SECT. I.

IN performing the operation for what is called a Strangulated Rupture, the portion of in⯑teſtine, or omentum, which had paſſed out from the abdomen, has ſometimes been found in the ſame cavity, and in contact with the naked teſticle.

THIS is a caſe which has been men⯑tioned by one or two late writers, who have ſuppoſed it to be produced by a [2]breach, or laceration, of that production of the peritoneum, which formed the hernial ſac, and contained the portion of inteſtine, or omentum, when firſt it paſſed out from the belly.

IN order to underſtand rightly the kind of rupture, which makes the ſub⯑ject of my preſent inquiry, it may be neceſſary to premiſe a general deſcrip⯑tion of the more frequent ſpecies of in⯑teſtinal and omental rupture, and to ſhew wherein conſiſts the eſſential dif⯑ference between theſe and that.

THE portion of inteſtine or omen⯑tum, which by being thruſt forth from the cavity of the belly, forms a common rupture, is contained in a firm, ſtrong, membranous pouch or bag, called the hernial ſac: this ſac is formed by a production of the peritoneum, puſhed out by the inteſtine, &c. through the opening in the tendon of the obliquus deſcendens muſcle of the abdomen, paſ⯑ſing [3]in ſome no lower than the groin, in others into the lower part of the ſcrotum.

THE peritoneum, of which this ſac is formed, is extremely dilatable, as preg⯑nancy, dropſy, and many diſeaſes prove; and inſtead of ſeeming thereby in dan⯑ger of burſting, is frequently found to become thicker and ſtronger in propor⯑tion to its diſtention.

IN this ſac are contained a portion of inteſtine, or omentum, (or both) and a ſmall quantity of a fluid; the ſpermatic veſſels paſs down behind it, and its cavity is perfectly diſtinct from, and has no communication with, that ſacculus in which the teſticle is generally included.

THIS is a ſuccinct account of a com⯑mon inteſtinal or omental rupture; but in that which makes my preſent ſubject, the inteſtine or omentum, or both, are found in the ſame bag, and in contact with the naked teſticle.

THEY who ſuppoſe this to be pro⯑duced by a breach, or laceration of the peritoneum, ſuppoſe alſo that the inteſ⯑tine, &c. paſſed out from the abdomen in a hernial ſac, ſormed in the uſual manner; that this ſac originally com⯑poſed a cavity perfectly diſtinct from that in which the teſticle was included (cal⯑led tunica vaginalis teſtis); but that by ſome means this ſac ſuffers a breach or laceration, that the membrane which divides the tunica vaginalis teſtis, from the tunica vaginalis of the chord, is broke through alſo, and that by this means the inteſtine and teſticle are brought into contact with each other in the ſame common cavity.

BY this means the ancient doctrine of a hernia cauſed by breach or rupture of the peritoneum, is revived, though the diſſection of the parts has always proved it to be untrue; the peritoneum forming a hernial ſac, whatever ſize it may be [5]diſtended to, being always found entire, unleſs it has been wounded, or is mor⯑tified.

RUPTURES attended with that parti⯑cular circumſtance which brings them under the deſcription mentioned in the Title, are ſaid to be very rare; but, from what I have obſerved, both in the living, and in the dead, I am inclined to be⯑lieve that they happen much oftner to adults, than they are ſuſpected to do.

WHEN I publiſhed my General Trea⯑tiſe on Ruptures, I had not enough con⯑ſidered this particular kind, to be able to ſay any thing poſitive concerning it; I thought the breach of the peritoneum highly improbable, and from what I had ſeen of the caſe, was ſure that it muſt be owing to ſome other cauſe; but, as I was not perfectly ſatisfied what that was, I did not chuſe to aſſert any thing about it, and ſpoke of it as a thing not frequent, and produced by accident.

