No.824.

LONDON, SATURDAY, JUNE 15, 1839. [1838-39.

CLINICAL LECTURES,DELIVERED AT UNIVERSITY COLLEGE HOSPITAL,

BY

ROBERT CARSWELL, M.D.,Professor of Pathological Anatomy in Uni-

versity College, London; and of ClinicalMedicine in University College Hospital.

HYSTERIA.-FEBRIS MACULATA.—PNEUMONIA.

—PLEURITIS.—PERITONITIS.—PHLEBITIS.

GENTLEMEN:—The history of the case

which I have to lay before you to-day, isthat of Jane Evans, in which many of youmust have taken a deep interest, not only onaccount of the serious and complicated cha-racter which it assumed soon after the ad-mission of the patient, but also on accountof the nature and extent of the morbid ap-pearances found in the body after death.She was admitted with well-marked symp-toms of hysteria, and after three weeks,when improving under the treatment em-ployed, was seized with that form of spottedfever which has existed, and still exists,sporadically in London, and other parts ofthe country. From this she never fully re-covered, but lingered for a considerablelength of time, and at last sunk under thecomplications which so frequently ariseduring the course of this form of fever. Thefollowing is the history of the case of thispatient :-

Jane Evans, set. 23, admitted Feb. 5th,lS39 ; a single woman ; nervous tempera-ment ; spare habit; unhealthy appearance;has never been well since the age of pu-berty ; the whole family phthisical, and sub-ject to spitting of blood ; her mother diedfrom abscess of the liver.

She was seriously ill about six years ago,with pain in the right side, which she sayswas enlarged ; also pain in the head, chest,and loins. Her skin was then sallow, andthe urine high coloured. Leeches and blis-ters were employed, and her mouth wasmade sore. About nine months after shehad a similar attack. During the last sum-mer another attack, very like the precedingenes, but. of shorter duration. Since then

the pain has shifted to the left side, and isat times very severe.

Present symptoms.-Complexion sallowand ansemiated; motions and manner indi-cating debility; pain in the head, extendingover the temples; worse when standing orstooping, better in the horizontal position ;superficial tenderness ; vertigo and dimnessof sight; pain also in the left hypochondriacregion, with tenderness on slight pressure;opposite this, but on the right side of thespine, there is also a considerable degree oftenderness ; dyspnoea on exertion ; actionof the heart greater than ordinary, but easilyexcited ; bellows-sound accompanying thesystole, most distinct at the base of theheart; complains of palpitation; globushystericus ; borborigmi ; depraved appe-tite ; sometimes none at all, at others vora-

cious ; flatulence; constipation; scanty andsaffron-coloured urine.Reviewing these symptoms, presented by

the patient at her admission, there was nodifficulty in detecting the existence of hys-teria by the presence of several of its moremarked symptoms and complications. The

depraved appetite, with flatulency; theglobus hystericus ; the palpitations andanormal sounds accompanying the heart’saction, with anemia; the headach and ver-tigo, with impaired vision ; the pain in theside ; superficial tenderness in several partsof the body, but particularly in the regionof the spine, were symptoms obviously cha-racterising the presence of hysteria. The

prognosis, however, as regarded a speedyand perfect recovery, was not favourable.The patient was not only weak but lean, in-dicating a defective state of the nutritivefunction generally, and had obviously notonly suffered considerably from her previ-ous attacks, but had become predisposed torelapses from exposure to slight excitingcauses. With this view of her case the in-dications of treatment seemed to be to allaythe irritability of the nervous system, to re-gulate and improve the digestive function,and, consequently, that of haematosis, theimperfect accomplishment of which wasmanifested by the anemic condition of thepatient; she was, therefore, ordered the fol- -lowing medicines:ń - ’,’

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Cornp. aloetic pill, six grains;Comp. galbanum pill, four grains. Tobe taken every other night; and,when necessary, the senna draught inthe morning.

In addition, she was to take of the muriatedtincture of iron ten minims, in an ounce ofthe infusion of wormwood, three times daily,and to be allowed the ordinary diet.

Feb. 9. Pain in the head much the same,preventing’her from sleeping.-The tinctureof iron to be increased to fifteen minims.

