Two Medico-Chirurgical Observations, by Monsieur Le Cat: Communicated in a Letter to Mr. Serjeant Amyand, Dated at Rouen, Feb. 10. 1740. N. S. Translated from the French by T. S. M. D. F. R. S.

Cases of Conception is the Pathognomonic Sign of something preternatural) her Breasts, she concluded her Menstrues were leaving her at their usual Period. But, upon the First of April, being taken with great Pains in her Back, and having other Symptoms antecedent to Delivery, there came away, at short Intervals, a very large Number of Hydatides, of all the intermediate Sizes, from a Nutmeg to a Pin's-head, some filled with clear, others with bloody Lymph; all of them propagated in the manner of a Cluster of Grapes from a spongy Substance, answering the Purposes of a Placenta. After the Discharge of these, in a few Days she recovered her accustomed Health. Upon boiling some of these Hydatides, they appeared like the Ovary of a boiled Hen, with this Difference; in the Hen, the Contents of the Ova concrete; in this Case, not; but the Transparency was changed to the Colour of Bile diluted with Water. XII. Two Medico-Chirurgical Observations, by Monsieur Le Cat: Communicated in a Letter to Mr. Serjeant Amyand, dated at Rouen, Feb. 10. 1740. N.S. Translated from the French by T.S. M.D. F.R.S. 1. An Observation on Hydatides, with Conjectures on their Formation. September 21. 1739. a Woman died in our Hôtel-Dieu, who had an Abscess in the Right Hypochondrium, through which she discharged Hydatides; with with a considerable Tumour at the Left Hypochondrium. Her Body was opened. The Abscess of the Right Hypochondrium was between the common and proper Membrane of the Liver. The Tumour on the Left Side was almost as thick as one's Head, and twice as long. It was between the common and proper Membrane of the Spleen. It ran between the floating Parts of the Abdomen, had displaced them, and went so far as to push against the Integuments of the Belly, in its Passage adhering to the Stomach. I laid this Tumour open, and found it filled with Hydatides of all Sizes, with clear Water, and mucilaginous Membranes, which were the Remains of large Hydatides, that were bursted by the Motions of the Patient. I examined with Care both the Hydatides, and their Bag: The Hydatides were composed of Two mucilaginous transparent, and yet very elastic Membranes. The inward Membrane had on its concave Surface a sort of Villocity wrinkled and mamillated, that pretty much resembled the Surface of a rough Skin, or what is called a Goose's Skin. The softest and most gelatinous of these Membranes were very like the vitreous Humour of the Eye. The Water contained in all these Hydatides was intirely like the aqueous Humour of the Eyes. There were Clusters of these Hydatides quite resembling the Ovary of a Hen, or a Bunch of Grapes, which were made up of Globules of all Sizes. The Bag that contained these Hydatides was pretty smooth on the Side opposite to the Spleen; that is to say, that Part of the Bag formed by the common Membrane of the Spleen, or by the Peritoneum, was pretty smooth; but on the Side next the Spleen, the Bottom of the Bag was very thick, and composed of several Lamelle half destroyed, which fell off in Bits or Scales, and in Slime, at the least Touch. It appeared plainly upon the Inspection of these Remains of the Bottom of the Bag, that that was the Source of the Hydatides; and, upon considering what Sort of Parts are found on the Surface of the Viscera, under their Integuments, it seems evident to me, that these lymphatic Globules were nothing else but the glandulous and lymphatic Grains of the Surface of the Spleen, dilated into Excrescences by the Disease, and puffed up by the Lymph, which the Distemper caused to accumulate therein.—And thus I conceive this Effect to be produced. I have proved in my Physiology, which is actually in the Press, that these glandulous Grains are nothing but the Ends of the Nerves, or nervous Papillae, which receive the Ends of the lymphatic Vessels into their spongy Texture: And I have, among others, instanced in the Papillae of the Tongue, called glandulous Papillae, which are at the same time the Organ of Taste*, and the Receptacle of the salival Lymph. A Part of the Nerves, which are distributed into the Substance of the Liver and Spleen, terminate in the Surface of those Viscera, under the Form of glandulous or pulpous Grains. This same Surface is the Seat of a great Number of lymphatic Vessels: And it is not to be doubted but those glandulous Grains are as necessary for those Lymphatics, as the parotid * See his Traité des Sens, Rouen, 1742. 