SINCE that time I have ſought for, and found many opportunities of inqui⯑ring into this matter, and of verifying what was then only probable conjecture? I have with great care examined a va⯑riety of ſubjects, and flatter myſelf that I have traced the diſeaſe to its true cauſe. The anatomy of the parts appeared to me as I ſhall repreſent it in the follow⯑ing pages, and all the deductions, and inferences which I ſhall make from them, are ſuch as appear to me to be na⯑tural, and true, and ſuch as place the origin of this kind of rupture in a clear light.

SECT. II.

THE diſeaſe of which I am about to ſpeak, though ſometimes met with in adults, is moſt certainly firſt produced in early infancy; and, as I ap⯑prehend it to ariſe from the natural ſtructure and diſpoſition of ſome parts of the child while it is yét unborn, I ſhall begin with a ſhort account of theſe parts during the reſidence of the foetus in the uterus.

THE parts which I mean, are, the ſpermatic veſſels, the teſticles, and epi⯑didymis, a part of the peritoneum, the aperture in the abdominal muſcle, and the ſcrotum.

BY diligently obſerving the ſtructure, diſpoſition, and connexion of theſe in ſo early a ſtate as that of a foetus of five or ſix months; and by following them in their growth and progreſs, to that of [8]an infant; ſuch information may (I think) be obtained, as will fully and clearly illuſtrate the preſent matter.

THE teſticles of all children are ori⯑ginally formed and lodged in the cavity of the belly; they remain there till the child is born, or till very near that time; and paſs out from thence, each through an opening which leads into the groin; here they generally remain ſome little time; more or leſs in diffe⯑rent ſubjects, and at laſt deſcend into the ſcrotum, where they are ſuſpended partly by their own veſſels, and partly by the general attachment and connexion of the membranes, &c. which include them. The diſpoſition of the teſticle, and of its appendix the epididymis, while they remain in the abdomen of a foetus, their connexion with each other, and with other parts, their progreſs toward the opening by which they paſs out, their determination to that opening, and the ſtructure and diſpoſition of the parts [9]appointed for their reception both imme⯑diate, and future, are circumſtances, which, if properly attended to, will lead us not only into a knowledge of the parts themſelves, but of other matters of no ſmall conſequence in the animal oeconomy.

WHEN I ſay that the teſticles are lodged in the cavity of the abdomen, I muſt deſire not to be miſunderſtood, as if I meant to ſay that they were within the peritoneum; they certainly are not, but are within the cavity of the belly, in the ſame manner as the inteſtines, and ſome other parts are, which, ſtrictly ſpeaking, are behind the peritoneum; but they are ſo looſe, and ſo dependent from a kind of ſtalk, formed by the in⯑ſertion of the ſpermatic veſſels into them, and project ſo much into the cavity of the abdomen, as to ſeem within it—and in one ſenſe are ſo.

THEIR ſituation is not ſo very preciſe, as not to vary a little ſometimes; but [10]the moſt frequent is ſome way below the kidney, pretty near parallel to the upper part of the urinary bladder as it is upheld by the urachus, &c. and reſt⯑ing upon the pſoas muſcle. The ſper⯑matic veſſels lie behind the peritoneum enveloped in the membrana cellularis, and the body of the teſticle projecting into the abdomen is looſe and move⯑able from that pedicle formed by the inſertion of the ſpermatic veſſels into it; it is of an oblong figure, and its greateſt length is upward and down⯑ward: The epididymis lies ſtretched out behind the teſticle, in the ſame di⯑rection—that is upward and downward.

THE inferior part of each epididymis is extended downwards, and inſinuates itſelf into a ſmall orifice toward the lower part of the belly, almoſt oppoſite to the aperture in the tendon of the abdominal muſcle.

IF the teſticle be held aſide, and the epididymis be moderately ſtretched, this [11]orifice will become very viſible, and the extremity of the epididymis will be ſeen entering into it.

BY this orifice I have ſeveral times, without force or breach, paſſed a very ſmall probe into the groin; the probe always paſſed through the aperture in the tendon of the abdominal muſcle, and upon dividing the ſkin, ſeemed to be co⯑vered by, or enveloped in, a ſmall mem⯑branous pouch, or ſacculus, made by a protruſion of the peritoneum.

