IN 20 28 The ſigns of the kirfokele are not ſo eaſily ca diſtinguiſhed, which lays a foundation for its being frequently miſtaken, without a grea deal of attention. In order to know the kirſokele, we lay hold of the ſpermatic corda with our fingers; (it is eaſy to lay hold of the veins which compoſe it, becauſe, in this caſe, they form a body, ſometimes one, it ſometimes two, and ſometimes three inches broad, eſpecially on the ſide of the teſticle, and this body is more and more ſhriveld towards the top, ſo as to form a kind of to pyramid.) We lay hold, I ſay, of the ipe I metic cord with our fingers, by which means of we feel the veins hard, inflated, and of the conſiſtence and bulk of the inteſtine of ſmall bird, which makes ſome patients bermo lieve that they are their inteſtines ; or they appear like earth-worms intermixed with each other. This intermixture of veins . leaves vacuities which preciſely characterik the kirſokele, and render it diſtinguishable from certain epiploceles, which furgeon little accuſtomed to the treatment of thelem diſorders take for fuch; that is, they take true kirſokeles for epiploceles , and epiploca for true kirſokeles. The reaſon of their miſtake in this particular, ariſes from this that there are certain epiploceles fo fmals a that they can hardly believe them to be more than the fpermatic veins dilated. But Po they would not be deceived in this, if they pe TO 10 W mo m ma On be care- Of H ERNIAS, 267 G. &C. from cauſes of 3 carefully adverted to the inſterſtices left be- tween the veins, when they are inflated and dilated, and to all the cylindrical parts which are ſenſible to the touch, on account of the augmentation of their ſurfaces. The kirſokele is, of theſe two diſorders, Prognof- dhe moſt common and diſagreeable ; though tics drawn it may be ſaid, that it has nothing dangerous particular itſelf; we ought rather to look upon it as the kirſo- w indiſpoſition brought on by a melancholic kele. habit, which is always the effect of a very thick blood, which flows with difficulty in all the veſſels. As the fpermatic veſſels are, of themſelves, of a very flender texture, and w they are not, like thoſe of the other parts, fuftained by ſtrong muſcles, which, by cor- mborating them, augment their action, it is ist furprizing that the coarſe and thick blood, which flows in them, ſhould be there accu- mulated on account of the retardment of its motion. Now, the blood cannot be accu- mulated in theſe veſſels, without dilating them a great deal beyond their natural dia- Though this diſorder is very obſtinate, it Cure. may , nevertheleſs, be cured, if the patient, on his part, is fufficiently careful to give a itle more fluidity to his blood by diffipation and motion. He ought to indulge himſelf a itle in pleaſure, and uſe moderate venery: For this reaſon celibacy is very improper for perſons incommoded with this diſorder. meters. 2 The 268 Of HERNIAS, &c. The ſcrotum ought to be always ſuſtain'd by the ſuſpenſory bandage, which collects and keeps it compact. u olmuşlo's grava ow In order to begin the uſe of the proper re- medies with ſucceſs, the patient is to be blooded twice in the arm, allowing a day to intervene between the venefections. He is for two months, every morning and evening, to uſe broth made of fillet of veal, four ounces; to which we may add of wild fuc- cory, fumitory, and water-creffes, each one handful. He is in the day-time to drink the follow. ing ptifan at his meals. Take of the roots of China, farſaparilla, and rubia tinctorum, each an ounce : Boil them all in fix pints of water, reduced to four, pelo gen But ca bera NO will of thor 020 When the patient has uſed theſe remedies for fifteen days, we muſt order the following bolus to be taken every other day, Take of wood-lice reduced to powder fifteen grains, Æthiops mineral ten grains, Thubarb fifteen grains, and of the confec tion of hamech a fufficient quantity , make into a bolus, bacal in Theſe boluſes ought to be continued ees leaſt for a month, and even fix weeks," which time the patient will have twenty or ette Uw twenty- Of HERNIAS, &c. 269 nigd wenty-two boluſes. From the beginning to he end of the cure, we muſt apply the fol- owing cataplaſm to the ſcrotum. Footer 91 79007 as o od Take feald earth, Armenian bole, dragons blood, and red roſes, all reduced to a powder, of each two drahms, of hares fur one ounce, and two whites of eggs : Beat the whole together, till the mixture acquires a thick conſiſtence, and then ap- ply it to the ſcrotum. aking hen. This remedy muſt be changed every day, care to ſhave off the hairs now and . It now only remains that I ſhould ſpeak Pneuma- f the pneumatocele, which is thought to be tocele. enerated by wind contained in the ſcrotum, but I paſs over this diſorder in filence, be- auſe I am neither acquainted with it, nor elieve its exiſtence. As we ought never to wak, and much leſs to write, of things we now not, I hope my ſilence on this ſubject All not be blamed. I know that moſt au- kors have admitted this diſorder, and I have sown a great many practitioners who have Hempted to prove its reality ; but I have lways found, that what they took for a dif- oder of this kind was far from being wind, ad that it was only water, or ſpontaneous inflations of the veſſels of the ſcrotum and a klicles. OF ( 270) do autol oli dolivostota besa . 1970 mundo வாளின் Immortal sido Faroj plocembriin mered abrolho Fiscalizat B ai HERNIAS ge W I TH Gation is cool ADHERENCES bo PART II. SECT. II. 11 H so CO Of an ра. ERNIAS complicated with adhe- rences, require as many particular operations and methods of treatment, as there are different kinds of adherences , In order to demonſtrate this theorem, ſhall eſtabliſh the true character of adheren- ces, point out their differences, cauſes and fymptoms, enumerate their figns, and lay down the moſt rational and accurate means of removing theſe terrible diſorders, which happen but too commonly to the inteſtines in hernias. By the word adherence, we mean no more meant by than a preternatural union of ſome bodies : This accident is frequently the conſequence til of inflammatory diſorders of the abdominal OT pa What is the an adheren- ces. and OF HER NIAS, &C. 271 . and thorac viſcera. We alſo ſometimes ob- ferve the dura and pia mater united together, and even the cortical fubftance of the brain intimately join'd with this laſt membrane, after inflammatory diſorders of the brain. But the word adherence taken in a lefs exten- five fenfe, ſeems to be peculiarly appropriated to hernias, when the inteſtine and the epi- ploon are united together, or when the epi- ploon or inteſtine ſeparately, are united with de herniary fac. In order to account for the mechaniſm How ad- which nature employs in forming adherences herences in hernias, we muſt have recourſe to princi- ples drawn from the ſyſtem of the ſolids and luids . An account of this ſyſtem is abſo- Intely requiſite for our preſent purpoſe, ſince, according to the unanimous conſent of the greateſt phyſicians, it is a matter not to be conteſted in the art of curing diſeaſes. It is ſufficiently known, that all the parts of the human body are compoſed of veffels and fluids ; that the fluids are deſtin'd to re- pair the continual loſs of ſubſtance which the body ſuſtains ; and that the veſſels are the organs which convey the fluids to particular parts . So long as the diameters of the vef- are not changed, nor the fluids alter'd, theſe laſt circulate altogether in large veſſels, and are ſeparated from each other in propor- ton as they approach the capillary extremi- lies of the fanguiferous arteries. Here fels 272 OF HER NI Á S, &c. Secretions where made. i ز Here the ſecretions are made; that is to ſay, the whole part of the blood enters into veſſels of different figures and diameters ſome of which are deſtined to ſeparate the nutritive lymph, and convey it into the ſub- ſtance of our parts, in order to repair the continual loſſes they ſuſtain; others of theſe veſſels are deſtined to divide, attenuate, and change the redundance of this lymph, in order to make it ſerve other uſes for which the author of nature deſigned it. But when the motion of theſe fluids is changed, either by a too great relaxation or rigidity of the ſolids, or by their being compreſſed by ſome external agent, changes happen in the order which theſe fluids ought to preſerve; for they either circulate ſlowly in their ſecretoty ducts, or become ſtagnant in them. If their motion is flow, it muſt neceſſarily happen that the blood muſt alſo loſe ſome of its mo- tion in the arteries proper to it, and confe- quently the fanguiferous arteries will fuffer a kind of obſtruction. This firſt degree of obſtruction is what we call phlogofis : But if the fluids ſtop and become ſtagnant in their ſecretory ducts, the blood will alſo ſtop in the ſame degree in its proper veſſels, and forme different degrees of inflammation, in proport tion to its different degrees of fágnation, the firſt degree of obſtruction it muſt hapi pen, that the lymphatic veſſels will be dil de tended, and their pores being more dilated W and 3 OF HERNIA S, &c. 273 a a and enlarged, will permit a part of that nu- tritive and fulphureous lymph which is fuf- ceptible of infpiffation to be tranfuded thro' their texture. The infpiffation of this liquor will ſerve as a kind of glue or cement to unite and join the parts between which it is depoſited ; and in proportion as the obſtruc- tion of the veſſels is more confiderable, the lymph will be extravaſated in a greater quan- tity; on this occafion it will, as it were, ſeal the e parts between which it is extravaſated to- gether. But if the nutritive juice is only ex- travaſated in fome points, it will be there gradually collected, and form a kind of fibres more or leſs long and ſolid, which will keep parts thro' which they are convey'd, as it were mutually chain'd to each other. Ina word, when the obſtruction has arrived at its laſt degree, the lymphatic and fanguiferous veffels will be obliged to yield to the effort of the fluids, there will be a rupture of their proper membranes, and conſequently ſmall ulcers will be formed, whoſe nutritive juices flow- ing from them, will ſerve to join the parts whence they are diſcharged, ſo intimately, we ſhall eaſily obſerve in theſe adhe- rences an organiſation ſimilar to that which we find in the cicatrices, formed in all the different parts of the body. A commu- nication of fluids will be eſtabliſhed, in or- der to nouriſh, fortify and augment this new feth. But if thefe juices are of a bad quality, T that or 274 Of HERNIAS, &c. no Differen- herences. DO + or if the rupture of the veſſels only happens in the ſurface of a ſingle part, a fort of fungous excreſcences will be formed, which will keep the parts between which they are, joined, or compreſs them in ſuch a manner, as to hin- der their return into the abdomen. chia bus Upon theſe principles, it is eaſy to eſtablish ces of ad. the different ſpecies of adherences, with which nature preſents us, and which have not been unknown to authors ; namely adherences by agglutination, obſerved by Drelincourt * fibrous adherences remarked by De Graaff f, fleſhy adherences, of which Bonetus relates an example I, and ſpongious adherences, ſpecified by the obſervation of Abel Rofcius || The remote cauſes of the adherences of adheren- the inteſtines in hernias, are all thoſe things which are capable of infpiffating the fluids , of retarding their motion, or of rendering them too copious; ſuch, for inſtance, are the abuſe of the non-naturals, exceſs of wine ; and all ſpirituous liquors, pinguious aliments and ſuch as are of difficult digeſtion, a fer dentary and idle life, too much fleep, and too long a retention of the fæces; all which render the maſs of humours too thick, or too copious, and by theſe means hinder them from entering freely into the capillary veſſels. * Manget Biblioth. Chirurg. p. 436. sulg bus + De viror. orgun. Cauſes of ces. a S 70 dhor I Sepulchretum obf. 13. Fabr. Hildanus obf. 70. cent. 6. di vd battaya Theſe Of HERNI A S, &c. 275 Theſe are therefore diſtended beyond their natural tone, and their pores become conſe- quently larger and more open, whence the infiltration of the fluids neceſſarily follows. Theſe, as I have before faid, are extravaſated and inſpiffated in the interſtices of the in- teſtines, or between the inteſtine and its ad- jacent parts, where they either intimately unite different parts of the inteſtine with each other, or with the parts contiguous to it. The immediate cauſes of adherences are Immedi- all things capable of making violent and ir- ate cauſes, regular preſſures on the inteſtines, ſuch as falls, blows, inflammations, cholics, diar- Thaas, bloody-fluxes, the bulk and weight of the uterus augmented by impregnation, or hard and fcirrhous tumors, &c. But the moſt common cauſe of adherences ariſes from truffes , either ill-made, or unſkilfully ap- plied, which wound and mutilate the in- teftines and epiploon, or the herniary fac. All theſe things conſtrain the action of the veffels, and retard the motion of the blood, which is forced to flow back into the ad- jacent veſfels, whoſe diameters are, by that means, neceſſarily augmented. The infiltra- bon of the nutritive juices, conſequently pro- duces, firſt a kind of mucilaginous humour, which is accumulated in the interſtices of the parts , and glues and unites them together in il the extent of the furfaces which are im- vegnated by it. In proportion as this liquer T 2 276 Of HERNIAS, &c. is infpiffated and condenſed, the more it joins the parts to each other. By this means the adherence by agglutination is formed. If there is a reciprocal ſolution of continuity in the veſſels of the adjacent parts, the nutritive juices are extravaſated in a greater quantity , and in more points. Theſe juices are here accumulated, and form fibres more or leſs ſtrong, and more or leſs long, and this cir- cumſtance characteriſes fibrous adherences . But if the nutritive juice diffuſes itſelf in a greater ſurface, real "cicatrices are formed, which are more or leſs firm, according to the extent of the ſolutions which have hap- pened to the veſſels, or according to the quantity and long continuanće of the extra- vaſated juices. If the dilaceration of veſſels only happens on one furface ; for example, if the folution of continuity only happens to the veſſels of the inteſtine, with- out a reciprocal one in the part which it touches, fungous excreſcences will be formed on the ſurface of the inteſtine, which will για rather compreſs the parts, than render them adherent to each other , though 'tis ſometimes obſerved, that theſe excreſcences become ag. glutinated with the parts they touch. Symptoms Of whatever kind adherences are, it is not poſſible to diſtinguiſh each of them in par- ticular, except in performing the operations when the parts are laid bare. But be this as it will, the ſurgeon ought to be carefully in- the to of adhe- rences. Structed Of HERNIAS, &c. 277 Morgan pebgoa tuttligt ſtructed with reſpect to the ſymptoms which characteriſe them in general, ſince thoſe which might enable him to know them in particular would not more effectually furniſh him with the means of cure, than thoſe which the general fymptoms offer to his knowledge; for whether the adherences are by agglutination, fibrous, fleſhy, or ſpon- gious, they all tend to produce the ſame effects, which conſiſt in diſturbing the func- tions of the inteſtines. The ſurgeon there- fore ought to have only one view or inten- tion, which is, either to deſtroy them, or remove the ſymptoms of them. But if there are no differences in the ſymptoms, there are a great many in the means of removing them, or in the manner of performing the operations neceſſary for their cures, as we ſhall ſhew in the ſubſequent part of the work. The general ſymptoms of adherences are to be conſider'd differently, ſince hernias are either with or without ſtrangulation If there is no ſtrangulation, the parts, tho' Symptonas adherent, may either re-enter the abdomen, or remain without it. The eaſe with which when her- the parts, tho' adherent, enter the abdomen, proceeds from this, that the inteſtine is only duced. adherent to itſelf, or to the epiploon, or to the herniary fac, without the union of this laſt with the membranes of the ſcrotum. When the inteſtine is adherent to itſelf, the fymptoms are very flight, and ariſe from the difficulty INS of adhe. rences nias may be re- T 3 278 Of H ERNIAS, &c. difficulty the fæces find in paffing, and from the conſtraint the inteſtine ſuffers in this part, in performing its natural motions. The pa- tient complains of fmail colical pains, which are with difficulty diſtinguiſh'd from thoſe of a bilious colic. It is only when theſe colics do not yield to the remedies generally uſed againſt ordinary colics, that this fymptom loſes its equivocal character: But great expe- rience and attention are requiſite to diſtinguiſh it, ſince the patient is render'd worſe by the uſe of remedies; whereas a ſober and regu- lar manner of living is fufficient to mitigate this fymptom, which is not very confiderable. When the inteſtine is adherent to the epi- ploon, the patient, after meals, conſtantly complains of colics, whether the hernia is return’d, or remains without the abdomen. In both caſes the patient alſo complains of twitchings of the ſtomach, which are aug- mented in proportion as the digeſtion is car- ried on, and do not ceaſe till it is entirely finiſh’d. If the inteftine is adherent to the membranous bag of the peritoneum, which forms the herniary fac, beſides the colics which are always felt, (tho' flightly indeed) the patient complains of a kind of formica- tion, or crawling in the part of the hernia, whether at the navel , the groin, or elſewhere. Theſe formications or crawlings happen ther when the patient has eaten liberally than ra- cimed when Of HERNIAS, &c. 279 or 3 when he is faſting, or has only eaten mode- rately. It is 100 Sometimes the epiploon is adherent to the peritoneum, without being join'd to the in- teſtine ; neither is it leſs difficult to diſcover this , unleſs we are converſant in the treat- ment and cure of theſe diſorders. On this occaſion the patient has no colics, but com- plains of gentle twitchings about the region of the ſtomach, which characterizes the dif- ference of the adherence of the epiploon from that of the inteſtine. The patient, in this cale, expreſſes himſelf quite contrary to the laws of ætiology; for he ſays that his ſto- mach twitches; but the ſurgeon is not de- ceived by this means, fince he knows that this is only the twitching of the ſtomach, which is forced to follow the motions com- municated to the epiploon by the inteſtines and abdominal muſcles. The ſtomach is twitch'd in proportion as the patient has eaten liberally, becauſe the inteſtines, being at that very full, their diameters become larger, and they poſſeſs more ſpace; in conſequence of which the ſtomach is puſh'd upwards towards the diaphragm, ſo that the epiploon muſt become tenſe, and deſcribe a ſemi-cir- cular ſurface: It therefore draws the ſtomach as much to the abdomen, as the curve which it deſcribes is ſhorter. Theſe are the ſymptoms of adherences when the hernia returns. Let us next inquire into time . T 4 280 Of HERNIA SA Errodon adheren- , into thoſe which appear when the hernia does i not return... 20. norsogo into ao Symp- When the hernia does not return, the paro toms of tient, beſides the ſymptoms already enume- ces, when rated, has the habitual continuance of the the parts parts in the ſcrotum or elſewhere. If the reduced. parts remain in this ſtate for ſome months or years, but continue ſoft and flexible, the , means which either the patient or the fur- geon can uſe only diminish their bulk, by making the wind, or other matter contain'd in the inteſtine, return, whilſt the greater party of the tumor remains without. If in this caſe the parts are adherent to the herniary facil without its adhering to the teguments, we eaſily collect all the tumor to the brink of the aperture, which permitted it to flip down but if the fac itſelf adheres to the tegumentajia or to other parts, thoſe contain'd in the turis mor do not ſo eaſily approach to each otherii The teſticle follows the bulk of the parts, and the ſcrotum follows the teſticle. The ſkin produces the ſame effect, if the hernias is crural or ventral. At this time the tumor, being left to its proper weight, always retains the figure of a round pear, if it is the intel- tine ; and of a flat pear, if it is the epiploon; , and this tumor is more or leſs long, in pro- portion to the quantity of the parts which compofe it. In the parts thus united or join'd, there is ſometimes happen violent irritations or twitche a an th a WW Stromyl coll ings Irritations of the parts; Of HERNIAS, 800 287 330bs ings, which excite fpafmodic or convullive their ef- motions. On this occafion the tumor be- sebe ofects. comes painful, the patient complains of co- lics, and is coftive; the ſtomach is contracted, of is om whence ariſe vomitings of the faces; the new 2*5 diaphragm alſo fuffers, and conſequently any de hiccup is often produced, as violent as in the backom moſt plain and evident ftrangulations: A fe ver is alſo induced, and the patient ſeems to be in the moſt dangerous ſtate. But this condition is only terrible to thoſe who, for want of practice, confound the equivocal figns which all the fymptoms indicate, without having any regard to the pathognomic or de cifive fign, with reſpect to the ſtate of the patient. This fign is drawn from the eaſe with which the wind, the bilious matter, and the fæces paſs thro' the anus. There are however, caſes of ſtrangulations of the inteftine in which the matters paſs freely, and which would ſeem to render this fign equivocal : But the ſymptoms are different, si fhall ſhew in the pinchings of the inteſ- tine, that is, when there is only one part of the orifice of the inteftine ftrangulated gard But, furniſh'd with all this knowledge, Neceſity with reſpect to adherences, we are not to re--f fperaty main in a ſtate of inaction. If we negle& relief. peedily to adminiſter the proper remedies , all theſe ſymptoms are augmented, and inflamma- ion and ftrangulation may alſo fupervene ; the unor becomes hard; the patient complains of 282 Of HERNI A S, &c. 100 We may of violent gripes, which foon fucceed each | tu other; the vomitings and hiccup are more w frequent ; the fæces are more copiouſlydil charged by the mouth; the fever is auget mented; the pulſe is contracted and intermite tent; the urine is fuppreſs’d or retain’djux mortification ſeizes the ſtrangled parts, and very foon ſpreads into the abdomen: Then the pulſe becomes ſo weak, that it can hardly be felt; the eyes, tho’ before ſparkling, liver ly, and fix'd, become heavy and languiſhings the eyelids fhut, and the noſtrils open; the lips are feiz'd with convulſions, the colic ceaſes, the belly fubfides, all the parts fall into a putrefaction, and the patient dieselili In order to prevent or remove all thele betrh pre ſymptoms, ſurgery does not at preſent cont fine itſelf to the operation, which is only the adheren- method it has recourſe to, when the others have been either neglected, or have proved unſucceſsful. I now proceed to lay down all theſe different means, with as much order and perſpicuity as I poffibly can. I have before obſerved, that the abuſe of the non-naturals is the remote cauſe of adus prevented, herences, and that the immediate cauſes of them are falls, blows, &c. It is therefore in- cumbent on patients afflicted with ruptures to avoid all theſe things, by guarding againt thoſe external agents which may offend them and by leading a ſober life, free from all those exorbitant paſſions, which are capable of dile bas remove ces. end mit How ad- herences may be we and turbing Of HERNIAS, &C. 283 turbing that order cf the animal economy, which leaves the parts at that liberty which the author of nature firſt gave them. Pa- tients themſelves may, by theſe means, pre- vent adherences: But as nothing is more ca- pable of wounding the parts which concur o form hernias, and conſequently form ad- herences in them, than the improper uſe of muffes of all kinds, which are daily em- loy'd to contain them, we ought, in order u prevent theſe fymptoms, to be extremely ttentive not to make irregular compreſſions y the application of the compreſſes or bands ammonly uſed, eſpecially for infants and dildren. This fault is ſo frequent in nurſes, wat moſt hernias with adherence are form’d is the earlieſt infancy. The indiſcreet zeal f theſe women induces them to treat the uptures of their foſter-children, and by thus acroaching on a part of furgery no leſs deli- te than intereſting, they lay a foundation w various other diſorders, very difficult to be tevented by the moſt ſkilful practitioners, ithout the greateſt care and attention. It "ght therefore to be the buſineſs of ſurgeons, ell acquainted with theſe parts, to prevent dherences as well in adults as in infants, by great care exactly to reduce the parts, their dexterity in applying the truffes as that the parts may not be ex- flad to their injurious compreffions. The Aportance of this affair ſeems here to de- mand 5 heir juftly, 284 ga bel ma 09 or wie Two me- thods of remedy- OLVO rence. Dar H30 Of HERNIAS, &c. mand ſuch remarks as are neceſſary for the reduction of the parts, and to require rules not for the juſt poſition of truſſes. But by a w attempt of this kind, I ſhould be obliged to el enter into details which would lead me to the far. The different ſpecies of hernias, and different patients, require ſuch differences of truffes, aš the moſt extenſive memory cam hardly retain. We remedy hernias, complicated with ad- herences, firſt, by defending the adherent parts ing her- from the accidents which may happen to nias with them. This method is executed by the methodical application of the trufs : Ano fecondly, by dividing the united parts ſome ſharp inſtrument. To fulfil the firſt intention, it is neceflary to act differently, accordingly as the hernia dying her. nias with either enters, or does not enter the abdomena If the inteſtine is adherent to itſelf, to the epiploon, or the herniary fac, and if the ex enter the ternal ſurface of this laſt does not adhere to the membranes of the ſcrotum, it is eaſy:po make it enter into the abdomen, when the tumor is not of a confiderable bulk. In this caſe the only intention which ought to be to purſued, is to retain it there exactly with a truſs, whoſe cuſhion is fufficiently vated, ſo that, preſſing exactly on the ring the it may not permit the parts to continue in the paffage formd by the thickneſs of the tki, out with elaboratori di ift means of reme- alim MO adheren- ces, when the parts MO abdomen. GAL а con Songs ele thu ex the Of HERNIAS, &c. 285 the fat, and the muſcles, without which pre- dáution the herniary fac, which till then had not been adherent by its external ſurface, would not fail to become ſo, by uniting it- Alf to the abdominal muſcles. The ſtate of the patient would, in this caſe, be worſe than before, as I once ſaw it happen: The her- mary_ſac had introduced itſelf into the in- turiſtices of the muſcles * and had there be- come adherent. In this laſt caſe we muſt not truſſes; but if the application of one s neceſſary, the cuſhion of it ought to be at, and very foft. The patient ought to void all efforts capable of determining the parts to fall out; for tho' they cannot fall out, on account of the adherence of the fac with the muſcles, yet the colics, which are lways felt in this laſt caſe, greatly incom- node the patient; but are to be removed by at, clyfters, and emollient, carminative, and elolvent fomentations applied to the tu- DIB35 If the hernia does not re-enter, and if we Means of in collect it into a moderate bulk at the edge Femedy- aperture, which permitted it to flip nias with out, we muſt uſe a trufs whoſe cuſhion is adheren- incavė, and of a bulk proportion'd to the the parts ageneſs of the tumor. This truſs, being do not is apply'd, generally forces the hernia to -enter the abdomen, if we are attentive, Mal ni Oro Ol 2019 This fymptom, which is difficult to comprehend, will explained elſewhere. from mor. a the ing her ces, when re-enter. 