Of the BUBONOCELE.
WHEN the Intestine or Omentum falls out of the Abdomen into any Part, the Tumour in general is known by the Name of Hernia, which is farther specified either from the Difference of Situation, or the Nature of its Contents. When the Intestine or Omentum falls through the Navel, it is called a Hernia Umbilicalis, or Exomphalos; when thro' the Rings of the Abdominal Muscles into the Groin, Hernia Inguinalis; or if into the Scrotum, Scrotalis: these two last, tho' the first only is properly so called, are known by the Name of Bubonocele. when they fall under the Ligamentum Fallopii, thro' the same Passage that the Iliac Vessels creep into the Thigh, it is called Hernia Femoralis. The Bubonocele is also sometimes accompanied with a Descent of the Bladder: however, the Case is very rare; but when it occurs, it is known by the Patient's Inability to urine, till the Hernia of the Bladder is reduced within the Pelvis. With regard to the Contents characterising the Swelling, it is thus distinguished: if the Intestine only is fallen; it becomes an Enterocele; if the Omentum (Epiploon) Epiplocele; and if both, Entero-Epiplocele. There is besides these, another kind of Hernia mentioned and described by the Moderns, when the Intestine or Omentum is insinuated between the Interstices of the Muscles, in different Parts of the Belly: This Hernia has derived its Name from the Place affected, and is called the Hernia Ventralis; and lastly, there have been a few Instances, where the Intestines or Omentum have fallen through the great Foramen of the Ischium into the internal Part of the Thigh, between and under the two anterior Heads of the Triceps Muscle.
All the Kinds of Hernias of the Intestines and Omentum are owing to a preternatural Dilatation of the particular Orifices through which they pass, and not to a Laceration of them, which last Opinion (together with a supposed Laceration of the Peritonæum) has however prevailed so much, as by way of Eminence to give Name to the Disorder, which is known more by that of Rupture, than any of those I have mentioned; on which account I shall beg leave to make use of it myself.
The Rupture of the Groin, or Scrotum, is the most common Species of Hernia, and in young Children is very frequent, but it rarely happens in Infancy, that any Mischiefs arise from it. For the most part, the Intestine returns of itself into the Cavity of the Abdomen, whenever the Person lies down, at least a small Degree of Compression will make it. To secure the Intestine when returned into its proper Place, there are Steel-trusses now so artfully made, that by being accommodated exactly to the Part, they perform the Office of a Bolster, without galling, or even fitting uneasy on the Patient. These Instruments are of so great Service, that were People who are subject to Ruptures always to wear them, I believe very few would die of this Distemper since it often appears, upon Enquiry, when we perform the Operation for the Bubonocele, that the Necessity of the Operation is owing to the Neglect of wearing a Truss.
In the Application of a Truss to these kinds of Swellings, a great deal of judgment is sometimes necessary, and for want of it, we daily see Trusses put even on Bubos, indurated Testicles, Hydroceles, &c. But for the Hernias I have described, I shall endeavor to lay down two or three Rules, in order to guide more positively to the Propriety of applying or forbearing them.
If there is a Rupture of the Intestine only, it is easily, when returned into the Abdomen, supported by an Instrument; but if of the Omentum, notwithstanding it may be returned, yet I have seldom found the Reduction to be of much Relief, unless there is only a small Quantity of it; for the Omentum will lie uneasy in a Lump at the Bottom of the Belly, and upon Removal of the Instrument, drop down again immediately; upon which account, seeing the little Danger and Pain there is in this kind of Hernia, I never recommend any thing but a Bag-truss, to suspend the Scrotum, and prevent possibly by that means, the Increase of the Tumour. The difference of these Tumours will be distinguished by the Feel; that of the Omentum, feeling flaccid and rumpled, the other more even, flatulent, and springy.
Sometimes, in a Rupture of both the Intestine and Omentum, the Gut may be reduced, but the Omentum will still remain in the Scrotum, and when thus circumstanced, most Surgeons advise a Bag-truss only, upon a Supposition that the Pressure of a Steel one; by stopping the Circulation of the Blood in the Vessels of the Omentum, would bring on a Mortification: but I have learnt, from a multitude of those Cases, that if the Instrument be nicely fitted to the Part, it will be a Compress sufficient to sustain the Bowel, and at the same time, not hard enough to injure the Omentum; so that, when a great Quantity of Intestine falls down, tho' it be complicated with the Descent of the Omentum, the Rupture will conveniently and safely admit of this Remedy.