IN ſome I have traced this little ſaccu⯑lus through the opening in the muſcle, (which it always paſſed) into the upper part of the groin, and always found it to be a continuation of that part of the peritoneum which lines the muſcles of the abdomen.

THAT extremity of the epididymis, which paſſes into the mouth of this little ſacculus is attached, or adherent [12]to the inſide of it, in ſuch maner, that though the teſticle is ſo looſe at the inſer⯑tion of the ſpermatic veſſels as to permit very free motion from ſide to ſide, yet if either it, or the ſpermatic veſſels, be pul⯑led ſtrait upward, toward the kidney, this adheſion will be found to detain it from going higher, unleſs the epididymis breaks, which a ſmall degree of force will effect, it being very tender.

WHILE the teſticles continue in the abdomen they are always naked, that is, they are not enveloped in that looſe bag in which they are conſtantly found when in the ſcrotum, called tunica vagi⯑nalis teſtis.

AS the foetus increaſes in ſize and advances towards maturity, the teſti⯑cles proceed lower down, and approach nearer to the openings in the abdominal muſcle; and if they have not paſſed out juſt before the birth (which is ſometimes the caſe) the diſtention of the lungs and [13]thorax by the air, and the action of the muſcles of reſpiration, ſoon puſh them forth from the belly, through the muſcle, into the groin.

THE ſafe and certain paſſage of the teſticles from the abdomen into the ſcrotum, is a circumſtance of great con⯑ſequence; and, like every other part of the animal oeconomy, is provided for, and executed with ſuch order and beauty, as to beſpeak its great director.

I HAVE already taken notice, that on each ſide, of the lower part, of the in⯑ſide of the cavity of the belly, was a ſmall opening; that in many ſubjects I could, without force or breach, paſs a ſmall probe, by means of this orifice, through the aperture in the tendon of the abdominal muſcle; and that the probe, when thus paſſed, appeared to be enveloped in a very ſmall membranous ſacculus, formed by a production of the peritoneum.

BY this means a proper and convenient receptacle for the teſticle is provided, and kept ready for it in due time.

IN moſt of the foetus's which I have examined, it has appeared to me that theſe little ſacculi were parts originally formed; but whether it is conſtantly and invariably ſo, I will not pretend to ſay: Nor indeed is it of much conſe⯑quence to my preſent purpoſe, whether they are conſtantly ſo, or not; for the event will be exactly the ſame, whether ſacculi are formed by a production of the peritoneum paſſing through the tendinous aperture in the abdominal muſcle, and placed ready to receive the teſticle when it ſhall be puſhed through; or whether this tendinous opening is looſely covered by a membrane, ſo very dilatable, as to give way to any impulſe, and paſs out before the body which is puſhed againſt it.

IN either caſe the teſticle, as ſoon as it has paſſed the opening in the muſcle, will be found inveloped in a ſacculus, formed by a production of the perito⯑neum, the upper part of which ſacculus paſſes through the muſcle, and commu⯑nicates with the cavity of the abdomen by an orifice, patent, and viſible.

THIS the mere examination of the foe⯑tus makes to appear highly probable; but its truth is, I think, proved incon⯑teſtably (at leaſt with regard to the effect) by the following facts.

• 1. THAT the Teſticles of almoſt all Children, though originally formed and lodged within the belly, yet ſooner or later after their birth, are found either in the groin, or in the ſcrotum; that is, they are found on the outſide of the abdominal muſcle.
• 2. THAT the ſcrotum has no com⯑munication with the cavity of the abdomen, but through the mouths or entrances of the membranous ſacculi in which the teſticles are included.
• 3. THAT when the teſticles are got into the groin, or ſcrotum, by hav⯑ing paſſed through the aperture in the tendon of the abdominal muſ⯑cle, they are always found envelop⯑ed in a looſe membranous bag, in which they were not contained while they were within the belly.
• 4. THAT the entrances from the ab⯑domen into theſe ſacculi containing the teſticles, are generally to be ſeen open in a new born child. And,
• 5. THAT by laying theſe ſacculi open, the teſticles are found within them [17]naked;—that is, they are found in the ſame ſtate with regard to co⯑vering as they were in, while with⯑in the cavity of the belly.