286 CF HERNIA S, &c. re it on from time to time, to put compreſſes into lism cavity, which may fill the vacuity which the # diminution of the tumor leaves in it. If the hernia does not re-enter at all, or if part of it only re-enters, a truſs of this kind at leaſt hinders it from augmenting, and the patient always reaps a great advantage from a machine of this kind. But great experience and care are requiſite in the uſe and applica- tion of theſe truſſes, ſince they always preſs upon the large veſſels of the thighs, from which circumſtance violent accidents have ſometimes proceeded. When the bulk of the tumor is fo con- ſiderable, that almoſt all the inteſtines, the meſentery and epiploon, are in the ſcrotum, it is not poſſible to collect the tumor ; for the diminution which happens in it by the re-entry of the fæces, does not amount to a twentieth part of its ordinary bulk. Then the meaſures we are to take for the relief of the the patient, or for his radical cure, are very different. The ſurgeon ought to be at a great deal of pains to diſcover whether the adhe- rences are near the part thro’ which the hero se nia flips, or whether they are in the bottom of the tumor. If the adherences are at thei mut . ſuperior part of the tumor, it is eaſy to pelul ceive them ; becauſe there can be no reduco 6 tion of the parts by the taxis, or but very little of them are reduced, fince generally only the wind and fæces re-enter the abdo- bri the ex dor men. OF HERNIAS, &c. 287 men. In this caſe, we muſt be content with affording relief to the patient, by diminishing the bulk of the tumor by veneſection, which is to be reiterated according to the plethora, by frequent clyfters, and by a proper oregi- men. By theſe means, we empty the veſiels, free the inteſtines from the matter contained in them, and prevent the formation of new matter in them, we muſt contain the tumor tu leffened, by the bandage called the fuf- paulary bandage. The patient ought now nd then to repeat theſe remedies, and ob- krve this regimen. to be a at tumor. dhe If the adherences are at the bottom of the What is tumor, and none of them at its ſuperior part, we may eaſily reduce a certain quantity when the the parts , which compoſe it, and by adheren- singing the bottom of the tumor towards the bot- We ring, we perceive that the teſticle, and tom of the fometimes the ſkin of the ſcrotum, follow tumor. In this caſe, we may not only spect to make the hernid re-enter the ab- wmen, and to contain it there, but there is do reaſon to hope for a radical cure, how- sen large the tumor may be, which is ſeem- gly a paradox. However, it is a certain ruth, as I ſhall now ſhew, that the larger a amor is, the more eaſily the patient is cured fit This end is firft obtained by making parts re-enter, and in containing them ter they are entered. In order to make kem enter , we muſt, beſides general reme- dies, a 2 288 of HERNIA S, &c. ved in or- parts. What is to dies, ſuch as veneſections and clyſters, apply be obſer.be to the abdomen emollient fomentations and der to re-oleous embrocations for a conſiderable time, duce the in order to releaſe the muſcles, which are adherent the more tenſe and rigid, the longer the parts have remained in the ſcrotum. During this time, we put the patient on the uſe of re- medies capable of diffolving and evacuating the humours. Mercurial diffolvents feem to act with the greateſt efficacy, fuch Æthiop mineral, the aquila alba, or panacea. We muſt, however, have a proper regard to the conſtitution of the patient, to which thele remedies are ſometimes very oppoſite ; for if the patient was in a ſtate of extenuation, brought on by a diſeaſe of the lungs, by a ſcrophulous or ſcorbutic affection, or by any general or particular nervous diſorder, thele remedies would be hurtful, and even dan- gerous. OBSERVATION I. About four or five years ago, a man of difolvents fifty years of age, who had remained in an ill applied. Irabitual convullive ſtate, after an acute di a eaſe, was like to have been killed by the La violence of the convulfions into which he was thrown, by the indiſcreet uſe of théle of remedies. This man had an old hernia, fordi which he came to Paris to ſeek relief. He fcil into the hands of a truſs-maker, who had heard of ſome fingular cures of this kind m pa Mercurial VIO Day which of HERNIAS, &c. -289 low which I had performed, by means of mer- curial diſſolvents, and who imagined he hadde nothing more to do but to make him ſwal mercury. He was ignorant of the caſes in which it is neceſſary to avoid this remedy, and the precautions which the uſe of it de mands. He had no ſooner excited a ſaliva-- tion, than it was impoſſible for him to ſtop Without the aſſiſtance of Mr. Boudon, furgeon-major of the Hotel-Dieu, the pa- tient would have died. Mr. Boudon put the patient under my hands, and after con- Jultation with him, I only made it my bufia neſs to contain the hernia. The patient, fa- tisfied with my manner of treating him, was, in a ſhort time, in a condition to go five hundred miles from Paris, to ſeek for the means of relief againſt his convulſions, (which were extremely augmented) in the uſe of the mineral waters of Aix in Provence. But if the extenuation and leanneſs of the Caſes in patient are cauſed by the ſtate of the convul- fions, and by the irritation which the bulk to make and weight of the tumor may excite, mer- ufe of mercurial curial remedies will not be improper, pro- diſſolvents : we ſupport the tumor, put the patient Precau- a a ſituation proper to hinder the twitching uſed. of the parts, and prepare him for theſe me- dicines, by means capable of moiſtening the whole fabric of the body, and of relaxing and extending the injured parts, by general and which it is proper vided tions to be particular remedies. U Some- 290 Of HERNIAS, &c. 6. Ο Ν Ι. οίομαι Ulcers of the me- Sometimes the meſentery, which is always beva affected in large hernias, is ſo inflated by the s obſtruction and infarction of its glands, that it becomes an invincible obſtacle to the re- entry of the parts, if we do not labour with a great deal of attention, to diffolve theſe tu- to mors by diffolvents, appropriated to the fault of the humours which produce the ob- ſtruction. st OBSERVATION II. Ono I was witneſs to the death of a poor man fentery of about fifty years of age, belonging to pariſh of St. Euftachius, who, from his in- fancy, had a moſt terrible rupture. As he was recommended to me, I viſited him often, that I might not loſe him. I took the ad- vantage of his death to inform myſelf, with reſpect to his ſtate, which was as ſatisfactory to me as it had been fatal to him. Among ſeveral curious things which I diſcover'd (in preſence of Meff. Courtoiſe and Le Comte, then furgeons for the poor of that pariſh) in the confuſed heap of parts which compoſed the tumor, I obſerved a prodigious number of the glands of the meſentery, ſome of which were ulcerated, others contain'd a pu- rulent matter, others a gypſeous, and other an ichorous matter. All theſe glands were of different bulks ; but the largeſt paffage of the ring, and in figure and fine reſembled pigeons eggs. In this part there prove mortal. U were in the he were OF HERN I A S, &c. 291 were three of them, which probably proved the cauſe of the patient's death, by the obſta- cle they made to the free courſe of the mat- ters into the inteſtine, and of the blood into the meſenteric veffels. There is reaſon to believe, that if, in due time, the ſource of theſe diſorders had been removed by alterative and diffolving medicines, ſuited to the fault which had produced them, the patient's life might have been prolong’d, and perhaps he would not have died of that diſorder. The continual pains he ſuffer'd were ſo perceptible in his countenance, that they were a kind of advantage to him in his calamity, by exciting to the commiſeration of all thoſe whoſe charity he implored. Theſe remedies, continued for a due time, given with difcretion, and affifted by a ſpare diet , reduce the patients into a kind of lalu- tary conſumption or atrophy, which neceffa- tily puts the pinguious and membranous parts, which generally form the greateſt part of the tumor, into a ſtate of deficcation or dryneſs. The glands are diſengaged and diſſolved, and the tumor is fo conſiderably diminiſh'd, that If is eaſy to bring the parts in the ſcrotum towards the ring; then we include them in the concave cuſhion of a truſs regularly made, and retain them in this poſition. The patient to work and walk, fince, in proportion as be uſes motion, the parts gradually re-enter. We are to fill the hollow found in the cavity be 3 a U2 of 292 OF HERNIAS, &c. What is proper to parts can- of the cuſhion, in proportion as the parts re enter; and when they are totally re-enter'd, inſtead of a concave we uſe a pretty convex cuſhion, made round or pyramidal, and more or leſs large, in proportion to the diameter of the ring, and other circumſtances to be after- wards pointed out. ol dead bod When the parts cannot be reduced alto- be done, gether, which ſometimes happens by various when the obſtructions, which we can neither determine not be al- nor ſurmount, we muſt be content to keep together the collected parts in the cavity of the truſs , and not to compreſs them too much, with, out which precaution the patient would be expoſed to all the injuries which external agents might inflict on the tumor. He would alſo be ſubject to more conſiderable colies than before, when the parts ſhall have re- fumed their natural bulk, by the corpulency which foon after returns, and by which it is eaſy to explain how the cure of ſimilar her- nias is brought about. Of this the follow- ing obſervation is one of the moſt remarkable examples with which practice can reduced. poſſibly furniſh us. con unden ad 101 How the cure of of age, and of a OBSERVATION III. Mr. Boudon recommended to my decealed the largeft father a man of forty years hernia, very ſtrong conſtitution. He was extremely is brougir meafure. His name was Mr. Trogneux . He fat, and fix foot and an inch high, French with ad. , about. Was Of HERNIAS, &c. 293 was an inhabitant of Clamſey in the dioceſs of Auxerre. He had an hernia from his in- fancy, which had never re-enter'd. It was thirty-two inches in circumference at its low- eft part, nineteen at the ring, and fixteen in length. For more than ten years his penis had been loſt in the bulk of the tumor, ſo that the preputium form'd a kind of depreſ- fure like that of the navel; ſo that in making water his urine was diffuſed over all the tu- mor, which was very troubleſome to him. As he was a timber-merchant, his buſineſs obliged him almoſt every day to ride forty or fifty miles on horſe-back, which induced him to invent a large cavity in the fore-part of his ſaddle, in which he placed his tumor. Being at laſt reduced to ſuch a condition that he could no longer follow his buſineſs, and being afraid that this diſorder, no leſs terrible than inſupportable, would foon put an end to his life, he determined to apply for relief. It was in 1726 that he was introduced to us. He found a great deal of comfort from the а recent example which my father and I gave him, of the cure of a ſimilar diſorder. He ſubmitted to every thing we preſcribed, either for his relief or radical cure, but on condi- tion, ſaid he, that he ſhould have a little to cat; for he was a prodigious glutton. Per- tons of this kind may obſerve a very ſtrict even by eating a little. We may therefore recede from the general rule in their favour, a regimen, U 3 294 OF HERNIAS, &c. favour, without any fear of doing harm; for their great appetite requires this kind of liberty. He was blooded ſeveral times, then purged, and afterwards uſed twelve or fifteen baths. Twice a day I made ſtrong embro- cations of his abdomen with oil of melilot, and cover'd the whole tumor with a plaiſter, compoſed of the emplaftrum de Vigo, pre- pared with a good deal of mercury, of the diabotanum, and the mucilages; and this plaiſter I renew'd every four days. We made him every morning take ten, twelve, fifteen, or twenty grains of mercur, dulc. He drank plentifully, and had four emollient and pur gative clyſters injected every day. Every four days we purged him with caflia, with an in- tention to evacuate the humours, and prevent a falivation. This method ſucceeded very happily ; for the evacuations laſted fixteen days, and were. fo copious, that they every day redoubled the patient's aſtoniſhment The tumor during this time had loſt about three quarters of its bulk, and more than a half of the remaining quarter we made to re-enter by the taxis ; fo that the hernia, ben ing thus reduced to an eighth part of its bulk, was in a condition to be contain’d in the holu low cuſhion of a trufs. It afterwards dimi- niſh'd inſenſibly for eight or ten days, during which time we took care to fill the cavity of the cuſhion, in proportion as the bulk of the tumor diminiſh'à. On the 36th day from 3 a the I Of HER NIAS, &c. 295 the firſt venefection, the parts re-enter'd all together, and the teſticle alfo. We then uſed a convex, inſtead of the concave cuſhion. The patient in a very ſhort time reſumed his ſtrength and fleth, and follow'd his buſineſs with a great deal of more vigour than ever he had done. The firſt thing he did at his return home, was to render his wife pregnant, with whom he had had no amorous converſe for ten years before. He quitted the uſe of the truſs eighteen months after ; that is to ſay, in 1728. Twelve years after, he had occaſion to come to Paris, where he call'd for me im- mediately on his arrival, rather to teſtify his gratitude than for any other reaſon: But as I did not know him, he put me in mind of every thing that had happen'd in 1726. 1 examin’d the parts, which I found fo firm and ſolid, that one could have hardly ima- gined that he had formerly labour'd under an hernia. The ſkin of the ſcrotum was re- turn'd to its natural ſtate, only it was very thick ; and the bottom of the ſcrotum which had approach'd to the ring, on account of the herniary fac of the teſticle, was fix'd or glew'd over the ring. This portion of ſkin ſeem'd to make a kind of ſtopper, which filled the cavity of it. But tho the diſorder had no appearance of a relapſe, I order'd the patient to wear a truſs by way of prevention: The reaſons of which I ſhall afterwards give in a particular inſtance. From CEL U 4 2960 Of HERNIAS, &c. : From this obſervation it is fufficiently evi- dent, that what at firſt appear'd a paradox, il a truth eaſily perceived by perfons of pericku tration; but as it may perplex the more igán norant and illiterate part of mankind, I ſhall , for their ſake, render it ſtill more intelligible, by a method of reaſoning as clear and per- fpicuous as I poflibly can, The parts had inſenſibly accuſtom'd them- felves to this new abdomen which nature had form’d for them: They had there fix'd a per- manent reſidence for themſelves, whence it was impoſſible for them to remove, on account of the adherences they had contracted. Without the methodical aſſiſtance afforded, it was im- poffible that they fhould ever of themſelves have re-enter'd the abdomen: But by the difpofition into which they were put, they were forced to reſume their natural place, Tho' they were lean and emaciated, yet when they were reduced, they reſumed their former bulk, in the ſame proportion as all the other parts of the body reſumed their fleſh. Now they could not fip out again, after they were once in the abdomen, becauſe they were become larger than the diameter of the ring; ſo that the patient muft necel- ſarily have been cured long before he left off the uſe of the trufs, los as . છેકોડ The W OF HERNIAS, &c. 2973 The following fable applied to this ſubject, will more fenfibly enable us to comprehends what hinders theſe forts of hernias from res entering, and what obliges them to remain. 1) in the abdomen, after they are reducedoon oldigellati atom brot obrot sdt 107 Forte per anguftam tenuis nitetula * riad mam, doo I cuoroid Repferat, in cameram frumenti, pafiaque, bi rurſus omvis fire foras, pleno tendebat corpore, fruftra Cui muftela procul, fo vis, ait, effugerer to iſtinc, no tog met Macra cavum repetas ar&tum, quem macro ſubiſti. Hor. Lib. 1. Epift. or Log per crept ; Into a wicker caſk, where corn was kept, is Perchance of meagre corps, a field mouſe baisios But when ſhe fill’d her paunch, and ſleek'd her hide, into How to get out again, in vain ſhe try'd.io A weazel, who beheld her thus diſtreſs’d, In friendly ſtrain the luckleſs mouſe ad- dreſs'd: Would you eſcape, you muſt be poor Dal " and thin, no hay Mia ” To paſs the hole thro' which you ven- « " tur'd in. 2015 > Edit. Lond. ann. 1747. by Rev. Mr. Phil. Francis. We 298 Of HERNIAS, &C. We may, by this fable, account for the method in which a great many hernias are cured, without having recourſe to the forced yoqs sand unnatural explications, which two cele- to brated members of the royal academy of fci- ences have given us of their cure. OBSERVATION IV. Mr. Daleſme *, a man of feventy-nine years of age, finding no relief from truffes to contain a hernia he had laboured under fori fourteen years, was content, with his own hand, to reduce the parts, whenever they fell out, and he obſerved that they re-entered more eaſily when he lay on the fide oppofte to his rupture. This obſervation was very uſeful to him, for he had accuſtomed himſelf , to lie on that fide, having ordered his bed to be made in a manner ſuited for that purpoſe; which circumſtance cured him up. This obſervation evinces, that it is fofi- cient to contain the parts in the abdomen, either by the truſs or the patient's ſituation, and that nature takes care, oftener than they who are ſurprized at Daleſme's cure, to free thoſe who labour under this diſorder from it. In Fabricius Hildanus | we find an example I of a fimilar cure, in a gentleman who was freed from an hernia, under which he had * Effai ſur des hern. par feu M. Roncaume, pe 1899 + Idem, p. 186. † Cent. 6. obli 70. toto bonito é o ibo polaroid las Of HERNIAS, &c. 299 carcaffes cures. aboured for twenty-eight years, by keeping his bed for fix months on account of another diſorder. b310 The opening of the carcaſſes of thoſe who The aper- lave died, after having been cured of fimi- ture of Ir diſorders, ſufficiently diſcovers the me-diſcovers chaniſm which nature uſes in performing the me- ich cures. I have frequently found the in- -chanifin latine adherent to the peritoneum, in the ca- ture uſes ny of the abdomen, at the margin of the in theſe ing, ſo that it could not quit the place it poffeffed, which is fufficient to hinder the aling down of the hernia. I have in other übjects ſeen the internal ſides of the herniary fo intimately united, that the parts could 101 freely enter it. Of this we have an sample drawn from a living perſon, in the obſervations of Mr. Le Dran, p. 159. tom. 2. But commonly this bag contracts, when it reduced into the abdomen. It becomes dherent to the ring internally, where it re- mains thus contracted and collected between te fides of the ring to which it is intimately sited, and forms a ſort of ſtopper fo firm ad folid, that nothing is capable of expel- ng it. It was probably this part which Ambroſe Paré took for an adipoſe ſubſtance, u the carcaſs of Mr. Simonet, clerk of St. André des Arts. Cures of this kind are not therefore ſo difficult to be explained, when We are at the pains to ſearch for their effects nature, inſtead of building ſyſtems, which, having 300 Of HERNI A S, &c. of adhe- Tences not with thoſe teſtine. having no foundations, fall of their own adi cord. There are alſo ſome other means which nature uſes for the cure of hernias, when ſhe is ſtimulated by art. This I proof poſe to ſhew, when I come to treat of the re- medies proper for the cure of habitual her of nias, their method of acting, and the choice we ought to make of them. Symptoms When by any irritation whatſoever, the fymptoms I have mentioned happen to heruis to be con- nias with adherences, ſuch as ſpaſmodic and founded, convulſive motions, with pain, colics, vom of ſtran- mitings, hiccups, and fever, without a ſtran- gulations gulation of the inteſtine, we ought to be ex- tremely attentive not to confound theſe ſymp- toms with thoſe of a ſtrangulation ; for there is but very little difference between the one and the other. In a ſtrangulation there is a fuppreſſion of the bilious matter by the anus, and this paffage affords no diſcharge of the wind, except in caſes where a part of the orifice is at liberty, and allows the faces and the wind to paſs freely, as I ſhall afterwards thew. But in hernias with adherence, the fymptoms only ariſe from irritation, and are not fo violent; the colics are at a conſiderable diſtance from each other, the fever does not fupervene fo foon; the hiccup and vomiting are leſs frequent; the bilious matter and wind paſs through the anus, either naturally, or by the affiſtance of clyfters and evacuants If, however, as I have before obſerved 3 INO ; OP IC OF HERNIA $, &c. 301 ces, we uſe no method of removing theſe ymptoms, a ſtrangulation fupervenes in theſe nary parts, which renders the true character of the diſorder difficult to be known by thoſe who are not well acquainted with this branch of practice. Tom 10 zarben sEvery thing capable of relaxing and ex- Means of anding the parts, which are in a štate of ir- alleviating the ſymp- station and convulſion, induced by the fymptoms of toms of adherences, is, in this caſe, benefi- adheren- cal and ſucceſsful. Accordingly we make Averal veneſections, which are to be repeated ccording to the conſtitution of the patient. Ve order him clyſters of the decoctions of mollient herbs, or other things of ſimilar ature, except oils of all kinds, for reaſons hall by and by give. We apply over the umor anodyne cataplaſms, with which we mix oils of chamomile, melilot, dill and rofes; or we content ourſelves to make warm embrocations with theſe oils. The remedy which has always ſucceeded beſt with me, and which is an invention of my own, is a kind of liniment prepared in the following zove manner. aldes cof Take of melted wax, of the oil of nuts, and that of ſweet almonds, each two ounces ; gum ammoniac diffolved in vinegar, to two drams; and of laudanum, twelve n grains : Make all into a liniment. vo old This 302 OF HERNIA S, &c. a This remedy, which is at once emollient , reſolvent and antifpofmodic, is to be ſpread swarm, on the tumor and the whole abdo- men, as far as the region of the ſtomach b If the fymptoms do not ceaſe by the first application, which ought to be conti- nued for two or three hours, yet they are at leaſt ſo alleviated, that we may affure ourſelves whether the inteſtine has a free communication with the anus, whence we are to draw the ſign which characterizes the ſtate of the diſorder; that is to fay, diſcover if there are only ſimple adherences, or if there is a ſtrangulation with adherences. In order to be convinced of this, we order the patient to take a ſpoonful of oil of Twet almonds every quarter of an hour. If there is no ftrangulation, the oil paſſes totally thro' the anus, and carries ſome part of the bilious matter along with it. I have before fald, that no oil ought to be put into the clyfters becauſe we could not judge whether it pro- ceeded from the ſtomach, or the inteſtines , (which difficulty does not happen, when we only exhibit it by the mouth. This remark is of great importance in all ambiguous cales of ftrangulation. If the oil paſſes, and elpe. cially if it carries bilious matter along with it, it is an almoſt certain proof , that the fymptoms only proceed from adherences , when, from the relation of the patient, we have affured ourſelves of the permanent fate C of OF HERNI A $, &c. 303 of the hernia for ſeveral months or years. This is an almoft certain proof; becauſe, in caſe of the contraction of a portion of the orifice of the inteſtine, the bilious matter may flow as freely as in the caſe of pure and fimple adherences; but in thefe laſt caſes, the pain of the tumor is hardly perceptible, and there are no gripes, or if there are, they are very gentle, at a conſiderable diſtance of time from each other, and of a ſhort dura- tion. In theſe circumſtances our principal aim ought to be, to make the effect of ſuch 2 diſorder ceaſe, if poſſible, without attempt- ing to remove its cauſe. With this intention we muſt repeat the veneſection, continue the liniment, keep the patient to the ſtricteſt re- gimen, and make him drink often, and little at a time, of a weak infufion of lime-tree Howers, with a very ſmall quantity of fal prunellæ. We must alſo give him clyfters every four hours, making him take after each clyfter, from four to eight grains of the tem- perating powder of Sthall, or fome drops of the anodyne mineral liquor of Hoffman. If theſe admirable remedies, with which theſe great men have enriched the healing art, can- not be had, we may uſe laudanum, fyrup of diacodium, or fyrup of amber. This laſt has always appeared to me the beſt of theſe laſt mentioned remedies, finee it is rather anti- {poſmodic than narcotic. If the fymptoms do not ceaſe by theſe remedies, or if inſtead of 304 OF HERNIAS, &c. 4 E Adheren- of being diminiſhed they are augmented, we muft, without heſitating, proceed to the oper ration, in order to free the inteſtine from the adherences, which keep it as it were chained up. It is by the operation that we diſcover the different ſpecies of adherences, and in it we find the laſt reſources of the art, when we have not ſucceeded in alleviating the ſymptoms. We ſhall next enquire what are the dif- ferent methods of proceeding, with which the art of operating preſents us, in order to deſtroy adherences. work It is fufficiently obvious, that adherences ces by ag- have not, in theſe laſt ages, been unknown glutinati- on known to Franco and Paré, who ſpeak of them in to Franco ſuch a manner, as to diſcover the difficulties which occur occur in the operation for them, Paré, in particular, has excellently dilin- guiſhed the adherence by agglutination.*, but neither the one nor the other lays down the method of removing it, and Paré does not to much as preſcribe the means of alleviating its ſymptoms. This ſpecies of adherence is the moſt com- ces by ag mon, and is particularly obſervable in thoſe moſt com- ftrangulation. There are few ſurgeons who on, tho' hernias which have ſuffered a conſiderable have not obſerved it, even though they have eafily re- either ſeen or performed but very few operan and Paré. 1 1 Adheren- mon, are yet moſt inoved. * Lib. 8. cap. 14. tions no Of HERNI A S, &c. 305 tions for hernias. Hernias, whether large or ſmall ; recent or of long ſtanding, crural or ventral, or thoſe of the ſcrotum, are all ſubject to this kind of adherence. But if this ſpecies of adherence is moſt common, it is equally true that it is moſt eaſily removed. It is, for the moſt part, eafily detached, by paſſing the fore- finger gently between the parts, and diſunit- ing them in the ſame manner as we ſeparate the thin leaves of which a playing card made. Sometimes indeed a portion of the external membrane of the inteſtine is de- froyed, when the inflammation is very con- fiderable, and has already diſpoſed that membrane to putrefaction. The chapter on hernias with putrefaction, furniſhes us with ſome examples of this; but if we give nature her due, we muſt confeſs that the moſt frequently takes care of this misfortune, ſince the very ſoon repairs this membrane, when the operation is performed with that ſkill which the parts require ; for the inteſtine, when replaced in the abdomen, moſt generally contracts a new adherence with ſome of its own contiguous parts, by means of the extravaſation of the nutritive juices, which tranſude from the extremities of the dilacerated veſſels. door bevinde so O BISTRVA THON V. rednis In the year 1722, a man of thirty-five years of age died at Paris, in the charity hof- X pital, ul 306 Of HERNIAS, &c. pital, twenty-four hours after the operation for the bubonocele, performed by Mr. Ge rard. At that ſurgeon's requeſt I opened the body, and found the part of the ileum, which had been compreſſed in the tumor, fo adhe rent for three or four finger-breadths, to an- other part of the ſame inteſtine, very near the aperture in the abdomen, that I could not ſeparate them without a great deal of pre- caution, which was abſolutely requiſite to preſerve them entire. This part of the in- teſtine was black and livid, and the reſt of the ſmall inteſtines were inflamed and dif- tended to ſuch a degree, that their diameters were as large again as in their natural ſtate. In the middle of the meſentery there was a confiderable abſceſs, which had probably been the cauſe of the patient's death; inflammation of the inteſtines, a mortification and adherence do not always prove the caules of death. If it was ſo, it would be rare to ſee inſtances of ſucceſs in the cure of theſe diſorders. However, we can ſay, to the praiſe of modern ſurgeons, that we have more inſtances of ſucceſs than of bad luck in per- forming this operation, even in caſes of ad- herences. Method of The common method of detaching this detaching ſpecies of adherence, by paſſing the fore- rence with finger between the inteſtine and the parts agglutina- to which it adheres, is moſt frequently practiſed : It is even much furer than that for an tion, directed Of H ERNI A SS ತೀ . 307 , &Cdirected by ſome authors, who uſe a biftory, by encroaching, ſay they, with this inftru- ment on the parts to which the inteſtine ad- heres . (This is the ſtrain in which they talk, without determining any ſpecies of ad- "herences.) But to me this method never ap- peared practicable in all caſes. For example, when the inteſtine is united by this ſpecies of adherence, with the herniary fac, in the part where it is compreffed by the ring, there is not room enough for the finger to turn round the inteſtine, and it is abſolutely impoſſible to remove this obſtacle, without a ſmall in- ftrument *, ſuch as that which I generally uſe, even in all caſes where the finger can be employed. It is much eaſier to paſs this in- frument between the fac and the inteſtine, and by its means detach this ſpecies of adhe- rence with far greater facility. It ſometimes happens, that when the membranes of the inteſtine are collaſped and ſoft, whatever me- thod the furgeon uſes, theſe membranes are lacerated, and the inteſtine allows the matter it contains to ſlip out. This caſe is indeed very diſagreeable to the operator, becauſe perfons little ſkilled in practice accuſe him of having performed the operation ill. But he 10 пого 30% This inftrument, which is alver, is five or fix ir ches Jong, and at one of its extiemities has a kind of hook, or fit tail, four or five lines long, round, and whoſe edges are very blunt. At the other end of the inſtrument there is a Ismall heak, destined for uſes which I fall afterwards men- tion. X2 is 308 OF HERNI A S, &C is notſtartled at this accident, if he operates before good judges. Far from abandoning the patient by oppoſing the intentions of na- ture, he ſcorns the filly and indiſcreet con- duct of thoſe who, by this means, pretend to cover their fault, if it is one, fince, in this cafe, they only retain their reputation for a few minutes. On this occaſion, the princi- pal intention is to procure a free evacuation of the matter, by ſupporting the inteſtine at the margin of the aperture in the abdomen. It is eaſy to anſwer this indication, by a pro- per management of the reſt of the adheren- ces, if they are not before deſtroyed, or by fecuring the inteſtine by the different means laid down in the chapter on hernias with putrefaction. bagus បង no b O B SE R V A TION VI. In the year 1726, I performed the opera tion for a crural hernia, as large as a hen's egg, on a man, in preſence of Mr. Dutartre and another furgeon. The adherent inteſtine opened into an extent almoſt round, and twò or three lines in diameter, when I ate tempted with my finger to ſeparate it from the fac, to which it was ſtrongly adherent If I had uſed the above-mentioned inſtru- ment, this accident would not perhaps have happened; but unfortunately I had it not about me. Be this as it will, the faces were foon copiouſly diſcharged, and frighted the 10 Stall fur- OF HERNIAS, &c. 309 furgeon whom I have not named. He judged it proper that I ſhould abandon the patient; becauſe, in his opinion, there was no hope of a cure. However, without being alarm’d at his diſcourſe, I introduced a probe into the inteſtine, to ſatisfy myſelf whether it was not too much compreſſed by the ligamentum pau- perti, ſo as to hinder the free diſcharge of the feces. I found there was fpace enough to prevent my making the dilatation of the liga- ment. I left the inteſtine externally, and dreſſed it like the reſt of the wound, with a fimple pledget covered with the linimentum arcæi, and the oil of St. John's wort, and fe- cured the whole by a plaiſter of cerate. The dreſſing was renew'd each time the patient felt the foeces diſcharged from the wound; and the gangrenous eſchars were totally ſeparated on the eighth day. At the end of twenty days the inteſtine was cicatrifed, and on the thirtieth the patient was entirely cured : Ever ſince he has laboured under no incon- venience, except fome colics, which have ſeized him at different times, for the ſpace of four years; but more than fifteen of theſe colics were ſo flight as hardly to be felt, ex- cept when he laid afide his truſs, which he was obliged to uſe ; for though the hernia does not fall out when he wants his truſs, pet, in the place of the cicatrix, he feels fmall pains and a colic, probably cauſed by the weight of the inteſtines, which not being ſur- X 3 310 Of HERNIA S, &c. food fuſtained, diſpoſe the adherent portion to fall out, by which means it ſuffers painful twitch- ings. Theſe pains would not fail to be aug- mented, if the patient ſhould altogether lay aſide the uſe of his truſs, and perhaps the inteſtine would even rend at the part of the adherences; at leaſt this accident may hap- pen in the beginning of the cure, as may be ſeen in the chapter on hernias with putre- faction, by the example given by Mr. Talin, of a man whoſe inteſtine opened feveral times in the ſame year. The obſervation I have now related, proves that the danger ariſing from the aperture of the inteſtine in the detachment of adhe- rences is not irreparable, ſince no greater damage ariſes from it, than in hernias putrefaction, of the happy cures of which we have ſo many inſtances in