There are some Surgeons, who, to prevent the Trouble of wearing a Truss, when the Intestine is reduced, destroy the Skin over the Rings of the Abdominal Muscles with a Caustic of the Size of a half Crownpiece, and keep their Patients in Bed till the Cure of the Wound is finished; proposinging by the Stricture of the Cicatrix to support it in the Abdomen for the future: but, by what I have seen, the Event, tho' often successful, is not answerable to the Pain and Confinement; for if, after this Operation, the Intestine should again fall down, which sometimes happens, there might possibly be more Danger of a Strangulation, than before the Scar was made. This Practice seems to be more adviseable on Women than Men; because in Men, the Danger of injuring the spermatic Cord sometimes intimidates us from using a Caustic of sufficient Strength to do the proper Office.
I have hitherto considered the Rupture as moveable; but it happens frequently, that the Intestine, after it has passed the Rings of the Muscles, is presently inflamed, which enlarging the Tumour, prevents the Return of it into the Abdomen, and becoming every Moment more and more strangled, it soon tends to a Mortification, unless we dilate the Passages thro' which it is fallen with some Instrument, to make Room for its Return; which Dilatation is the Operation for the Bubonocele.
It rarely happens that Patients submit to this Incision before the Gut is mortified, and it is too late to do Service; not but that there are Instances of People surviving small Gangrenes, and even perfectly recovering afterwards. I myself have been an Eye-witness of the Cure of two Patients, who, sometime after the Operation, when the Eschar separated, discharged their Fæces thro' the Wound, and continued to do so for a few Weeks in small Quantities, when at length the Intestine adhered to the external Wound, and then was fairly healed.
In Mortifications of the Bowels, when fallen out of the Abdomen into the Navel, it is not very uncommon for the whole gangrened Intestine to separate from the sound one, so that the Excrement must necessarily ever after be discharged at that Orifice: there are likewise a few Instances, where the Rupture of the Scrotum has mortified, and become the Anus, the Patient doing well in every other respect; nay, I have had one Instance of this Nature under my Care, in which the Excrements were voided totally by the Scrotum for three Weeks or a Month, yet by Degrees, as the Wound healed, they passed off chiefly in their natural Course, and at last almost wholly so. These Cases, however, are only mentioned to furnish Surgeons with the Knowledge of the possibility of such Events, and not to mislead them so far as to make favourable Inferences with regard to Gangrenes of the Bowels, which generally are mortal.
Before the Performance of the Operation for the Bubonocele, which is only to be done in the Extremity of Danger, the milder Methods are to be tried; these are, such as will conduce to soothe the Inflammation; for as to the other Intent of softening the Excrements, I believe it is much to be questioned, whether there can be any of that degree of Hardness as to form the Obstruction; and, in fact, those Operators who have unluckily wounded the Intestine, have proved, by the thin Discharge of Fæces which has followed upon the Incision, that the Induration we feel, is the Tension of the Parts, and not the hardened Lumps of Excrement.
Perhaps, except the Pleurisy, no Disorder is more immediately relieved by plentiful Bleeding than this; Clysters repeated, one after another, three or four times, if the first or second are either retained too long, or immediately returned, prove very efficacious; these are serviceable, not only as they empty the great Intestines of their Excrements and Flatulencies, which last are very dangerous, but they likewise prove a comfortable Fomentation, by passing through the Colon all around the Abdomen. The Scrotum and Groin must, during the Stay of the Clyster, be bathed with warm Stoops wrung out of a Fomentation; and after the Part has been well fomented, you must attempt to reduce the Rupture; for this Purpose, let your Patient be laid on his Back, so that his Buttocks may be considerably above his Head; the Bowels will then retire towards the Diaphragm, and give way to those which are to be pushed in. If, after endeavouring two or three Minutes, you do not find Success, you may still repeat the Trial: I have sometimes, at the End of a Quarter of an Hour, returned such as I thought desperate, and which did not seem to give way in the least, 'till the Moment they went up; however, this must be practised with Caution, for too much rough handling will be pernicious.
If, notwithstanding these Means, the Patient continues in very great Torture, tho' not so bad as to threaten an immediate Mortification, we must apply some sort of Pultice to the Scrotum; that which I use in this Case is equal Parts of Oil and Vinegar made into a proper Consistence with Oatmeal: After some few Hours, the Fomentation is to be repeated, and the other Directions put in Practice; and if these do not succeed, I am inclined to think it adviseable to prick the Intestine in five or six Places with a Needle, as recommended by Peter Lowe, an old English Writer, who says He has often experienced the good Effects of this Method in the inguinal Hernia when all other Means have failed.