THIS is the ſtate of the teſticle when it is got into the ſcrotum, the place ap⯑pointed for its reſidence; and, leſt it ſhould deviate from the right path, and by not paſſing through the aperture in the muſcle, be detained within the ca⯑vity of the belly, that portion of the epi⯑didymis which precedes it in its paſſage toward the abdominal opening, inſinuates itſelf into the orifice which leads to the ſacculus appointed for its reception; by this means determining the paſſage of the teſticle, and preventing its deviationThis muſt be underſtood as a deſcription of the ap⯑pearance theſe parts make at firſt view: for both the epididymis and teſticle are truly behind the peritoneum..

IT is true, that in this, as well as every other part of the animal frame, the general laws of nature are ſometimes interrupted by accident, and mal-for⯑mations [18]are produced; but, in general, this is the proceſs, and this the appear⯑ance.

THE bag, which contains the teſticle when in the groin, is looſe and large, compared to the ſize of the teſtis; it is of a globular figure, is covered on its out⯑ſide by a cellular ſubſtance, and commu⯑nicates with the cavity of the belly by paſſing through the oblique muſcle.

IF the teſticles remain any time in the groin, (a thing not very unfrequent) the communication between the ſacculi and the belly continues open all that time, at leaſt I have always found it ſo in all thoſe whom I have examined.

WHEN the teſticles are got below the groin into the ſcrotum, the ſacculi which contain them aſſume a pyriform kind of figure, having their largeſt end loweſt; they are connected with the membranes of the ſcrotum by means of the common [19]cellular ſtructure, but ſo very looſely in young ſubjects as to be ſeparable with the utmoſt eaſe.

THEY ſtill for ſome little time con⯑tinue to communicate with the cavity of the belly, by a large orifice capable in a mature foetus, or in a child newly born, of admitting a common crow-quill. This the eye-ſight, the paſſage of a probe, or the deſcent of a fluid poured upon the mouth of the opening, will prove to the ſatisfaction of any inquirer; and if the ſac⯑culus be now laid open, either from its bottom upward into the belly, or from its orifice within the belly downward, the moſt clear and convincing proof will ap⯑pear, that the membrane which conſti⯑tutes the inſide of it is a production of, or a continuation from, that part of the peritoneum which lines the abdominal muſcles, and covers the ſpermatic veſſels, &c. &c If this is doubted by any who have no immediate opportunity of examining it, I can ſhew it to them in more than one ſubject, which I keep by me..

UPON this diviſion of the facculus it will alſo appear, that the teſticle and epi⯑didymis within it have no other cover⯑ing than what they brought out from the abdomen, and that notwithſtanding they are protruded into, and apparently contained within the ſacculus, yet they ſtill are (as they were originally) behind the peritoneum.

WHETHER it be by the weight of the teſticle now become pendulous from the ſpermatic chord, or from the action of the abdominal muſcles, or from what other cauſe, I know not; but ſoon after the teſticles are got fairly into the ſcro⯑tum, the orifices and paſſages to theſe ſacculi are cloſed, and obliterated in ſuch manner, that neither a probe, nor a fluid will now paſs from the belly into them, nor from them into the belly.

THE paſſage of communication be⯑comes cloſe ſome way above the epidi⯑dymis, [21]and the bag by this means forms a cavity much larger than the teſticle, which is looſely included in it, and kept moiſt by a fine lymph conſtantly found there.

