Of a Bubonocele or Rupture in the Groin, and the Operation Made upon It; By Claud. Amyand, Esq; Serjeant Surgeon to His Majesty, and F. R. S.

II. Of a Bubonocele or Rupture in the Groin, and the Operation made upon it; by Claud. Amyand, Esq; Serjeant Surgeon to His MAJESTY, and F. R. S. UPON the 8th Day of October 1737, my Lord Thomond's Coachman's Wife, Mrs. Bennet, of a thin Habit of Body, aged 70, had a Return of a Tumour in the Groin, with unusual Pain, which was soon followed with a cruciating one in the Belly, and such Colicks, Reachings, and excrementitious Vomitings, as usually attend the Strangulation of the Gut in the Miserere mei. This came upon her unaware, and the Distress she was in, made her forget that for 25 Years last-past she had had a Swelling in the Groin as big as a Hasel-nut, which seldom had given her any Uneasiness, and which she never suspected to be a Rupture. Of late she had been more subject to Colics than usual, but that was imputed to bad Digestions; and that Day she had used no Motion capable of producing a Rupture: So that it was by chance that Mr. Despaignol, who was sent for the next Day, discover'd the Cause of the Complaints. She was blooded, clyster'd, fomented, poulticed, and embrocated; but the Complaints subsisting, with a continual Singultus, I was called in, the 11th. The Tumour was now oblong, about the Bigness of a Hen's Egg, somewhat inflamed, yet not tense, nor so painful as to take much Notice of it. Upon the repeated Use of the forementioned Means, and of lenient Purges and Opiates, the Vomitings and Hiccough were at times stopped, and the Patient made so much easier, as to ground Hope of Success; but as during six Days, the Patient had had no Passage, and the Tumour could not be reduced, so we thought it unsafe to delay the Operation any longer. At this Time she was free from Fever, the Belly was not tense, and she had great Intervals of Rest. The Tumour felt unequal (though it appear'd even) and pappy, as the Tumours of the Omentum generally are, and therefore of that Kind that is always most difficult to reduce; the Omentum wanting that elastic Springiness which favours the replacing of the Guts. Upon Dissection we found it was imbodied in the hernial Bag, and that upon the external Surface of the Slits in the abdominal Muscles, the Folds of it had form'd a round Protuberance, not unlike the Os Tincae, in the Vagina, or like a Bourlet, which, by compressing the Gut, prevented the Return of it into the Belly, and by obturating the Opening, as the Gut was press'd upon it, had strangulated about an Inch of the Gut incompass'd by it in the Hernia. This being the 6th Day from the Beginning of this Evil, the Gut there was found of a very swarthy Colour, but yet springy, so that it was not totally mortified. It lay inclos'd in a Net form'd by the Omentum, as a Fish in a Fishing-net, strangulating the Gut under its Pressure without the abdominal dominal Muscles: It was with some Difficulty the Omentum was torn off and separated from the Bag it was attach'd to; and as this lay in the way of the Reduction of the Gut, and almost sphacelated, so it was cut off without any previous Ligature, though its Vessels were turgid and large, as it was impossible to pull it out so as to make the Ligature upon the sound Part of it; after which the Reduction of the Gut might easily have been made, without inlarging the annular Slit; for this made no Stricture to prevent it. But the Quantity of the Omentum within it being great and voluminous, and the Gut in a very crazy State, it was thought more expedient to inlarge it, to make the Reduction of the whole easy: Afterwards the Omentum was detach'd from its Adherence round this Place, and pull'd further out; and a Ligature being made upon the sound Part of it, that was also replaced in the Belly, and the Entrance stopp'd with a conic Tent, dipp'd in the Yolk of an Egg, and Oil of St. John's-wort: The Belly was embrocated, and the Dressings well secured; for as the Patient was greatly oppress'd with an Asthma, so she was oblig'd to be sitting in Bed. From this time the Hiccough and excrementitious Vomitings have disappear'd, but the Reachings and Vomitings continued near five Days longer, before the Faeces detain'd above the strangulated Gut could make their way downwards, though they were frequently invited by Clysters, and lenient Purges. She was blooded immediately after the Operation, and soon after took an emollient and carminative Clyster, which was repeated Night and Morning; and an oily oily Laxative of two Drachms of Manna, and half an Ounce of Oil of sweet Almonds, in Mint and small Cinamon-water, every four Hours. At first the Evacuations were extremely fetid, black, griping, and frequent; but they became more moderate as she took Absorbents and Diluents; but yet so frequent, that it was thought proper to restrain them by gentle Astringents, so that she might be enabled to bear them. In five or six Days, the Stools had remov'd the Tension, which appear'd on the Belly after the Operations; the Reachings and Vomitings, and the remaining Symptoms, went off; the Wound digested well, and the Patient continued in a mending and recovering way. It has been observ'd, that this old Woman was greatly afflicted with an Asthma; she had, at times, violent Fits of it, and the 14th Day from the Operation she had one, with a total Stoppage of the Discharge