After all, should the Pain and Tenseness of the Part continue, and Hiccoughs and Vomitings of the Excrements succeed, the Operation must take place; for if you wait 'till a languid Pulse, cold Sweats, subsiding of the Tumour, and emphysematous Feel come on, it will be most likely too late, as They are pretty sure Symptoms of a Mortification.
To conceive rightly of the Occurrences in this Operation, it must be remembered, that in every Species of Rupture, a Portion of the Peritonæum generally falls down with whatever makes the Hernia, which from the Circumstance of containing immediately the Contents of the Tumour, is called the Sac of the Hernia. Now, the Portion of the Peritonæum which usually yields to the Impulsion of the descending Viscera, is that which corresponds with the inmost Opening of the Abdominal Muscles, just where the Membrana Cellularis Peritonæi begins to form the Tunica Vaginalis of the Spermatic Cord, so that the Sac with the Viscera insinuate themselves into the Tunica Vaginalis of the Spermatic Cord, and lie upon the Tunica Vaginalis of the Testicle: nevertheless, upon Examination, I have also frequently found the Contents of the Hernia in Contact with the Testicle itself; that is to say, within the Tunica Viginalis of the Testicle; which I confess has surprised me, as one would imagine that it could not have been effected, but by bursting through the Peritonæum. But a late Discovery has offered an easy Solution of this Appearance; which is now established as a Fad, though esteemed a few Years since as incredible. It appears by this Discovery, that for some Months during Gestation, the Testes of the Fætus remain in the Abdomen, and when they descend into the Tunica Vaginalis, there is an immediate Communication betwixt the Cavity of the Abdomen, and the Cavity of the Tunica Vaginalis, which, in process of Time, becomes obliterated by the Coalition of the Tunick, with the Cord, but if it happen before the Coalition be effected, that the Intestine or the Omentum fall into the Scrotum, they will necessarily remain in Contact with the Testis; and in this manner, what we esteemed so extraordinary a phenomenon, is readily accounted for.
From this Description of the Descent of the Viscera, it is evident that the Herniary Sac is contained within the Tunica Vaginalis, and ought to give the Idea of one Bag inclosing another; but in the Operation, this Distinction of Coats does not always appear: for the Herniary Sac sometimes adheres so firmly to the Tunica Vaginalis, that together they make but one thick Coat: this Adhesion may possibly result from the present Inflammation of the Parts, which has rendered the Operation necessary, but I am inclined to believe, that the Herniary Sac adheres in all Bubonoceles which are not very recent, and that, when we restore the Hernia into the Abdomen, and support it by a Truss, it is only the Viscera, and not the Herniary Sac which is reduced; at least I have found this to be the Case in several that I have dissected.
The best way of laying your Patient will be on a Table about three Feet four Inches high, letting his Legs hang down; then properly securing him, you begin your Incision above the Rings of the Muscles, beyond the Extremity of the Tumour, and bring it down about half the Length of the Scrotum, through the Membrana adiposa, which will require very little Trouble to separate from the Tunica Vaginalis, and consequently, will expose the Rupture for the farther Processes of the Operation; but I cannot help once more recommending it as a thing of great Consequence, to begin the external Incision high enough above the Rings, since there is no Danger in that Part of the Wound: and for want of the Room this Incision allows, the most expert Operators are sometimes tedious in making the Dilatation. If a large Vessel is opened by the Incision, it must be taken up before you proceed further.
When the Tunica Vaginalis is laid bare, you must cut carefully through it and the Peritonæum, in order to avoid pricking the intestines; though, to say the Truth, there is not quite so much Danger of this Accident as is represented; for sometimes the Quantity of Water separated in the Sac of the peritonæum raises it from the Intestine, and prevents any such Mischief.
It has been considered by some as an Improvement in the Operation, where the Disorder is recent, to forbear wounding the Peritonæum, and to return the Sac intire into the abdomen, thinking, by this Means, to make a firmer Cicatrix, and more surely to prevent a Relapse for the future; but besides that, it is often impracticable by reason of its Adhesion, the seeming Necessity there is of letting out the Waters that are frequently foetid, of taking away any Part of the Omentum that may possibly be mortified, and which we cannot come at without the Incision, and lastly of leaving an Opening for the Issue of the Excrements out of the Wound, in case an Eschar should drop from the Intestine; (all which Accidents happen sometimes very early) put out of Dispute, in my Opinion, the Impropriety of this Method.
