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is almost always much greater than that of women. M. Andral distinctly states that the disease is most common in the male sex.
Of the 228 cases, there were 141 of acute, and 63 of chronic bronchitis; in four, the disease was complicated with pulmonary emphysema, and in the remaining 22 with phthisis.
More than one-half of the cases were cured in from two to nine days, after commencing the use of the inhalation. As might be expected, the cure of the chronic disease was more tardy than that of the acute form: on an average it occupied from sixteen to thirty days or so.
Dr. T. has given the reports of numerous cases, to shew the efficacy of the chlorine inhalation in the various forms of bronchitis.
It seems, however, unnecessary to extract any of them. Suffice it to say, that according to these statements, the remedy seems to be a very potent and useful one in checking the profuse expectoration, and in restoring a healthy action of the bronchi.
In conclusion, it may be stated that Dr. T. has no faith at all in any sort of medicated inhalations in genuine pulmonary phthisis; and in the truth of this opinion we (Rev.) believe that almost all practical men will agree.—Gazette Medicale de Paris.
REMARKS ON, WITH CASE OF, PNEUMO-THORAX.
The following case lately occurred in the practice of M. Chomel, at the Hôtel Dieu.
A man, affected with pulmonary tubercles in a state of softening, was suddenly seized with a violent pleuritic pain or stitch, which caused extreme difficulty in breathing, and considerable febrile action in the whole system.
On examining the chest, it was observed to be altogether fuller and more capacious than it had been, and at the same time to be much more resonant on percussion, while the respiratory murmur had become much more indistinct.
When lecturing upon this case, M. Chomel took occasion to state that, in his opinion, the disease of Pneumo-thorax is never idiopathic,-or, in other words, that air is never secreted from the pleural surfaces-but is always the result of a communication between the air cells of the lungs and the bag of the pleura. Such a communication may take place in one of two ways; either by the ulceration of a vomica outwards, as in the present case, or in consequence of a purulent effusion into the pleural cavity being followed by an ulceration at some point of the lungs.
He stated at the same time that he took the same view of tympanites abdominalis-the effusion of air being, according to him, always the result of an intestinal perforation.
Such a perforation may have taken place either from within outwards, as is occasionally the case in some cases of typhus fever, or from without inwards, as now and then happens in consequence of a purulent collection in the abdominal cavity. An instance of this sort occurred very recently in M. Chomel's clinique in a woman, who died from an immense abscess in the pelvis: ulceration had taken place at one point of the large intestine, and had penetrated through all its coats, except the mucous one.
It is necessary to distinguish the peritoneal tympanites, which we not unfrequently meet with in dissection, when there is certainly no perforation of the intestines, from that alleged or presumed form of the disease, which has been attributed to the secretion of air during life: it is entirely owing to incipient cadaveric decomposition. M. Chomel mentioned a very remarkable instance of this cadaveric tympanites, which he recently met with. A restaurateur in Paris,
who was immensely fat, but seemed to be in very good health, was most unexpectedly found dead in his bed. The body was examined 30 hours after death. The season was Summer. No sooner were the abdominal parietes divided, than a loud explosion, which M. Chomel compares to that produced by the discharge of an air-gun, was heard; so violent was the rush of the confined air from the aperture which had been made into the cavity of the abdomen.
But now to return to our case of pneumo-thorax.
On the following day, after the presumed rupture of the vomica, and the communication between the air-cells of the lungs and the pleural cavity had taken place, the expansion and also the resonance of the thoracic parietes were found to have considerably increased.
In proportion as the pneumo-thorax was more decided, the auscultatory signs became more and more distinct and decisive. At the lower part of the chest a sound, analogous to the amphoric bruit, was perceptible; and more externally a distinct metallic tinkling was to be heard. Over the scapular region a bruit de secousse, such as is caused by striking a drum with the finger, was audible when the patient spoke.
Along with these symptoms, there was extreme anxiety and difficulty of breathing, amounting to orthopnoea, &c. and, as we have mentioned above, the chest was remarkably resonant on percussion.
The treatment which M. Chomel adopts in almost all cases of internal perforation, whether of the thoracic or of the abdominal viscera, consists in the exhibition of opiates, until they produce a decided narcotism of the system. The object is not only to quiet the pain which is almost always present, but also bring on a state of inertia of the whole system, so as to permit Nature to exercise her own medicative and reparatory efforts.
From the results of several cases of presumed intestinal perforation, this treatment certainly seems to be by far the most advisable.-La Lançette Française.
OBSERVATIONS ON THE PERFORATION OF THE INTESTINES BY WORMS.
By DR. MONDIERE OF LOUDUN.
We may premise the following remarks by stating that a perforation of the intestines by worms may take place in two ways-either by the worms lodged within the alimentary canal making a way outwardly into the cavity of the abdomen, or fairly through the abdominal parietes, or, by the bursting of an ́abscès vermineux,' (developed, as such usually are, in the inguinal and umbilical regions) into some part of the canal.