from her Lungs, which choaked her upon the 17th Day. I should have been glad to have had the Opening of her, but could not obtain her Friends Consent. This Case confirms me in what I have frequently observ'd upon the like Occasion, that as the Omentum is the principal Obstacle to the Reduction of the Guts in Ruptures, so it is the Occasion of the greatest Accidents that attend that Evil. It wraps up and incloses the Gut prolapsed, like a Net, whose fasten'd End within the Belly strangulates the Part detain'd in the Rupture without the abdominal Apertures where it is confin'd; and is productive of such Folds in it, and Pressures of the Gut wrapp'd up in it, as is oftener the Cause of a Strangulation and Miserere mei, than the tendinous Slits of the external oblique Muscles in the inguinal Rupture, or tendinous Opening in the Navel, which upon these seldom is found inflam'd, and can never contract so suddenly, as to obstruct the Return of the Gut into the Abdomen, when the Omentum is absent: Agreeable to which, it is rare to find any strangulated Rupture that is not attended by it. The fatty Substance of the Omentum subjects it to Inflammations, Suppurations, and Putrefactions, that contaminate the neighbouring Parts. It wants that elastic Springiness the Guts have, which favour the Reduction in Ruptures. It frequently stays behind when the Guts are reduced, and therefore bars the Patient not only from the Benefit of retentive Trusses he stands in need of for his Security, but it directs the Gut into the Rupture where it lies, the Guts being most apt to slide down along it; and when it is fix'd in the Rupture, it too often pulls and draws into it the Cæcum and Colon it is attach'd to, and even the Stomach itself, in proportion as the Quantity of it in the Rupture happens to be more or less; and therefore the umbilical Ruptures are most dangerous of any; for as the Omentum lies over the Guts, so it is always press'd in foremost, in the Ruptures of this Part, which, when large, will also cause an Elongation of the Fundus of the Bladder that way, and a Difficulty of Urine, in proportion as the Urachus attach'd there is stretched forwards towards the Navel. The Pain attending the Prolapsus, soon swells the Vessels of the Omentum, and that will fill up the Apertures in the abdominal Muscles, through which the Viscera are fallen out, prevent their Return, and bring on an Inflammation. If, by plentiful bleeding, the Vessels emptied do not facilitate the Return of the Parts prolapsed, and all the Consequences that generally are observ'd upon the like Occasion, and if these do not operate soon, it is very seldom that any thing is got by the Application and Use of all the other Means prescribed. Certain however it is, that 'tis very dangerous to depend too long upon them; and that a Suspension of the Symptoms is no Security, whilst the due Course of the Faeces is interrupted. The Case I have here mention'd, may be a Warning to others, not to delay too long an Operation whereby the Parts are to be releas'd from Confinement, and which oftener would be successful, if it was not delayed so long. In the case of a Rupture with a Miserere mei, some deny that Excrements and Clysters from the lower Guts can ascend, and be discharged through the Mouth, upon a Presumption, that the Strangulation that prevents and stops the Descent of a thin Fluid downwards, must prevent the Ascent likewise, and especially of such solid Substances as are reported to be discharged upwards; and the rather, that the Valvula Coli, and the Wrinkles or Valves of the Guts, must impede the Ascent: But the Fact is true, and there is no one conversant in Practice, but has seen Faeces and oily Clysters discharged upwards. If this be allowed, it will follow, that in the Gut-Rupture, there is a Passage through their Pipe, and consequently that the Strangulation must be less than it is generally ascertain'd. The Inflammation of the Guts inverts, but we do not know how, the peristaltic Action of them, and the Discharge, and that so long as that is continued, tinued, insomuch that this will continue even some Days after the Reduction of the Gut is made. Parts inflamed, and in Contact, will soon stick and coalesce together: Pain is the indicating Sign of Inflammation, and an Inflammation is an Intumefaction of the Vessels in the Parts inflamed. If then Pain happens to be an Attendant of a Rupture, wherein the Omentum is concern'd, and the Parts so inflamed continue in Contact, that is, if the Parts prolapsed in a Rupture are not soon reduced, they will swell in the Bag, and be knit together, and by filling up the Opening, by which they had prolapsed, choak up the Passage, clog and prevent the returning back, compress the Guts under the Pressure, and strangulate them more and more, in proportion as their Bulk shall increase, so long as the Fluids can flow into the compress'd Canals; in which at last they stagnate, and upon Extravasation suppurate, or the Mortification of the Parts compress'd ensues. III. An Account of a Pin taken out of the Bladder of a Child, by Mr. William Gregory, Surgeon; communicated in a Letter to Sir Hans Sloane, Bart. Pr. R. S. Brompton near Chatham, Jan 4. 1733-4. I Was call'd to the Assistance of a Woman in Travail. The Foetus presented in a transverse Position; I soon recover'd the Feet, and in a few Minutes deliver'd the Woman. The Funiculus Umbilicalis was