12. Much the same.-Increase tincture ofiron to twenty minims.

16. Better.-Increase tincture of iron totwenty-five minims.

19. Stronger; more colour; less pain.-Increase tincture of iron to thirty minims.

23. Not quite so well; frightened thesetwo days by a delirious patient; bowelsfreely open; more colour.-Shower-bath at80° daily.- Tincture of iron thirty-fiveminims.

26. Improving.-Increase tincture of ironto forty minims.

29. It was reported that some feverish-ness had taken place since the last report.On the previous day the pulse was 120,and weak; the skin hot, and considerablesupra-orbital headach. This change in thestate of the patient was the commencementof the fever to which I have alluded, andwith which two other patients in the sameward were affected. The symptoms werethen slight and undefined, and did not indi-cate the nature of the fever until some daysafter. However, the previous treatmentwas laid aside; one-sixth of a grain of tar-tarised antimony, and half a drachm of thesulphate of magnesia, in an ounce of water,was ordered to be taken three times daily,and low diet.March 2. Pulse still 120; skin less hot,

and moist, but no sleep; pain in the chest,shooting through to the back; complains ofbeing sore all over; supra-orbital headach ;bowels not freely open.-Ten ounces ofblood to be taken from the nape of the neckby cupping, and a sinapism to the spine.

5. Headach and pain in the chest some-what relieved by the cupping and sinapism,but the feverish symptoms still continue.-The antimony to be increased to a quarter ofa grain.

7. Considerable pain in the integuments,under the left breast, and in various parts ofthe chest; pulse 132, and very weak;breathing short; bowels much acted on bythe antimonial mixture ; skin still very hot;no appetite and no sleep ; much less head-ach ; great weariness. In consequence ofthe purging, and the great weakness of thepatient, the antimonial mixture was omitted;and, in order to obtain for her some repose,she was ordered to take at night twentyminims of the tincture of the meconate ofmorphia.

9. Very little sleep has been procured;complains of more headach and thirst, withoccasional vomiting, and great tenderness atthe epigastrium on pressure.-Ten leecheswere ordered to be applied to the epigas-trium ; and a draught, composed of onescruple of carbonate of soda, and fifteengrains of tartaric acid, in an ounce and ahalf of water, to be taken every fourhours.On the following day a great number of

rose-coloured spots, about the size of a splitpea, appeared on the chest, abdomen, arms,and thighs. The pulse was still quick andweak ; she complained of pain in all herlimbs and joints; there was great heat ofskin, but less thirst; great nervous excite.ment.On the llth there was very little change;

the eruption was fading. As the head wasstill the seat of pain, and very hot, it wasshaved, and,the bowels being confined, threedrachms of castor oil were ordered to betaken immediately.

12. The eruption gone; the pain in thehead, over the eyebrows, continues; slightpain in the abdomen on pressure: tonguedry; bowels open sufficiently.-Six grainsof the nitrate of potash to be added to thethe saline mixture, and cold lotions to thehead.

’ 13. Some lividity of the nose and lips;

respiratory murmur rough ; tongue verydry ; pulse 136 ; head very hot; great rest-lessness and agitation in her manner, andsome intolerance of light.-Eight leeches tobe applied to the temples.

14. Head symptoms increased; difficultyof articulation and muttering; nose andcheeks flushed and livid; skin hot; pulse120, and hard; tongue very dry.-The anti-monial mixture was ordered to be givenevery three hours.

15. Heavy, vacant expression of the coun-tenance ; pulse 132 ; skin very hot; vomit-ing occasionally ; and she passes her faecesinvoluntarily. The left lung (the side onwhich she lies) is duller on percussion pos-teriorly than the right; anteriorly there is

puerile respiration in both lungs, but mostmarked in the right. There is bronchial re-spiration in the left lung posteriorly, andabsence of vesicular respiration at same

point.-Increase tartarised antimony to halfa !1"B’ain: milk dailv.16. Passed a quiet night; no delirium;

more composed this morning ; tongue dry,fissured ; and red rose-coloured spots quitegone ; medicine does not cause sickness orpurging ; skin not too hot or dry; she has

great noise in her head, but the head doesnot feel hotter than other parts of the body;; very thirsty ; pulse 126., 17. A good deal flushed this morning, butdoes not seem to be in any respect worse;f slightly purged by the antimony, which hasbeen omitted; pulse smaller, 108; articu-