[This distinction is not very perspicuous, the language of the writer being obscure.-Rev.] As the main object of this memoir is to afford proofs of these occurrences, we shall at once proceed to mention a few illustrative cases.
A young girl had been for a length of time troubled with worms, many of which she had passed at different times, not only from the rectum, but also from the mouth. After a violent attack of colic, induced by the exhibition of some vermifuge medicines, a small swelling made its appearance in the left iliac region. At first it was attended with a heavy dull pain; this was afterwards replaced by a most annoying sense of pricking.
The swelling became gradually larger and softer, as well as more prominent; it was opened, and a quantity of pus escaped. But what was our surprise, when we observed a lumbricus worm, five inches and a half long, discharged at the same time! Notwithstanding this, the abscess healed up, and the patient experienced no subsequent inconvenience. It is particularly to be observed, in reference to this case, that in the discharge from the abscess there was not the slightest trace of any intestinal matter in it.
Dr. Mondiere is of opinion that, in such cases, we may fairly suppose that the worm has not made any regular ulcerated perforation in the parietes of the intestine, but has merely separated (ecarté) the fibres of the canal, and that thus no fistula has been occasioned.
Medical men have been much puzzled to explain such an occurrence as the preceding. Thus M. Destrez, who has recorded a case very similar to ours, asks: "Whence are we to suppose that the worm proceeded? It must indeed have been developed in the intestines; but how did it escape, without causing a perforation of their parietes, and, if so, without being attended with the symptoms of intestinal rupture? It may possibly have come from the appendix vermiformis, whence it might escape without such serious consequences.'
That M. Destrez's conjecture respecting the appendix vermiformis cannot be received is manifest from the tumors, of which we are now treating, being observed frequently on the left, and not on the right, side. In the following case, the swelling was in the umbilical region.
A girl had long suffered from attacks of verminous colic; an abscess formed near the umbilicus; along with a copious discharge of purulent matter, a round worm, dead, and between four and five inches in length, escaped from the orifice. The abscess however gradually healed without any unpleasant symptoms.
Dr. Mondiere alludes to a case which occurred many years ago to M. Chailly (and which is recorded in the Nuovo Giornale della piu recente Litteratura Medico-Chirurgica d'Europa, for 1795), of a young child, in whom an abscess formed in the hypogastric region giving exit to a strongylus, and who recovered perfectly.
In the Journal des Progres, for 1834, is related the case of a negro, 11 years of age, in whom after a most severe attack of verminous dysentery, during which a great many lumbrici were evacuated, there formed near the umbilicus an abscess, which gave exit to a dead lumbricus.
Dr. Mondiere here alludes to the occasional, but certainly rare, occurrence of entozoa making their way from the intestines into the urinary bladder, through the parietes of both viscera; and he explains the process or manner in which this is done, by referring to his previous observations respecting the gradual ecartement or separation of the fibres of their different coats effected by the animalcula, without this being necessarily accompanied with an ulcerated perforation.
We do not intend, however, that it should be supposed that an ulcerated opening through the intestines is never occasioned by the escape of worms from their cavity. That such is really the case sometimes is made manifest by numerous instances on record. Take for example the following case.
A girl, 12 years of age, died dropsical and in the last stage of scrofulous disOn dissection, the small intestines were found to be perforated in five or six different places; and hanging from these apertures were observed lumbrici more or less completely protruded. Other worms, of the same description, were found in the abdominal cavity, floating in the serous effusion which was there. The apertures in the intestines corresponded exactly with the size of the lumbrici.
Rem:-Dr. Mondiere seems to think that, in this and in similar cases, the perforation took place after death: if so, we cannot regard it as an example of ulcerated opening.
Dr. M. sums up his observations in the following propositions :
1. Intestinal worms may make to themselves a way through the walls of the bowels and even through the abdominal parietes, by merely separating, and, as it were, splitting the fibres of the intervening tissues, and not, as has been commonly imagined, by gnawing and corroding the parts.
* Journal der Pract. Heilkunde, 1834.
2. The immediate obliteration of the passage, through which the worm has escaped, is to be attributed to the contractility of the intestinal fibres, and to the closure thus effected.
3. Cases of the escape of intestinal worms have been usually noticed in persons, who have been annoyed with vermination, and who may have voided many of those entozoa both upwards and downwards.
4. We are ignorant of the cause which leads these animalcules to move about : in some cases it would seem to be owing to the irritation excited by acrid anthelmintic medicines.
5. The symptoms, which have been noticed to be induced by the escape of worms through the intestinal parietes, are usually a painful pricking or puncturing pain at one fixed part, and then the formation of a phlegmonous swelling over this part; the swelling becomes gradually larger and softer, till at length it breaks or is opened, and the worms are discharged along with the pus.
6. These swellings may form at any part of the abdominal circumference; but most frequently they are observed either in the umbilical or in one of the iliac regions.