8vo. Gland is necessary for the Lymph of the salivai Duct, and the glandulous Papillae of the Tongue for the Liquor that distils from them. In Quality of Glands, they are the Receptacle of those Liquors: As nervous Papillae, they furnish the Spirits necessary for the Functions of those Liquors. All these Truths are proved in the Work above-cited. Let us now come to the Consequences of this Structure. As long as the glandulous Papillae are sound, their excretory Pores pour forth the Lymph according as their Cavities receive it from the Lymphatics: But if these Pores happen to be obstructed by a Disease; if the Surface of these Grains is altered by any Erosion; or if the natural Tone of these Solids is perverted; the Lymph brought into these Grains will be retained therein: It will stretch these Globules; their Substance, having lost its Elasticity, will easily give way; the nutritious Juice, which they will not be able to drive farther, will be there assimilated, and will contribute to the Dilatation. In fine, a Vesicle will be formed filled with Lymph, or an Hydatide, such as those we have examined. This Congestion of Lymph, or Hydatides, will not fail to soften, relax, and raise up the Membrane that covers them; and thus a Bag will be formed like that which we found. When an Hydatide swells to a considerable Size, the Volume of the Fluid will become disproportioned to the Force of the Teguments; these will be burst by the Shaking of the contained Fluid, upon the least Motion of the Body. This Fluid will extravasate into the common Bag, upon opening which the Waters and Membranes, which result from that Rupture, will be found. Most Part of the glandulous Grains are distributed into Clusters, as is well known to Anatomists; wherefore Hydatides will also be found disposed in Clusters, like Ovaries. Yet the greatest Number of this Heap will be composed of separate Hydatides; because, when one of these Globules has acquired a certain Bulk, it will generally break the too feeble Pedicle, which held it attached to the Cluster; and thus it will fall into the common Cavity. This kind of Eruption, or general Disengagement from the Surface of the Bowel, must destroy its natural Texture, and reduce it exactly to the State in which we found the Bottom of the Bag of Hydatides, that were the Subject of this Observation. 2. An Observation on the singular Consequences of an incomplete Hernia, and on the Functions of the Intestines exposed to Sight. Catharine Guilmatre, of St. Adrian, near Rouen, aged 50, had a Rupture in the Right Groin, for Seven Years last past. At Easter 1739, there happened a Strangulation in her Rupture; and, having no Assistance, the Tumour suppurred, and opened of itself. The Excrements followed the Pus, and the Patient escaped at the Expence of Vomitings, and a little Fever. The Intestine cicatrized with the Integuments, but there remained externally an Opening, through which the Excrements passed. The Anus ceased to perform its its usual Functions; and, that excepted, the Patient was cured. Towards Whitsuntide, there issued out at the Wound, besides the Excrements, a Gut Three or Four Inches in Length; but this Gut was turned Inside out, that is, the villous Coat was outward, and it conveyed no Excrements; these were always discharged through the Wound, on one Side, and below the Gut that was come out. In the Month of August of the same Year 1739, there came forth at the Wound another Gut, turned as the First, making with it a continuous Canal, but at its End supplying Faeces, which had before been discharged through the Fistula; so that, instead of the Fistula, there was found, as it were, the Trunk of Two Intestines, which made a kind of Fork, as appears in Fig. 1. 2. and 3. Tab. IV. The Woman, tired of this Inconveniency, resolved at length to seek Relief. Fortune presented her with no other than the Hôtel-Dieu of Rouen. She was brought thither in December. I was then in the Country: She was told, that her Distemper was incurable; and yet she was kept there till my Return, to shew her to me by way of Curiosity. In Effect, I found her Case deserved my utmost Attention; and I had her carried to my House, in order to examine it more at Ease, and to have Drawings taken of her Distemper, as may be seen in Fig. 1. 2. and 3. What was curious in this Distemper, was not an Anus formed contrary to Nature in the Groin (that Accident is pretty common); but it was the Two Guts turned Inside out, their villous Coat, and their Functions, Functions, demonstrated to the very Eye; as also the Enigma occasioned by these Two Guts, which were both of one Piece, as appears in Fig. 3. Tab. IV. and which notwithstanding had Two Openings, the lower whereof voided the Excrements, and the upper discharged nothing. I know of no other Person but Mr. Chefelden, who has observed an inverted Gut in a living Body: But my Observation adds to his, 1st, Experiments on the Action of Purgatives: 2dly, The singular Figure of this Hernia, the Discovery of which has an Influence on the radical Cure of this Disease, and on those of the same kind which may possibly happen, as will be seen by the Sequel. I