the chap- ter on that ſubject. There are caſes, how- ever, in which it is far better not to de- tach them. It is particularly fo where there is a putrefaction of the inteſtines, and where we run a riſque of expoſing ourſelves to the reproaches of the by-ſtanders and the pa- tients, eſpecially ſince it is then of conſe- quence to ſuſtain the inteſtine without the abdomen, when it is in danger of opening, becauſe, if it was not adherent there, it would, perhaps, be neceſſary to ſecure it by ſome ſtitches of future. Mr. Guerin, fur- orio sta geon- OF HERN I AS, &c. 311 а geon-major of the muſqueteers, avoids all inconveniencies, by leaving all the adheren- ces between the inteſtine and the herniary fac undeſtroyed, as we find in the following obſervation, which may ferve as a rule in fi- milar caſes. th ad on OBSERVATION VII. A woman of fifty years of age, in 1726, was feized with a crural hernia, which was hot remedied till twelve or fifteen years after, becauſe a ſtrangulation happened in it; the inteſtine was then reduced, but there re- mained a kind of prominence, which was only afterwards diffipated by means of reſol- vent cataplaſms and diſcutient plaiſters. It was at laſt contained in a trufs. In the year 1740, which was fourteen years after this accident, ſhe had a ſtrangulation, which did not terminate fo happily. Mr. Guerin em- ployed all the remedies he judged proper, to which, nevertheleſs, the fymptoms did not yield, which circumſtance obliged him to perform the operation. He found the in- teftine adherent to the herniary fac, almoſt in all its ſurface; and as the inteſtine was in a gangrenous difpofition, and very cold, he thought it beſt to let it remain out of the abdomen, without detaching the adherences. He dilated the ligament of Fallopius, and dreſſed the wound gently. The wound re- fifted putrefaction for twelve days, during X 4 which 312 Of HERNIA S,&c. ca C which time the patient went to ſtool in her uſual manner. At the end of twelve days, the fæces began to be diſcharged throughi the wound, and continued to do ſo till thel ſeventieth day after the operation, when thed greateſt part of them began to be evacuated by the anus, and ſome days after the woundid was entirely cured without a fiftula. bermmll If ſeveral circumvolutions of the inteſtine are joined together by this ſpecies of adhe- rence, it is of great conſequence to ſeparate.. them from each other, when the bulk ofbd the inteſtines contained in the tumor exceeds the diameter of the ring, and when the glands of the meſentery are very much ine) flated; for when the whole can paſs together through the ring, fufficiently dilated, it is not neceſſary to be at that trouble, nay, we would even do a great deal of injury to thew inteſtine, by leaving it too long expoſed to the air, I have performed ſeveral operations, in which I have found the inteſtines adherent to each other, without being at the pains tob detach their adherences, and I have nevery ſeen any accident happen on that accountal neither do I preſume that any can happen. S OBSERVATION VIII. In the year 1733, Meff . Malaval anda Foubert, and Mr. Noel, a furgeon of Oto leans, were witneſſes to the operation I permis formed on General Perrot, a man of eighty re 16 I IS 9910 HO GS 28 Hot bolesale le 2 years -- HERNIA S, &c. 313 SI om dainw a OF years of age, on account of an incomplete hernia, about the bulk of a tennis-ball . The inteſtine was adherent to itſelf, and formed ſeveral foldings, intimately united together by an old agglutination. I contented myſelf to ſet the ring and fac at liberty, and to re- duce the parts without diſuniting them. Immediately after the reduction, the patient went to ſtool, and continued to do ſo for ight days, without any obſtacle; but at laſt he died of a conſumption, entirely indepen- dent of this diſorder. If, however, this ſpecies of adherence keeps the inteſtine folded over itſelf, and compreſſed in ſuch a manner, that though reduced into the abdomen, the fæces have not liberty to paſs through it, in this caſe it sabſolutely neceſſary to detach them, other- wife the patient muſt infallibly die. gao OBSERVATION IX. us on I have ſeen in the carcaſs of a man, who died three days after the operation for a entral hernia, a part of the inteſtine, which lad been compreſſed in the hernia, folded ver itfelf, and embracing another portion of iself as large as a filberd. The part which ftrangulated was found, and that which embraced it was putrified. However, by means of the inſtrument before-mentioned, I was able to detach them, without dilacerating the membranes of either of them. The 0 20101 was 2 fur- 314 Of HERNIAS, &c. 3 ſurgeon confefs’d that he had found theſe parts thus adherent in the time of the opera- tion ; but ſaid he durft not venture upon dil uniting, for fear of tearing them. It then appear'd to me, that the death of the patient muſt have unavoidably happen'd; but fur- gery, then leſs perfect than at preſent, with refpect to apertures of the inteſtine, which was a terrible accident, only preſented obſcure ideas to the ſurgeons, intimidated by the want of uſe and practice in accidents of this kind. As for fibrous adherences, when the nu- tritive juice, inſtead of being extravaſated on an extended furface, is diſcharged from one or more points, ſeparate from each other, it is by little and little accumulated, and forms a kind of bridles, more or leſs long and folid, which keep the inteſtine and the epiploon united to each other, or either of theſe parts to the herniary fac, till the ſurgeon has re- moved the obſtacle. This ſpecies of adhe rence has well characteriz'd differences, as is eaſily obſervable in practice: Some are very fine, flender, and have no folidity, being only as it were mucilaginous. Others acquire cer- tain degrees of folidity, which is more or leks confiderable, in proportion to the time fitee their formation. Others are fo folid, that they are as it were tendinous : Such are thoſe deſcribed by De Graaf and Drelincourt. Some are round, and others flat. Some have one -312 CU extre- Of HERNIAS, &c. 315 و extremity large, and the other pointed, which renders them as it were pyramidal. Some are compoſed of many fibres, ſeparating them- felves from each other at one extremity, and uniting at the other. All theſe fibrous adhe- rences alſo differ in this, that they are fituated differently; for ſome are in the abdomen, and others in the tumor itſelf, between the la and the inteſtine, which they keep join'd together, as Drelincourt well expreſſes it, * by fibres fimilar to the branches of ivy. Theſe fibres are ſo implanted in the ſub- ſtance of the inteſtine and the herniary fac, that it is impoſſible to detach them from each other, without lacerating the whole." However, notwithſtanding the opinion of this author, who does not think it poſſible to de- ach thefe fibres without tearing the parts, jet it is very eafy to cut them, eſpecially when they are not in the abdomen. They may be cut either by the ſciffars or the bifto- 13.3 but I prefer the ſciſfars, on account of the efforts we are obliged to make, when theſe ridles are very ſolid. A ſharp biftory, with button at its point, has with me anſwer'd very well in this caſe. The following obſer- sation contains ſome remarkable particulari- dies on this ſubject. In OBSERVATION X. 1726, I perform'd the operation for a mural hernia, in preſence of Meff. Dufay, Fre- 316 Of HERNIAS, &c. Fremont, Perrier, and Gallin, on an old maids is who, for ſeventeen days, labour'd under Cally the fymptoms which may be produced by adherences. Theſe were ſo well characteriz'dy that none of the gentlemen in conſultation doubted of their exiſtence. The tumor was ! of very long ſtanding, fince for ten years, without ever re-entering, it had always con tinued to be of the ſame bulk. The vomito ings exiſted for 17 days, but they were not frequent, and at a conſiderable diſtance of time from each other. The patient went to ftool; but this effect was procured by means of clyfters. She had gripes at certain intera vals; but they were flight, and conſequently fupportable. Being convinced, that the ſtrane gulation had lefs ſhare in the ſymptoms thail fome adherence, which bridled and confined. the inteſtine, I propoſed the operation as the cle which produced theſe diſorders, and of only remedy capable of deſtroying the obftalı preventing their conſequences. Every one of the gentlemen in conſultation agreed to preſling neceſſity of performing it. At fird!! found the herniary fac ſtrongly adherent, in all its external ſurface, to that texture which fuſtains the fat. When I had open’d the face, I found a portion of the inteſtine as large as a hen's egg. There was no epiploon, the inteſtine was adherent to the herniary ſao by ſeven bridles, ſo diſtinctly ſeparated each other, that they feem'd to be ſituated Na epiploon, and the from Soul around Of HERNIAS, &c. 317 a ز a round the inteſtine at the entry of the fac, with the ſame order as the ſpokes of a wheel ound the common nave. Some of them rere of different lengths, and the longeſt were about two lines and a half; whilſt the horteſt were only one line; and both were bout half a line in diameter. They had the blour of tendinous parts. They were all old , and ſo hard that it was neceſſary to make a conſiderable effort in order to cut sem; for which purpoſe I uſed the ſciſfars. s foon as the laſt of them was cut, the in- fine re-enter'd of its own accord; for there s no ftrangulation either from the ligament Fallopius or the herniary fac. The inter- te was ſomewhat inflamed, but otherwiſe a very good ſtate. The ſymptoms ceaſed imediately upon the operation, and four- sa days after, the patient went to church to ank God for her cure. Since that time ſhe shad no fymptom of her hernia, of which was cured without relapſe.at The thin, flat, and ſoft bridles are eaſily n by the finger ; but it is more prudent to At them, in order to avoid all inconvenien- once ſaw the inteſtine torn by a very at furgeon, in attempting to break one of Ne bridles, which kept the epiploon adhe- at to the herniary fac. He thought there nothing to be dreaded, but the epiploon was adherent to the inteſtine, which cover'd, refifted the effort of the bridle, and (es. I which 318 Of HERNIAS, &c. eafy to and cauſed the dilaceration of the inteſtine , at the part where it was adherent to the epi- ploon. This part correſponded exactly to the bridle of the epiploon. When theſe bridles, of whatever nature, are in the abdomen beyond the ring, it is difficult to diſcover them, eſpecially when there are none externally to indicate their exiſtence. We perceive them, when not being able to return the inteſtine, we convey the finger into the abdomen, in order to know what the obſtacle is which oppoſes the re- duction. We then diſcover whether there are bridles which retain the inteſtine. If they are within reach of the finger, it is judge of what kind they are; as alſo of their ſituation, length, and conſiſtence. Some of them are placed perpendicularly ; that is to ſay, they are fix'd in one ſide, to the arch form’d by the muſcles of the abdomen, and at the other extremity are attach'd to the in- teſtine. Others are ſituated obliquely, of . from right to left. In a word, they may be ſituated in other different poſitions , which are diſcover’d by the touch. If the ring is not fufficiently dilated to permit the free entrance of the finger, it muft be open'd'as much as poſſible for that purpoſe . If it is . the ligament of Pupart, we run no riſque in dilating it pretty much in women, only taking care to thun the epigaſtric artery. But in men we muſt take other meaſures, of which or all of Of HERNI A S, &c. 319 I ſhall ſpeak elſewhere, on account of the danger there is of cutting the ſpermatic vef- fels. When we have diſcover'd and touch'd the bridles, we introduce the ſciſſars, laid flat on the finger, and touching the bridle with the end of the finger, we aſſure ourſelves of the place where we muſt cut it. It is the extremity of the finger which diſcovers this place, for finding which we can lay down no fure rules, if not, that we muſt keep at as great a diſtance as poſſible from the inteſtine. The inſtrument which Mr. Petit has invented to cut the ligament under the tongue, may, n this caſe, be more advantageouſly uſed than the ſciſſars. The exiſtence of ſuch bridles proved by the following obſervation. po . OBSERVATION XI. In 1725, I was call'd to Argenticelle, a I town about ten or twelve miles from Paris, by a furgeon of that place, to ſee a patient on whom he had, two days before, perform’d le operation for a complete hernia, without being able to reduce the inteſtine, which alone compoſed the tumor. There was no adhe- tence externally, and the ring of the muſcle was ſo well dilated, that it was eaſy for me to introduce my finger pretty far into the abdo- men, but without perceiving what oppoſed re-entrance of the inteſtine. The patient died the ſame day, and upon opening his car- afs I found three bridles, of a ſubſtance and colour the a 2 320 Of HERNIAS, &c. 12 colour like thoſe of tendinous parts, and of the bulk of common fiddle-ſtrings. They were all three ranged in a line, but they were of different lengths. The leaſt was about three lines long, the next about four or five, and the third ſeven or eight. They were at- tach'd on one ſide, to that part of the meſen- tery which was next to the prolapſed inteſtine , which they pulld towards the linea alba, whither they went to implant themſelves ob- liquely in the ſubſtance of the peritoneum. Tho' I was very young when I made this ob- ſervation, I reproach'd myſelf with not having been more exact in ſearching, with my finger , for that which hinder'd the inteſtine from re- entring. If, inſtead of conveying my finger into the abdomen, according to the direction of the fpermatic veſſels, I had turn'd it towards the linea alba, I could not have faild to find theſe bridles, which were within reach of my finger ; neither could I have been condemn’d for cutting them. But the ad . vantage I reap'd from this obſervation was not loft, ſince it enabled me to preſerve the life of a man, who probably would have died as well as the other, if I had not known how to put this fingular remark in practice. OBSERVATION XII.. 001 VO In the year 1733, I was call'd in conful- tation for a man of 60 years of age, on whom Mr. Malaval perform the operation for a j WO BA com- OF HERNÍ A S, &c. 321 complete hernia of a very conſiderable bulk. He detach'd ſeveral glutinous adheſions, fet the rings at liberty, and did what is com- monly done to make the inteſtine re-enter ; but his efforts were to no purpoſe. I at- tempted the ſame means; but with as little fucceſs as he ; which induced me to ſearch in the abdomen, with my finger, for the cauſe which oppoſed the re-entry of the parts. I found, about the depth of four finger-breadths in the abdomen, a bridle three inches long, of a hard and ſolid conſiſtence, which retain'd the inteſtine. Mr. Malaval, and Mr. La Site, elfo touch'd it, and eafily diſtinguiſh'd it. It was fituated in ſuch a manner, as to run obliquely from that part of the inteſtine which touch'd the meſentery, towards the inferior extremity of the linea alba, above the blad der; ſo that it touch'd the inteſtine, and form'd a very acute angle with it, ſo as to hinder the return of the inteſtiné into the abdomen. Mr. Malaval gave me the honour of finiſhing the operation, by cutting this bridle. I convey'd the ſciffärs on my finger to the bridle; then, opening the ſeiſfars to lay hold of it, I cut it with a great deal of eaſe. The inteftine afterwards enter'd almoſt of its own accord, and the patient was cured with- out any accident. As for fleſhy adheſions, they are, properly ſpeaking, hard and ſolid cicatrices, even ſome- times with calloſities, which unite the parts of hotinogo jos y fo . 322 OF HERNI AS, &c. . ſo intimately with each other, that it is im- poſſible to ſeparate them, and that we even ought not to attempt their diviſion. This ſpecies of adheſion is generally found in old hernias, as Bonetus obſerves * Thoſe of the navel are moſt commonly complicated with this fymptom, becauſe they are the moſt dif. ficult to be reduced: When they are arrived at a certain bulk, it is almoſt impoſſible to re- duce them, eſpecially in the large and foft abdomens of women who have born a great many children. Theſe kinds of hernias are much expoſed to hard and troubleſome im- preffions, which produce in them irritations , inflammatory excoriations, and ruptures of the veſſels; whence hard and callous cica- trices neceſſarily ariſe. Old complete hernias of the ſcrotum are generally ſubject to this fpecies of adheſion, when they are left to themſelves, or when they have been impet- fectly contain'd. Simple bubonoceles and crural hernias are ſometimes accompanied with this fymptom, when they are of very long ſtanding. In both, this misfortune is al- moſt always owing to ill-made truffes, which only contain the parts imperfe&tly, and by their irregular compreffions lay a foundation for theſe diſorders, except in rare caſes, as in hernias which have been complicated with abſceſſes, and in thoſe wherein cauteries have been indiſcreetly applied, &c. * Sepulchr. Anatom. Obf. XIII. su do Imo on Thele Of H ERNÍ A S, &C. 323 Theſe kinds of adhenſions differ among themſelves, (as well as thoſe of which I have already ſpoke) in this, that fome of them join together ſeveral circumvolutions of the inteſtine, and even fometimes of inteſtines of different kinds, without their having any co- heſion with the herniary fac. In this caſe we are not to be at too great pains to detach all theſe adheſions, but make it our buſineſs to reduce the parts if poſſible. In this we ſometimes ſucceed, by detaching the adhen- fons which the inteſtine has contracted with the external parts, ſuch as the fac or the ſkin. OBSERVATION XIII. In 1732, I was forced to perform the operation for an old umbilical hernia, on a woman, about fifty years of age. The tu- mor reſembled ſeveral bladders filled with air . Theſe bladders were marked through the ſkin by the different circumvolutions of the inteſtine. This ſkin was ſo very delicate that it reſembled a very fine membrane. The inteſtine was entirely adherent to it in all its furface. The tumor was at leaſt five inches in diameter, and more than two inches pro- minent above the ſurface of the abdomen The patient was extremely fat; ſo that the tumor muſt, of conſequence, have been at leaft five inches high, taking it directly from Its exit from the abdomen. Such an opera- tion Y 2 324 Of HERNIAS, &c. tion was ſo full of difficulties, that I thought I had juſt reaſon to decline performing it However, as the patient was juſt on the brink of death, her ſerene highneſs the dutcheſs of Orleans *, to whom ſhe belonged, was un- willing that ſhe ſhould die for want of the beſt means of relief. Her daughter, abbeſſe of Chelles, fent for me, to give her an account of the diſorder ; ſhe ordered me to perform the operation, and encouraged me, by telling me, that ſhe would take all the conſequences which ſhe foreſaw upon herſelf. In a word, ſhe ſaid the moſt obliging things, to engage me to ſurmount all the difficulties which this operation preſented. I called into conſulta- tion Meſſieurs Marſollan, Soumain, Cazabon, and my father, all ſurgeons of the houſe of Orleans. I attempted only to detach all the adhenſions which the inteftine had contracted with the ſkin. The ſkin alone ſerved them for a fac. There was not the leaſt appear- ance of a peritoneum, whether it had been torn, and the parts paſſed through its fub- ſtance, or whether it had been totally effaced by ſtretching, in proportion as the parts out the abdomen ſtretched. Both theſe ef- *** This princeſs, who had a natural turn for all the arti knew furgery perfe&tly. She not only blooded herſelf, the that was not to be done without difficulty, but there were alſo few chirurgical operations which ſhe had not performed on living ſubjects. She acquired a perfect theory of furgery by reading the beſt authors, after having obtained a compe tent knowledge in anatomy. She had for Winflow, and ſeveral eminent furgeons. 1000 20 a with- Mr. preceptors, fects Of HERNIAS, &c. 325 fects happen frequently. It is rare to find any peritoneum in theſe kinds of hernias. When I had patiently diffected all the extent of the ſkin which covered the parts, the inteſtinum colon formed three parts of the tumor, and poffeſſed the whole circumference of it, while the jejunum poffeſſed the center, They ad- hered ſo intimately to each other, that they ſeemed to conſtitute but one and the ſame body, which had no reſemblance to the inteſti- mal canal. A large quantity of the epiploon, which ſerved as a ſupport to all the circum- férence of the tumor, ſeemed to have ſerved as a fac to 'it in the beginning, and to have been afterwards torn, in order to let the in- teſtines paſs through its ſubſtance. The hardneſs which the epiploon had acquired, and the adherence it had contracted with the muſcles, with the membrana adipofa, and the colon, formed with theſe parts one con- tinued maſs, in which nothing particular could be diſtinguiſhed. I thought it impro- per to ſeparate the inteſtines from the bridles which kept them united, but made it my buſineſs to return the whole maſs into the abdomen. I diffected it all round in the thickneſs of the epiploon. It was ſo con- iderably hard, that it diſcharged little or no flood, and I had the happineſs to return all parts into the abdomen, without any le- fion. The patient bore this operation with Y 3 and the 326 Of H ERNI A S, &c. and a quarter . Every thing went happily on till the fifteenth day after the operation, The pains, vomiting and hiccups ceaſed from the firſt day; the patient ſlept tolerably well for five or fix hours each night; the fever ceaſed on the fifth day, after the wound was in ſuppuration ; but on the fifteenth day, when 'every thing was in fo good a ſtate, as that there ſeemed to be nothing to be dread- ed, the patient was indiſcreetly compelled to eat to excefs, and drink ſome wine. She had an indigeſtion, which terminated in 2 diarrhæa, accompanied with an hepatic flux and a violent fever, which proved mortal on the ſeventeenth day after the operation, As it is cuſtomary to remove carcaſſes from royal houſes, as ſoon as the perſons are dead, it was not poſſible for me to make the aper- ture of the body. If I had, I ſhould have certainly found a great many uſeful circum- ſtances, the want of an opportunity of obſer- ving which, is greatly to be regreted in ſuch caſes. This obſervation ſhews, that it is not al- ways impoſſible to deſtroy adherences, reduce the parts into the abdomen. If however, there is fo manifeſt an impoſſibi- lity that we cannot, without great danger , detach the adherences, it is ſufficient to dilate the parts, and to leave them without the ab- domen. In a word, nothing worſe can hap- pen, than what the patient fuffered, perhaps gribe and for --V38 Of HERNIAS, &c. bris 327 for four, eight, or ten years before the ope- ration. The fæces were freely diſcharged from it; the patient lived with her misfor- tune, and was fo familiarized to pain, that her calamity became fupportable, ſo that ſhe might have been left in the condition ſhe was in, only removing the obſtacle which cauſed the preſent ſymptoms. This is not imprac- ticable, as we ſhall thew by and by. But we muſt firſt obſerve, that if the adherence unites the inteſtine and the epiploon, and if each of theſe parts is found, we are to reduce the whole together, or remove the epiploon after it is detached, as in ordinary caſes. But if the parts are ſo confuſedly mixed together, and in fo great a quantity, that it is impoſſible to diſtinguiſh them from each other, as in the obſervation I have related, we are, in ſuch caſes, to make ſome diſtinctions with reſpect to the means to be employed; for the her- niary fac either will not be adherent by all its external ſurface, which very rarely happens, or it will be adherent. In the former caſe, if it is poſſible to dilate the ring, and reduce altogether into the abdomen, we muſt not heſitate to do ſo, if there is no contra-indica- tion; that is to ſay, if there is ſpace enough in the abdomen, as I ſhall thew elſewhere, on the contrary, the fac is adherent by its external ſurface, and if we can detach the adherences , we may make the reduction e- e- qually well, as in the preceding caſes, always pay. Y 4 B28 - OF HERNIAS, &c. paying a due regard to the contra-indications, lielit But if all the parts are adherent together, and if the adherences of the fac are ſo intimately united with the cellular texture and the fat, that it is abſolutely impoſſible to detach itzaio di we muſt, in this caſe, alter our method; for the parts are either found, or in a ſtate tend- ing to mortification, or totally gangrened. If the parts are not altered, we muſt content ourſelves with dilating the ring, if there isiw any ſpace which may permit the entrance on of the dilating inſtrument, and leave the parts without the abdomen, preſerving them from the injuries of the air, by mild and fimple dreffings; but above all things, taking care to avoid too oily and pinguious medicinesri Then we are to obtain the reunion of the it divided ſkin, by which means the patient cured. This practice is authorized by the obſervation related by Mr. Morand, in thead remarks on Dionis, p. 348. and by another of Mr. Petit, who uſes the following method in a nearly ſimilar caſe. 2017 10. OBSERVATION XIV. A man had an habitual hernia from his,' infancy, in which, when he was aboutit twenty years of age, there appeared all thell fymptoms, which induced Mr. Petit to per ai form the operation. The tumor, which full drill the ſcrotum, was as large as the head of aw child a year old. The parts were ſo ſtrongly 3000 mi 1900 no ad Of HERNIAS, &c. 3293 to dherent, that Mr. Petit thought it improper o detach them; he only ſet them at eaſe, by dilating the ring. He dreſſed the whole of the parts with the moſt ſimple medi- eines , by which means the patient was S horoughly cured. Since the operation, he |jas been ſenſible of no other inconveniences, zcept now and then ſome gentle colics, which cuſtom made him almoſt forget, and which never reduced him to a neceſſity of eglecting his buſineſs, which requires a. reat deal of activity. He is drawer to a zrern, and conſequently obliged to more notion and ſtirring than moſt other perfons. The adherences which hinder the progreſs of her tumor, and a concave bandage which ulains the weight of it, have for thirty years reſerved the life of this patient, and may 5 lo fo for a great while longer, though he ad probably died, if any other method had been uſed.br But if the parts are fo adherent with the ing, that there does not remain the ſmalleſt pace to introduce the dilating inſtrument, I bink it proper to apply to the parts about be ring, fomentations capable of relaxing be tendinous fibres which compofe it. Theſe ibres , when become too rigid and tenſe by the nflammation and inflation of the parts engaged n the ring, are to be relaxed and unbent; but we muſt carefully avoid all oily and pinguious medicines, which would not fail to augment the 0 330 OF HERNIAS, &c. In W cal the inflammation, and excite fuppurations in the divided parts, by infinuating themſelves into the open veſſels, and by ſtopping up their extremities by the thick and glutinous molecules, of which they are compoſed. Theſe fuppurations, far from bringing the parts to a relaxation, as attenuating fuppura- tions do, would rather caufe an irritation, and augment the crifpation and inflamma- tion, the uſual effects of previous fuppura- tions. Aqueous lotions, on the contrary, by flowing off in proportion as the parts imbibe them, relax and unbend them, without blocking up the orifices of their veſſels . Weak, emollient and ſweetening decoctions, ſuch as thoſe of mallows, marſh-mallows, and others of a ſimilar nature, are much more proper in this caſe, and were fucceſs- fully uſed by Mr. Petit, in drefſing the her- nia I have now deſcribed. There is reaſon to hope, that he will not fail to give this ob- ſervation at full length, in his treatiſe of ope- rations, for which the public waits with im- patience. If this method does not ſucceed, parts are either gangrened, or in a ſtate next to gangrene, which does not permit the ule of theſe remedies, we muſt not heſitate, but, in order to prevent the death of the patient, muft lay open the inteſtine, and by that , means procure a free diſcharge to the fæces, This method ſeems to me fo much the more Ilus or if the proper, Of HERNI A S, &c. 331 proper, as nature indicates it to us in ne- glected hernias, Putrefaction opens a paſſage or the fæces through the membranes of the inteſtine and the ſkin. Some hernias have been cured, without any other care than that which nature takes of her own accord, or at taſt by the means which nature indicates to the patients, and this has happened to pa- dents the leaſt capable of reaſoning and mlecting on their ſtate, I have related examples of this in the chapter on hernias with putrefaction. Now, if nature indi- . ates this method, we ought not only to ad- mire, but alſo to imitate it; for if the inteſ- tne is cicatriſed, even after having been gan- mened, which always happens with loſs of ubſtance, it muſt be cured much more urely, when it has only ſuffered a gentle nflammation, and when it has not at all been attacked with a gangrene. The follow- og obfervations are proofs of the pofibility of fucceſs in ſimilar caſes, tion: OBSERVATION XV. In the month of October, 1733, I was fant for to ſee a woman of 45 years of age, Mack'd by a crural hernia with ſtrangula- The ſymptoms were fo violent, and he pulſe in a state fo.convulfive, that her ſur- gon had abandon'd her, becauſe he deſpair'd affording her any relief. I thought it pro- Per to perform the operation with all:expe- dition, 332 Of HERNIAS, &c. th dition. I callid Meff. Chauvin and Talin into conſultation. Upon opening the herniary fac, I found the inteſtine ſo ſtrongly adherent to this covering, that I had a great deal of trou- ble in ſeparating them. There were about two inches of the ileum ſomewhat livid ; but the membranes of this part had not loſt all their ſpring. I detach'd the inteſtine from the fac as much as I poſſibly could, which gave us an opportunity of examining it better, Then I ſaw that it was ſo adherent to the fac, at the part where it paſs’d under the ligament of Poupert; and that the fac itſelf was ſo ad- herent to the ligament, that all theſe parts together feem'd to form one fleſhy maſs, which it was not poſſible to deſtroy without dangerous dilacerations. We only thought of the beſt means of proçuring an evacuation of the fæces, and for this purpoſe believed it moſt expedient to open the inteſtine. I made a longitudinal inciſion in it, which facilitated the evacuation of the bilious matter contain'd in the prolapſed inteſtine. But the ſtrangu- lation made by the tendinous ligament of the muſcles, hinder'd the diſcharge of the feces from the abdomen, which obliged me to cut the bridle. As there was no vacuity between the fac and the inteſtine, which could adniit the paſſage of the dilating inftrument, we de liberated on the neceffity of introducing the button'd biſtory far enough into the inteſtine to cut it, the fac, and the ligamenti. This I al 100 mee Of HERNIAS, &c. 333 method was forthwith put in execution: 1 introduced my biſtory into the inteſtine, thro' the aperture I had made in drawing it out- wards; and at the ſame time raiſing my wriſt, Icut all at once, and with a ſingle ſtroke. Immediately upon this the bilious matter was diſcharged fo copiouſly, as to convince me that the whole was ſufficiently dilated, and u give me reaſon to hope, that the fæces would be evacuated thro' that aperture. dreſs’d the wound with a pledget, dipt in a digeſtive, compoſed of the liniment of arcæus and oil of St. John's-wort. This pledget was kured by a plaiſter, which permitted the evacuation of the fæces. We took care to change the dreſſing every time the abdomen diſcharged its contents. The evacuations were ſo conſiderable on the firſt day, that the dreſſing had but very ſmall time to remain on the wound; but they were diminiſh'd every !; day after till the fixth, when the wound was intirely deterg’d. Then, in the room of the digeſtive, I ſubſtituted the vinum mellitum, or oil of St. John's-wort . I uſed theſe remedies alternately every other day, or every two days, according to the criſpation or irritation which the former remedy produced, or according to the too great relaxation occaſion'd by the oil . The inteſtine was gradually retracted till the 15th day, when it appear'd almoſt on a level with the ſkin, ſo that we could hardly diftin, guish the aperture of it. At the end of a month 334 110D OF H ERNI A $, NOWN . , &c900 . month the fæces ceaſed to be diſcharged from the wound, which was cicatriſed on the for- tieth day This woman has; fince her cure; been obliged to confine herſelf to a regimen the leaſt capable of generating groſs excrementa ; for by the fmalleſt uſe of ſolid aliments the was tormented with violent colics, which could only be occaſioned by the ſhriveling up of the inteſtine, which did not permit an ealy paffage to the groſs fæces, which were cola lected at the ſhriveld part of the inteſtine ; and cauſed obſtructions, which have been ſeveral times likely to have proved mortal to 6 the patient. Theſe obſtructions were always follow'd with colics, and frequently with vo mitings. A great many clyſters, and large 6 potions of oil of ſweet almonds, were the remedies by which I afforded her the moſt ſpeedy and efficacious relief. Theſe fymp- toms laſted for ten years ; but after that time the patient lived like other people. The in teſtine had probably affumed a greater diame ter than it had before. A ſingle obſervation of this kind would ſeem too ſurpriſing, if it was not ſupported by another of a ſimilar nature, which autho rizes this method. Groot 107 Wolf of OBSERVATION XVI. In the month of November, in the ſame year, I perform'd the ſame operation We 6 de 9W 2 SS DOO See on a woman Of HERNIAS, &c. 335 woman of 67 years of age, in the ſame cir- cumſtances, in preſence of Mefl. Vermont and Talin. The hernia was inguinal, and the inteſtine was not alter'd by gangrene; but it was ſo ſtrongly adherent to the internal ſurface of the herniary fac, and eſpecially at the part of the ring, that the ring itſelf, the kc, and the inteſtine ſeem'd to form only one body, which reſembled an old, hard, and allous cicatrix. The membranes of the in- kline were extremely thick in the part next o the ring. I made a longitudinal inciſion In the inteſtine with a ſtraight biftory. I in- voduced my blunt biſtory within it, and cut he inteſtine, fac, and ring at a ſingle ſtroke. 