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rus, just as the dashing of cold water on the 1face, or on the general surface, induced sobbinginspirations. The same principle wouldguide us in the treatment of syncope and as-phyxia. The surface to which the douchewas applied should be first warmed; theimpression of the cold might then be se-

cured.Mr. PROCTER believed that the applica-

tion of cold in connection with uterine actionwas highly important. The douche appliedfrom a distance produced remarkable effects;he had introduced his hand into the uteruson some occasions, but he regarded this modeof proceeding as of questionable utility ; hepreferred pressure with the hands upon theabdomen. In one case the uterus contractedwell after delivery, but a few hours subse-quently it was found that this organ had beenrelaxed, and was distended with blood;pressure with the hands upon the abdomenin this case was useful. He recommendedpressure, together with the application ofcold from a distance, in cases of non-contrac-tion of the uterus after delivery.Mr. HEADLAND obiected to Mr. Pilcher’s

views regarding locomotion ; if so manyphenomena were to be referred to the spinalmarrow, of what use was the brain? and this

organ in man evidently performed an import-ant part, judging from its size. The actionof the uterus was occasionally induced bymental impressions ; when fright producedmiscarriage, the expulsory eflort was cer-

tainly referrible to the mind.Dr. CHOWNE observed, that it was incor-

rect to maintain that, because excito-motorymovements, as of the uterus, continued forsome time after the removal or destruction ofthe brain, that the actions did not dependupon this organ, for the brain might impartan influence which might remain for sometime after its removal. There was such a

thing as a prospective store in nature ; eatingwas essential to life, yet a man might existfor some time without food ; he would notconclude that because excito-motory move-ments took place after the destruction of thebrain, this organ was not subservient tothem.

Dr. HALL remarked in reply, that thefoetuses in which the brain, and the brainand spinal marrow never did exist, af-forded a sufficient proof that the spinal mar-row was not merely charged by the brain, orthe ganglia by both. Here the battery is

charged without the electrical machine.

Monday, Dec. 20, ls41.The discussion on Dr. Alison’s paper wasresumed this evening.

Dr. CLUTTERBUCK said, that he was notprepared to assent to the doctrine of excito-motory action ; the various actions whichhad been referred to this system were ex-plicable on the old doctrines, and he referred

them to the brain, which was the chief depo-sitory of the nervous influence. The spinalmarrow, the ganglia, and the nerves, andperhaps even the organs themselves, becomecharged with this force from the brain.There was little correspondence in the viewsof the advocates of the new doctrine.

Mr. HIRD said,the locomotion of man wasnot excito-motory. There was certainly aspinal action. The locomotive efforts of thelower animals were referred to instinct.

Mr. CRISP mentioned that he had latelyattended a gentleman affected with paraple-gia ; on tickling the paralysed limbs with astraw, muscular efforts were induced.

Mr. PROCTER said, that no animals livedlong without thf affirm of the brain. In

rapidly-mortal examples of apoplexy, as thoseproceeding from copious effusion of blood, noexcito-motory movements took place.

Dr. BENNET could not account for manymovements which took place in apoplexy,such as the raising of the arm, turning inbed, &c. ; there could be no volition, yetthere were what were usually called volun-tary motions : the excito-motory doctrine ex-plained many facts previously unintelligible.

Several other members joined in the dis-cussion of the excito-motory doctrine, but

nothing new was elicited.In the course of the evening, Dr. Theophi-

lus Thompson exhibited to the society twogall-stones which had been taken from thegall-bladder of a man who had died of jaun-dice and disease of the heart. The gall-stones were about the size of small filbert-nuts.

WESTMINSTER MEDICAL SOCIETY.Saturday, Dec. 19, 1841.

Dr. GOLDING BIRD, President.CASE OF ACUTE PERITONITIS CONSEQUENT UPON

THE RUPTURE OF A FECAL ABSCESS INTO

THE CAVITY OF THE PELVIS, WITH CHRONICDISFASE OF THE CÆCUM AND ULCERATION

OF THE APPENDIX VERMIFORMIS.