think I may give the Epithet of Singular to this sort of Hernia; because, upon Inspection, one instantly conceives, that the Gut which voided the Excrements was continuous to the Stomach, and the other to the Anus. But how was it possible, that these Two inverted Guts should be of one Piece? Let one imagine a Gut cut through by a Strangulation: There remain Two Orifices, one that runs to the Stomach, the other to the Anus: If the Canal of each of these Orifices turns Inside-out, and prolapses, as it happens, to the Anus; you then have Two Guts prolapsed and turned, but they are distinct one from the other, far from being of one Piece. It must be allowed, that the Enigma is puzzling: And indeed, a good Number of Surgeons saw this Singularity, but not one of them accounted for it. The Reader, if he be an Anatomist, has but to attempt the Solution, in order to be sensible of the Difficulty. The Figures, Tab. IV. annexed to this Transaction, perfectly resemble Life, only somewhat contracted. The villous Coat, and the Functions of these Intestines, being exposed to the Eye, afforded a Circumstance still more curious and useful. These Two Portions of Guts seemed to be Two large living Worms. They move here-and-there, twisting, shortening and lengthening themselves like Reptiles. The lower Gut was much more alive, and sounder. One time that I handled it, it twisted round my Fingers like an Eel. The upper Gut, that answered the Anus, had less Motion, and was beset with Pustules. The Expulsion of the Faeces engaged our particular Regard: We remarked in its Mechanism Two Sorts of Motion. The First is the vermicular Motion, allowed by most Authors. In this, the Gut first swells, and becomes smooth; then grows narrower, running into Wrinkles, and forming Waves the whole Length of the Gut, where these Two Motions happen alternately. The Streightening is performed behind, and upon the Excrements, to drive them down; the Dilatation happens before these Faeces, in order to open them a Passage: For Example: When the Faeces were at the Orifice, through which we saw them issue, this Orifice was spread open. The Second Sort of Motion that we observed in the Guts, generally preceded the one above described. In this Motion the Surface of the Gut, being swelled and smooth, was rendered uneven by many small Impressions [or Hollows] distributed here-and-there, and which seemed to be formed by little local Convulsions, circumscribed by the intestinal Fibres. These convulsive Impressions resembled, in little, those that are made in the Abdomen, upon contracting some one of its Muscles. They made the Surface of the Intestine a little pale, and thereby formed a sort of Undulation on its Surface. It was chiefly in this sort of Motion, that there was squeezed out of the villous Coat of the Intestines, a Mucilage and Serosity, which flowed from it in Abundance. Both these seem to serve for diluting the Faeces, and preparing them an easier Passage. The cold Air did not fail to excite these Motions, and the Woman felt some Touches of the Colic. After having made these Observations on the natural Functions of the Intestines, it occurred to my Thoughts to observe the Effect of Cathartics therein. One does not often see the Inside of the Guts of a living Person in good Health, and freely performing his Functions: Wherefore I was willing to make use of so uncommon an Occasion. First, I put a little Pulp of Cassia on several Places of these Two Portions of Gut. This Medicine made very little Impression on those Parts; they stirred very little, especially the upper Gut. Next, I laid on Manna. This, when somewhat dissolved; formed a sort of Froth, and then the Gut was agitated by vernicular Motions, and by small convulsive Contractions, much more distinct than in the Conditions I had examined it before. I took off the Manna, and strewed Powder of Jalap on the Gut. At first it had no Effect; but, when it was moistened, the Gut was violently agitated, discharged much Serosity, and the Patient complained of Gripings. I removed the Powder, and under it I found a great Quantity of Mucilage, that was already gathered there. I thought it needless to harass this Woman by further Trials, which would prove much the same with the foregoing; and therefore turned my whole Attention on the Means of curing her of this Accident, and thereby rewarding her for the Services she had rendered us. At first Sight of this Disease, I was as far as the other Surgeons from comprehending the Ænigma of the Figure of the Two Ends of the Gut continuous [or of one Piece.] I plainly saw, that they were Portions of the Ileum; but I was obliged to meditate on it a second time, in order to guess at the rest; and yet nothing so easy when a Person has hit it off. The Hernia which this Woman had at first, was one of those named an incomplete Hernia properly so called; that is, a Hernia