THE time at which this communica⯑tion is ſtopt, by the paſſage being ſhut, is uncertain and various; for though it moſt frequently happens ſoon after the teſticles are got into the ſcrotum, yet it is not conſtantly ſo; I have ſeen them open at four years old; and in an adult; and others have ſeen them open at a time between theſe: but whenever they do cloſe, they form thoſe bags which are then called the tunica vaginales teſ⯑tium, from or to whoſe cavity there is no longer any paſſage.

THUS it plainly appears, that what in the foetus was the little ſacculus for the reception of the teſticle, and what was the looſe bag which contained it while it ſtaid in the groin, (during all which [22]time there was a free communication with the cavity of the belly) does, by the cloſing and obliteration of that com⯑munication, become the tunica vagina⯑lis teſtis, and conſequently that the tu⯑nica vaginalis teſtis is a production of the peritoneum; and that the cellular membrane which envelopes the ſpermatic veſſels behind the peritoneum, by being gradually ſtretched and lengthened as the child grows, becomes the tunica va⯑ginalis of the chord.

SUCH is the ſtate and progreſs of theſe parts from the foetus to the next ſtage beyond early infancy; after which they undergo little or no alteration, which has any connexion with my preſent ſubject: but from their ſtate in a foetus, from the alteration they undergo, and the progreſs they make, from conception to infancy, the diſeaſe contained in the Title may, I think, be clearly and ſatisfactorily ac⯑counted for.

SECT. III.

THE diſeaſe in queſtion is that kind of rupture, in which the portion of inteſtine or omentum which has paſ⯑ſed out from the belly, is found in the ſame bag, and in contact with the naked teſticle; in contradiſtinction from the more frequent ſpecies of inteſtinal or omental rupture, in which the parts fallen from the belly are contained in what is called a hernial ſac, whoſe cavity is per⯑fectly diſtinct from, and has no commu⯑nication with, that in which the teſticle is included called tunica vaginalis teſtis.

I TOOK notice at the beginning of this Tract, that an attempt had been made to account for this, by ſuppoſing that the peritoneum ſuffers a breach, or is torn.

THEY who ſuppoſe this to be the caſe, do alſo ſuppoſe that the portion of in⯑teſtine or omentum paſſed out from the belly at firſt in a common hernial ſac in the uſual manner; but that by time, or accident, a breach is made in the pe⯑ritoneum forming that fac, and thus theſe parts are brought into contact with the naked teſticle; which, moſt certainly is not the caſe: it is an origi⯑nal diſeaſe, unaltered by time or acci⯑dent; and, though ſometimes met with in the adult, is always firſt produced in early infancy.

THE ſacculus which receives the teſticle when it has paſſed the aperture in the abdominal muſcle, is open to the cavity of the belly; and the ſame, cauſes, and the ſame force which puſh the teſticle into it, do alſo ſometimes thruſt in a portion of inteſtine or omen⯑tum.

IN a natural ſtate, and according to the moſt uſual courſe, the openings or mouths of theſe ſacculi become cloſe, and the paſſages obliterated, ſoon after the teſticles get into the ſcrotum; the tunica vaginalis teſtis is thus formed, and all communication with the belly pre⯑vented; but if a piece of gut or caul has ſlipped in with, or juſt after the teſ⯑ticle, the opening cannot cloſe; the tuni⯑ca vaginalis teſtis cannot be properly formed, but the inteſtine, teſticle and omentum muſt be all together, in imme⯑diate contact with each other within this ſacculus, whoſe mouth muſt ſtill remain open to the abdomen.

AND, as I have already taken notice, that the mouths of theſe ſacculi always remain open while the teſticle continues in the groin, a much longer time is by this means furniſhed in many ſubjects for this accident to happen in; not to mention again, that in ſome children [26]they do not cloſe till the teſticles have been a great while in the ſcrotum, and that they have been found open in adults.