1 fmall quantity of bilious matter was dif- charged, which gave me reaſon to believe bat it would flow freely. I dreſs’d the I wound as ſimply as it required. Next day I bund the patient almoſt in the agonies of death, and there had been no evacuation ſince the operation, which I had perform'd the night before. Without ſearching for the cauſe of this, any other where than in my cifion, I again convey'd my biftory into the heifion as deep as I could, and enlarged the former inciſion. The bilious matter was érthwith copiouſly diſcharged, and continued b flow for three hours. In the evening I went to ſee the patient, and found her in as good a ſtate as I could have wiſh'd for; the ibdomen had totally ſubſided, and all the 3 fyınp- 10. KLO 1900 336 of HERNI A S; &c. 0 C in W 110 fymptoms were alleviated; neither had I any thing to ſtruggle with, except the appetite the patient, who inceſſantly call'd for food. The wound was entirely deterged on the fifth day, and Mr. Vermont, who was ſo good as to take the charge of the patient, made a complete çure in twenty-five days. The pa tient, who during the whole of this time had hot been at ſtool, by the anus, went to the clofe-ftool two days after the perfect reunion of the inteſtine, and by means of a clyſter dil- charged ſo large a quantity of groſs foeces, that it was judged they had remained in the colon during the whole of the diſeaſe. Such an inſtance of ſucceſs ſeem'd as if it would have prolong'd the life of the patient ; but the died on the fourth day after the re-union of the wound, in which there only remain'd a ſmall ulcer, which was not ſo large as the nail of one's little finger, and which the pa tient dreſs’d herſelf with a ſmall plaiſter. The cauſe of this woman's death proceeded from the ignorance of Mr. Vermont's boy. She had a preſſing neceſſity for going to ſtool ; but, when there, could diſcharge nothing She ſent for Mr. Vermont, whoſe boy in his ſtead. He imagined that her complaint proceeded from this, that the excrements were no longer diſcharged from the wound. He therefore took a probe, with a deſign to re-open the inteſtine. He tore the cicatrix, and cruelly pierced the inteſtine thro' and 100 W: an Da thro came he NA bre ebio Of HERNIAS, &c. 337 thro', as was found in the aperture which I made of the body. The bilious matter was extravaſated into the abdomen by the wound of the inteſtine, which correſponded to the cavity of the abdomen. If he had known what he was about, he would have only ſim- ply renew'd the firſt wound of the inteſtine, ho' that was not neceſſary; but it might have been cured as well as at firſt, as is eaſily per- dived by the examples I ſhall afterwards give In the cure of hernias with putrefaction. I found the cauſe of the difficulty the patient had in going to ſtool in the rectum, which was full of groſs, dry, and indurated fæces. clyfter or two would have been fufficient to facilitate the evacuation of this matter. In hernias of a long ſtanding, and of a very conſiderable bulk, if the parts are gangrened, there are different methods of remedying them. For our principal view we ought al- ways to have the deſtruction of the gangrene, and the procuring an evacuation of the foeces. Thus if the gangrene only ſeizes a part of the inteſtine, we muſt only remove the gangrened fart, and dreſs the wound regularly. Nature akes care of the reſt, and re-unites the in- line in the part where it has been deprived its ſubſtance by new coheſions, which the paſſage of the fæces, and enable patient to live, provided he obſerves the precautions neceffary to his ſtate ; that is to provided he ſuſtains the tumor, and Z avoids MO eftine be UVO 10p up the 338 Of HERNI A S, &C. avoids all aliments capable of producing any obſtruction in the contracted or ſhriveld inteſtine. But when there are ſeveral parts of the in- teſtine gangrened, or when all of it, which is contain'd in the tumor, is attack'd or threatend with a gangrene, it is proper to remove the whole; that is to ſay, the found as well as the putrified parts. If we ſhould only de- ſtroy the different gangrenous ſpots, it would perhaps happen, that the patient ſhould in like manner be cured, becauſe a new canal might be form’d by the addition of new ad- herences, which the inteſtine might contract , or by the approach of the adjacent parts. But this canal would be always very imper- fect, and its action, which would be very difficult, would perhaps expoſe the patient to great inconveniencies, which would render life a burden, and put it out of his power to follow any kind of buſineſs. We muſt, in this caſe, therefore act as if the whole tumor was gangrenous. The methods of acting in this.cafe are indeed full of toil and labour; but when we are ſupported by the experience of others , we take courage, by calling to mind the examples with which their practice fur- niſhes us. We alſo fecure ourſelves againſt the outcries ſoon raiſed by jealouſy or when, after having taken the beſt counſel , we make a prognoſtic of the diſorder to the pa tient's friends and relations. It is the ſurelt malice, I me- Of HERNIAS, &c. 339 a method to ćut every thing in the tumor, whe- ther the inteſtine or epiploon, or even the teſticle, if it is very confuſedly mix'd with the reſt of the parts. The obſervation of Mr. De la Peyronie on this ſubject, in the firſt vol. of his work, is a ſure guard againſt all accidents. It ought ſo much the more to inſpire the ſur- geon with courage, as the operation is much lefs difficult in this caſe, where the adhe- rences, which retain the parts to the brink of the ring, fave him the trouble of ſecuring the inteſtine by means of the loup, which Mr. De la Peyronie has practiſed with ſucceſs. But, in order to undertake an operation of this kind, the great point is not to cut a bun- dle of the inteſtines, which is ſometimes monſtroufly large ; but in order to perform it with ſucceſs, we muſt alſo reflect on the rea- fons which oblige us to it, and on the fymp- toms and accidents which may appear, as on the hæmorrhage, which would not fail to happen, if we ſhould rafhly cut the veſſels of the meſentery without taking the necef- lary precautions. The different degrees of putrefaction will determine the different me- thods to be taken for the extirpation of the parts to be cut. If there is but one part of the inteſtine gangrened, it is fufficient to cut the alter'd part, without incroach- on the ſound part, which is always on the ſide of the mefentery. There is no 22 dread ing 340 Of HERNI VIAS а. A S, &C. dread of a conſiderable hæmorrhage in theſe caſes, becauſe when the veſſels are arrived into the ſubſtance of the inteſtine, they are extremely ſmall. Beſides, there is no longer any communication of liquors in theſe vef- fels, becauſe they are deſtroy'd by the gan- grene; but when the inteſtines are totally gangrened, and when the gangrene is con- tinued to the veſſels of the meſentery, or when the inteſtines being only gangrened at particular diſtances, ſo that there are ſome ſound parts, which muſt be removed for the reaſons I have mention'd, we muſt neceſſarily make ligatures on the veſſels of the meſentery, in proportion to the quantity of them which have flipt out; for in this caſe great precau- tions are to be taken againſt an hemorrhage. It is therefore neceſſary to make ſeveral liga- tures, in each of which we may comprehend ſeveral veſſels. We muſt afterwards cut the inteſtinal canal, in proportion as the ligatures are made ; tho' I think it is more proper to apply the ligatures in proportion as we cut the inteſtine, becauſe by this means we have a better opportunity of rendering them fuffi- ciently tight, if they are not ſo. We ſprinkle the meſentery with colophony, reduced to a powder; or we apply to it pledgets dipt in fome ftyptic liquor. We ſee by the follow- ing obſervation, of what importance it is to follow this method ; ſince, notwithſtanding fourteen ligatures carefully made on the me- feritery Wa BE 103 101 de of HERNIAS, &c. 341 100 fentery, the patient had almoſt died of a hemorrhage ten or twelve hours after the operation. foto U OBSERVATION XVII. In 1732, I was called to Ibouvillé, a town about forty miles from Paris, to ſee Mr. Doudeuill, a man of fixty years of age, who had a complete hernia twenty-fix inches in circumference. It deſcended to the middle part of the thigh. The tumor was very ſoft, and ſeemed as if it would re-enter eaſily. The patient told me, that it was near fix years ſince it had arrived at the ſame bulk; that it was almoſt twenty in aſſuming that argeneſs ; that for four or five years paſt he was afflicted with colics and faintings, which ften obliged him to ſit down for relief, and apport the tumor with his hand; but that eight or nine days paſt he felt a great al of more pain than uſual. For five days he had vomited his fæces, and went but very itle to ſtool, though the wind was freely lcharged through the anus. The tumor was ſoft and very ſenſible. From theſe figns concluded, that adheſions were the cauſe theſe ſymptoms, and therefore thought he only method to be taken, was to perform We operation. Nothing could be added to e general remedies, which had been uſed with all poſſible care. I took the advice of Coſte, furgeon of Miru, who agreed with TOP Z3 342 Of HERNIAS, &c. with me, on the preſſing neceſſity for the operation. I appriſed the patient's friends and himſelf of the danger there was in un- dertaking an operation of this kind; but told, at the ſame time, that there was no other method of preſerving his life. The courage of the patient, who was a man of a robuſt conſtitution, was animated by the hope of a cure, though uncertain, fo that he pre- vailed on his friends to confent that I ſhould perform the operation, which I did in this manner. I laid bare the whole tumor, by diffecting all the inteſtines, which made only one body with the herniary ſac, which was of a conſiderable thickneſs. I uſed all the neceſ- ſary precautions not to open the inteſtine, in which attempt I ſucceeded. However, it was gangrened in a great many places, which were of different bulks and figures. Some of them were round, others long, others triangular, and others of irregular figures Some of them were half an inch broad and long, whilſt others were two, and others three inches. But there were diſtances be- tween them, conſiſting of five or fix inches of the ſound parts. I at laſt laid all the parts bare, after an hour and a quarter’s hard labour. Then being fatigued to ſuch a de gree, as almoſt to have loſt the uſe of my limbs, I was obliged to reſt myſelf, and in the mean time covered the tumor with a fine linnen cloth ſoaked in tepid water. I deli- berated OF HERN FAS, &o, 343 berated with Mr. Coſte on the method to be taken, in order to finiſh the operation. The confufion of the parts, by means of the thick and fleſhy adherences which kept them to gether, and the mortification which had ſeized moſt of them, made me propoſe cut- ting off all that was without the abdomen. I told the patient this ungrateful piece of news, which, inſtead of terrifying him, aug- mented his courage. The large portion of the meſentery, which ſuſtained the ileum, which was leſs altered than the colon, was the principal object of my attention. I could not remove this inteſtine, without dreading an hemorrhage from the meſenteric veffels. In proportion as I made the ligatures, I cut the inteftines where the tied veſſels termi- nated. I then tied the veſſels of the coecun with a ſingle thread, and cut that inteſtine. I made three or four ligatures on the meſoco-- lon, and cut the inteſtine which it ſuſtained, and which was very gangrenous in all its length, which confifted of about eight or ten inches. All this parcel of the inteſtine thus cut fucceffively, according to its length, being totally removed, there no longer remained any thing in the ſcrotum, except the teſticle, which was found, and included in its mem- branes, and the meſentery with the ends of the colon and the ileum, each of which came about two inches without the ring. There was no portion of the epiploon in the tumor. 24 My 344 Of HERNIAS, &c. OV My deſign at firſt was to ſtitch the two endse of the inteſtine together, but the determinaadid tion they had taken to come out of the ab-oll domen, was ſuch an obſtacle, that I could i not have ſucceeded in this attempt. They came out in ſuch a manner, that the colone paſſed above the ileum, and was ſituated to wards the penis, whilſt the ileum lay to-ot to wards the thigh. Beſides this circumſtance,id bu they were intimately adherent not only toww each other, but alſo to the ring itſelf. In the order to have joined their extremities, it would have been neceſſary to detach theſela adherences, which was not poſſible; it was op therefore neceſſary to leave them in this ſitu- ation. As the ring greatly compreſſed the two ends of the inteſtine, and as the fæcesti had not a ſufficient free diſcharge, I made as to dilatation in the ileum and ring, by introducingo to my buttoned biſtory into the remaining partyi hyp of the ileum, which I boldly divided. Butiset I acted otherwiſe with reſpect to the ringa ! which I was obliged to diſengage on the fide of its inferior pillar. I only made a ſmall am dilatation in it, on account of the epigaſtriod artery, which, in ſuch caſes, is very this pillar. The fæces were forthwith difM charged in a very large quantity, and the ex- crements were involuntarily voided, for ten or twelve hours without intermiffion. Noteid withſtanding the many ligatures I had made, 1 a great number of ſmall veſſels, which hade ed ma nean) 2 eſcaped , Of H ERNI A S, &c. 345 10 OB M eſcaped, diſcharged a good deal of blood during the operation. I permitted this diſcharge fo long as it did not incommode me, both to facit litate the evacuation of the veſſels, and becaufe I had no body to aſſiſt me, except a woman, who ſecured the parts whilſt the patient himſelf held the candle; for Mr. Coſte was obliged to leave me, on account of ſome preſſing buſineſs. I dreſſed the wound with dry lint, with which I covered the maſs of the meſen- try . I left the extremities of the inteſtines free, only covering them with a ſimple pledget dipt in the yolk of an egg. I com- preſſed the meſentery as regularly as I could, y means of compreſſes and a bandage. The hemorrhage ceaſed, but it was only for twelve or fifteen hours; for I was obliged o dreſs the patient twice in the night, and to uſe the ſtrongeſt ftyptics, in order to brace up the extremities of the ſmall veſſels, which other could not be comprehended in the li- gatures, or which had eſcaped from them, and whoſe orifices were become much larger, and permitted fo great a quantity of blood to be extravaſated, that the patient muſt have died, if I had not continued with him ; for Mr. Coſte was obliged to go to his own home, which was about three miles diſtant. Next day there furvened a hiccup ſo violent, that I thought the patient could not ſurmount for he was ſeveral times like to die for vant of intervals fufficient for inſpiration. haq The 346 Of HERNI A S, &C. a The great quantity of blood he had loſt by the hemorrhage, and by two copious vene- ſections, did not permit me to ſeek for re- lief in the aperture of a vein ; I was there fore obliged to uſe laudanum in ſubſtance, the doſe of which I augmented by half grains every half hour; ſo that in two hours he took four grains and an half of it, which at laſt alleviated the hiccup. He remained a- bout five or fix hours as it were intoxicated and without fleep, but during that time he enjoyed an agreeable tranquility, and the hiccup was ſo diminiſhed, that nothing dan- gerous was to be dreaded from it. It con- tinued, however, three or four days, but al- ways became leſs and leſs. By the exami- nation we made of the quantity of the in- teſtines I had taken away, we found that there were more than ſeven feet of them. The patient, by the care of Mr. Coſte, was cured in fix weeks. Three months after the cure, I adviſed him to come to Paris, that I might try to reunite the extremities of the inteſtine. Meffieurs Petit, Le Dran, Morand and Verdier, whom I called to conſult on the means which might be employed to re- inedy this inconvenience, found that the re- union was fo much the leſs impracticable , becauſe the direction which the ends of the inteſtine had taken, could not have permitted it during the operation; beſides, the portion of the ileum was ſo retracted, that it was out hardly OF HERNI A S, &C. 347 bardly poſſible to perceive it. It formed a kind of body like a hen's arſe, whoſe mar- gins re-entered internally. The colon had totally diſappeared. All the part of the me- fentery, which had remained out of the ab- domen after the operation, was ſo diffolved, that no mark of it was to be felt, either in the ferotum, or about the ring. It after- wards created no trouble in the dreſſings. This remark is of great importance, becaufe it lays a foundation for ſome reflections on the cauſe of that perplexity, which a part of the meſentery remaining without the abdo- men created to Mr. Le Dran, in the opera- tion deſcribed in the fixtieth obſervation. Our patient was therefore obliged, during the remainder of his life, to uſe an artificial anus. But his induſtry rendered this incon- yenience more fupportable to him, than it would have been to any other perſon. He was very careful not to offend others by the bad ſmell, which they muſt neceffarily feel, if he had not ſubjected himſelf to fome little pieces of art and contrivance, which freed him from that diſagreeableneſs which his misfortune muſt have otherwiſe produced. He had made ſeveral peffaries of cork covered with wax, in the form of a bottle cork, pro- portioned to the bulk and largeneſs of the inteſtine, and about an inch and an half long. This peífary was tied with a ſmall cord to the principal compreſs. He introduced it into the 348 Of HERNIA S, &c. 1 the inteſtine, and laid three or four other compreſſes on the former. He ſecured the whole by a bandage compoſed of a ſingle circular, and a flip, which paſſed under the thigh, from behind forwards, in order to be fixed to the circular by a pin. He undid this apparatus every morning and evening, in order to empty it as occaſion required. He was ſometimes obliged to facilitate the dil- charge of the excrements, though always of a very liquid conſiſtence, by means of a clyfter. At other times the ſmalleſt por- tion of the fæces was not diſcharged into his apparatus. By this means he enjoyed lix years of perfect health, and at laſt died of an indigeſtion. door As for fpongious adherences, theſe though leſs common, are nevertheleſs found in ſome hernias. Abet Roſſeius obſerv'd in the car- cafs of a man, who died after the ſymptoms of a ſtrangulation of the inteſtine which he remarks as a thing as ſingular as it really is) a fungous excreſcence which cover'd the in- teſtine, at the circumference of the ring, and which was fo adherent to the herniary fack, that he had ſome difficulty to detach it with his nails. Neither this author, nor Fabrin cius Hildanus who relates this obſervation, lay down any methods of remedying theſe kinds of extraneous bodies. However they H mos * Cent. 6. obr. (ន * 100 omil bo 70. are OF HERNIAS, 8c 34.9 &c. are ſo much the more dangerous, fince be- fides the ſymptoms they produce by ſtrangu- lating, compreſſing and keeping the inteſtine adherent, they may degenerate into carcino- matous tumors, and have conſequences which would render the diſorder more terrible and more difficult to be cur’d. The following obfervation evinces, that this is not a conjec- ture made at random. 10 O B S E R V A TION XVIII. Mr. Braze furgeon major to the king of France's armies, who applied himſelf parti- cularly to the treatment of hernias, diſorders in the cure of which, he had acquir'd as much knowledge as reputation, at Madrid, aftur'd me that he found in a complete her- nia , immediately at its departure from the ring, a carcinomatous tumor on the ſurface of the inteſtine, as large as a wall-nut. This extraneous body not only hinder'd the inte- line from re-entering, but alſo compreſs'd it o fuch a degree, that tho' there was no ſtran- gulation, it nevertheleſs hinder'd the paſſage of the fæces, and the patient had all the ymptoms of a ftrangulation. Mr. Braze aliſted by the advice of Mr. Legendre, firſt urgeon to the king of Spain, cut off the carcinomatous tumor, and reduc'd the inte- fine, by which means the patient was cur’d, and ſurviv'd the operation a whole year. He died of the fame fymptoms which accom- 2 pany 350 OF HERNIAS, &c. m pany a ſtrangulation, after having fufferd continually ſince the operation. Mr. Braze upon opening the carcaſs, found the ileum adherent to the peritoneum, in the part which correſponds to the bottom of the bladder. This adherence, was formd by an ulcerated carcinomatous tumor, as large as a hen's egg. The inteſtine was putrified and ulcerated, for ſeven or eight lines below the carcinomatous tumor, that is to ſay, in that part of the inteſtine, which correſponds to the jejunum. I have ſeen this tumor pre- ferv'd in ſpirit of wine, more than four years after its extirpation from the abdomen : I am of opinion, that it would have been much more advantageous to the patient, to have I remov'd in the time of the operation, all the part of the inteſtine in which the cancer had a taken root. Was not there reaſon to have believ'd, that the inteſtine might have been cur'd and even cicatriz'd? What could be worſe than the pains, to which the patient was ſubject after the operation ? Or could death which follow'd them fo near, be re- mov'd to a greater diſtance ? But ſurgery not then tread in fo fure ſteps, as it does at preſent. I have from my deceas'd father's manu- fcripts, taken the following obſervation; the affinity of which, with that of Abbé Rol feius induce me here to relate it. 270 OBSER e ei a did 0 CO 0 Of HERNIAS, &c. 351 ; OBSERVATION XIX. In 1709, a man of fifty years of age, who five years before had had a ſtrangula- tion, on account of an inguinal hernia, of which he had been radically cur’d, was at- tack’d by a periodical vomiting every four days, for which he took all the remedies which were judged moſt proper for remov- ing that fymptom; but he reaped no advan- tage from them. At the end of a month, there appeared a tumor as large as a nut, in the place where his hernia had been five years before. Dr. Thuillier fuſpected that this tu- mor might be the cauſe of the fymptoms. He ſent for my father, in order to have his opinion. He found the tumor very hard and rough with many inequalities. It was fixed on the os pubis, a little below the ring. It was even ſufficiently remote to permit the entry of the finger into the ring, which was empty and contained none of the parts. Be- fides, the patient had no colics. By the ex- amination my father made of all the other parts where any ſtrangulation might happen, he found an induration in the region of the pylorus , which he took to be the cauſe of the vomiting. This circum- lance authorized my father in his opi- nion that the tumor of the pubis, was an ex- traneous body, and that it might poſſibly be of the ſame natare with that of the ſtomach. The 352 Of HERNIAS, &c. ) The patient died ſome days after, and Mr. Gilet furgeon, upon opening his body in pre- ſence of Mr. Thuillier and my father, found a hard tumor as large as a hen's egg, which ſhut up the pylorus, and hindered the ali- ments from paſſing into it. The ſtomach and pancreas were putrified: He alſo found on the os pubis near the ring, a tumor of the ſame nature with that of the pylorus. In the obſervation, there is no mention made, of what kind theſe tumors were, whether that of the pilorus, was external or internal, and to what part that of the pubis was adherent . Be this as it will, we always perceive from this obſervation that the tumor of the pubis, had been capable of rendering itſelf adherent to the inteſtine, if it could have been brought into contact with it, in caſe the hernia had manifeſted itſelf, or that it might at leaft have ſo compreſſed it as to hinder its re-en- trance into the abdomen. It is therefore of great importance, to be apprized of the pola libility of theſe extraneous bodies, of the adherences they may contract with the parts , and of the obſtacle they prove to the redug tion ; that ſo we may either deſtroy them ib the operation, or make a certain prognoſtic of their events, which in incurable cafes, does as much honour to the ſurgeon, moſt ſucceſsful operations in ordinary caſes, du 101 101 100 as his 101 ગઈ . at siste OF 5 ( 353 ) baibe fra de Baib Terse 351 2100 BRO bro BIS B OF THE Strangulation of the Inteſtine, by the Peritoneum. PART II. SECT. II. S T. has Is different kinds, its cauſes, Symptoms, ſigns, and the method of curing it by a chirurgical operation. T HE peritoneum, as every body Nature of knows, is a fine membrane; but the diſeaſe ſuſceptible of a very confiderable explained, degree of extention. It yields and ſtretches itfélf through the natural or preternatural openings of the belly, in order to form her- nas , in proportion as the contained parts of the abdomen, but eſpecially the inteſtine and omentum force it before them, when they de protruded by the contraction of the mul- dies of the abdomen and thorax. That part of this membrane which immediately covers contents of the hernia or rupture, we call the hernial fac The A a 354 OF HERNIAS, &c. 1 2 2. The entrance of the hernial fac, which I ſhall ſometimes call its orifice, or mouth, is always that part of the fac, which is the moſt diſtant from the fundus or bottom. When the rupture is arrived to a certain pitch in its encreaſe, the conſtant preffure of the parts through which the protrufi- on is made, contracts the orifice of the fac, and ſhrivels it up, like the finger of a glove drawn through a very narrow ring. If the hernial fac remains a long time in the ſame ſtate, without coming gradually lower down, which ſometimes happens, it acquires ſuch a firmneſs at its orifice, as one time or other may occaſion a ſtrangulation. If the rup- ture is forced lower down by ſome new effort, and remains in this ſtate long enough to ſuffer a compreſſion from the so gou opening through which the protruſion is ban made, a new ſtricture may be formed above the firſt; and this feeond ftri&ture, in the ſame manner may one time or other occa- fion a ſtrangulation of the inteſtine. The fame way a third ſtricture may afterwards be formed above this ſecond; it may even form a ſtrangulation of the gut, independantly of the paffages through which the rupture is forced, ſuch as, the rings of the abdominal muſcles, fallopius's ligament, &c. This multiplicity of ſtrictures fometimes thews itſelf externally; ſometimes again there is not the leaſt appearance of them outwardly. When Of HERNIA S, &c. 355 When they appear outwardly, the tumor af- al fumes the ſhape of the chemical veſſel, called olan aludel, which is compoſed of a number of ſmall round glaſs veffels, one placed on the top of another ; that is, the hernia is inter- fected by ſeveral furrows or notches, which ſeem to divide it into ſo many different parts. This particular appearance or ſymptom is very equivocal, as I ſhall afterwards ſhew, for there are other kinds of ſtrangulations, where we find the ſame ſort of interfections. It commonly happens that there is but one ſtricture upon the fac, and in that caſe, one Strangulation only * can enſue; ſometimes there are ſeveral ſtrictures upon the fac, as I have already explained ; and in this caſe, there may happen ſo many ſtrangulations of the gut; nay, it may happen that the in- teſtine may be ftrangulated in one or more parts by the ſtrictures of the fac, and at the ſame time fuffer a ſtrangulation, from the rings or any other orifice of the belly, thro' which the bowel is forced. That theſe truths are of importance, in order to form a right idea of the different kinds of ftrangu- lations, to which the hernial fac is liable, will become more evident by the application I ſhall endeavour to make of the obſerva- tions, which I have collected from others, and thoſe which my own experience has fur- niſhed me with. By comparing this firſt, with the third caſe. Аа 2 The 356 OF HERNIAS, &c. The firſt part of what I have advanced is proved by the 58th obſervation of Mr. Le Dran *, by that of Mr. La Faye t, and by the ninth obſervation of this ſection. In theſe obſervations we find, that neither the ring, nor Poupert's ligament, had any ſhare in the ſtrangulation of the guts. The following caſe will ſerve as a proof of what I advance in the ſecond part, viz. That the herniary fac may form ſeveral ftrangula- tions of the gut, one above another. OBSERVATION I. en In the year 1741, Dr. Guilbert ſent for me to Linois, a village about five miles from Paris, to viſit an officer, 65 years old, who for three days had labour'd under a moft violent iliac paffion, occafioned by a ſtrangulated gut. On aſking the neceſſary queſtions, the patient told me, that he had had an inguinal rupture , for thirty years, which having rightly kept up by the truffes, had conſtantly been upon the increaſe. When the ſtrangu- lation came on, the tumor was about nine or ten inches in length, and about two inches in diameter every where. Dr. Guilbert and Mr. Le Franc, ſurgeon, who had attended him, told me, that the tumor was lefſen'd more never been 910 Tom. 2. * Obſervation de Chirurgie, Paris Edit. An. 1731, + Remarques fur Dionis, Edit. 1740, p. 350, from line 2d. and more و به than OF HER NIAS, 80. 