MR. ROBERT DUNN detailed the followingcase. The patient was a young lady, justattaining her twenty-first year, and on the eveof marriage. Mr. Dunn had attended her be-tween two and three years previously for asevere attack of continued fever, when shesuffered so much from a dysenteric state ofthe bowels, that ulceration was dreaded.In the present instance he was called to heron Sunday week, and found her labouringunder sickness of stomach, griping pains inthe bowels, frequent inclination for motion,great thirst, and general febrile disturbance,all attributed to her getting wet and cold onthe previous Wednesday. He found hermuch relieved the next day, after havingtaken a dose of hydrargyrum cum creta, withDover’s powder, and some effervescing

484

saline medicine. Upon examination, how- be supposed. In several cases of this de-ever, he detected a tumefaction in the region scription he had found some prominentof the pelvis, which was very painful on symptoms which would seem to afford un-

pressure. A purgative of calomel and equivocal evidence of the real nature of therhubarb was ordered, as the bowels had not disease : thus the patients were always in-been relieved. This produced two or three disposed for a short time previous to theevacuations, and the bowels were again re- attack,-this was sudden-there was usu-lieved on Wednesday. The sickness had ally pain in the region of the caecum pre-abated, but there were still pain and tender- vious to that symptom becoming generalness on pressure, which were attributed to over the abdomen-a distinct tumour wasthe catamenia which appeared to-day. On generally to be felt in the situation of thethe day following she was so much better small intestines, arising from flatulent disten-that she was allowed to get up, and went sion of these viscera; and there was in alldown stairs. The fatigue of this appeared cases which he had seen a peculiar kind ofto be too much for her, and she was very ill hiccup, apparently connected with eructationthroughout the night. When Mr. Dunn of wind. These symptoms he had usuallysaw her early the next morning, she was found connected with disease of the caecumlabouring under unequivocal symptoms of and its appendix. In Mr. Dunn’s case, heacute peritonitis, with great prostration of thought that the original foundation of thepower. The abdomen was tympanitic, and mischief had been laid by the fever underon a careful examination he could detect a which the patient had laboured two or threedistended state of the bowel arising from the years before, for we knew that fever fre-right iliac region, and giving the sensation to quently left injury in the intestines.the hand as though it were an ovarian cyst. ____

This led to the opinion that there was ob- ,.,,-, being called j, for his paperstruction at the caecum. Leeches were im- Mr. SNOW being called on for his papermediately applied, and calomel and opium

on

PARACENTESIS OF THE THORAX,administered every four hours ; and in the PARACENTESIS OF THE THORAX,afternoon of the same day she was seen by stated, that whenever any fluid, whether aDr. Addison. The tympanitic state of the liquid or a gas, accumulated within theabdomen had become so general, that the pleura, it was desirable that it should be gotpeculiarity on the right side could no longer rid of. Tapping the thorax, however, wasbe felt. There was now incessant sickness, the means adopted only in those cases wherewith a constant effort to expel flatus from the the liquid was known or presumed to be pus,stomach, and obstinate constipation. Dr. or where there was serum or air in oneAddison took the same view as Mr. Dunn of pleural sac in such quantity that one lungthe case, and attributed the sudden invasion was rendered useless, and the mediastinumof the alarming symptoms to some latent was pushed aside, and the function of thedisease about the caecum. She lingered on other lung so interrupted that life was endan-till Sunday afternoon, and then expired. gered. And under other circumstancesOn a post-mortem examination, the perito- than these, the ordinary modes of performingneum was found to be universally inflamed. paracentesis of the chest, whether by theThe small intestines were excessively dis- trocar or the bistoury, would not diminishtended, particularly the last portions of the the existing evils. So soon as an artificialileum. The parts about the caecum were opening was made into the pleura, the lungagglutinated together, and it was at once on that side collapsed, in accordance with itsmanifest that a large fæcal abscess had own elasticity, and remained unaffected byburst into the cavity of the pelvis. The the motions of the ribs and diaphragm. Itcaecum was in a state of chronic disease, and mattered not whether the air pressed imme-a great portion of the vermiform process had diately on the surface of the lung, or throughsloughed. In consequence of the ulceration the medium of a liquid effusion, the effectof the appendix vermiformis, it would ap- would be the same. It followed, then, thatpear that the faeculent matter in the caecum at the conclusion of paracentesis performedhad passed into the peritoneum, which, ex- in the ordinary way, the lung must be col-citing a circumscribed inflammation, had lapsed, and the space between it and the ribswalled in the effused matter, and thus pro- occupied by air, provided all the liquid hadduced the faecal abscess, which had been been removed ; and, in fact, the air could begradually enlarging, and had at last suddenly heard passing into the chest by bubbles, asburst. The walls of the abscess were evi- the liquid flowed out during the operation.dent. The sudden invasion of the peritonitis This introduction of air into the pleurawas, doubtless, to be ascribed to the rupture would most likely be injurious wheneverof the abscess, and the escape of its contents that membrane was in a state of innanuna-into the cavity of the abdomen, tion ; but the greatest evils arising from the

Dr. ADDISON believed that cases similar to admission of air were occasioned by its me-the one recorded by Mr. Dunn were of fre- chanical resistance to the expansion of thequent occurrence. They were not, he lung. The lung on that side could only bethought, so difficult to diagnosticate as might brought into use in proportion as the air con,