WHOEVER has a clear idea of the ſtate of theſe parts, muſt ſee, that what⯑ever paſſes into theſe ſacculi while they remain open, let the ſubject's age be what it may, muſt be in the ſame ca⯑vity, and in contact with the naked teſticle; and though the paſſage from the belly will become cloſe and be obli⯑terated, if the parts which have fallen into it are returned back, and kept up by proper bandage; yet if they are not re⯑turned into the belly, or not kept there when returned, the paſſage can never cloſe, and the hernia muſt for ever re⯑main; and, while it does remain, will neceſſarily be of the kind mentioned in the Title.

FOR though this is a diſeaſe produced by ſuch a ſtate of parts as is peculiar to [27]an infant, and which a ſmall ſpace of time makes ſuch an alteration in, as to prevent its happening after that ſtate of infancy, yet if it is not taken proper care of when it has happened, it will moſt probably continue during the life of the patient; and that therefore it muſt ſometimes be found in adults.—A caſe, which I am convinced, happens much oftner than is ſuſpected.

THE more I have thought of this matter, the more I am convinced of the truth of what I have ſaid in the pre⯑ceding pages; even accidents and mal⯑formations, which prevent the uſual and regular proceſs, contribute to elucidate the ſubject; and though they are devia⯑tions from the natural courſe, yet help to inform us what that would be, if it had not been prevented. A truth, which will appear in two of the following caſes.

SECT. IV.

J. GOODCHILD, a man who had been ruptured from his infancy, was brought into St. Bartholomew's Hoſpital labouring under ſuch ſymptoms from ſtricture, as to render the opera⯑tion immediately neceſſary, but to leave little room to expect that it would be ſucceſsful.

THE operation was performed in the uſual manner, but upon returning the inteſtine into the abdomen, I found that the teſticle was naked, and that the gut had been in contact with it.

THE man died the next day, and the parts were in ſo gangrenous a ſtate as not to permit any ſatisfactory examina⯑tion of them; all that could be learnt was, that the inteſtine had been in the ſame cavity with the teſticle, and that [29]the ſac containing them was open to the abdomen; this was all that appear⯑ed in this ſubject, which, though it did not give me much ſatisfaction in preſent, determined me to examine more cloſely ſuch caſes in future.

March 23, 1756. WILLIAM PEARCE, a healthy ſtout man, twenty-five years old, was brought into St. Bartholomew's Hoſpital, complaining of a painful ſwel⯑ling in his right groin, a ſlight degree of nauſea, and an incapacity of diſcharging any thing by ſtool.

THESE complaints had ſubſiſted three days, when he was taken into the houſe.

IN the groin on the right ſide was a ſwelling, about the ſize of a middling le⯑mon, of an oblong figure; its greateſt length being tranſverſe or ſtretching from the pubis to the ilium, the tumor ſeemed pretty full, was conſtantly painful in ſome degree, but much more ſo upon being handled.

THE ſcrotum on this ſide was defi⯑cient from his birth, and neither teſticle nor ſpermatic proceſs could be diſtin⯑guiſhed.

THE man being aſked, ſaid, that he had had more or leſs of this ſwelling ever ſince he could remember; that he had never been ſenſible of any teſticle on that ſide, and that he had formerly wore a bandage, but could not endure the pain it gave him.

THE ſymptoms being ſuch as indicated a ſtricture on ſome part of the inteſtinal canal, I endeavoured to return the con⯑tents of the ſwelling into the belly, but could not ſucceed.

As his pain was not very great, ex⯑cept when the part was handled; as he had but little fever, and neither vomit⯑ing nor hiccup, I ordered him to be largely bled, to have a purging glyſter, [31]to cover the tumor with a ſoft pultice, and to keep in bed.

THE next day the ſwelling ſeemed rather abated, and leſs tenſe; his ſickneſs continued, but without any vomiting; he was perfectly eaſy in his belly, but had diſcharged nothing by ſtool.