357 than two thirds of its length, by their en- deavours to reduce it on the firſt day of the ftrangulation. Upon examination Í found that the tumor was not in the leaſt diminiſh'd either in length or diameter ; for what ſeem'd wanting outwardly, form’d an internal tumor under the muſcles, reaching from the ring to within two finger-breadths of the anterior and ſuperior ſpinal proceſs of the os ilium. I was immediately ſatisfied about the neceſſity of the operation, and the urgent nature of the caſe. I was of opinion, that it was the peri- toneum which made the ſtrangulation. What convinced me of this, was the eaſineſs with which the tumor enter'd, its exiſting ſtill un- der the muſcles, and being of the fame de- gree of hardneſs with that part which was external ; beſides, the patient felt the ſame kind of pain from the fame degree of pref- fure, whether applied to the external or in- ternal tumor. Theſe reaſons, together with fome examples of analagous caſes which I acquainted theſe gentlemen with, procured me their approbation of my determination. Timmediately fet about the operation : I cut as deep as the hernial fac, and laid it bare the whole length of the external tumor. As ſoon as it was cleard from the membranes of the ſcrotum, the contents of the rupture appeared manifeſtly ſtrangulated by a ftricture of the dac, about a finger-breadth diſtant from the abdominal ring. This ſtrangulation was pointed Аа 3 358 of HERNIAS, & а pointed out by a furrow or notch of four ora five lines in depth, round the whole circum- ference of the tumor. There was no appear- ance of this ſtricturei externally through the ſkin of the ſcrotum, ever fince the partial read duction; but Mr. Le Franc told me, that he was very ſenſible of it before the reduction. The thickneſs which the ſkin acquired after the reduction, no doubt, was the reafon of the ſtricture's being then conceald. After reflecting upon this circumſtance, I affured the gentlemen preſent that there was another ftrangulation at the upper extremity of the tumor, towards the os ilium. The reaſon was evident: If there had not been a ſtran- gulation higher, the parts could not have formed ſuch a long, hard, circumſcribed tu- mor. Upon this ſuppoſition (as it proved juft) I endeavoured to bring out that part of the tumor which was lodged in the belly *; but the adheſions which the fac had contracted during theſe three days, fruſtrated the attempt. I was obliged forthwith to reſolve upon two operations inſtead of one; that is, to go on with the firſt, by laying the fac open, and cutting the lowermoſt ſtrangulation, and then to make a ſecond opening upon the upper part of the tumor that was within the belly, 311 * I uſe this expreffion here a little improperly : the tumor in theſe caſes is without the peritoneum. 276 sottogehammond By for ¿A Of HERNIAS, 1800 359 By the firſt operation I found four or five inches of the inteſtine very much ftrangu-it lated, very livid, and flightly adhering to the internal ſurface of the fac. I cut the mems branous ring of the peritoneum, which was at leaſt a quarter of an inch in thickneſs, and as much in breadth, and almoſt as firm as the cartilage itſelf. By the ſecond operation I open'd the iliac region upon the upper part of the tumor, in order to get readily at the uppermoſt ftrícture, and to avoid the great hayock which I ſhould have been obliged to make upon the abdominal ring, in dividing its inferior tendinous band, by a great length of inciſion. I obſerved the fame precautions as in performing the firſt operation; and when I had laid bare the ſubjacent part of the fac, I open'd it the whole length of the ex- ternal inciſion, which was about three inches, By this opening I brought to view a confi- derable fold of the gut, different from that contained in the inferior part of the fac, and which had become quite livid, with a portion of the omentum lying along it. Neither of theſe parts had got down to the lower cavity of the fac, and neither of them was adhering; the other circumvolution of the gut, viz. that which pals'd through this fuperior cavity of the fac, in its way to the inferior, was as near to the ſtate of mortification here as below. I introduced my finger towards the ori- a Аа 4 3600 Of HERNIAS, 80.00 DO orifice of the fac, and there found ſuch a tight iſtricture, that it would have been im-ant practicable to convey a director into it, without of very great circumſpection. Mr. Le Franc fa- tisfied himſelf about this circumſtance, by examining with his finger. I dilated the ori- fice of the fac with the probe-pointed biſtory of my invention *, as I always do, without aveb သည် မ the sition on 909 * Some of my own countrymen, Mr. Le Dran to , and Mr. La Faye I, having ſpoke of this inftrument, the one with ſome degree of more indifference than the uſefulneſs of the thing det contempt, the other with only ſerved ; I look upon myſelf as under a neceffity, on occaſion, of endeavouring to remove theſe prejudices. Foreigners have not behaved in this manner ; but, they have more diſcernment, they adopt things in portion to their uſefulneſs, without partiality. We find in Mr. Sharp's Treatiſe of Operations, that he thinksla very differently from Mr. Le Dran, with regard to the advantages of my inſtrument. His words are, « dilate the wound with ſafety, an infinite number of s inſtruments have been invented ; but, in my opinion, 6 there is none we can uſe in this caſe with fo great " advantage as a knife; and I have found my finger in s the operation a much better defence againſt pricking " the bowels than the director, which I intended to em- ploy. The knife mult be a little crooked, and blunt " at its extremity, like the end of a probe. How differently does Mr. Le Dran ſpeak of this in- ftrument? « Some furgeons, ſays he, in making the $ dilatation of the ring uſe a ſharp biſtory, the point of 10 + Treatie des Operat. de Chirurg. An. 1742, p. 12747 I Cour. d'Operat. de Chirurg. de Dionis, Edit. 1740; P. 345, laſt remark, which on this ODE qasos pro- 30 , « Tool 999 a 93 Of HERN I AS, 80.00 361 16 $ 3 the aſſiſtance of a director; and as ſoon as i10 the dilatation was made, I had very little dif- git ficulty in returning the parts into the abdo Saqlaruodio men. 9 pd goneta Juode toit bortait " which is guided by a little button : This they intro- xs " duce between the orifice of the fac and the inteſtine, with its back turned towards the laſt of theſe, and ſo cut the ring. They perfuade themſelves that they can- not wound the gut; but, for my part, I do not believe "it, and would not adviſe any body to follow that me- " thod." Would not one imagine from this, that Mr. Le Dran is neither acquainted with this inſtrument, nor the manner of uſing it? Yet he knows that in the year 136, the advantages of this very inſtrument were warm- y canvaſs'd between Mr. Petit and me, during a conver- ition of two hours ; and that, in the opinion of the whole cademy, it was judged to be the moſt convenient and the moſt fafe of any dilating inſtrument. Perhaps Mr. Le Dran, who then held a diſtinguiſhed place in the academy, and gave his voice in favour of this inftrument as well as the reſt, was a little diſguſted to find that it has always got the preference to his her- nial biſtory, which in the opinion of good judges, has every inconvenience of all the dilating inſtruments, and none of their advantages. Since I am upon the ſubject of frangulations from the hernial fac itſelf, let me aſk Mr. Le Dran, how he could dilate the orifice of the fac with his inſtrument, fuppoſing it as deeply ſituated in the bel- %, as in caſe 5th of this ſection ? Tis in vain for him to endeavour to perſwade us that there is great danger of wounding the gut with my biſtory. No body can think ſo, who confiders that an inſtrument, which is directed by the finger and carried through the ſtricture by the motion of the fingers alone, muſt be much furer, than one which is plunged by the motion of the whole atm, and conducted to the proper depth only by vague conjecture. My biſtory has not this inconvenience; be- cauſe a 362 OF HERNIA S60 men. The cure was completed in five weeksi time. 19 gastier During the progreſs of the cure, indeed, there aroſe ſeveral bad fymptoms, which have WE ma le va re cauſe the finger fupplying the place of the director, moves along in proportion, as the inſtrument works its way through the ſtrangulation. But, the moſt unex ceptionable proof that can be brought of the uſefulnefs of the inftrument, and abfurdity of Mr. Le Dran's criti- cilin, is that Mr. Le Dran (though he muſt allow me for theſe twenty years bypaſt to have performed at leaſt ſeven in ten of all the hernial operations in Paris) cannot produce one inſtance of my having wounded the gut. And if that accident had ever happened to me, it would be no difficult matter to convict me of it; be- cauſe as I always performed theſe operations, in pre- ſence of ſome of my brethren, there are very few ſurgeons in Paris, who have not been eye-witneſſes to my method Mr. Sharp, who judges without partiality, gives the preference to this, rather than any other inſtrument ; becauſe he finds the finger a much better guard againſt wounding the gut, than any grooved director. Allow ne to add a few reflections upon this ſubject. Firfly That I have frequently ſeen the gut pierced by the ex- tremity of the director when introduced without much circumſpection, which the operator is apt to neglect be th ca , by truſting to its bluntneſs as a fufficient fecurity againſt this accident. Now, this cannot happen in uſing my biftory ; becauſe its ſharpneſs will always put the opera- tor in mind of ufing the neceffary precautions, in order to avoid doing an injury to the contents of the hernia. Secondly, The finger being employed as a director, wil not bruiſe the parts fo much as that inſtrument would We cannot with it, as with the finger, keep down the city without bringing on or increaſing the ecchymoſis. Farther , in large ruptures, where the turgid inteſtines are very much in our way, one finger direets the biſtory, while the ad fa cu relt OF HERNI A S, &C. 363 ber. have no connection with the preſent ſubject. I ſhall only obſerve from the preſent caſe, that the herniary fac may form two ftrictures, at the diſtance even of fix inches one from the other; and if two, it feems plain from the nature of the thing, that it may form like- wife three, and poflibly even a greater num- 0 son We may obſerve alſo from this hiſtory, hat the method of operating in theſe caſes, hould be varied according to the circum- tances; and the ſurgeon's diſcretion ſhould ike place of the general rules, in particular afes. Generally, indeed, we make no coun- er openings in hernias; but in this particular vafe, prudence required a deviation from the general practice. SERIES sudo eft are ſpread upon the inteſtines, which certainly muſt be a more effectual and leſs miſchievous protection than the ſharp, ſmall wings of Mr. Le Dran’s biſtory, which cannot but gall the parts upon which they lean. I did not intend to draw up a full criticiſm upon Mr. Le Dran's biſtory in this place, nor to point out all the advantages of mine, fince that would have led me too far. But from what I have here faid, and from other parts of this work, I think it is fufficiently evident, that there are very few cafes in which his inſtrument can be convenient; and at the fame time that mine has the advantage of every dilating inſtrument hitherto invented, both in the general and in the particular caſes ; ſo far sit from being proper only in the caſe of a ſtrangula- lion beyond the ring, as Mr. La Faye ſeems induſtri, vuilly to infinuate, by mentioning it only in that caſe. 364 OF HERNIAS, &c. fuf- I might relate ſeveral other hiſtories of caſes, to prove that the hernial ſac may form ſeveral ftrangulations, one above another but as it is not my intention to give a journal of my obſervations, one or two examples of each caſe will be ſufficient. The thirteenth obſervation, which I was obliged to intro- duce in another part of this ſection, may ſerve as another proof of what I have ad- vanced, fince in that caſe there were evidently three diſtinct ftrictures in the fac. Towel I come now to the third part of my pro- pofition, viz. to prove that the gut may fer a violent ſtrangulation at the ſame time from the hernial fac, and from the ring ; for which purpoſe, I ſhall give the following hiſtories. gestroy Vejen OBSERVATION II. April 8, 1728, Mr. Pinau, ſurgeon Hotel-Dieu of Melun in Burgundy, per- formed the operation for a ſtrangulated gut, on a woman of 43 years of age. Upon cutting into the lower part of the hernial fac ſome liquid ſerum was diſcharged; and this opening was carried upwards, till he came to a ſtricture, which, at firſt, he took for the ring. In this cavity of the fac was lodged a portion of the omentum, with a view to return which, he dilated the ſtricture, and was ſurprized to ſee pus diſcharged along the groove of his director, to the quantity of two 10 to the s 1 or Of HERNIAS, &C. 365 a or three ounces. The dilatation of the ſtric- ture brought to view a fold of the gut opened by fuppuration; then he dilated the ring, which made the ſtrangulation upon this up- permoſt hernia, if I may be allowed to call it fo. The patient was cured without a re- maining fiſtula. Mr. Pinau, who had never met with a ſimilar caſe in any author, pro- nounced upon this phænomenon with ſome incertainty indeed, though in a manner wor- thy of a good ſurgeon. He fays, the ſtric- ture, which he at firſt took to be the abdo- minal ring, in all appearance was only a con- friction of the hernial fac; and adds, that he has obſerved theſe ſtrictures in old rup- ures : Then takes an opportunity of putting young furgeons on their guard; They might readily enough,” ſays he, “ ima- gine, they had reduced the inteſtine or epiploon, when they had only returned theſe parts from the loweſt cavity of the hernial fac into the ſecond, or from the moſt diſtant, into that which is next 38 16 to the ring." BE In the preceding hiſtory we may obſerve, that the ſtrangulation cauſed by the hernial fac was below the ring; but in the fol- on the contrary, we find that the fricture from the hernial fac was above the lowing fing SA ONE பழ Tootba OBSER- 366 OF HERNIA S, &c. 9700 echte beintocadere OBSERVATION III. In the year 1726, I went to Argenteuil, A village about nine or ten miles from Paris, to viſit a man forty-four years of age, who had been twenty-four hours under a ſtrangulation of the gut. His rupture was a complete in- guinal one of the left ſide. The violence of the ſymptoms obliged me to perform the operation without delay. Frere Jean Morel, monk and furgeon of the abbey of St. Denis, Mr. Montier, furgeon of Argenteuil, and ſome other ſurgeons of the place, were pre- fent. In the hernial fac I found ten or twelve inches of the ilium, of a dark livid co- lour, and a portion of the omentum almoſt completely mortified. I dilated the ring in my uſual manner, but could not reduce the gut. I introduced my finger, in order to diſcover the obſtacle that oppoſed the redio tion, and at the depth of two inches beyond the ring, I felt, with the point of my finger, a very cloſe and firm membranous cir- cle, which made even a tighter ſtricture 4 upon the parts, than the ring itſelf had done. I knew immediately that it was the perito- neum which formed this ftrangulation, and deſired each of the ſurgeons preſent to fatisty 1 himſelf that it was fo; though caſes of this kind were at that time ſo little known, that they were not ſo much as heard of in the ſchools. I dilated this ſtricture with my 2. probe OF HERNIAS, &c. 367 probe-pointed biſtory, conducted upon the fore-finger, with much more ſafety than I could have propoſed with any other inftru- ment; nay, I will venture to ſay, that no other inſtrument could have been employed upon this occaſion, without very great dan- ger. The ſtricture was ſo firm, that the found of the knife in cutting was heard by every perſon preſent. The gut was re- duced, &c. So much only relates to our preſent purpoſe. I ſhall take this opportu- nity, however, of relating another very par- ticular circumſtance of the preſent caſe, which, I perſuade myſelf, will pleaſe, by its fingularity. It has been told already, indeed by Mr. La Faye *, but in ſuch a romantic manner, that it has too much the air of the miraculous to make a proper impreſſion. The patient was extremely ill for a few days, and then continued indifferently well till the 18th day from the operation, when he voided by ſtool a large and intire piece of the two inner coats of the inteſtine, with fome ſhreds of the muſcular one, the com- mon coat having refifted the mortification. It had a moſt offenſive, putrid ſmell. I put a cylindrical piece of wood three quar- ters of an inch in diameter into this mem- branous pipe; and when ſtretched to its full Jength, without any laceration of its fibres, ME a bad | Remarques ſur Dionis, edit. 1740. p. 350. it son sdorg 368 Of HERNIAS, &c. C it meaſured twelve or fifteen inches; but in drying it ſhrunk to one half of its firſt length, in which ſtate Mr. Morand ſtill pre- ſerves it. The wound, which was made by the dilatation of the ring, was ſtill open, and no kind of fæces had ever been diſcharged from it. After this ſeparation from the gut, I kept the wound of the belly ſtill open for the ſpace of a full month, left the common coat like- wife ſhould have given way, and the contents of the inteſtines have been extravaſated into the abdomen. But in five or fix weeks the pa- tient was perfectly recover'd, without having ever diſcharged fæces by the wound. I ſhall confine my reflections upon this extraordinary phænomenon ſimply to what has a relation to our preſent ſubject; ſince the cauſes and effects of this feparation, together with an account of its conſequential fymptoms, are explained in that part of the work, which treats of ruptures with mortification. To make the application, then, of this cafe to our preſent ſubject, I ſay, not only that the hernial fac may ftrangulate the gut, but that its ſtricture may act more violently upon the ſtrangulated bowels, than even the ring itſelf; and that in the preſent caſe it was the immediate cauſe of the ſeparation the inner coats of the inteſtine. The reaſon is obvious. The compreſſion upon the bowels from this membranous circle is equal and of uniform 369 a TH of HERNIAS, &C. ti tudi S5WASH juniform all round; whereas the ring, or Poupart's ligament, does not make a ſtric- ture quite round, becauſe neither of them acts upon the lower part. The known ſtructure of theſe two parts puts this into fo clear a light, that it would be needleſs to explain it more particularly. The uſe which may be made of this obſervation, and pathological remark, is, that we ſhould have recourſe to the operation as ſoon as poſſible, in every caſe where we have reaſon to conjecture that the ſtrangulation is made by, or complicated with a ſtricture of the fac. The parts of the peritonæum, which are contracted in theſe caſes, may be more or leſs fo, according to the different degrees of preſſure and inflammation which they have undergone. Theſe contractions may be dif- ferent likewiſe, in regard to the breadth and thickneſs of the parts. There are caſes in which the membranous ring of the fac is not the 24th part of an inch in breadth, and in thickneſs; in others again it may be a 12th, a 6th, a 4th of an inch, or even more perhaps. Theſe accidental differences are very material in practice, as we may perceive from ſome of the ſubſequent hiſtories. Thantes 1. Beſides theſe, there are three other cir- cumſtances in which ruptures of this kind differ from each other. Firſt, In ſome caſes the hernia being once reduced, remains ſo; or if it falls down again, it is only in the Bb begin 370 OF HERNIA S, &c. beginning of the diſorder. Secondly, In others the hernia is eafily reduced, and as eaſily fall down. Thirdly, In others the tumor can- not poſſibly be reduced. All theſe aſſertions we ſhall prove by unqueſtionable facts. In the firſt caſe, viz. where the hernia being once reduced, remains fo, &c. what prevents the tumor from falling down is, that after the reduction, the parts may ſwell, and thereby become too bulky to be protruded again, or the fac may become adherent to the cellular membrane of the peritoneum. The laſt of theſe caſes is proven by the fe- venth and ninth obſervations of this ſection. The firſt of theſe obſervations is the fifty- eighth of Mr. Le Dran's work, and as I was preſent at the operation, I ſhall relate that part which concerns our preſent ſubject , which he has neglected. OBSERVATION IV. The rupture was crural, and the tumor about the ſize of a common hen's egg, the fymptoms firſt appeared. About ten or twelve hours after the firſt pain, which the patient felt from the ſtrangulation, I reduced the inteſtine; and during the two following days it was left at liberty to come down, which it did whenever the patient coughed; and ſometimes went up again of itſelf with eaſe. But from that time, during the re- mainder of the diſorder, which laſted eight when or Of HERNIAS, &C. 371 or nine days, it came down no more. The patient died on the ninth day, and on open- ing the body, we found the bowels, which had formed the rupture, ſtill included in the hernial fac; and the tumor was increaſed to more than two thirds of its firſt bulk. It was ſituated without the cavity of the belly, be- tween the peritoneum and inſide of Poupart's ligament. The reſt of the caſe has been fully told by Mr. Le Dran. I think we need not heſitate to affirm, that the increaſed bulk of the tumor, in this caſe, was the cauſe that it never came down after the two firſt days of ftrangulation. But the moſt conſiderable obſtacle to the deſcent of the tumor in theſe caſes, (for I need not mention the uſe of a truſs as one of the ob- ftacles) is the adheſion which it contracts with the adjacent parts, while lodged between the peritoneum and muſcles. The following hiſtory will ſerve as an evident proof of this affertion; and when, ſpeaking of the effects of theſe adheſions, I have explained how they happen. OBSERVATION V. In the year 1736, a man of a robuſt con- ftitution, of thirty-eight or forty years of age, with an inguinal rupture of the right fide, was ſeized with a ſtrangulation of the gut. His ſurgeon in ordinary reduced the tumor on the firſt day; but not finding the Bb 2 ſymp- 372 Of HERN I AS, &C. fymptoms in the leaſt mitigated, he thought proper, on the third day, to order a purging potion. Mr. Henry, the apothecary, who had ſome ſcruples about the matter, did not think fit to give it him, till I had firſt de- termined the reduction to have been properly made. I waited upon this patient, attended by Mr. Romanin; and underſtood, from the patient's own mouth, that the rupture had always been a complete one, ſeven or eight inches in length; and that for above fifteen years it had never been kept reduced. However, he had wore truffes of various kinds, with an intention only, as he was told, of preventing the increaſe of the rup- ture; the ordinary cant of ignorant truſs- makers, who know nothing of the nature of the diſtemper they pretend to cure. Mr. Romanin, as well as I, found the parts , in all appearance, ſo well reduced, that he was at a loſs how to account for the continuance of the bad fymptoms. The patient's belly was extremely tenſe; his vomitings were violent, but not very frequent, and brought up what is commonly taken for fæces in fuch caſes; he had no paſſage downwards , not even for one drop of oil, though he had ſwallowed four pints. I told Mr. Romanin, that I imagined the cauſe to be a ſtrangula- tion, occafioned by a ſtricture of the perito- neum ; and that the ſtricture muſt certainly be upon that part of the fac which had ful- tained Of HERNI A S, &c. 373 he had wore. tained the preſſure of the pads of the truſſes What led me to think fo, was, the eaſineſs with which, I was inform- ed, the tumor had been reduced. In order to ſatisfy myſelf more thoroughly, I exa- mined the ring, (which was very wide) plunged my finger into it, upon the extre- mity of which, I felt the reſiſtance of a very hard tumor ; I ordered ſome aſſiſtants to raiſe the patient, and defired him to make the proper efforts for determining the parts downwards. By theſe means the tumor was . brought nearer to the ring, and I could then more diſtinctly feel its reſiſtance upon my finger, which was like that of a bladder diſ- tended with a fluid, the inſeparable character of a ſtrangulated rupture. As I was now fully convinced that the fac itſelf formed the ftrangulation, I propoſed the operation, as the only means of relieving our patient. It was put off till next day, and then I per- formed it in preſence of my brethren, Meffieurs Marfolan, Cadet, Foubert, La Faye and Romanin. When I had laid the ring bare, I found it fo large that I could not take hold of the lower part of the her- nial ſac; however, as the tumor ſeemed to be of a larger diameter than the ring, I judged it adviſable to procure a little more freedom, by making two pretty deep fcari- fications. By this means I had ſufficient room for opening the fac, which I did, to the ex- a ز Bb 3 tent 374 Of HERNIAS, &C. tent of about an inch. Then I attempted to bring the rupture out, through the ring laying hold of the two flaps of the fac with my fingers, and pulling towards me; but in vain. I was therefore obliged to finiſh the operation in a much more laborious manner than would have been neceſſary, had I been able to come at the tumor properly. I intro- duced my finger into the fac, in order to diſ- cover its depth, and to aſſure myſelf of the quantity and kind of the bowel which it con- tained ; and wherever I could convey my finger I met with nothing but a portion of the inteſtine. The fac, however, was fo deeply ſituated, that I could not reach its orifice ; I was therefore obliged to make a I third dilatation of the ring. This incifion was made through the middle of the ten- dinous arch, which forms the upper part of the ring; and as it was finiſhed without re- moving my finger, I had then room enough to carry my finger quite to the orifice of the fac. By this means, I diſcovered that the inteſtine alone was fallen down; that it did not adhere to the fac, but was under a very violent ftrangulation from the orifice of the fac. I withdrew my hand, and deſired the gentlemen called into conſultation, to exa- mine, and aſſure themſelves of theſe facts, one after another, which they all did ac- cordingly. We found that the tumer run along the muſculus rectus, as far as within two OF HERNIA S, &c. 375 a two ſmall finger-breadths of the navel. It feemed to be nearly two inches in diameter at the lower part, and became gradually ſmaller towards its orifice, ſo as to reſemble a cone in figure. After we had made theſe fcrutinies, I tried again to bring out the rup- ture, but with as little ſucceſs as before ; the adheſions which the fac had contracted with the contiguous parts upon which it lay, con- fined it ſo much that it could not be moved ; I was therefore obliged to contrive a ſafe and fure method of cutting the ſtrangulation ; for this purpoſe, I introduced the middle finger of my left hand quite up to the mouth of the fac, and upon that carried in my probe- pointed biſtory, in order to dilate the ſtric- ture ; which I did, to the ſatisfaction of all the gentlemen preſent, and the immediate relief of the patient. As this fingular diſorder was very different from all the others, both in its kind and in its ſituation; it was indiſpenſably neceſſary to lay aſide the common method of operating, and ſubſtitute a new one. In moſt caſes, it is no difficult matter to conduct the knife upon the fore-finger; the ſurgeon never loſes fight of the inſtrument, he places himſelf with his back obliquely towards the patient's feet, and his face towards the part affected, his elbow in the mean time reſting upon the inſide of the patient's thigh. But in this caſe, all theſe precautions were uſeleſs, fince 3 Bb 4 ng 376 OF HERNIAS, &c. nothing could be done but by gueſs, tho' feel- ing only could ſafely conduct the operator. The depth of the fac, and its being filled with the gut, ſo as to leave little room for the introduction of the finger, were two circumſtances, which obliged me to conduct my hand in a different manner, from what is uſual upon theſe occafions. My back was turned obliquely towards the patient's head, in my elbows were bended to a right angle, my hand was bended conſiderably at the wriſt, and thus I introduced the whole of my mid- dle finger into the fac: Though this poſture may ſeem a little aukward, yet it is the only one, which could poſſibly have been uſed upon ſuch an occaſion*. Had I introduced my hand in the uſual way, I ſhould have di- lated the ring, rather than the orifice of the fac, by the inciſion; becauſe in that poſition I could not have funk my wriſt enough. introduced the biſtory, with its flat fide to- wards my finger, in order to avoid a farther dilatation of the ringt. When the point of a a my a * It would not have been poſſible in ſuch a caſe, to dilate the ſtricture with Mr. Le Dran's biſtory: fince the point of that inſtrument could not have reached half way to the ſtrangulation. + This made Mr. La Faye ſay, in his remarks upon Dionis, p. 345. “The ſurgeon introduces the fore- “ finger quite to the ſtrangulation, and upon that con- veys a probe-pointed biftory, with the flat fide to- 56 wards the finger”. But he ſhould have made a di ftinction between this fingular caſe, and thoſe which com- Of HERNIAS, &c. 377 a my biſtory had reached the ſtricture at the ori- fice of the fac, I carried it inwards under the edge of that ſtricture, taking the advantage of a ſmall vacuity left between the two por- tions of the doubled inteſtine; and in pro- portion