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lation very indistinct; she is extremely 30. She is very irritable; face flushed ;weak. appetite not so good; still has ringing in

18. Not so much flushed; pulse 116; the ears. There is less bronchial respira-tongue dry, glazed, and cracked ; some tion posteriorly and inferiorly, but it is stillcough and expectoration, but has not distinct; pulse 152 ; mouth very sore ; occa-strength to get rid of it; respiration less sional sickness; abdomen somewhat tympa-puerile anteriorly, strongly bronchial pos- nitic; bowels confined.-Omit beef-tea andteriorly.-Antimonial mixture to be repeated ant. mixture. To take two drachms of sul-as before. phate of magnesia, five minims of dilute

19. Very weak; passed a quiet night ; sulphuric acid, in ten drachms of water,tongue cleaner, and not so dry; bowels twice in the course of the day.open three times during last night and this April 2. Better, stronger; still very nerv-morning ; less ringing in the ears; no dif- ous; pulse not so quick; heat moderate ;ference in the lungs posteriorly; less puerile tongue red and moist; less noise in the ears ; ;respiration anteriorly than yesterday; alto- mouth sore; some diarrhoea.-Sulphate ofgether improved; face less livid.-As the magnesia mixture to be omitted ; and to takemixture causes purging, to be again omitted. half a grain of sulphate of cinchonine, inHalf a pint of beef-tea daily. three drachms of infusion of wormwood, and

20. Pulse 120 ; much better and stronger ; two drachms of cinnamon water, three timesless heat of body; complains less of her daily.head; tongue less dry; very little thirst; 6. Much better; more cheerful; bronchialcough very troublesome, but she is unable respiration less distinct ; tongue less red ;to expectorate freely from weakness. Respi- pulse not so quick; she disliked the cincho-ratory sounds much the same ; percussion nine from its producing a feeling of cold ingives a dull sound posteriorly and infe- the stomach, and it was therefore laid aside.riorly. 9. Much purged yesterday, for which she

21. Better, stronger; pulse less frequent; was ordered an ounce and a half of chalkskin warm and most ; less headach; tongue mixture, to be repeated when necessary.cleaning ; appetite improving ; quite ra- More restless to-day and last night; no deli-tional ; breath less difficult. rinm; evacuations light coloured ; purging

22. Complains more of her head this checked ; aphthous spots on the tongue ;morning, but the tongue is cleaner and more has asked repeatedly for porter, and wasmoist ; pulse 96; not purged ; less cough ; ordered to have half a pint, to be taken dur-bronchophony plainly heard posteriorly and ing the course of the day.inferiorly. 12. Considerable tenderness of abdomen ;

23. There is bronchial respiration still in pulse quick; tongue dry, loaded, and aph-the left lung. She was very hot and restless thous; great thirst; vomiting ; very rest-last night, and was occasionally sick; pulse less.-She was ordered four grains of mer-now 120; tongue dryer than yesterday ; curial chalk, and four of Dover’s powder,more headach, and noise in the head. Com- three times daily ; and a mustard poulticeplains now of pain in the left side. Her to the pit of the stomach. The porter to becough is less, and breathing more free. Her omitted.manner not so quiet and collected as yester- 13. Much the same as yesterday ; stomachday ; bowels rather confined.-She was or- very irritable ; vomits frequently a largedered to take two drachms of castor oil; quantity of bile.-To take an effervescentand’to have two eggs daily. draught every four hours ; to have a blister

24. Very little sleep last night, but not to the epigastrium, and fomentations to thedelirious. Still lies on her back and right abdomen.

side ; headach and noise in the ears con- 16. Abdomen still tympanitic and painfultinue; tongue dry and red ; some thirst ; on pressure, but not so much so as it was.bowels moved several times from the castor Vomiting less since the 14th. Objects veryoil. Has no appetite for food, but takes the much to her medicine; is more quiet andbeef-tea. composed, but obtains no sleep.-Efferves-