485

tained in its pleura was absorbed, and thecomplete absorption of it must occupy, at theleast, several days; and during this time notonly must the patient suffer from limited

respiration, but time was allowed for thelung to become bound down by the consoli-dation of the coagulable lymph which mightbe effused, and thus permanently detainedwithin its shrivelled dimensions. Providedthe serum could be removed without beingreplaced by air, its removal, whilst in mode-rate quantity and recently effused from pleu-risy, would prevent the diminished lung andcontracted chest which often followed thatcomplaint. When, from pneumothorax, oreffusion of serum, the lung was pressedclose to the spine, the mediastinum pushedto one side, and the ribs and intercostal

spaces distended, the common operation ofparacentesis gave great relief, because itallowed the thorax to return to a state of

equilibrium, and relieved the lung of theother side. But even in this case, or wherepurulent matter was removed, it would be agreat advantage to leave the patient with thepleura empty and the lung expanded, andfilling the chest. To make an opening intoeach pleura, and allow both lungs to collapse,would be to cause instant death by asphyxia;accordingly, the two sides of the thorax couldnot be tapped in the ordinary method on thesame day. And when dyspnoeaexisted fromliquid in both pleurse, the patient could notdispense with one of his embarrassed lungs;he evidently could not live with half the re-spiration he has got, accordingly paracen-tesis was not performed in hydrothorax ; adisease which nearly always occupied bothsides of the chest, and one which if not re-lieved by medicine soon proved fatal. But

provided the serum could be removed with-out making a communication between theexternal air and the pleura, he did not seewhy tapping might not be performed on thethorax with the same safety and success ason the abdomen. Dr. Davidson, of Glas-gow, had lately proposed the use of cupping-glasses over the canula, introduced for em-pyema, in order to prevent the ingress of air,and related cases of their application. Nowthis was, to a certain extent, an improve-ment, but it still left the operation far from astate of perfection; for, not to mention otherobjections, it was obvious that on the removalof the cupping-glass, air must rush into thechest before the canula could be withdrawn,or other means taken to stop the opening;and in a case Dr. Davidson related, thesplashing of fluid was heard on performingthe hippocratic test of shaking the patient,three days after the operation, and they knewthat could only take place when there wasboth air and liquid in the thorax. The chiefobject of his paper was to bring before thenotice of the society an instrument (a draw-ing of which was handed round), by whichany fluid could be withdrawn from the chest

without making any direct communicationbetween that cavity and the external air. Itconsisted of a trocar and a canula, with astop-cock in it, the trocar to pass through theopen valve of the stop-cock. Between theshoulder of the trocar and the part where itbegan to be pointed, there was a cylindricalportion made to fit accurately to the whole

length of the canula. In withdrawing thetrocar from the canula, after their joint intro-duction, it could be brought so far as to beclear of the stop-cock, which could then beturned before the complete removal of thetrocar, so that no communication with theatmosphere would take place. The otherpart of the instrument, viz., a double-actionsyringe, with two distinct valves, like a sto-mach-pump, and a short piece of elastictube, to connect it by means of a screw-jointwith the canula, could then be adapted tothat tube, and the valve of the stop-cockbeing reopened, by working the pump thefluid would be discharged from the thoraxinto a basin, held to receive it. Before in-troducing the trocar, the skin should bedrawn a little from its situation; and then, bywithdrawing the canula slowly at the end ofthe operation, the correspondence betweenthe superficial and deeper wounds would belost before air could enter the pleura. It

might happen that the lung might be bounddown in a case of effusion, and then it wouldevidently not be practicable to draw off thewhole of the liquid. The resistance to usingthe pump, and the sense of uneasiness in thepatient, would indicate when to stop, as inusing the enema-pump ; and if the liquidwere serum, it would be preferable to leave alittle in the thorax, rather than decant it offand replace it by air ; if, however, it werepus, the pump could be removed and air ad-mitted : or, if warm water were thought pre-ferable, it could be introduced by adapting abladder filled with it to the canula. Itwould be obvious that the instrument wouldpossess great advantages in cases in whichparacentesis was at present performed, andthat it would extend the occasions on whichthe operation might be resorted to with ad-vantage.Dr. ADDISON asked what objection there

was to the introduction of air into the

pleura? He admitted that the instrumentwas a very ingenious invention to preventthat occurrence, but he had never seen anyevil result from it. The action of the pumpcould not expand the lung, if it were bounddown by organised lymph, and, therefore, hedid not see the advantages of it ; for if the

lung were not bound down it would expandand contract with the motion of the chest,although air was contained in the pleura.He did not see the necessity of removing theeffusion in order to prevent the lung frombeing bound down, for when there was anyquantity of liquid it was of a sero-purulentand not of an orgallisable nature, and oc-