as I puſhed the biftory forwards, I followed it with my finger, in order to con- duct it in ſuch a manner as not to injure the inteſtine, and the better to judge when I had ufficiently removed the ſtricture. While I was employed in this part of the operation, one of the aſſiſtants, laid hold of the fac, and kept it fixed, that it might not yield ſo s to eſcape the knife. By the dilatation which I was obliged to make, I gueſſed that he contracted part of the peritoneum, which formed the ſtricture might be almoſt half an nch in breadth. This operation being per- formed, every one preſent was fatisfied, from the looſe ſtate in which we found the inte- fine, that the dilatation I had made was fuf- ficient. As it was impracticable to introduce two fingers into the fac, in order to return the inteſtine, I judged it adviſeable to leave the inteſtine to return of itſelf. Neither did I think it proper to attempt laying open the commonly happen; becauſe there is danger of wound- ing the turgid inteſtines with the edge of the knife, when introduced in this horizontal poſition ; though, in the preſent caſe, that danger was diſregarded, when com- pared with the greater one of cutting the epigaſtric ar- ery, which probably muſt have happened, had the back of the knife reſted on the finger. fac, ba 378 OF HERNIA S, &c. a fac, the whole way from its bottom to its orifice. This I knew was impracticable, be- fides, I was upon my guard againſt an acci- dent which might have enſued, and which common enough, though hitherto ſcarcely obſerved. Before the patient was quite drel- fed, he had a free and copious ſtool; and the firſt time I had occaſion to remove the dreſs- ings, I found the inteſtine returned. From this time, he daily went more and more freely to ſtool, had no bad fymptom, not even a feveriſh fit, and in a month's time was per- fectly recovered. I ſhall at preſent, paſs over a great many circumſtances of this caſe, which young fur- geons may wiſh I had explained: Such as, why I did not make a counter-opening, in this, as well as in another caſe related in this fection? Why I did not attempt ſeparating the adheſions of the fac, which certainly might have been done? Why I did not lay the fac open in its whole length ? Theſe en- quiries would be irkſom to the intelligent ſurgeon, and lead me from the main purpoſe I had in relating this caſe, viz. to prove, that , the fac may become adherent to the adjacent parts after the hernia is reduced, and the tu- mor lodged within the muſcles. Let us therefore examine how theſe adheſions are produced. The peritoneum is every where connected with the ſides, or containing parts of the abdo- 20 Of HERNIAS, &c. 379 abdomen, by means of a cellular membrane, which may be ſaid, indeed, to be a part of the peritoneum. Its internal furface is fmooth, uniform, and truly membranous. It is this internal part of the peritoneum chiefly which, in ruptures, is ſtretched and protruded thro' ſome natural, or preternatural aperture of the abdomen. Such a protufion of the perito- neum cannot happen, without carrying the cellular membrane in ſome degree along with it . But as this cellular membrane is con- nected with the ſides of the abdomen, it can- not deſcend with the peritoneum, without the membranous little cells which compoſe it , being lengthened, ſtretched, and ſome of them even torn. If the fac, which is thus formed by an elongation of the peritoneum, ſhould become contracted in ſome part, ſo as to occafion a ſtrangulation of its contents, and if the tumor ſhould be reduced while that ftrangulation ſubfifts, there muſt happen another ſtretching and laceration of the cel- lular membrane, but in a contrary direction to the former. By the protrufion of the her- nia at firſt, the cellular membrane is ſtretched downwards ; by the reduction, that mem- brane is drawn upwards: as will evidently appear, if we conſider, that the tumor, in the reduction thruſts that part of the perito- neum, which is round the orifice of the fac before it, and this being thereby ſeparated from the muſcles or other parts, to which it is 380 Of HERNIAS, &c. is naturally contiguous, gives place for the tumor's being lodged in the cellular mem- brane of the peritoneum, or, in other words, without the cavity of the belly, between the peritoneum and muſcles. That the ſituation of the tumor is fuch, after reduction, is fufficiently proven by the iſt, 4th, 5th, and 13th obfervations of this ſection. In this caſe therefore, the cells of that elaſtic mem- brane, muſt ſuffer more or leſs violence in proportion to the bulk of the tumor ; the effect of which may be, an inflammation of all theſe cells round the tumor, whence an adheſion between the fac and neighbouring parts may ariſe; for the cellular membrane being inflamed and ſwelled, muſt embrace the tumor more cloſely; the ſmall veſſels which have given way, upon the great ſudden dilatation they were ſubjected to, will immediately be united to the fac, being diſ- poſed to this union by their cloſe contiguity , and cemented, as it were, by the juices which ariſe from them. Though the expli- cation I have given of theſe adheſions, may at firſt ſight appear a ſpeculative nicety , yet if properly attended to, it will be found extremely uſeful in practice. But to return The ſecond ſpecies of hernia, as we have faid is that, in which the tumor is eaſily re- duced and as eaſily falls down again. In ſuch caſes, the fize of the tumor continues almoſt invariably the fame, and is not confi- 00 and le derable Of HERN I AS, &c. 381 i derable enough to do much violence to the cellular membrane when puſhed into it by the reduction; or, the reduction may be made in a gradual and gentle manner, the umor nat being forcibly puſhed, but ſoftly infinuated into that yielding membrane; or, aftly, the contents of the abdomen may be nder ſuch a compreſſion from the diſtention f the inteſtines, that the tumor is not ſooner turned, than it is forced out again ; which cumſtance, by preventing its ſtay, muſt fectually hinder its contracting adhefions. hernias of the ſecond ſpecies, the ſtricture hich occafions the ſtrangulation, may be ound fome lines, nay an inch or more, a- ove the paffage of the belly, through which de hernia was protruded, according as the umor may have been more or leſs deter- mined inwards. This fact is fufficiently al- stained by the preceding obſervations, and uoſe afterwards related. In the third ſpecies, viz. that where the Amor cannot poſſibly be reduced, it is ex- remely difficult to judge, whether or not here is a ſtrangulation from the fac; and adeed this cannot be known certainly but by informing the operation. The obſtacles to he reduction muſt either be first. The ex- alive bulk of the tumor; or ſecondly, an dheſion formed between the fac and the pants without the belly, among which it is laced . Indeed, whenever a ſurgeon is un- der ز 382 OF HERNIAS, &c. a a der a neceflity of having recourſe to the ope- ration, of whatever kind the rupture may be, he ſhould remember the poſſibility of a ſtran- gulation from the fac itſelf; which is ſome- times complicated with a ſtrangulation from the ring or paſſage, through which the rup- ture falls. I have frequently met with ſuch caſes, and have been conſtantly on my guard, ever ſince I was firſt informed about them, which happened to be, before any thing had been publiſhed concerning fran- gulations from the hernial fac. I am in- debted for this information to Mr. Ricot , ſurgeon at St. Denis, about two miles from Paris. He made the diſcovery, by opening the body of a man of ſixty-eight years of age. : who died after the operation had been im- perfectly performed; and communicated his obſervations to me in the following letter . OBSERVATION VI. . Sir; Our patient has made me paſs a very diſagreeable night. He cried out in- ceffantly from the time you had performed “ the operation, to the inſtant of his death, " which happened this morning about ten " o'clock. I procured leave of his relations “ to open and examine the affected part; “s and then ſet about it immediately. The e fac, on the ſide of the os pubis, deep, firm, denſe, and every where ad- “ hering. I could not poflibly ſeparate it (6 60 was very (6 s from Of H ERNI A S, &C. 383 6 " from the gut, without tearing it. After " having divided all the adheſions which “ were round the orifice of the peritoneum, "I made an inciſion upon that orifice two “inches long, in order to facilitate the re- "turn of the bowels, which were pro- " truded, otherwiſe it wouid have been im- " poſſible to return them ; for nature had " formed a ſecond belly on the outſide of " the peritoneum, by means of the quantity of inteſtines and epiploon, which this fpu- “rious belly contained. All theſe accidents were occafioned by the ſtricture of the pe- ritoneum. I ſhould think myſelf infen- fible of my duty, if I did not acquaint you with the impoffibility of being fuc- ceſsful in an operation of this kind. I know that I have informed you of nothing which you did not foreſee; but I thought it might be agreeable to you to know what "I had learned from the teſtimony of the " ſenſes themſelves, in opening the body " after death. « I am, &c. St. Denis, 66 RICOT." 15 e Feb. 13, 1725. It was not long before I had an opportu- nity of reaping the advantage of the inſtruc- tion I received from this letter ; for about a year after, it was the means of my preſerving the life of the patient whoſe hiſtory is re- lated in the third obſervation of this ſection. 2 The 384 A Of HERNIA , &C. a SS Ort The difficulty I found in reducing the in- teſtine, notwithſtanding a large dilatation had been made upon the ring, immediately called to my mind the cauſe of that patient's death, related in the foregoing letter. My thoughts being fixed upon the ftricture of the perito- neum, prompted me to ſeek for it; and after I found it, immediately ſuggeſted the method of finiſhing the operation, by dilating the orifice of the hernial fac, as deſcribed above . Had it not been for Mr. Ricot's care in exa- mining, and his friendſhip in communicating his obſervation to me, I ſhould not, per- haps, have dreamt of that circumſtance; for it was not known at that time. OBSERVATION VII. The ſame year, a parallel cafe happened in one of the hoſpitals at Paris, and the man died. The ſurgeon, who performed the operation, not having forefcen this circum- ſtance, (though a man of great knowledge and fagacity) when he could not reduce the inteſtine, pricked it ſeveral times. In this he followed the practice of ſome old au- thors *, who tell us, that the incloſed air 100 * Pet. Pigreus, M. Aur. Severinus, and as Mr. Sharp informs us, Pet. Lowe, an Engliſh author, te, commended this method. The two firſt greatly extol it in Gaftroraphy, only, when the inteſtine cannot be reduced. I will not pretend to diſcard this practice as uſeleſs: I muſt only fay, that there are many where it would be dangerous. Such is the preſent caſe, as the event may teach us. cales 2 of HERNIAS, &c. 385 a is ſometimes an obſtacle to the reduction. The inteftine ſhrunk, but the difficulty of returning it, was not in the leaſt abated; and the patient died, before the operation was finiſhed. I was immediately informed of what happened, by one who was preſent at the operation, and took upon me to aſſure him, that a ſtricture of the hernial fac itſelf had been the real impediment to the reduc- tion, ſo that even an inciſion two inches long upon the inteſtine, would not in the leaſt have anſwered the deſign of the operation. What I advanced, was next day confirmed by opening the dead body. There is another circumſtance about theſe ruptures, which deſerves a ſerious conſidera- tion. It is natural to imagine, when a her- nia is returned, while the ſtrangulation from the orifice of the fac fubfifts, that the tumor will be placed directly upon the inſide of the ring, or paſſage through which the reduction was made. But there are examples which prove, that the tumor may affume different fituations; and this circumſtance conſtitutes a fourth ſpecies of theſe hernias. The rup- ture which was the ſubject of our firſt ob- fervation, took its place towards the bone of the ileum; that of the third obſervation was ſituated along and under the mufculus rectus. It is of fo much importance to be aware of the various ſituations in which the tumor may be placed in theſe caſes, that I think it a Сс nes- 386 Of HERNIAS, &c. neceſſary to give ſome obſervations on that fub- ject. And, though theſe obfervations do not demonſtrate all the different poſitions of theſe tumors after reduction, yet they ſhew, that there may be a very great variety of them. The two following hiſtories were commu- nicated to me by Mr. Vacher, furgeon of the military hoſpital at Beſançon in Franche- Compté, in a letter dated March 4th, 1740, as follows. e aw 2189 “ Sir, Your affiduous application in mak- ing obſervations upon ruptures, and the " zeal with which you are known to en- quire after, and collect every peculiar cir- « cumſtance about them, engages me to “ fend you two obſervations, which perhaps may contribute ſomething towards your 20 a >> CC « deſign." 3 a 10 66 lo OBSERVATION VIII. " I was called to a conſultation in the € caſe of a hernia with ſtrangulation, where “ the operation was reſolved upon, and exe- “ cuted, in all appearance, with the utmoſt “ exactneſs. The dilatation ſeemed to be “ made in a very proper manner, the inci- “ fion having been carried about a finger- “ breadth upwards from the ring. But the “ fymptoms were not by this means appeaf- * and the patient died the next day, . “ The body was opened, and it was found & that the hernial fac, which had been laid open 66 m2 Of HERN I AS, &C. 387 > "open in the operation about a fingeren " breadth above the ring, extended about two inches farther, and there its orifice " formed a very tight ſtrangulation. That “ orifice was placed upon the pſoas muſcle.” OBSERVATION IX. " A man of fifty years of age had been troubled with an inguinal rupture for ſome years. It was about fix months before he * firſt found any great difficulty in returning "it . His ſurgeon being fent for, reduced " the rupture, and made the patient wear a "trufs. From that time the rupture came no more down; but the patient was now "and then ſeized with gentle colics, which were removed by warm topical applica- " tions. In February laſt he was ſeized with a moſt violent iliac paſſion; and as the rupture was not down, it was fuppoſed not to contribute to this diſorder. Every thing was done for the poor man that could be thought of; but in vain, for he died on the eighth day. Upon opening the body, we found that the inteſtine was not under a ſtrangulation from the ring. We were all furprized to diſcover a bag about the bulk of a hand- ball formed by the peritoneum, in which full three inches of the ileum were included by a tight ftrangulation, and mortified. This bag, or fac, was ſituated behind the , Сс 2 ring 16 s 388 Of HERNIAS, &c. 6 CC ring of the external oblique muſcle, its « bottom inclined towards the bladder, and « its mouth adhered to the ring.” skolen Mr. Vacher does me the honour of leaving to my judgment, the uſeful inferences which may be drawn from theſe two obſervations, with regard both to the theory and practice in ſuch diſeaſes. STO But before I make any reflections, by way of application to the preſent ſubject, I muſt do Mr. Vacher the juſtice, which his mo- defty demands. He advances by way of conjecture only, what to me ſeems an un- queſtionable truth. The nearnefs of the « “ fac,” ſays he," and its adheſion to the ring, made us conjecture, that the fac and " the portion of the gut which it contained, were the very parts which formerly had « made the rupture; and that, after the re- « duction, the gut ſtill continuing in the fac, « had lodged itfelf in that place; being pre- ** vented from coming out, by the conſtant " preſſure of the truſs upon the ring.” This conjecture of Mr. Vacher, muft appear to every body ſuch a well-grounded truth, as requires nothing to be faid in fupport of it . As Mr. Vecher has given me leave, make fuch remarks upon his two caſes, as do think will be uſeful; but firſt I muſt apply them to our preſent purpoſe, which regards the different fituations of the tumor in fach hool Babazada 19 to In fhall 1 caſes. Of HERNI A S, &c. 389 21. In Mr. Vacher's firſt caſe, the mouth of the hernial fac was ſituated upon the pſoas muſcle; in his ſecond caſe, the orifice of the fac was cloſe to the abdominal ring, and its bottom inclined towards the bladder; both which fituations are different from what we have hitherto met with. It is plain there- fore, that in fuch ruptures the tumor may take very different ſituations internally, ac- cording to the direction which is given to it in the reduction. 'Tis no matter whether the tumor has been returned by the gentle method, called taxis, or by an operation with inciſion; it is ſufficient to characterize this fourth kind of rupture with ſtrangula- ition from the fac, that the tumor be puſhed between the peritoneum and adjacent parts, ſometimes upwards, ſometimes downwards, fometimes to the right, and ſometimes to the left; and that it continues in the place, into which it has been conveyed. This con- fequence, which is uſeful in the prognoſtic of ſuch diſeaſes, is ſo plain, that I need not ſpend more time upon it. To acquit myſelf now, with regard to Mr. Vacher's invitation, I think that the reaſon why the orifice of the fac was not dilated, in dilating the orifice of the rupture, which makes the fubject of the firſt caſe, did not proceed from the orifice's being at the diſtance of three finger-breadths above the ring. It was after the reduction of the parts, that the mouth of Сс 3 390 Of HERNIA S, &c. of the fac was found fo diſtant from the ring, viz. when it had been forced from the ring, and conveyed from the pfoas muſcle, by the very action of returning the inteſtine ; but before the reduction, no doubt, the orifice of the fac was placed in the ring itſelf, or but a little above it. The only true and fure means of removing the ſtrangulation, would have been to introduce the dilating inſtrument into the mouth of the fac, and cut its ſtric- ture. The ftricture itſelf muſt have been diſcovered, had the operator introduced his finger as foon as the ring was dilated. If Mr. Vacher, who was only a ſpectator, had performed the operation, undoubtedly before he attempted the reduction of the inteſtine, he would have made the proper fcrutinies with his finger, and could not then have miffed diſcovering the ſtrangulation from the fac. He who performs an operation, is much more fenfible of the difficulties that ariſe, than a ſpectator can poſſibly be; fince it is Tot always what the eye fees, but frequently what the hand feels, that directs to a maſterly Ittoke. The furgeon who performed this operation, probably had nothing in view but the ftri&ture of the ring, though, perhaps, that had a ſhare in the ſtrangulation, and there- fore the inteſtine was left as much in a ſtate of ſtrangulation, as if the operation had not been attempted. We ſhould, conſequently , hold it as an eſtabliſhed maxim, never to a per- Of HERNI A S, &c, 397 a 1991 perform the operation upon any kind of rup- ture, without informing ourſelves, after hav- ing made the dilation of the ring, whether or not there is a ſtrangulation internally. The 7th Obſerv. is a fatal proof of this maxim; and I ſhall relate another very remarkable one, both becauſe it will corroborate that, and becauſe it hath ſome connection with our ſubject. OBSERVATION X. In the year 1730, I was called to Rouen in Normandy, to perform the operation for a hernia with ſtrangulation of the gut, upon a collector of the revenues. Mr. de Mante- . ville, a celebrated phyſician as well as fur- geon, who was one of my conſulting furge- ons upon this occaſion, aſked my advice a- bout a woman, upon whom he had perform- ed the operation for a crural rupture, thirty fix hours before, but with little ſucceſs; for the ſymptoms had not abated in conſequence of the operation. I told him, I could form no judgment without ſeeing the woman, and examining the wound. We went thither forthwith, attended by two other furgeons. I introduced my finger deep into the wound, and found the reduced inteſtine, hard and stenſe, on account of the air, which it con- tained. I could even fenfibly diſtinguiſh a fricture at the orifice of the fac, making a firm ſtrangulation upon the gut. The other fur a 3 С с 4 392 OF HERNIAS, &C. furgeons examined in the ſame manner, one after another, and were all ſatisfied of thed fact. I did all I could to bring out the facu and inteſtine, but to no purpoſe: There was therefore no choice left, fince there was a neceſſity for performing the operation, by, cutting in the bottom of the wound, whence we could procure no information but from the touch. Mr. de Manteville, did me the honour of preſenting me with the knife, and obligingly ſaid, as you have found the fox, it is fit you ſhould kill him. I introduced my finger quite to the orifice of the fac, which lay about three inches deep under the mu- ſcles, towards the ſuperior and anterior fpi- nal proceſs of the os ilium. I dilated the ftricture of the fac with my probe-pointed biſtory, conducted upon my finger. The patient went to ſtool about an hour after ; all the bad fymptoms diſappeared, and the recovered in the uſual time. nobre To return to Mr. Vacher's obſervations. If the ſurgeon who reduced the hernia mentioned in cafe fecond, had been acquainted with the ſigns which I have laid down in this ſection, he would ſoon have diſcovered the nature of the caſe, after the reduction, and he would have preſerved the patient from theſe colics , which perpetually haraſſed him for fix months ſucceſſively; by promoting the com- ing out of the tumor, he would have pro- ceeded to the operation. At leaſt, I think vasion SOLO 3 this Of HERNIAS, &0.0 393 this the ſureſt way; and it is better to em brace this method (eſpecially when the tu- mor is out, and expoſed to our inftruments) than to leave a patient to conſtant diſtreſs and certain death, for want of a ſolid expe- perience to rouze us to that laudable reſolu- tion, which the ignorant think raih and au- dacious* The extraordinary ſituation into which the tumor was put by the reduction, will ſerve to explain the reaſon of the patient's being continually ſubject to colics, during the re- maining part of his life. In this kind of rupture, after the reduction of the tumor, the orifice of the fac, is commonly that part of it, which is diſtant from the ring. In the preſent caſe the orifice of the fac, was not only contiguous, but even adhering to the ring ; conſequently the gut was obliged to form a very conſiderable angle, both in go- ing into, and coming out from the fac; the free courſe of the inteſtinal contents, muſt ban * Mr. Martine, truſs-maker, one day in a numerous company (when ſomebody happened to mention a very fingular operation, which I had performed upon a man, a little before) faid, He is more fortunate than wiſe, for having fo raſhly undertaken that operation, when 1 and two ſurgeons had given the patient over ; and one of the company, a monk, made him this anſwer. If none of all thoſe, whom you have given up for dead, had after- wards applied to Arnaud, that man there (pointing to the vicar of Paſly) and I, fhould not have been now in a condition to tell you, that this is mere calumny. b99 thereby 米 ​ad 394 Of HERNIAS, &c. thereby have been conſiderably impeded and of courſe, the inteſtine muſt almoſt conſtantly have been thrown into thoſe ſpal- modic twitchings, which ordinarily are the forerunners of an iliac paffion, 'till at length, a more violent irritation than uſual, affecting the whole nervous fyftem, the patient was ſeized with a confirmed ftrangulation. In juſtice to Mr. Vacher's zeal for the im- provement of furgery, I muſt here give an extract of another caſe, which he communi- cated to me in the ſame letter, becauſe with regard to the ſymptoms of the caſe, it ſeems to have a connection with the preſent ſubject. “ In the year 1734”, ſays Mr. Vacher , << I was called to Dole, to viſit Mr. Lampinet , 66 advocat general to the chamber of ac- «s counts, and a man of 45 years of age. “ He had been ill for four days, of a com- plete rupture, with a fever and a very painful tenſion. I reduced the rupture " without having occafion to uſe the leaft violence, and the patient was conſiderably as eaſed. At my return to Beſançon, I was « informed, that the following night, he “ had been ſeized with an hiccup, a vomit- ing of foeces, &c. and expired about twenty-four hours after the reduction had « been made.----I make no doubt, had his body been opened, but there would have 156 been found a ſtrangulation from the fac, as " in the preceding caſes”. 66 (0 60 Though of HERNIAS, &c. 395 a Though Mr. Vacher's judgment upon this cafe, may ſeem very well founded, yet he muſt give me leave to ſuſpend mine. The caſe indeed appears to have ſome reſemblance to the two preceding, and to the LVIII. of Mr. Le Dran* ; but ſtill it is poſſible the pa- tient may have died of a volvolus, or an in- ternal ſtrangulation of another kind. I muſt however anſwer an objection, which might naturally enough arife upon reading theſe words, I reduced the rupture, without having occafion to uſe the leaf violence, and the pati- ent was conſiderably eafed. At my return to Beſançon, i was informed, that the follow- ing night he had been ſeized with an Hic- cup, a vomiting of fæces, &c. Suppofing the ftrangulation to be made by the hernial fac, it might be faid, that the inteſtine muſt have been freed from the ſtricture which formed the ſtrangulation, ſince the patient was confiderably eaſed, and a new ſtrangula- tion muſt have been formed the following night, becauſe then the fymptoms returned. The anſwer to this is very eaſy, and applicable to every caſe, where there is a ſtrangulation, of whatever kind. Ruptures even with the tighteſt ftrangulations, like many other dif- eaſes, have their intervals of alleviation. (In continual fevers we call this the remifli- on of the diſtemper.) Some patients under * In his chymical obſervations. Agaton 396 Of HERNIAS, &c. a ftrangulation will be 4, 6, 10, and even 12 hours without ſuffering the leaſt pain, the pulſe being quieted, perſpiration feem- ingly re-eſtabliſhed, the vomiting gone, and the belly become ſofter. By ſuch ſpecious appearances we are apt to flatter ourſelves , that we have conquered the bad fymptoms, when in reality they are only concealed for a time, to break out with the greater fury in the next paroxyſm. And the longer theſe remiſſions are, the worſe it is for the patient. It is now an eſtabliſhed maxim in phyſic , that the atonia, or remiffion, is always in proportion to the violence of the ſpaſms. But perhaps there is no diſeaſe in which the ſpaſ- modic irritation is carried to a greater height , than in the iliac paffion, cauſed by a ſtrangu- lated gut; and therefore the atonia or remiſ- fion, will be ſhorter or longer in proportion to the duration and violence of the preceding paroxiſm. Hence it is, that we ought to be upon our guard, againſt being deceived by theſe ſpecious ſtates of eaſe. The truly fa- gacious are never impoſed upon by them; they can diſtinguiſh between genuine repoſe , and its counterfit ; between a calm and a funk pulſe; between the natural foftneſs of the belly, and the flaccid ſtate which it is in, when the bowels have loſt their ſpring ; be- tween the gentle moiſture of ſound perfpira- tion, and thoſe profuſe and cold fweats, which hang upon all the body, but eſpecially a a 500 upon Of HERNIAS, &c. 397 upon the extremities : The ceaſing of the hiccup, cough, vomiting, and racking pains, and even the patient's going to ſtool, which ſometimes will happen, all theſe things flat- ter the unexperienced ſurgeon, but the wiſe conſider them as the effect of a total ſuſpen- fion of the animal ſpirits, or an oppreſſion and finking of the nervous fyſtem. If beſides all theſe we obſerve the eyes fixed, ſhining, and incapable of diſtinguiſhing objects perfectly, we may judge that the paroxiſm is at hand, and that the patient will die under convulfi- ons. When Mr. Vacher made the reduction of the rupture, nature had been oppreſſed with the pain, which the patient had juſt un- dergone, and then funk into a remiffion. If Mr. Vacher had not been obliged to leave his patient, and if he could have ſtayed to obſerve the ſtate of things, he would have prevented or checked theſe diſorders by ſome cordials, and at laſt have ſtruck at the root of all, by performing an operation. But I have carried my reflections a little further with regard to that piece of practice, in treating of the ſtrangulation of the gut in general, and of the different means which ſurgery em- ploys for removing it. Let us proceed to the cauſes of ftrangulations from the peritoneum. 