25. Passed a very restless night; com- cing mixture to be omitted, and to take theplains now of a pain in the left side on following draught every three hours :-breathing ; pulse 146. Some twitching of Dilute kydrocyanic acid, three minimsthe muscles of the face. Tongue dry and Mucilage of gum arabic, one drachm ;red ; spirits very depressed, but appetite WateJ’, six drachms ; and the blister toimproved. The bronchial respiratory sound be repeated.heard posteriorly is not so loud as it was; 20. Better; features less contracted ; notit is loudest with expiration ; bowels open. much pain on pressure over the abdomen,The pain in the side is quite superficial. and what there is felt chiefly at the right

26. Pulse 124 ; still noise in the head ; hypochondrium; tongue very dry ; she is

very nervous; pain in the side much the very restless ; has little sleep; bowels moresame. quiet; urine very dark coloured.-Ordered

27. Much the same; more appetite; one half a pint of beef-tea and arrowroot daily.pint of beef-tea daily. 23. Much the same ; blisters do not draw

420at all ; stomach ’still very irritable.-The which there escaped a quantity of yellow-hydrocyanic acid to be increased to foar islt-grey puriform matter, which, with whatminims. was afterwards removed, amounted to be-26. Better; tongue cleaner, less aphtbous ; tween and five ounces. This cavityno vomiting since yesterday morning; takes was found to be formed by the walls of themore nourishment, but is extremely weak. abdomen laterally and posteriorly, by the

29. No return of the vomiting; no diar- border of the right lobe of the liver supe-rhoea ; a little stronger; tongue cleaning ; riorly, and by the intestines in the remaindermanner less restless. of its extent, and its internal surface linedMay 6. Complains of great tenderness of by an accidental membranous tissue, which

the extremities, particularly of the right foot thus connected together the parts aboveand leg, which are oedematous. These are named in the form of a shut sac. A similarvery sensible to the slightest pressure, over state of parts was found in the pelvic re-the whole surface of the skin, and also along gion. The greater part of the ileum, groupedthe track of the femoral vein, but there is no together and united by cellular adhesions,redness in either situation, very little in- was attached along the course of the iliaccrease of temperature, nor can there be felt vessels on both sides, and to the margin ofany fulness or hardness of the trunks of the the pubis, so as to close in the cavity of theveins.-Ordered more generous diet and pelvis. The cavity thus enclosed, was alsowine. filled with a puriform fluid, which emitted aThe swelling, tension, and oedema of the slight odour of putrefaction, and presented

right foot and leg increased considerably a slight yellowish-brown colour, both ofduring the four following days ; the general which circumstances depended on a com-symptoms became more and more aggra- munication existing between it and the in-vated, the debility extreme, and the patient testine. The opening into the intestine wouldsunk exhausted on the 10th of May. have admitted the point of the little finger,

I have been thus particular in relating to and was obviously the result of ulcerationyou the progress of this case, from the time proceeding from without inwards; that is toit was submitted to your observation to its say, ulceration commencing in the acciden-fatal termination, on account of our having tal membrane which covered the surface offound appearances after death which we the intestines in contact with the puriformhad not suspected to exist during life, in contents of the pelvis, and extending after-order that you may appreciate the more wards to the walls of the intestine. The

fully the importance of the circumstances quantity of fascal matter which had escapedwhich appear to have obscured, in part, our by the perforation must have been verydiagnosis, or may have prevented us from small, as the puriform fluid in the pelvicdoing that amount of good which, under cavity was but slightly coloured by it; andmore favourable circumstances, we might, from this circumstance it may likewise be

perhaps, have accomplished for our patient, inferred that the perforation of the intestineBefore alluding to these latter circumstances. did not take place till shortly before death.or the principal features of this interesting The intestines on the left side of the abdo-

case, I shall give you a description of the men were free from adhesions, but the epi-morbid appearances found in the body after ploon, deprived of the greater part of its fat,death, was included in the adhesions on the right

_ , side, and also in the pelvic region.Post-mortem 30 hours after Death. The stomach contained a quantity of fluidExternal appearance of the Body.—Great food; the small intestines a considerable

emaciation ; œdematous swelling of the quantity of yellow-coloured mucus ; and

right foot and leg less tense, subcutaneous the ascending and transverse colon someveins more marked than during life. consistent faecal matter. The mucous mem-