7. Cases of this sort generally do quite well; the abscess healing up without any unpleasant symptom, or sign of intestinal lesion. In some cases, the worms, have made their way into the urinary bladder, without causing any extravasation.
Of a much more serious character is the second description of cases, in which intestinal worms make an opening for themselves through the parietes of the bowels. In this, the worms having been congregated and agglomerated together at one point, at length excite inflammatory action in the part; the intestine becomes adherent to the opposed surface of the abdominal parietes; an abscess is formed, and when this bursts, the purulent matter which escapes is blended with worms, and also with the other contents of the bowels. The last named circumstance the admixture of fæculent matter with the discharge-establishes a strong line of demarcation between this and the preceding description of intestinal perforation. The former, we found, was attended with comparatively very little seriousness or danger; the perforation seldom or never giving rise to any alarming symptoms. The latter is necessarily of much greater moment. Extravasation of the intestinal contents into the cavity of the abdomen is indeed of rare occurrence; this calamity being prevented by the adhesion of the intestine to the abdominal parietes; but a dangerous fistula, communicating with the gut, may be established, and may remain open for a great length of time. In many cases however, which may seem alarming at first, the abscess, which has given exit not only to worms but also to fæcal matters, will be found to heal as rapidly as if it had been a simple phlegmon.
Case. A woman, 33 years of age, who had been annoyed with intestinal worms more or less from her infancy, found, after suffering for some time from colicy pains in the right flank, a tumor in her right groin; the swelling increased gradually in size and prominency, and, as it became more soft and pointed, she felt a strange moving or creeping sensation in it. No fluctuation could be detected in it, when Dr. Mondiere first visited this patient. In the course of a few days, however, the apex of the tumor having become gangrenous, a bistoury was plunged into it. A quantity of ordinary pus was discharged. On the following day a dozen of worms (ascaris lumbricoides) issued from the wound; some of these were still alive and moved about freely. During the next three or four days, seventeen more worms were discharged; and along with them some fæculent matter. Notwithstanding this unpromising state of affairs, the abscess healed slowly but kindly, and the patient's health, which had never suffered much, was completely restored.
Case 2. A child, seven years of age, had been subject, for upwards of a twelvemonth, to attacks of sharp abdominal pain about the umbilicus. A phlegmonous swelling made its appearance at length in this region; it gradually became softer and more prominent, and burst. In the purulent matter, which flowed out, was found a dead lumbricus worm. A fistula remained open for a great length of time; and at length upwards of forty living worms were passed presque tout à coup. The fistula continued open, and gave exit to eleven more worms. It had not healed at the date of the report, but had acquired all the characters of stercoral fistula; the attacks of colicy pain had however ceased.*
Case 3. A boy, 14 years of age, after suffering for upwards of a twelvemonth from attacks of violent colic, general decay of health, &c., had a swelling form near to the umbilicus. It was attended with a smart burning and pricking pain; and gradually it became more and more prominent, and at length burst, giving exit to some healthy purulent discharge. On the fifth day after this occurrence, the head of a lumbricus woim was observed projecting from the wound; it was pulled out without difficulty. During the following eight days, other three worms were extracted: after the escape of the last one, a yellowishcoloured and fetid matter, which was regarded as fæcal, flowed out. After the lapse of a considerable space of time, another worm, alive and larger than any of the preceding ones, escaped from the wound. This was the last; and the tumor and discharge now began to diminish very sensibly: at length, the wound healed entirely, and the patient's health was completely re-established.t
M. Mondiere has related several other cases, all illustrative of the formation of these verminous or worm abscesses. He sums up his observations in the following summary.
1. The formation at some point of the abdomen-usually the umbilical or inguinal region—of a tumor which on bursting gives exit to worms, is of occasional, and not very rare, occurrence.
2. These tumors are observed to occur most frequently in those who are and have been much troubled with vermination: hence most cases occur in young persons.
3. It is probable that, in the cases of which we are at present speaking, the worms have congregated at one part of the intestinal canal; that this part becomes distended and then inflamed; that the intestine forms an adhesion to the opposed surface of the abdominal peritoneum; and that ultimately the process of suppuration and of ulceration outwardly is established.
4. The formation of these tumors is always preceded and accompanied by the existence of sharp lancinating or vibratory pains in the part where the tumor forms this symptom is in some degree characteristic of the nature of the tumor.
5. In many cases, the health of the patient has suffered for a great length of time from obscure intestinal disease, before the tumor has become at all developed.
6. After the bursting of the abscess, a genuine intestinal fistula remains : this usually continues open until all the worms are discharged; and then it heals up without further trouble.
7. The ascaris lumbricoides is the worm which in almost every case is discharged. We know however of one or two instances where the worm was a tania.
8. In most cases, there are evident signs that the fistula communicates with the cavity of the intestinal canal. Occasionally, however, it would seem that
Il Filiatre-Sebezio 1837, and Gazette Medicale 1837.