3. The cauſes of a ſtrangulation upon the gut from the hernial fac, are, whatever is ca- pable of making a ſtrong, and frequently re- peated compreſſion upon that part of the pe- ritoneum, NOOR 2 398 Of HERNI AS, &c. ritoneum, which reſts in the opening of the belly through which the rupture is protruded. Such are, the circular tendinous ring at the navel; the tendinous bands from the external b oblique muſcle, at the abdominal ring ; that ſtrong tendinous arch under which the vef-m ſels paſs to the thigh. All theſe parts have il a force, much more than equal to any refif- is tance they can meet with from the herniali fac; in all the efforts of the abdominal muſ: cles, they are continually preſling upon the ſac; they thereby ſhrivel it up, and create obſtructions; whence ftagnations of the fluids enſue, the part becomes denſe and compact, to ſuch a degree at laſt, that if any inflam-9 mation ſeizes it, the inteſtine, which had m. but juſt room before, muſt neceſſarily be ex-(si poſed to a ſtrangulation of the tighteſt kind. The obſervations related in this ſection, fuf- ficiently aſcertain the truth of what I have of here aſſerted; and if the parts themſelves a have ſuch a natural tendency to produce ſtric- tures upon the fac, what may we not expect from truffes, which very generally are inju- diciouſly made, allow the parts every now and then to come down, and by their prel- fure (which is always irregular and ill plied) become the moſt powerful agents in contracting, condenſing and inflaming that part of the fac upon which they reft. 03 a 19 ap- Soool SYMPa Of HERNI A S, &c. 399 pro- ruar boburtoi SYMPTOM S. pessoate vlid As the conſtriction, which the gut is un- & der, in theſe caſes, puts a ſtop to the pro- greſive motion of its contents, the ſymptoms muſt be the ſame, as in every other kind of frangulation; therefore I ſhall not mention them at preſent, but endeavour to relate the igns which enable us to diſtinguiſh a ſtran- pulation produced by the hernial fac, from the more common ftrangulations. S16 BB biuro SIGN S. fo Firſt, In a ſtrangulation from the perito- neum, when the rupture is reduced, the tu- mór returns all at once, and, as one may ay, in a lump; the operator is not ſenſible of a ſucceſſive and gradual diminution of the tumor, as in other caſes; and the reſiſtance to the returning of it continues equal and conſtant to the laſt. An example of the contrary nature will make me better under- flood. In ruptures with the ordinary ſtranu gulation, whatever their fize be, when the burgeon finds the reduction practicable, he firſt returns the flatulencies and other con- tents of the inteſtine; which occaſions one degree of diminution in the tumor: Then he returns part of the inteſtine itſelf; this makes a fecond degree of diminution ; in the ſame manner a third, &c. is produced, till at laft the whole tumor is returned. It is this gra- dual 400 of HERNIAS, &c. dual diminution of bulk in the tumor, which, I have ſaid, is never obſervable, in return- ing ſuch ruptures, as are accompanied with a ſtrangulation from the fac itſelf. Secondly, In all other ruptures whatever, the fac is never reduced at the ſame time with the bowels; but after them, or not at all. When it is returned, it characterizes . this ſort of ruptures, in being the laſt part which goes up; and when it remains down, after the bowels are returned, in that very circumſtance it fufficiently diſtinguiſhes theſe ruptures from the one we have been treating of; becauſe in this the fac and its contents are always returned together. Thirdly, The ſmall rumbling noiſe which is heard in reducing a rupture of the ordinary kind, is never ſenſible in this; becauſe the flatulencies and fluids contained in the gut, cannot be forced through the conſtricted part of the gut towards the belly, the inteſtine, its contents, and the fac itſelf, being all re- turned together. Fourthly, When a hernia of this kind is reduced, and is not forced out again, the fymptoms continue as before the reduction; beſides, the patient complains of a ſharper pain than uſual, in the part where the tumor is lodged; and it is always from this part that the ſhooting pain proceeds, which after- wards ſpreads itſelf over the whole belly, This fign is perfectly the ſame with what ( ( a de Of HERNIAS, &c. 401 re of this time i denotes a volvulus, when there has been a reception of the gut internally, in returning a common rupture; but in that caſe the tu- mor had been reduced ſucceſſively, and by piece-meal; fo that this pain, though com- mon to both diſtempers, is not an equivo- cal fign. Fifthly, After a rupture of this kind is re- turned, if the tumor be lodged by the ſide of the bladder, it occaſions a dull pain in that part, with frequent inclination to make water ; if the tumor is upon the pſoas muf- cle and iliac veſſels, it is followed with a numbneſs of the lower extremity of that fide ; not from the weight of the tumor upon theſe parts, but from the compreffion which it fuffers from the peritoneum's having been greatly ſtretched in making way for it; be- fides, the ſwelling of the inteſtines within the cavity of the abdomen, and the tenſion of the abdominal muſcles contribute to in- creaſe that uneaſy fenfation which the tumor occafions, by reſting againſt theſe parts. Sixthly, if the tumor goes up, and comes down again eaſily, we feel as much reſiſtance in the tumor itſelf, the moment it comes as when we were reducing it. But it is not ſo in other ruptures; for in them, Some degree of time, at leaſt, is required be- fore the fac can be diſtended, ſo as to give a firm conſiſtence to the tumor; beſides that, there muſt be a ſtrangulation, Dd down, Se 402 Of HERNIAS, &c. а Seventhly, and laſtly, The fign which is 2. moſtly to be depended upon is this: When the finger is cautiouſly introduced into the I orifice through which the rupture was re- turned, we feel the ſame fort of reſiſtance, e as when we preſſed the tumor with the point of our finger before its reduction. This re- fiftance is very different from that which proceeds from the inteſtines, however in- famed and ſwelled ; for while theſe are not under a ſtrangulation, they give way to the impulſe of the finger ; but the reſiſtance from the tumor is as firm as that of a foot- ball. If we are called too late, indeed, the gut being already mortified, then the re- n fiſtance to the finger will not be ſo diſtinct : However, by aſking proper queſtions of the furgeon, who may have attended in the be- ginning of the cafe, or even of the patient himſelf, we may inform ourfelves of ſome v or other of the preceeding figns. One or = two of theſe figns will be ſufficient for pronouncing upon the diſeaſe; and with re- gard to the cure, nothing but the operation can be of ſervice. It differs from the com- mon operation for ftrangulated ruptures, only in fome particularities, which muſt be varied according to the circumftances of the caſe, and which therefore cannot be explained but in proportion as experience leads the way, and furniſhes us with a fufficient variety of examples. We have already ſeen the un- 3 too com- OF HERNIAS, &c. 403 ti common methods which I have been obliged ne to take in obſervation firſt and fifth of this ſection, and in obſervation fourteen we ſhall fee another variation, which I was obliged to introduce in the method of operating no I ſhall ſay nothing here of the ſigns of this fort of rupture, when there is no ſtrangula- tion upon the gut; becauſe I confine this I part of the work to ſtrangulations occafioned 32 by ſtrictures of the hernial fac, having ſpoken o of the others when treating of the ſigns of hernias in general. 5 I obſerved formerly, that the ſtrangulation of the peritoneum is ſometimes pointed out by a ſort of circular furrow, and that ſome- times this fúrrow is even obſervable through the external integuments. This I have not -- mentioned among the pathognomonic ſigns ; Ins becauſe it is not peculiar to this ſpecies of onrupture, and therefore might lead us into 1 miſtakes. Since, firſt, that ſort of furrow happens in ruptures where the bowels are ſtrangulated by ſome tranſverſe fibres, which wrun acroſs from the fafcia lata, to be fixed into the fymphyſis of the pubis *. Theſe V ftrangulations from the tranſverſe fibres, are more or leſs in breadth and depth in dif- ferent caſes, but generally reſemble that fort of furrowed conſtriction, which ſometimes 78 odabro * Mr. Garengeot, in his Splanchnology, (edit . 1740 vol. 2. p. 9 and 10.) bas given an idea of this fort of ftrangulation.ba D 2 appears CA SIS 1 404 Of HERNIAS, &c. 20 21 WIV appears in the caſe of a ſtrangulation from the fac itſelf. However, ſhould the ſurgeon be fo far deceived, at any time, as to mif- take one of theſe caſes for the other, no great miſchief could thence enſue, as there is no method of giving relief in either caſe, but by the operation. The moſt dangerous error he can be led into, is, that finding a circum- ſcribed tumor from the ſtricture of the her- nial fac downwards, he may judge it a hydro- cele; and he may the more readily fall into this miſtake, when the inteſtine only, dif- tended with flatulencies, makes the contents of the rupture; becauſe, in this caſe, when a candle is held cloſe to one ſide of the tu- mor, it will appear, in ſome degree, tranf- parent. The following hiſtory will be in- ſtructive with regard to this point. OBSERVATION XIII. In the year 1730, I was called, by Mr. Violette Dubois, in conſultation with Mr. Gerard, to a man of ſeventy years of age, who had been three days afflicted with all the fymptoms of a ſtrangulated gut, occa- fioned by an inguinal hernia. Mr. Dubois had preſcribed all the medicines generally uſed on ſuch occaſions. The tumor was fix inches long, from the abdominal ring to its lower extremity, ſhaped like a gourd, the bafis being about three fifths of the whole rupture, which was fourteen inches in cir- IS crore SUV ST cum- Of HERNIAS, &c. 405 а. . cumference. The upper part, which mea- . ang fured eight inches, was perfectly diſtinct from the lower, by means of a circular furrow, which was about two lines deep. A hernial ſurgeon had ſeen the patient, and affirmed that the lower tumor was a hydrocele; be- cauſe the light of a candle paſſed through it. . This prejudice greatly endangered the pa- tient's life, becauſe it was pretended, that the gut could be returned with more eaſe, after having pierced the ſuppoſed hydrocele. I oppoſed this ſcheme, with fufficient objec- tions to procure me a deliberate hearing. I had one pretty ſure ſymptom in my favour ; viz. when I preſſed that part of the tumor, the patient complained of a ſharp pain, of the ſame kind as when I preſſed the upper part of the rupture; and with regard to the tranſparency, I could not but mention it to them as an equivocal ſymptom ; becauſe the thin hernial fac, the diſtenſion of the gut with air, and the thinneſs of the integuments of the ſcrotum, in the preſent ſtate of diftention, might admit of as much tranſparency in the tumor, as if it had contained a clear water. Mr. Dubois and Mr. Gerard were both con- vinced that this ſuppoſed hydrocele was in reality a rupture, with a ſtricture upon the hernial fac, and that nothing beſides the on peration could be of ſervice. However, the patient and his relations, being flattered by the ſpecious diſcourſe of our opponent, were in Dd3 3 406 Of HERNIA S, &c. inclined to believe it a hydrocele, and deſired that it might be pierced. Each of us defired to be excuſed, and even the author of the opinion had not the courage to make the puncture. The diſpute was to have been de- termined next day, at a more numerous con- fultation ; but, in the mean time, the patient became ſo low, that the conſultation was countermanded, and in twenty-four hours he expired. ditore The intereſt I had in being able to de monſtrate ſuch an important truth, and in extending the number of my obſervations, would not let me flip this opportunity. ! procured leave to open the body, and took care that Mr. Dubois and Mr. Gerard ſhould be preſent. We began by examining the abdomen, and found the ftomach and inteſ- tines very much inflammed, and livid in ſome places, and the gut towards the ring com- pletely mortified. The orifice of the fac was ſo cloſe contracted, that it would have been impoſſible to draw out the gut, without tear- ing it to pieces. The epiploon had no thare in the rupture. I next ſeparated the perito- neum, on the outſide of which we found an empty ſpace all round the ring, of nine or ten inches in circumference; or, to expreſs it, perhaps more intelligibly, we found the per fitoneum, all round the ring, ſeparated from the muſcles , from the os pubis and adjacent part of the bladder. This ſeparation of thefe parts Of HERNIAS, &c. 407 parts formed a cavity; and in that cavity was lodged a tumor, of the fize of an egg, being the upper part of the hernial fac and its con- tents. The tumor was under a tight con- traction at one extremity from the orifice of the fac, and as firmly ſtrangulated at the o- ther extremity by the abdominal ring. After this examination of the internal parts, I laid the rupture bare externally, in its whole length, with the ſame precautions as if I had been performing the operation upon a living body. And now having a full view of all that part of the fac which was without the ring, we found it diſtinguiſhed by a ſtricture into two parts, much more ſenſibly than it appeared to be while covered by the integu- ments. I dilated the abdominal ring, and took out the hernia entire; then emptied it carefully in a diſh, in order to collect what water there might have been in the fac, but there flowed from it at moſt but two ſpoon- fuls of a bloody fluid, common enough in ruptures with mortification. As the fac was entire, I fixed a pipe into it, by A) incloſing all in a ligature about an inch above the orifice of the fac, blowed it up, and dried it. I have ſtill preſerved this preparation, which is ſhaped like a gourd, with a double ineck and round belly, as in the figure Assisqa abbati The a '' Dd 4 408 Of HERNIAS, &c. The inferences which might be drawn from this hiſtory, are ſo evident, that every reader muſt anticipate them in his own mind. I ſhall only obſerve in general, that this caſe is a confirmation of what we have already advanced, concerning a multiplicity of ftric- tures upon the hernial fac. I fhail finiſh this ſection with the hiſtory which I mentioned already otwo So it *) OBSERVATION XIV. fas A young man of eighteen years of age, employed in the drudgery buſineſs of the wax manufacture, at Antoni, a little town about twelve miles from Paris, had been ſub- ject to a complete hernia from his birth, which had never been rightly kept up. Jan. 28, 1738, he was ſeized with colics, nau- ſea, vomitings, and a fuppreffion of his ftools . The furgeon of the place, who preſumed that the diſorder was a common ſtrangulation of the gut, made uſe of all the ordinary means in ſuch caſes, and called me into con- ſultation on the fourth day. Upon examin- ation I found the tumor complete, very hard, and about the bigneſs of a turkey-hen's egg. I reduced it with great eaſe; but immediately it came down again : I reduced it a ſecond time, and ſtill it came down as before, with- out the leaſt change in its fize or hardneſs. When I had reduced it the third time, I fol- lowed it with my finger, to feel of what 2016 a con- Of HERNIAS, &C. 409 confiſtence it was, when reduced ; and find- ing it then as hard as ever, I concluded there was a ſtrangulation formed by the perito- neum, and propoſed the operation, as the only means of relieving the patient. What I faid, ſeemed to ſurprize the furgeon in or- dinary, who thereupon deſired that ſome fur- geons of the neighbourhood might be called in, to which I readily gave my conſent. No- thing could therefore be done till next day; and in the mean time the patient had a re- miſion of three or four hours, and was fo quiet when theſe ſurgeons came, that they could ſcarcely believe that there was a ſtran- gulation in the caſe, eſpecially when they found that the tumor could be reduced and come down again with freedom, and that none of the uſual bad fymptoms appeared. aſſured them they would find the fymp- toms return more violently than ever, when the remiffion was over ; which accordingly happened. The patient fell into an exceſſive vomiting, his belly grew harder, his fever encreaſed, &c. and then the operation was agreed to. I performed it in the preſence of three conſulting furgeons and the ſurgeon in ordinary. I had no ſooner laid bare the fac, than they were all convinced of the truth of what I had advanced. There was an evident ſtricture of the hernial fac, reaching about a line below the ring. I pulled the tumor gently outwards, in order to judge of the pre- 8109 410 Of HERNIAS, &හ a C. preciſe length of the ſtricture, which appear ed then to be, at leaſt, three lines. The whole tumor was ſhaped like a pear, that part which was in the ring, reſembling the ſtalk, was about an inch in circumference, and as I have ſaid, three or four lines in length. My next intention was, to open the fac; but it adher'd fo intimately with the whole ſurface of the inteſtine, that it was impoſſible to open it, in the common wa without the greateſt danger of wounding the gut. In a caſe of neceſſity, indeed, I ſhould not have regarded this circumſtance, fince I have frequently opened the inteſtine with ſucceſs*. But in the preſent caſe, I knew I could avoid that accident, by going a little out of the common road in operating. I di- lated the upper part of the ring, the length of four or five lines. I drew the tumor as much outwards as I well could, and deſired an affiftant to hold it in that ſtate ; then 0- pened the peritoneum above the ſtricture, and introduced my probe-pointed biſtory, through the wound I had made in the peri- toneum, firſt into the cavity of the belly, and then into the orifice of the fac. By this means, the d’lation of the ſtricture was ac- compliſhed with all imaginable eaſe ; and the inteſtine, though every where adhering to the ſurface of the ſtricture, and in a very ten- Sonit bistromobo Imob db See memoirs of the Academy of ſurgery.. Vol I. p. 604. su 3 pose to der OF HERNIAS, &c. 411 der ſtate, being quite livid, was not injured by the biſtory, becaufe its rounded blunt point, ferved to ſeparate the adhering parts; as I expected, indeed, it would, when projected this method of operating. What argument might I not raiſe from this, againſt Mr. Le Dran's ſophiſtry! But, to proceed: When I had thus dilated the ftri&ture at the orifice of the fac, I ſeparated the lips from the inteftine, with an inſtrument which I commonly ufe upon ſuch occafions, the ex- tremity of which is formed ſomewhat like a ſpatula po; then, with the ſame inſtrument, gently worked my way down to the bottom of the fac, which made room for introducing a director, and cutting up the fac, in its whole length. Then I proceeded to the ſe- paration of the fac and gut, which adhered all round. The adhefion was of that kind, which I call agglutination ; except in one #, place, about the extent of the nail of the thumb, where it was of the third kind, or that by incarnation. I was fortunate enough to compleat the ſeparation all round, without injuring the gut. I returned the inteſtine, and drefted up the patient, who recovered perfect- 7 SDH + I demonſtrated the uſe of this inſtrument at one of Mr. Hunter's Lectures, before a great number of his 1970 In the part of this work, which relates to hernias with adheſions, I have demonſtrated four different kinds of adheſions, and pointed out the proper management Sodo ly pupils, arba of each, 412 Of HERNI A S, &C. ly in three weeks, without any ſenſible ex- folication from the gut. The ſubject of this effay is ſo new, that it would require a ſtill more circumſtantial detail of facts, and more extenſive reflections X upon them; which I hope I ſhall be able to accompliſh hereafter : When I ſhall have received the neceſſary eclairciſſements from 90 the able practitioners of this kingdom, I ſhall dare to own my conjectures. belove zoo gil sodom tomus co bo A did 091 Odot text bider que tot IH duals to 10 199 60.5 315 mob ms7733 old Sila als amungo 900 slastonba, 2007 నాడి - thou modo con 1 тиія Wildets 2 sont artw anow il barbitolar Ho zied or exbod ads tobie SH or oriented od A VO- 975 - 3 А Я НАС 413 odos -25 l odw. Gossilo - Inchishod to 9100 Snow leb A VOCABULARY, or LEX- ICON of TERMS of ART, the Uſe of which could not be avoided. A A ADHESION, or ADHERENCE ſig- CCIDENT, or nifies the joining together Symptom, by this of the parts which form a word is meant that rupture, alſo their union which accompanies, or is ſub- with the parts wherein they fequent to a diſeaſe, as a cho- fall, as in the ſcrotum, or lic, vomitings, &c. in a with the labia pudendorum, rupture. or with the ſkin that covers ACUTE is an epithet, the navel. which characterizes violent ALIMENTS, are ſuch diſtempers, which terminate things as ſerve for our in a little time, either in life nouriſhment: Medicinal ali- or death. I make uſe of this ments are ſuch as are capa- word to expreſs the dange- ble of curing certain diftem- rous accidents of ruptures, in pers, as milk the conſump- oppoſition to chronic ſymp- tion, gout, &c. toms, which laſt as long as ALTÉRANTS, are rupture; whereas acute ſuch medicines as eſtabliſh łymptoms muſt be remedied and reſtore the folids and li- in a few days, elſe the patient quids of the body, to their dies. See fec. ii. ch. xvii. natural ſtate, without cauf- ing the 414 The EXPLICATION of TERMS of ART: on. . 22 Ing any ſenſible evacuation ; obſtructions by dividing the they diſpoſe the humours humours, and diſcharging to concoction and evacuati- them by urine. APPARATUS, is a ANALOGY, is a term of Surgery, by which term that ſerves to expreſs is underſtood everything the proportion or fimilitude that ſerves for dreſſing in any that is between one diftem- chirurgical diſtemper, ſuch per and another ; it is abſo- as lint rags, compreſſes or lutely neceſſary in the hiſtory bolſters, inſtruments, &c. c of diſeaſes of the ſame nature, removing the firſt apparatus to ſhew the parity and diffe- is the ſame as dreſſing the rence they have one with a patient a ſecond time. nother. ARITUDO, or lean- ANASARKA, is a neſs is a decay of the body kind of dropfy, wherein al- or of its parts, it is the ſame , moſt the whole body is ſwels as atrophia. led. ASTRINGENTS ANATOMY. By this are medicines that have a is underſtood, the ſtructure quality to clofe, ſhrivel and and order of the parts, which ſhorten the fibres, and cone compoſe the human body or tract the pores of the parts that of beaſts; the know where they are applied, they Jedge of the ſtructure of are made uſe of both in- theſe parts, is alſo called ana- wardly and outwardly, but tomy. rather and more efficacioully ANTERIOR, fig. inwardly. nifies that which is before, A TONIA, is the Α , as the anterior part of the weakneſs or relaxation of a head is the face. part having loſt its ſpringi ANTIPERISTAL- neſs. TIC, is a particular mo- ATTENUAT E, S tion of the bowels . See fec. the action of a remedy ui, part i. ch. vii. whereby it renders the li- APERITIVES, are quids of the body fuch medicines as remove pable of circulation in die gr more ca- luting The EXPLICATION of TERMS of Art. 415. , Of it, B forse as noile and dryg made up of one or more luting them, and thereby re- and others with a button at Eſtoring their fluidity. the end. stoylib yecha BLOOD. See the de- sa & TAB.A1A finition of it, ſer. i. part i. doido grua to mi ch. xviii. ATHS, are of two , is a , moiſt moiſt baths are known by powder and a fyrup, &c. to every body, they are either give it the confiftence of an hot or cold, emollient, a- electuary, divided in parts ſtringent or ſtrengthening of the ſize of an olive. or vulnerary ; a fand bath BONE, the bones are is what we call a dry bath. the hardeſt and moſt ſolid DE BALNEUM MARIS, paris of the whole human is a term of chymiſtry, it body. is made uſe of to hinder BORBORIGMI, the the action of the fire, to rumbl ng of the guts, is fo come near the druggs which called from the noiſe which are infuſed therein for diſtil- the wind produces in their lation, channels. CO BANDAGE, for her- BUBO, is a ſwelling in nia's . See fec. ii. part. i. ch. the groin and the adjacent xvii. glands, they are either be- BILE, is a bitter, oily nign, senereal or peftilen- and foapy liquor feparated tial. from the blood in the liver, BUBONOCELE, is it is conveyed from thence a rupiure in thegioin, which to the gut duodenum, to does not reach the ſcrotum. perfect the chyle and give it the laſt degree of perfection. 90cris ai basd BISTORY is a TAD TITVA Ι ſharp inftrument, to make CYANCER, iti: a di- inciſions in chirurgical o- ftemper of the glands, perations, th y are ſtreight and is conſidered either with or crooked, Tharp pointed, an ulcer or without b ing CAROUSAUSID 8 svonot contaiban rou ul- . 21 а C 416 The EXPLICATION of Terms of Arti a ulcerated; when it is not ture of one's conftitution, or ulcerated, it is properly a manner of living, I call re- See Scirrhus. When it is mote cauſes: Thoſe that with an ulcer, it forms proceed from too great a a horrid opening, black or redundancy of ſerum, ſo as livid an uneven, from to relax the parts, I call whence flows a fordid cada- immediate or joined cauſe , verous matter, the lips of it becauſe they diſpoſe the are hard and gaping; the parts to fill out in ruptures. blood veſſels in the circum- Thoſe which I call deter ference are obſtructed, and minate, when they act and ſeemingly like a crab's claw, produce a determinate effect , and this is the reaſon it is ſuch as an effort, or fall, a called a cancer, becauſe of blow, &c. its reſemblance to a crab, CAUSTIC, are ſharp called in Latin cancer. corroding medicine, that CARTILAGE. See burn the part and deſtroy its ſec. i. part i. ch. ii. texture when applied ; ſuch CASTRATION, is as arſenic, the infernal ſtone, an operation of ſurgery, cauterizing ſtone, &c. whereby the amputation of CAUTERIZE, a the teſticles is perform’d. part is to burn, conſume CATAPLASM, it is and deſtroy it. 2 remedy of a ſoft confi- CAUTERY, is a me- ſtence, like pap to be ap- dicine that deſtroys a part by plied to the outward parts of burning, it is divided into the body. actual and potential, the ac- CAUSE, is an unna- tual cantery, is a red hot tural affection of the body, iron, which is applied to a that produces a diſeaſe, or part to be deſtroyed, the po- concurs thereunto. Idivide tential is a ſubſtance, which cauſes into remote, imme- ſeemingly has no heat in it, diate or conjoined, and de- yet it has the quality of de terminate. As for example, ſtroying the part on which it ſuch as proceed from the na- is applied. CHRO a 2 The EXPLICATION OF TERMS of Art. 417 or W CHRONIC, is an epi- COAGULUM, is thet given to long and ob- the inſpiffation of any li- ftinate diſorders; I make quor to the conſiſtence of uſe of this term to expreſs curdled milk. the habitual accidents of COECUM, is the firſt ruptures, which though not of the large guts, See ſec. i. dangerous, yet they ſubfiſt part i. ch. xvii. as long as life. COLON, is the largeſt CHYLE, is the liquor of all the guts. See fec. i. or juice that reſults from vic- part i. ch. xvii. tuals when digeſted. See COMPLICATED, it fec. i. part i. ch. xvii. is ſo called when two CHYLIFICATION, is more diſtenipers meet toge- the action whereby chyle is ther. performed. See ch. ibid. CONCEPTION, is the CICATRISE, is a re- action of ingendring. See union of divided parts. ſec. i. part i. ch. xv. CIRCUMVOLUTI. CONCRETION, is an ON, is a term belonging to action whereby a liquid be- the bowels to expreſs the comes of a ſolid conſiſtence; order or manner they form it alſo produces tumors that portions of circles. Each contain a ftony or plaſtic portion is called a circum- ſubſtance. volution. CONTRACT, is to CIRCULATION, is a ſhorten or criſp a part. motion proper to the Auids CONTRACTION, is of the body, whereby they the action whereby a part is flow from the heart to all the ſhortened, fhriv led, parts, and back again to crifped. the heart. COUN TERIN DICA- CIRCULATION of TION, is a knowledge ga- the blood. See ſec. i. part i. thered from figns or fymp- . or toms, which hinders to put CLITORIS. See fec. i. in execution the means which part i. ch. xv. are indicated for the cure of Еe diſtem- vb. xviii. 418, The EXPLICATION OF TERMS OF ART. is called counter indication. * D ARTOS, is a muſ. diſtempers ; for example, wb Toro the great weakneſs of a pa- D. aut ya. tient will hinder the perfor- an cle belonging to the CONVULSION, is a ſcrotum, whereby it con- violent and unvoluntary con- tracts and is extended. See . fraction of the body, or of ſec. i. part i. ch. xiv. bubet ſome of its parts; when DECOCTION, is the the contraction is unequal, boiling of one or more in- irregular and ſucceſſive, it is gredients in water, milk, called a convulfive motion ; wine, or any other liquor, to when the contraction is con- extract its virtue; by this tinual and permanent, ſo as word is alſo underſtood the the whole body or a part liquor itſelf. thereof is unvoluntarily ſtiff DEJECTION, is the and immoveable, then it is evacuation of excrements by called a convulfion. the anus, it alſo means the CORPUS CAVER- excrements themſelves. NOSUM. See ſec. i. part DIAGNOSTIC, is figns 1. ch. xiv. or knowledge of the actual CREMASTER. See ſtate of fickneſs, or health, ſec. i. part i. ch. xiv. by marks which characte- CURE, is an action, an action, rize them. whereby the patient receives DIAPHRAGMA, is a cure ; there are two ſorts of large muſcle that ſeparates cure, radical and palliative, the cavity of the breaſt a radical cure is that where- from the belly. by the diſtemper is totally DIET, is a manner of deſtroyed: A palliative cure living, which conſiſts in ab- is that whereby a patient is ſtaining from aliments that cured imperfectly, by en- may be prejudicial to the , deavouring to correct and patient, and an obſervance prevent the moſt urgent of what is permitted him. fymptoms. DISSOLVENT, is a term Site The EXPLICATION of TERMS of ART. 419 , term of chymiſtry, fignify- ingredients made into pow- ing ſuch medicines as have a der, and incorporated with power or quality to diffolve fyrups orhoney. hard bodies, ſuch as aqua EMBROCATION, is regalis, which diffolves the moiſtening of a part with gold. dalam liquid medicines ſuch as DISSOLUTION, is the wine, oyl, melted fat, &c. reduction of a hard body EMBRIO, is the infant into a liquid form but contained in the womb, DIURETICS, are me. when it has not yet acquir’d dicines that encreaſe and fa- human form, it is called ge- cilitate the flow of the urine. nitura to the ſixth day.o surg DOGMATIC, is an ar- EMPIRIC, is he who tiſt, that acts upon found acts by experience alone; it principles, and juſt reaſon- is generally deceiving, as ings. VOH not being grounded upon any DUCTILITY, is an ac- principles. tion whereby any metal is EPIPLOCELE, it is a extended by a hammer. rupture of the epiploon... DULCIFY, is to blunt EPIPLOON, ſec. i. part the acrimony of any corro- i. ch. iv. i. . five fpirit by the help of EQUILIBRIUM, is a ſpirits of wine.d did a juft proportion between two DUODENUM, is the oppoſite parts that act one is firſt bowel. See fec. is part upon the other mutually, as i. ch. vii. for the folids and fluids in a ſtate bol qon of health. E. A ERECTION. See fec. STATU i. part i. ch. xiv. ode CPHRACTICS, are ERETHISMUS, is a remedies which have violent tenſion and irritation the quality to raiſe obſtruc- of the fibres and veſſels which hinders their action. ELECTUARY, is a ERIGNE, is an inſtru- compoſition of different ment of furgery, which ends Ee 2 in E tions.com 420 The EXPLICATION of Terms of ART. 91 ប in a hook, its uſe is to FLUIDS a term of ana- fuftain and raiſe the parts tomy, which fignifies all the which are to be cut or fpar- liquors of the body contain- ed. ed in the veſſels. EXCRETION, figni- FOETUS, this name is fies the caſting out of any given to the infant, whilft in offenſive humours. its mother's womb. EXTERN, by this is FOMENTATION, is underſtood the outward parts liquid medicines applied to of the body, as the ſkarf- different parts of the body, ſkin is the moſt outward in order to foften, moiſten, part of the body. afſwage, pain, reſolve, ſtrengthen, warm, and con- F. tract a part, according to the indication, is lar motion of the maſs G grimi of blood, accompanied with attad a frequent pulſe, exceſſive ANGRENE, is the heat and laffion of the func- beginning of a morti- tions of the body. fication and corruption of FIBER is the fineſt and the ſoft parts of the body, moſt ſimple part of the hu- whereby it becomes inſenſi- man body. See fec. i. part ble and of a livid colour, i. cb. ii. and a cadaverous ſmell ; FILTRATION, the when the mortification is ſame as fecretion ; it is a term compleat, it of phiſiology, which ſignifies SPHACELUS. the ſeparation of various GASTRORAPHIA, a humours, ſuch as the byle, term of furgery, it is a kind urine, falive, &c. from the of ſtitch or future, it is ge- blood. nerally uſed in deep wounds FLUXION, is a ſudden of the belly. depoſition of a humour on GENERATION. See any part of the body. conception ſec. i. part i. ch. G 3 IS called XV. GE The ExPLICATION of TERMS OF ART. 421 GENUS NERVO- HAIR. See their defini- SUM, ſignifies all the tion, ſec. i. part i. ch. xi. nerves of the body. HEALTH. That good GLANDS. See fec. i diſpoſition of all the parts 21 part i. ch. ii. of the body, which inables GLANDULES, are ve- them to perform their re- ry fmall and almoſt imper- fpective fuctions well. ceptible glands. HEMORRHAGE, is GLUTINOUS, is uſed an effuſion of blood, cauſed to expreſs the inſpiffation or by the opening of a veſſel. thickneſs of the lympha, HEMORHOIDS, is the &c. flowing of blood from the - GRIPES, violent pains, veſſels of the anus, or