The Peritonæum being cut through, we arrive to its Contents, the Nature of which will determine the next Process: for if it is Intestine only, it must directly be reduced; but if there is any mortified Omentum, it must be cut off; in order to which it is advised to make a Ligature above the Part wounded, to prevent an Hæmorrhage; but it is quite needless, and in some measure pernicious, as it puckers up the Intestine, and disorders its Situation, if made close to it: for my Part I am very jealous that Wounds of the Omentum are dangerous, on which account I cannot pass over this Process of the Operation, without cautioning against cutting any of it away, unless it is certainly gangrened; and when that happens, I think it adviseable to cut off the mortified part with a Pair of Scissars, near to the sound Part, leaving a small Portion of it to separate in the Abdomen; which may be done with as much Safety, as to leave the same Quantity below a Ligature.
When the Omentum is removed, we next dilate the Wound; to do which with Safety, an infinite Number of Instruments have been invented; but in my Opinion, there is none we can use in this Case with so good Management as a Knife; and I have found my Finger in the Operation a much better Defence against pricking the Bowels, than a Director which I intended to employ: the Knife must be a little crooked and blunt at its Extremity, like the End of a Probe. Some Surgeons perhaps may not be steady enough to cut dexterously with a Knife, and may therefore perform the Incision with Probe-scissars, carefully introducing one Blade between the Intestine and Circumference of the Rings, and dilating upwards, and a little obliquely outwards. When the Finger and Knife only are employed, the Manner of doing the Operation will be by pressing the Gut down with the Fore-finger, and carrying the Knife between it and the Muscles, so as to dilate upwards about an Inch, which will be a Wound generally large enough: but if, upon Examination, it shall appear that the Intestine is strangulated within the Abdomen, which may possibly happen from a Contraction of the Peritonæum near the Entrance into the Sac; in that Case, the Incision must be continued through the Length of the contracted Channel, or the Consequence will be fatal, notwithstanding the Intestine be restored into the Scrotum: on this account the Operator should pass his Finger up the Sac into the Abdomen, after the Reduction of the Gut, in order to discover whether it be safely returned into its proper Place.
The Opening being made, the Intestine is gradually to be pushed into the Abdomen, and the Wound to be stitched up; for this Purpose, some advise the quilled, and others the interrupted Suture, to be passed through the Skin and Muscles but as there is not so much Danger of the Bowels falling out when a Dressing and Bandage are applied, and the Patient all the while kept upon his Back, but that it may be prevented by one or two slight Stitches through the Skin only, I think it by all means adviseable to follow this Method, since the Stricture of a Ligature in the tendinous Parts may be dangerous.
Hitherto, in the Description of the Bubonocele, I have supposed the Contents to be loose, or separate in the Sac, but it happens sometimes in an Operation, that we find not only an Adhesion of the Outside of the Peritonæum to the Tunica Vaginalis, and spermatic Vessels, but likewise of some Part of the Intestines to its internal Surface; and in this Case there is so much Confusion that the Operator is often obliged to extirpate the Testicle, in order to dissect away and disintangle the Gut, though if it can be done without Castration it ought: I believe, however, this Accident happens rarely, except in those Ruptures that have been a long time in the Scrotum without returning; in which Case the Difficulty and Hazard of the Operation are so great, that, unless urged by the Symptoms of an inflamed Intestine, I would not have it undertaken. I have known two Instances of Persons so uneasy under the Circumstance of such a Load in their Scrotum, though not otherwise in Pain, as to desire the Operation; but the Event in both proved fatal; which I think should make us cautious how we expose a Life for the Sake of a Convenience only, and teach our Patients to content themselves with a Bag-truss, when in this Condition.
The dressing of the Wound first of all may be with dry Lint, and afterwards as directed in the Introduction.
The Operation of the Bubonocele in Women so nearly resembles that performed on Men, that it requires no particular Description, only in them the Rupture is formed by the lntestine or Omentum falling down through the Passage of the Ligamentum Rotundum into the Groin, or one of the Labia Pudendi; where causing the same Symptoms, as when obstructed in the Scrotum, it is to be returned by the Dilatation of that Passage.