I TRIED again to return the parts, but ineffectually; and, as the handling them was exceſſively painful to him, I ordered him to be again bled, to repeat his glyſter and pultice, and to take frequently two or three ſpoonfuls of a purging mixture, but ſtill could obtain no ſtool; and, on the third day, his pain being much in⯑creaſed, with the addition of hiccup and vomiting, I endeavoured to relieve him by the operation.

I BEGAN the inciſion in the uſual place, and continued it as low as the tumor reached.

UPON the diviſion of the ſkin and membrana adipoſa, a firm membranous bag or ſacculus came into view; this I took to be the hernial ſac; but, upon laying it open, I found that it contained a quantity of bloody ſerum, a piece of omentum, a portion of inteſtine, and the teſticle.

THE teſticle and its epididymis were both naked; that is, they were not en⯑veloped in a tunica vaginalis, and the bag which contained all theſe parts was open at its upper part into the cavity of the abdomen by a narrow neck, which neck paſſed through the aperture in the obliquns deſcendens muſcle, by the tendon of which that ſtricture was made on the inteſtine which produced the ſymptoms.

IN this caſe neither the inteſtine nor the teſticle were got below the groin, there being no ſcrotum on that ſide; but [33]the ſac which contained the teſticle, inteſtine and omentum, was plainly that ſacculus which was originally de⯑ſigned to become the tunica vaginalis teſtis; its communication with the belly, the ſtate of the teſticle and epididymis, and the date of the rupture, all prove this: The diſeaſe was from early infancy, the teſticle and epididymis had no co⯑vering but their proper and immediate coat; the ſacculus communicated with the cavity of the belly, and the teſticle was connected with its internal and lower part.

As the ſcrotum was deficient on that ſide, the teſticle could never deſcend ſo as to become pendulous, and thereby give the tunica vaginalis an opportunity of becoming cloſe at its upper part; and a piece of inteſtine having paſſed in, was another reaſon why the orifice could not contract itſelf; the teſticle always re⯑maining juſt on this ſide the abdominal muſcle, in the groin, was the reaſon [34]why he never could keep the inteſtine within the belly by a truſs, the pad or bolſter of which muſt preſs on the teſtis in ſuch manner as to give great pain.

IN July laſt, J. Leak, a man about thirty-five, was brought into St. Bartho⯑lomew's Hoſpital, with all the ſymp⯑toms and all the appearances of a ſtran⯑gulated inteſtine.

THE gentleman under whoſe care he had been, had uſed all proper means to relieve him, and had endeavoured to re⯑turn the parts, but without ſucceſs; and there was nothing left for me to do, but to perform the operation, which I did immediately. The ſwelling, which was confined to the groin, was more oblong than uſual, ſtretching from the pubis to the ilium, and had that inequality to the touch as implied a pretty large portion of omentum to be contained in it.

UPON making the inciſion, I obſerved that the hernial ſac was not enveloped by any tunica vaginalis, but that it lay immediately under the adipoſe mem⯑brane, and had none of thoſe fine tendi⯑nous bands or expanſions on its outſide, which are generally ſeen on the outſide of a common hernial ſac.

THE ſac being laid open, the ſtricture divided, and the parts (which were a large portion of omentum, and a ſmall one of inteſtine) returned, the teſticle was found juſt within the aperture in the tendon of the abdominal muſcle, in the cavity of the belly; it was naked, and a portion of the epididymis was adherent to the upper part of the neck of that ſac, which had contained the gut and caul juſt at its paſſage through the tendon; the ſpermatic chord was ſo ſhort, as not to permit the deſcent of the teſticle any lower.

IN this caſe, the teſticle not being ca⯑pable of paſſing through the aperture in the muſcle, the omentum and inteſtine were puſhed out in its ſtead, and had di⯑lated that ſacculus (which, if the teſticle had taken its natural courſe, would have formed its tunica vaginalis) into a hernial ſac, of ſize capable of containing a large portion of caul, and ſome inteſtine. This alſo was a rupture from early infancy, but the patient, not knowing what it was, had neglected it.