the of the belly, the winds ſwelling thereof; the fpeci- which regurgitate in the ob- fic remedies againſt this di- ſtructed hernias, and are the ftemper are deſcribed. Seca immediate cauſe of theſe ii. part ii. ch. xii. pains from a bulk in the HEPATIC, is every guts, which refemble cords, thing belonging to the liver, whence this fymptom is the ductus hepaticus, con- called chordapfus. This veys the bile from the liver word, which is very ſignifi- to the bowel duodenum. See cant, is derived from two ſec. ii. part i. ch. x. Greek words, which imply HERNIARY Surgeon, touching a cord, and in ef- is he who treats ruptures in fect the guts ſeem like an particular. extended cord. HERNIA, rup- ture. See ſec. ii. parti. ch. i. ATHI HSC HETEROGENEOUS, bas 8798 is that which is of a different ABITUAL, is an e- nature or quality. The he- pithet given to old terogeneous parts of the ruptures, becauſe the patient blood are thoſe which are becomes accuſtomed to the foreign to it. inconveniencies thereof. to in Еe 3 HO or H 100ROSD 422 The EXPLICATION OF TERMS of Art. omol JE HOMOGENEOUS, or HYPOCHONDRIAC, homogeneal. A term appli- an affection, or paſſion fo ed to things conſiſting of called in men, and vapours fimilar parts: in contradi- in women. ſtinction to heterogeneous. HYPOCHONDRIAC, HICKOUGH, a ſudden a name given to men trou- inſpiration, attended with a bled with the ſpleen or me- noiſe, by which the dia- lancholy vapours. phragm is ſuddenly and im- COD petuouſly hurried down- 1. wards. This motion pro- ceeds from the irritation of EJUNUM. The fe- the nerves. cond of the ſmall guts. HUMOUR, in phyſic, ILEUM, or ilion. The is underſtood of a liquid third of the ſmaller guts. produced in the human bo- ILIAC, a paſſion or vio- dy by the digeſtion of foods. lent pain chiefly felt in the HYDATIDES, are inteſtine ileum. This ma- bladders full of ferous mat- lady is alſo called the iliac ter, of various ſizes, and paſſion, miſerere, coltulus, formed by the dilatation of cordapſus. It is moſt com- the lymphatic veſſels. monly occafioned by a con- HYDRAGOGUES, traction, wringing, purgative medicines, that twiſting of the ilion in her- carry of waters and ferous nia's; and the perſons trou- humours. bled with it, are thought to HYDROCELE, a kind return their excrements by of falſe hernia. See it de- the mouth. If they do not fined, ſec. ii. part ii. ch. vomit them in reality : xxxi. or a what they give up has at HYDROPISY, or drop- leaſt the whole foetor of ſy. An illneſs cauſed by a them. See the chapter 0 gathering of water in ſome the contraction of the ilium. part of the body. INCISIVE. An epithet applied to remedies whoſe pro: The EXPLICATION of Terms of Art. 423 property it is to divide, thin, is brought on by way of in- and attenuate thick coarſe filtration, humours. The ſame is al- - INFLAMMATION, ſo applied by anatomiſts to a heat, or fire, attended with the two fore-teeth of each redneſs in the inward and out- jaw, which are called inci- ward parts, proceeding from five, or inciſory teeth. the intruſion of the blood INCISION, is the divi- into the lymphatic veſſels. fion of the fleſh made with An inflammation is always ſome cutting inſtrument, attended with the fever. ſuch as a biſtory, a pair of INFUSION, is an ope- cizars, a lancet, and other ration in pharmacy, by cutting tools. which the virtue and force of INDICATION, the certain medicines is extract- fymptomatical knowledge ed, by freeping them in cold of the habit of body of a or hot water, without mak- perſon, that determines the ing them boil. The liquor choice of the means to be impregnated with the virtue uſed to preſerve his life and of the druggs infuſed in it, is health, or cure the illneſſes likewiſe called infuſion. that come upon him, or at INGREDIENT. A leaſt to alleviate the acute- name given to the ſimple neſs of the ſymptoms: and ſometimes to the com- Which conſtitutes three pound medicaments, which kinds of indications, viz. enter into medicines, and The vital or preſervative, the largeſt compoſitions of the curatite, and the pallia- remedies. tive. INGUINAL. Belong- INFILTRATION. A ing to the groin. The word of modern uſe, ex- glands or kernels of the preſſing the action by which groins are called inguinal. a tumor gradually creeps They call inguinal hernia, and infinuates into the cel- that which is in the groins. lular texture of the parts. See ſec. ii. part i. ch.x. The dropſy called anaſarca, IN- Ee 4 424 The EXPLICATION OF TERMS OF ART. K brane in form of INJECTION, an acti- INVERSION, ſo is ſaid tion, whereby a liquor is of a part turned over as to introduced with a firinge in- have its inſide out, ſuch 9 to the parts of the body, ſuch the womb when overturned as the vagina, the funda- or inverted. See the inverſi- ' ment, wounds, fiſtula's, on of the womb. ſec. ii. part &c. Bloid do 20 i. ch. xxiv. சாவி INSPIRATION, that ITAL part of breathing, by which Kto traite the air enters into the lungs, through the mouth and no- is is ſtrils. a INTERIOR. This bladder, that makes a tu- word means the inſide of any mor full of matter either part. The interior, or cavity liquid or thick, fleſhy, fat, of the breaſt, contains the or of another nature. 10 Jungs and the heart. KIRSOKELE, or cirſo- INTERMISSION. A cele, a kind of falſe hernia. name given the intervals of See the deſcription of it. Sec . refpite, which happen in ii. part i. ch. xxxiv. the accident of maladies, fach as the moments of eafe L. ua injoyed at diſtances, between EHTOTY the gripes occafioned in her- ATERAL. Means nias by the contraction of the what is on the fide. ileum, and like that ſtate of The arms are on the two comfort which we experience lateral parts, that is on both in the intervals between the ſides of the body. lluq fits of fevers, &c. LAUDANUM. A re- INTERNAL. An at- medy, an extract of opiunt, tribute of the parts contain- of a narcotic ſoporiferous na- ed in the cavities, ſuch as ture, by which pains are ap- th: bowels. The words in- peaſed. It is the moſt af teſtine and bowel, are fyno- fwaging of medicines, nymous. Tornado onluq L LA The EXPLICATION OF TERMS OF ART. 425 M b LAVEMENT, or gli- tains the white part of the ster, a liquid remedy ſquirt- blood, called the lympha. ed with a firinge into the Haiw bubotu bowels through the funda dhulhod M.o ang als on ment. The Engliſh uſe a sapi soba conge GRY hog's bladder inſtead of a ARROW, an unc- firinge. tuous thick ſubſtance LIGAMENT. See the contained in the cavity of definition of it. Sec. i. part bones. i, cb, ji. MASS (The) of the LIGATURE. A term blood. A word implying of ſurgery. It is a waxed all the liquors which enter fillet uſed to ſtop the blood into the compoſition of the of the vefſels, by tying them blood, and make by their with it, as they tie the navel combination, a totality that of a new-born child. may be divided into many LIP. A term of anato- different parts. See blood. my, uſed to ſignify the MA STICATION, is brinks of the mouth. It is the action of chewing foods, alſo applied by way of fimi- and of grinding and thining litude, to the brinks of a them with the teeth. woman's privy-parts. MATRIX, (the) or LYPOTHYMIA, a womb, the chief organ of ſudden and conſiderable di- generation in women. minution, or failure of ani- MEDICAMENT, a ge- mal and vital actions, at- neral term, meaning any tended with a faint weak thing taken in or applied pulſe, an almoſt inſenſible outwardly, to reſtore the reſpiration, a paleneſs, and health. a chillineſs of the face, the SMEMBRANE. See the hands, and the feet. This definition of it. See. i. part is the firit degree of the fyn- i. ch. ii. cope, or ſwooning. MERCURY, or quick- LYMPHATIC (The) filver. A Auid mineral e- veffels, are thoſe which con- fteemed the moſt melting remedy in phyſic. ME- 426 The EXPLICATION of TERMS of ART. N: MESENTERY, one of MUSCLE. See the de- the parts contained in the ſcription of it, ſec. i. part i, belly. See the deſcription of ch. ii. , it. Sec. i. part i. ch. viii. . MILK, a white liquor N. deſtined for the nouriſh- bu ment of children, and of AILS (the). Thoſe the young of animals. See ſmall excreſcences that ſec. i. part i. ch. xx, grow over the ends of the MINERALS, are all fingers. the productions of the earth, NARCOTICK, a that are found petrified in fomniferous remedy, that its bowels or at the ſurface. has the virtue of appeaſing MORTIFICATION. and affwaging pains, as O- See gangreen. pium and laudanum do. MOTION, (anti-peri- NAVEL. A den, or ftaltic) is a motion contrary hollow, remarkable in the to the natural motion of the middle of the belly of both bowels, which is called pe- ſexes. riſtaltic. NAUSEA. A reaching MOTION, (periſtaltic,) to vomit, attended with diſ- is a vermicular motion, that guſt, and a watery mouth. is, a motion like that of NERVE. A part of the A common worms, or other human body. See the defi- reptiles, by which they nition of it, ſec. i. part i. lengthen or ſhorten. This ch. ii. motion is neceſſary in the NITRE. A falt full of bowels, that the chylus may the moſt ſpirituous particles enter into its veſſels, and of the air, that render it very to facilitate the carrying off volatile. It is fetched out of the excrements. of the rubbiſh and ruins of MOTION (the) of the old buildings. blood. The blood has a NYMPHÆ. A term -threefold motion. See ſec. i. of anatomy, fignifying two part i. ch. xviii. wrinkles or folds of the ſkin, be The EXPLICATION of Terms of ART, 427 O between the great lips of the fyrup, or-honey. They are woman's privy parts. See wrapt up in wafers to be fec. i. part i. ch. xv. ſwallowed up. ORGANS. See their de O. finition, ſec. i. part i. ch. ii. ORIFICE. The entry BSTRUCTION. A or aperture of a cavity. gathering of groſs hu- OSCHEOCELE. A mours in the cavity of the kind of hernia, wherein vefſels, that choak them up, the inteſtines or the inteſtines or omentum and hinders the circulation deſcend into the ſcrotum ; of the fluids. otherwiſe called complete OECONOMY (animal) hernia. The order, fitneſs, and har- OSCILLATION. It is mony, reſulting from the a motion common to all the proportion and equilibrium fibres of the human body, of the ſeveral parts of the and which they borrow from human body. their naturalelaſticity. They, OINTMENT, or un- by that means, triturate and gent. An unetuous remedy attenuate the fluids, and ac- of the conſiſtency of ſoft celerate their circulation and wax, which is ſpread upon fecretion. a piece of leather, or cloth, OSSIFICATION, is to be laid on the ſkin. the inſenſible converſion of OPERATION. A term membranous, fat, fleſhy and of ſurgery, the methodical other ſoft parts to bones, or manual operation of the fur- to ſubſtances that have the geon on the body of man, hardneſs or conſiſtency of to reſtore or preſerve his bones. health. OVARIES, or OVA- OPIATE, a name given RIUM, are membranous a to ſome kinds of ſoft reme- parts, wherein the eggs of dies, made of ſeveral pow- are lodged. See ders blended together with ſec. i. part i. ch. xv. women P. 428 The EXPLICATION of Terms of Art. PA ſec se nada als enabi poter vd treats of the cauſes and P. ar ais o Paw to this fymptoms of maladies.zib PENIS, a man's yard. DALLIATIVES, Re- see its deſcription, Sec.i. medies that mitigate part i. ch. xxv. the ſymptoms of diſeaſes, PERISTALTIC. See the cauſe of them ſtill re- Motion, og mil ball inaining. The ſame name PERITONÆUM. See is given to incurable mala- the definition of it, secasi. ladies, the ſymptoms of part i. ch. iv. OHITAJI which are aſſuaged by a PESSARY, or PES- kind of curing, called palli. SUS. See ſec. ii. part i. ative cure. cb. xxvii. PANACEA: A pre- A PHARMACY. That paration of mercury by way part of phyſic that teaches of ſublimation. how to chufe and prepare PANCREAS, a part medicines, 009 lodged in the belly. See the PHTHISIS, conſumpa definition of it, ſec. i. part i. tion, pulmonary conſump- cb, ix. tion. Bok PAROXISM, a violent PHYSICK, a ſcience fit of an increaſing illneſs, that teaches how to preſerve the moſt acute criſis of a and reſtore. The Engliſh malady. Paroxiſms are give the ſame name to any ſometimes periodical and re- purge. In Latin potio pura gular, as the acceſſes of in- gans. The French call it termitting fevers. They medicine. 9 plag have no regularity at all in PHYSIOLOGY. Thati the ſymptoms of the con- part of phyſick which treats traction of the ileum. of anatomy, and takes no- PATHOLOGIC, be- tice of the mutual relations longing, or relating to pan of the ſeveral parts of the tbology. STAT wo? body one with another, as PATHOLOGY, that well as of their reſpective part of the phyſic which uſes and functions. TALOW PILLS, towar > The EXPLICATION of Terms of ART: 429 b PILLS, are folid reme- by various accidents, the dies that have been made to chief of which are, ulcers in affume the form of little balls the private parts of both ſomewhat bigger or fmaller fexes, which are called ſhan- than peaſe. kers; by excreſcences in PLEDGET, a bung of thefe parts, and in the fun- flattened lint put on wounds dament, which are called and ulcers, in the dreſſing of vernias, criſta, thymus and them. ficus; by hard and ulcerated PLETHORA. A term puſtules, called condylomes, that fignifies a ſuperabun- which appear in thoſe fame dance of blood in the vef- parts in the fundament, and ſels. in the internal and ſuperior PNEUMATOCELE. parts of the thighs ; by a See the definition of this word, flow of pus from the yard in ſec. ii. part i. ch. xxxiv. men, and vagina in women, POCKY, or venereal, which is called a clap, or which holds of the pox. heat of urine, ſwelling of POSTERIOR, a rela- the yard, and inflammations tive epithet meaning the called phymoſis, and para- hind part of any thing. The pbymoſis ; by ſwelling in the calf of the leg is the hind groin called buboes, livid pimples in the forehead, POX, a diſorder of which tetters, leprous itches, ul- there are two different forts.cers, which gnaw the fleſh The firſt is that of which in different parts, particu- few people are exempt ; larly the mouth and noſe, namely, the ſmall-pox, of pains and achs, eſpecially at which every body has a night, in all the members, ſtrong idea. The ſecond is and many other ſymptoms the great pox.ux'Tis a con- under which this troublefome tagious diftemper, original- diſtemper diſguiſes itſelf, ly contracted by an impure without a fever. They don't commerce with a debauch'd all indeed meet in one and woman, and manifefts itſelf the ſame perſon ; but it fuf part of it. a 430 The EXPLICATION of TERMS of ART, fuffices that many of theſe by a diffolved body is cauſed fymptoms ſhould appear to- to ſeparate from its menftru- gether, to pronounce it the um, and fink to the bottom pox. The French ſoldiers of the veſſel ; like gold, having been infected: with which precipitates into a the pox, in the kingdom of powder, called gold-preci- Naples, under Charles the pitate. Eight, occaſioned it to be 1o PROBE. An inftrument called the Neapolitan diſeaſe. of ſurgery uſed to probe The Italians, on the con- wounds, to know their depth trary, thinking the French and extent, to diſcover the had brought it to their coun- ſtone in the bladder, or to try, called it the French dif- diſcharge the urine retained) eaſe, morbus Gallicus. The therein. They are uſed in Engliſh call it the French other caſes, and their diffe- pox, to diſtinguiſh it from rent uſes make the difference the ſmall-pox. As the great of the probes, which are pox is common in Spain, it characterized according to has the name of morbus Hif- their various ſhapes. 034 panicus, or the Spaniſh dif- PROGNOSTIC. A eaſe. Before the wars of judgment of the courfe and Italy under Charles the cataſtrophe of a diſeaſe, from Eight, this diſeaſe was ſo the forerunning and preſent little known, that ſome fymptoms of it. sola mark out that time as that PROGNOSTIC Signs; of its birth. A found wo- are thoſe that ſhew and make man proſtituting herſelf to us foreſee what good or bad many men alſo found, may may happen in a malady, catch this diſeaſe, and com- or even in a ſtate of perfect municate it to others; it health. . srebro may conſequently have its PROLIFIC. Fit for birth fince there have been generation. This epithet is debauched women. applied to men and male a- PRECIPITATION. nimals, to their feed, and A chemical operation, where the remedies that ſtrengthen > the The EXPLICATION OF TERMS of Art. 431 ces. RAD the genital parts, and in- times the runnings called creafe and invigorate the whites in women ſeed. PUS. A thick, fluid, un- PROSTATÆ. Parts natural matter, made of which enter into the com- blood and nutritive juicés, poſition of the genital. See altered and diſſolved, en- ſec. ii. part i. ch. xiv. dcow genderd in abſceſſes, or if- PROSTATÆ (the liquor fuing out of wounds and of the) is that projected by ulcers. mislist stiot eunuchs in amorous embra- tud GB OR. golato PULP. The mellow, fucculent part of fruits, and ADICAL, is faid of a of certain roots of which a cure that carries off the ſoft maſs is made. The pulp very root of a diſeaſe. of herbs is extracted by in- RECREMENT, a nanie fufion or boiling, making given the humours, which them paſs through a fieve. being firſt ſecreted from the PULSE. The beating of maſs of the blood, re-enter the arteries. It confifts in into it in part; ſuch as the the dilatation of the arteries, gall, the pancreatic juice, in which cafe th-ir pulfa-l &c. bono son tions are felt by the fingers RECTIFY (to) a liquor that touch them. This mo- or fpirit, is bringing it to tion is the reverſe of their its utmoſt perfection. test conſtriction. The fitteſt place RECTUM, is the laſt to feel the polfe is at the of the largeſt bowels. See wriſt or the temple; the ar- ſec. i. part i. ch. vii. teries in thoſe parts being REDUCTION, a term a more ſenſible than any where of ſurgery, denoting an o- elſe. D3 peration whereby diſlocated PURULENT, mixed parts are reſtored to their with pus. Such is the urine former places, ſuch as the of people troubled with ul- bowels and the epiploon in cers in the reins, and often- hernias. 02 2 RE- 432 The EXPLICATION of TERMS OF ART. a REMISSION, in vio- fpiration, and goes out of it lent acut= diſeaſes, is a miti- during the expiration. The gation or affwaging of ſuch reſpiration maintains the cir- fymptoms as begin again, culation of the blood in when the time of the remif- living animals. The fætus fion is over does not breathe in the REPERCUSSIVE re- womb, it ftanding in no medies, are thoſe that have need of it, on account of a the virtue of ſtriking back peculiar a conomy which the the humours within, by in- Author of Nature has eſta- creaſing the elaſticity of the bliſhed in the ſtructure of fibres. its lungs, till it feels the ex- RESERVOIR (the) of ternal air, whoſe impreſſion the chylus. See Pecquets obliges it to breathe. deſcription of it, ch. xvii. RUPTURE. See Her- feet. i. part i. NIA.bg RESOLVENTS. Re- medies applied outwardly, S. and laid on the ſkin. They have the virtue of attenua- ANIES, a term of fur- ting and dividing ſuch hu- Serye gery, a thin, ferous, mours as are ftopr, and ſtag-lympid pus ifſuing out of nate in any part, by making putrified fores. them perſpire through the SANGUIFICATION. ſkin, or in bringing them The Action whereby blood back into the way of circu- is made. See cb. xvii. ſect. lation, i. part i. RESPIRATION. That SARCOCELE, a kind motion of the breaſt where- of falſe hernia. See ch. xxxii. by the air alternately enters feet. ii. part i. into and goes out of the SCURVY. A very com- lungs. Theſe two motions mon diſeaſe among feamen, are called inſpiration and ex- and in the northern coun- piration. The air enters in- tries. It is a various com- to the breaſt during the in- plication of fymptomis, the moſt The ExpLICATION OF TERMS of Art. 433 ز moſt frequent of which are, the alimentary and excre- the relaxation, fwelling, li- mentitial humours, from the vidity, and bleeding of the groffeſt part of the foods, gums; the black dye, loofe- or from the maſs of the neſs, and fall of the teeth ; blood, into the ſeveral or- the ulcers and offenſive ſmell gans of the body. See ch. of the mouth; red, hvid, xvi. fe&t. i. part i. and ſometimes yellow ſpots SECRETORY. A name on the ſkin ; wandering given to certain ſmall vel- pains, laffitudes of the arms fels, that ſerve to ſeparate and legs ; livid, malignant, fome humour or other from ſtubborn ulcers in feveral the maſs of the blood. parts of the body ; the dry SEED. A matter fitted gangrene of the limbs ; the by the Author of Nature rottenneſs of the bones ; acid for the ingendering of one's crudities, offenſive belches, like. See ch. xiv. Seet, i. borborigmi, the obſtructions parti of the viſcera, head-aches, SENSE. An organ which faintneſſes, fyncopes, and a receives the impreſſions of multitude of other accidents outward objects, and tranſ- lurking under the appear- mits them to the ſoul. See ance of all ſorts of diſeaſes, ch. ii. feat. i. part i. which render them of long SEROSITY. The moſt duration, and very difficult lympid, tranſparent, water- to be cured; the whole be- ifh portion of the maſs of ing generally without ſever. the blood and of milk, of SCIRRHUS, that is which it makes the greateſt hard without pain, of the part. It is mixed and blend- nature of the fcirrh. ed with the lympha in the SCURVY, in the ad- lymphatic vefſels. jective fenfe, one troubled SEROUS, wateriſh, full with the ſcurvy. of ferous matter. SECRETION. The fil- SIGN. A viſible mark tration or feparation and re- or ſenſible character, that partition which is made of betrays what was not mani- FE feſted, 434 The ExplICATION OF TERMS of ART. Store OR feſted. In phyfic, as well are the ſame with ſpaſmo- as in furgery, the ſigns fhew dic motions. us the ſtate of the health, SPERMATICK veffels, the nature, cauſes, and du- which convey the blood to ration of the diſeaſes. They the teſticles, for the prepa- are diſtinguiſhed into diag- ration of the feed. See the noſtic and prognoſtic, univocal deſcription of them under the and equivocal. See theſe ſigns title of ſpermatick cords, in their reſpective places. part i. ch. xiv. Aliste SKIRRHUS, or SCIR- SPERMATOCELE. RUS, a hard, heavy, in- Falſe hernias cauſed by the dolent tumour, formed and retained feed. See ſéc. i. be growing, by flow degrees, part i. ch. xxxiii . in the ſoft parts of the body, SPHACELUS. An en- both internal and external, tire mortification of a part without any inflammation of the body, cauſed by an or change of colour. A interruption of circulation. . ſchirrus is generally form- SPIRITUOUS. A term ed in the liver, ſpleen, of chemiſtry. That which meſentery, pancreas, and is volatile, fubtile, penetra- in the womb; the glands ting, compoſed of light and of the external parts of the active particles, and very body are alſo ſubject to a much diſpoſed to exhale. ſchirrus. When a fchirrus SPLANCHNOLOGY. is imperfect or incompleat, That part of anatomy which it is called a ſchirrous tu- treats of the viſcera, SPLEEN. One of the SOLIDS, are in the hu- inward parts of the belly. man body thoſe parts which See ſec. i. part i. ch. xi. . at contain the fluids and hu- SPONTANEOUS mor. The Spontaneous diſorders are SPASM, is the ſame as thoſe which come of them- convulſion. ſelves, without any SPASMODIC, is ſaid of cauſe, as laffitudes, without convulſive motions, which having fatigued or walked. mours. manifeſt Spon- The EXPLICATION OF TERMS of Art. 435 Spontaneous evacuations are cauſed by fickneſs, or the thoſe which come of them- cauſes thereof, and which ſelves, without being excited diſappears when the cauſe by any remedy. od ceaſes. The cholick, vo- STAGNATION. A miting of the excrements, heap or collection of hu- &c. are the ſymptoms of a mours or blood, which have twitch in the guts, and they not abſolutely loſt their pro- ceaſe when this obſtruction greffive motion in the vef- does. ſels, but circulate flowly, SYNCOPE. A ſudden either on account of their a- and conſiderable faintneſs, bundance or thickneſs, or a an abatement of the forces, defect of the tubes through and of the animal and vital which they are to paſs, functions, in which the pa- STASIS. A delay of tients become pale and cold, the blood or humours in The fyncope is diſtinguiſhed ſome part of the body, in three degrees. The firſt where they are ſo engaged is lipothymic, of which I and ſtopped in the ſmalleſt have ſpoken in its place. veſſels, that they loſe their The ſecond is the fyncope, progreſſive motion: in which properly ſpeaking, which, the ſtafis differs from the beſides the forementioned ac- ſtagnation, in which there cidents, is accompanied with remains ſtill ſome motion, a cold fweat, a ſmall and al- though flow. moſt imperceptible pulſe, a SUPPURATION. A loſs of knowledge, motion change which is made of the and feeling, an inſenſible blood and other humours in- reſpiration. The third is the aſphyxia, in which are re- SUSPENSATORY. A marked not only the fore- kind of bandage of linnen or mentioned fymptoms, but a fultian, which ſerves to fuf- total ceſſation of che pulſe. tain the teſticles. SYRINGE. It is a hol- SYMPTOM. A non- low cylinder of metal or natural accident or effect, ivory. They are moſt com- noge Ff 2 monly to pus. 436 The EXPLICATION of Terms of Art IT a monly of pewter. Some are of T. 'Tis ſometimes made made of filver. This cy of three bands, two of which linder contains a piſtor gar- are atcached to the longeft, niſhed with flax, or any o- and form a kind of double ther the like matter, to pre- tail T. Ong TAA vent the introduction of the TABLETS, is a kind of air between it and the fides folid ele&tuary, compoſed of of the cylinder. It ſerves to powders, confections, pulps, to inject or inſinuate ſome li- or fuch like things, incor- quors into cavities, or to porated in ſugar, or fome pump out purulent matters; gums. This dried compo- for which reaſon fome are ſition is afterwards divided made to give clyfters, others into tablets, ſquare, round, to inject wounds, the blad- lonzenge-wife, or into any der, the vagina, the breaſt, other figure. Oral &c. and others for ulcers TAXIS. An operation and fiftulas. of furgery, by the means the SYRUP. A liquid ſweet- parts are reduced to their taſted medicament, of a vif- natural fituation. It has cous thickiſh conſiſtency, place chiefly in hernias, to made of decoctions and in- reduce the gut and epiploon fuſions, of the juice of cer- into the belly. How per- tain plants, mixed with fu- formed, fee in ſec. iic part ii. gar, and ſometimes with cb. xiii. honey. TEMPERAMENT. 2 By this word is underſtood T. the complexion or natural conſtitution of the body. T is kind TENDONS bandage uſe . ch. to keep on the dreſſing in TENTS. Lint or lin- the diſorders of the funda- nen, rouled in a piramidal ment and teſticles. It is form introduced into wounds made of two bands, of which to hinder their cloſing one is attached to the middle foon.es naveli of the other, to form a kind ! T Hardme madende of patie DONS . See sec. i. too a TES- The EXPLICATION of Terms of Art. T 437 TESTICLES. See the lo VAGINA. A conduit definition and compoſition which ſerves as a fheath thereof, fec. i. part i. ch. to the penis in the act of co- xiv.drob to 5 pulation. See fec. i. part i. TISANE, decoction of ch. xv. herbs, flowers, fruits, roots, VARIX, a ſoft unequal given to fick people for their ſwelling in form of a knot, ordinary drink. livid, blackiſh, without TONUS, is a ſtate of pain, occafioned by the di.. firmneſs of the parts of the latation of ſome vein, ob- body. ſtructed by the ſtay of ſome TRANSPIRATION, thick blood. This indiſpo-. is an evacuation of humours fition happens to the natural ferous, faline and ſulphurous, parts, to the thighs and which is inceffantly perform- legs of pregnant women, ed through the pores of the the teſticles with men, and entire habit of body, in the fometimes in their legs and form of imperceptible va- thighs. pours, there is the like tranſ- VARICOCELE. See its piration interiourly. definition, ſec. ii. part ii. TUMOUR, is a non- cb. xxxiv. natural elevation, which VARICOUS. An ad- happens on ſome part of the jective, implying parts af- fected with the varices; there TUCNI, is the ſame are women who have the as membrane. private parts all varicous. VEGETABLES. Are les productions of nature, which engender in the earth by ESSEL. The vef- fhedding their feed, and fels cilindrice there receiving nouriſhment tubes, which ſerve to con- and growth, as plants, trees, tain the blood and other hu- &c. The moſt part of our mours, and diſtribute them remedies are drawn from all over the parts of the bo- vegetables. dy. VE bm 2 body. V. V! are 438 The EXPLICATION of Terms of Art. VEHICLE, which ferves VIRGINITY, or maid- to convey, or facilitates the enhead, its figns are uncer- ſwallowing of a remedy. tain. See ſec. i. part i. ch. Broth, water and wine, ſerve xv. moſtly as vehicles. VIRUS. Venom, a | VEINS, are tubes, which malignant quality, pernici- bring back the blood from ous, venemous, an enemy to the parts to the heart. See nature. . ſec. i. part i. ch. ii. Lacteal VIRUS of the pox, veins. See ſec. i. part i. ch. of the ſcurvy, kings evil, xvii. the itch and leproſy. VENEREAL. Cauſed VISCERA See ſec. i. by the pox; a venereal bubo, part i. ch. ii. is a fwelling in the groin VISCOUS, any liquid proceeding from an impure that is too thick. coitus. ULCER. A dif-union VENTRAL. This of any part of the human word comprehends hernias, body, with a loſs of fub- which come at the anterior ftance, and a flow of matter; part of the belly. this kind of dif-union in VERMINOUS. All the bones, is called caries. that hath relation with UMBILICUS, a term of worms ; a verminous bag is anatomy, ſynonymous to a kiſtus filled with worms. the word navel. A verminous hernia, is that UNIVOCAL. The in which there are worms figns of diſeaſes, particular which ſometimes pierce thro' to each diſeaſe; the univo- the inteſtines, this kind of cal ſigns of a hernia, or hernia, requires ſo much the rupture, are the bulk it more attention, as it is but forms, the facility it has of little known. entring and coming out, VESICLES feminary, and the noiſe made by the the reſervatories of the feed. matter contained in the in- See ſec. i. part i ch, xiv, teſtine when its reduced. VO- STADIG TADEJ T 362 2009 ans X. 1199 mach, and even the inte- X cartilage, under that The EXPLICATION of Terms of ART. 1439 VOLA TIL. Subtil paſſage of the urine in menor light, which evaporates and ch.xiv, in women, fec. i. diffipates eaſily in fpirits, or part i. ch. xv. x 1918018 fublimates at the leaſt heat ; VULVA. See its definiti- ſuch are all ſpirituous li- on and deſcription. fec.i. part quors. i, ch. xv. ld on to and VOMITING, a violent ada egreſs by the mouth of the matters contained in the fto- , A Itines. URETERS. See the part commonly called the d deſcription thereof. Sec. i. pit of the ſtomach ; this part i. ch. xii. cartilage is vulgarly called no E THRA. The the brichet; 03 nsmih 10 — А я тих durio lol starto brow ooh 3o ESTRA vlada ball OMLE constant otom mom og F IN I S. w bolla auto TATO encontrar sti shoes "Ovo daina -Oving மான orolla 10. Ante can contains jilid di adidas oriuperci กรวย 20 za silon suda non som quo samos Wonton arit vd abron shte orld borot 22V CO fiori a bato solo book CM10kvist PSMO boubat 2 stw LOV torage 9 AVIS Sht 0.02 KE ARTES SCIENTIA LIBRARY VERITAS OF THE | UNIVERSITY OF MICHIGAN Shku TCEBOR KERIS PENINSULAMAMENVAS CIRCUMSPICE The George E. Wantz (UM Medicine 1946) Collection