wherein there was but a Portion of the Side of the Gut pinched within the Ring. This strangulated Portion mortified; the sound Lips cicatrized with the Integuments; the rest of the Canal remained within the Belly; and the Excrements, which this Remainder of the Canal received, issued at its Outlet towards the Groin. The Patient, being recovered, quitted her Bed, and by little and little occasioned the turning Inside out, and Fall of the Portions of the intestinal Canal, situated above and below the open Part. By this Inversion, the remaining Coats of the opened Gut came out likewise. This Part is situated between the Two Portions, one of which answers to the Stomach, and the other to the Anus; and with these Two Portions it makes but one and the same Part, or a continued tinued Plane: Wherefore it was found, out of the Belly, between these Two Portions, and formed, as it were, the Trunk of these Two Branches. The Portion, or Branch, corresponding with the Anus, must have had less Motion, and be less found; because it is deprived of the Share of Life that would come to it from the Continuity of the Fibres that were pinched and carried off by the Strangulation, and that it is continually exposed to the Air. The other Portion is full of Life, because its Continuity with the Stomach makes it enjoy all the Life that this Communication can furnish it with; and that besides it remains within the Abdomen, while the Patient is in a recumbent Posture. In order to give the Pupils of our Hôtel-Dieu a clear Notion of the Formation of this singular Rupture, I made one just like it on a dead Body. For that Purpose I made an Incision in the Abdomen, at the Place of the Rings. I passed into it a Gut, in which I made an Opening. I sewed the Lips of this Opening to those of the Wound of the Belly; and having turned Inside out the Portions of Gut placed above and below this Opening, they afforded us a Bifurcation of Guts continuous and intirely like that of the Observation. A Disease well known is sometimes half cured. This same Portion of Gut that supplied the Faeces, and that was so lively, was drawn back into the Belly, when the Patient lay down, as I have already said; and the other only constantly continued out. This Circumstance made me conceive Hopes of curing this Accident. Thus Thus I reasoned with myself: It is but first making this last Gut enter in, and bringing the Disease to its first State: Then, seeing there is a pretty large Portion of a Canal still remaining between these Two Guts, as appears by the Bigness of the Trunk of the Branches formed by them; what remains to be done, after the Whole is reduced, is to close the exterior Orifice of this demolished Canal; that is, to close the Opening made by the Strangulation and Mortification; and I conceive, that this last Operation is very feasible. The next thing to be done is to refresh the Lips of the Fistula formed by the Integuments of the Abdomen, which are thick enough, and on which shall be afterwards made a Gastroraphia proportionate to these Parts. The great Difficulty is, to reduce this End of Gut, which is grown hard, and full of Tubercles. I have already made a fruitless Attempt, both with Cata-plasms to repair the Damages, and with manual Operations proper for making it re-enter. I am actually watching a favourable Moment for this Operation. If I succeed, I intend to stay for making a second Operation, till this Gut has remained long enough in the Belly to repair itself, and resume its Functions. In order to that, I shall content myself for the first Eight Days, with keeping it in the Belly, applying resolving Fomentations, and giving proper Clysters. Then will I put into the Opening of the intestinal Canal, that answers to the Fistula, a silver Canula of the same Bore with the Gut; in order to push this Portion of a Canal into the Belly, to support it therein, and re-establish its Communication with the Portion newly reduced. This silver Canula will be fixed fixed by a Plate of the same Metal, guarded with Plaster and Linen, and placed on the Fistula, where it shall be secured in its Situation by a Bandage. I shall then redouble the Use of the Clysters, and when I shall be ascertained of the Re-establishment of the Communication of the Two Guts, and the Functions of the Portion continuous to the Anus; then I will withdraw my silver Canula, and will perform the Operation, as I have said above. EXPLANATION of TAB. IV. Fig. 1. The Woman with the Hernia in Situ. Fig. 2. The Hernia represented at about half its natural Size. A. The lower Part of the Intestine communicating with the Stomach, and emitting the Excrements. B. The upper Part of the Intestine, which is continued down to the Anus, and emits only Mucus, and serous Humours. Fig. 3. The upper Part of the Intestine raised up, that the Connexion of these Two Parts of the Intestines may the better appear.