SOON after this I had an opportunity of looking into the body of a youth about fif⯑teen years old, who died of another diſeaſe; but had been ruptured from his birth.

IN a ſacculus, which paſſed through the opening in the abdominal muſcle, were contained a large portion of the in⯑teſtine ilium, and a ſmall piece of the co⯑lon, in contact with the naked teſticle; the teſticle had no other covering than [37]its proper tunica albuginea, and the epidi⯑dymis was united with the poſterior part of the ſac: The ſac lay immediately under the membrana adipoſa, and had no covering from the tunica vaginalis of the chord.

THIS is preciſely that caſe, which is ſuppoſed to be occaſioned by the breach both of the peritoneum, and of the ſep⯑tum between the two tunicae vaginales; but which, I flatter myſelf, that I have proved in the foregoing pages, to be pro⯑duced in another manner: certain I am, that the anatomy of the parts, both na⯑tural and diſeaſed, give no countenance or ſupport to the former opinion; and, if I am not hindered by prejudice and partiality from judging properly, the lat⯑ter appears to me to have all the ſupport from it which it can give.

BY conſidering what has been ſaid it will appear, that in this particular kind of hernia the bag containing the parts which have paſſed out from the abdo⯑men, [38]although it be really a production of the peritoneum, and paſſes through the tendon of the oblique muſcle, yet is not what is commonly meant by the term a hernial ſac; but is that ſacculus, which, if the inteſtine had not been puſhed into it, would, by cloſing at its upper part, have become the tunica va⯑ginalis teſtis.

THAT this ſacculus cannot be includ⯑ed in the tunica vaginalis of the chord, no more than the ſac of the moſt frequent ſpecies of hydrocele is, it being the ſame bag in one caſe as in the other, with this difference only, that in the latter it is cloſe at top, and does not communicate with the belly; in the former it is open, and does communicate.

THAT the tunica vaginalis teſtis be⯑ing open at its upper part to the cavity of the belly, the teſticle cannot be enve⯑loped in it in the uſual manner, but muſt [39]be found naked in the ſame common ca⯑vity with the inteſtine.

WHEREAS in the common hernia, the tunica vaginalis of the chord envelopes the ſac, the ſpermatic veſſels lie behind it, and the teſticle is included in a diſtinct cavity formed by the tunica vaginalis teſtis.

THE former caſe happens while the paſſage for the teſticle is open, and con⯑ſequently there can be no hernial ſac in the uſual ſenſe of the term, but the tu⯑nica vaginalis teſtis is thus converted into one.

THE latter (or common hernia) hap⯑pening after this paſſage is obliterated, another portion of the peritoneum is thruſt before the inteſtine, &c. through the tendon of the muſcle into the groin or ſcrotum, thus conſtituting a hernial ſac; which ſac forms a cavity perfectly diſtinct from that of the tunica vagina⯑lis teſtis, lies anterior to the ſpermatic [40]chord, and is inveloped in the tunica va⯑ginalis thereof.

BY conſidering the ſtate of theſe parts in an infant, it will alſo appear, how ne⯑ceſſary it is to be ſure of the ſituation of the teſticle before the pad of a truſs is applied to reſtrain a rupture; ſince if the teſticle is ſtill in the groin, it muſt not only be bruiſed and hurt by the preſſure, but will alſo be prevented from deſcend⯑ing; whereas if it be got below the groin, the bandage will not only keep up the in⯑teſtine, but contribute alſo to the cloſing of the tunica vaginalis teſtis; the ſame ap⯑plication thus becoming a cure in one caſe, and adding to the diſeaſe in the other.

HENCE alſo the ſudden appearance, and ſometimes as ſudden diſſipation of tumors, either flatulent or watery, which are frequently ſeen about the ſpermatic chord, ſcrotum and teſticles of young in⯑fants, may be accounted for.

AND hence alſo may be ſeen the reaſon, why by far the greater number of children, who are ruptured in their early infancy, are males.