486

curred in cachectic and debilitated subjects,and not in those in whom coagulable lymphwould be thrown out during inflammation.He did not perceive any difficulty in tappingthe chest with the common trocar for hydro-thorax. He had lately had the operationperformed on a patient, who was relieved byit. One side of the chest was tapped, andthis contained considerably more serum thanthe other ; air entered, but was afterwardsabsorbed. He saw no objection to theentrance of air, for the hydrothorax did notcause inconvenience by preventing the ex-pansion of the lungs, but by pressing on themediastinum, and thus interfering with thecirculation of the blood. for thev know that

respiration might be greatly limited, and thatone lung might be altogether dispensed withwithout inconvenience.Dr. FREDERICK BIRD said, that the en-

trance of air into the pleura during paracen-tesis did no harm, and he mentioned two orthree cases in which there was pneumo-thorax immediately after the operation, butthe air was absorbed in a few hours. Hedid not consider that the present instrumentwas an original invention-it appeared to bea modification of a recent invention by aGerman writer, which was on the plan of theold enema apparatus. It consisted of anempty bag, which was drawn over the trocarand canula, and fastened to the chest by ad-hesive plaster ; the trocar, when withdrawn,was allowed to fall into the bag into whichthe liquid followed.The PRESIDENT said, that it should be re-

collected that the air admitted during para-centesis was a highly elastic and compressi-ble fluid, and would not offer so much resist-ance to the expansion of the lung as the liquidwhich had been removed.

Mr. SNOW replied, that the greatest objec- Ition he had to the admission of air into thepleura, was the mechanical resistance itwould afford by its bulk to the expansion ofthe lung; when that organ was left to itsown elasticity during the operation, it wouldleave a considerable space between itselfand the ribs to be occupied by air. He con- Bsidered the distinction Dr.Addison had Idrawn between the nature of the effusionwhen it was in large quantity and when thecontrary, was correct as a general rule; butthe fact that contracted chest sometimesfollowed pleurisy, was a proof that con-

siderable effusion might exist, and enoughorganisable lymph to bind down the lung, sothat the chest became pressed in on the fluidbeing absorbed. He was still of opinionthat if the dyspnoea were great from hydro-thorax, and the effusion pretty equal on bothsides, as it was very apt to be, that the patientcould not spare the use of one lung for a mo-ment to allow of tapping in the common

way, without a risk of losing his life. Whenhydrothorax caused difficulty of breathing,it must be by preventing the expansion óf

the lungs, for it could not ever interferewith the circulation in any other way thanby interrupting the function of the lungs, andso impeding the pulmonary circulation. Thepressure on the large vessels would alwaysbe the same as in health, however mucheffusion there might be in the chest, viz., itwould be a little less during inspiration, anda little more during expiration, than the at-

mospheric pressure. He was happy to hearof the German invention, for it at leastshowed that some persons objected to the ad.mission of air ; but though that inventionexcluded the air, it did not exclude the at-mospheric pressure, and it would evidentlybe impossible by its means to extract all theliquid, which would be a disadvantage, moreespecially in empyema. He admitted thatair was an elastic and a compressible fluid ;but this was an argument against its intro-

duction, and in favour of the instrument hehad proposed, for the air would expand dur-ing inspiration on attempting to expand thelung, and be compressed during expirationwhen the lung should be diminished.Mr. BROOKE proposed, in the absence of

the new instrument, that the canula shouldbe closed with the finger during inspiration,and then the patient should be made to expireforcibly, in order to expel the air from thepleura.

Dr. ADDisoN remarked, that it was impos-"ihlp. to fftTTtrnHnft the P.Y(-.rtinn, ofthp. nntipnf.

and said he had an invention of his own toprevent the admission of air. It consisted ofa very delicate valve to the canula, to allowfl Liid to pass out of the chest, but prevent thereturn of air. He should be happy, how-ever, to try Mr. Snow’s instrument when hehad a case requiring the operation.

Adjourned to January 8.

THE BICHLORIDE OF MERCURY.SMALL DOSES.

To the Editor of THE LANCET.

, SIR,-I beg a niche in your valuableJournal, in justification of my paper on

1 1.1 the exhibition of mercury in small doses,"inserted in August last, in consequence ofremarks made thereon by Mr. James Blard,of Macclesfield, one of your correspondents.In writing the paper alluded to, I felt con-vinced that the practice which’I I advancedwas a correct one, and would bear the testof experience; and I have been happy tofind my opinion supported by men of stand-ing and experience.

In the commentary of Mr. Bland there isa misunderstanding of the principles whichI attempted to show. He states my wordsto be, that 11 he itever saw a decided case ofptyalism from the exhibition of the bichlo-ride alone." Now, the words I used in THE

LANCET of August 21, were these,-that I I