Abdomen.—On laying open the cavity of brane of the stomach and intestines gene-the abdomen the visceral and parietal por- rally presented little or no trace of disease.tions of the peritoneum of the right side of In a small portion only of the ileum did itthis cavity, were found united together by present a fine capilliform injection, withrather fine cellulo-vascular adhesions. These slight softening. In the stomach it wasadhesions extended over the convex surface generally pale, natural in thickness andof the liver, uniting this organ with the dia- consistence ; it presented equally healthyphragm ; and also over its concave surface, characters in the whole of the small intes.

uniting it with a portion of the ascending tines except in the portion noticed ; and inand transverse arch of the colon, and the the large intestines it appeared, in somepyloric portion of the stomach. The spleen, parts, to be softer than natural, but withoutlikewise, was similarly connected with the any morbid discolouration.diaphragm, and the margin of the left lobe The liver presented no marked change,of the liver. On attempting to separate the except, perhaps, slight diminution of itsadhesions on the right side of the abdomen, consistence ; the kidneys and pancreas wereand towards the lumbar region, the fingers healthy. The urinary bladder and organspassed into a cavity in this situation, from of generation were not examined.

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The spleen, as-already stated, adhered tothe diaphragm and left lobe of the liver.On attempting to remove it a quantity ofpuriform fluid escaped from behind it, whichwas found to proceed from the left cavityof the pleura, through an opening of con-siderable size in the diaphragm. The spleenwas enlarged, firm, and, where it was incontact with the puriform matter, was de-stroyed to the depth of nearly half an inch.

Chest.—The left lung was united b3 cel-lular adhesions to the first fonr true ribs,near their union with the cartilages, to thecartilages of the other ribs, and to the peri-cardium down to the diaphragm. Thecavity of the pleura thus closed in, wasfilled with a puriform fluid, which com-pressed the lung upwards and against thespine. The whole of the lung, therefore,was separated laterally and posteriorlyfrom the ribs, from the diaphragm up to thesummit of the chest, from two to threeinches, by the accumulated fluid. Theupper lobe, however, was less compressedthan the inferior, and when inflated must, in the erect position of the body, have filled Ithe upper anterior third of the chest. Whenthis lung was removed and cut into, a con-siderable portion of the inferior lobe pre-sented traces of pneumonia. The pul-monary tissue was consolidated, of a paleyellow-grey colour, easily broken down intoa pulpy substance containing some thinpuriform matter.The right lung was inflated, elastic, and

crepitant, except posteriorly, where pneu-monia, in the first and second stages, wasreadily recognised ; the first stage alone inthe inferior part of the upper lobe ; and thefirst and second stages in the inferior lobe.There were, also, a few circumscribedpoints of vesicular emphysema.The right and left cavities of the heart

contained a small quantity of partially coa-gulated blood; the parietes of the leftventricle were thicker than natural; therewas fibrous induration at the base of themitral valve, and some opacity of the endo-cardium near the semilunar valves of theaorta. The external surface of the rightventricle, towards the basis of the heart,’presented two or three spots of an opales-cent colour, depending on the presence ofan accidental serous tissue in this situation.The brain was not examined.In order to ascertain if phlebitis was the

cause of the diseased state of the rightinferior extremity, the iliac vessels werecarefully dissected and exposed. Thesheath of the external iliac vein, and thecommencement of the femoral vein, wasfound opaque and thickened, and, on layingopen these vessels, they were found filledwith a fibrinous clot, adhering to their in-ternal parietes, and completely obstructingthe return of the blood. The sheath of thediseased veins was in contact with the acci-

dental tissue which united together theintestines over the cavity of the pelvis, andfrom this the inflammation had, no doubt,extended to these vessels.

In reviewing the history of this interestingcase I shall direct your attention more par-ticularly to the pathology of the morbid ap-pearances met with in the thoracic and abdo-minal cavities. I have already sufficiently no-ticed the affection for the cure of which thepatient entered the hospital, and which wasundergoing a favourable change at the timethe symptoms of the maculateli form of fevermade its appearance. This serious form offever, the dangers attending which,are alwaysgreatly increased by the complicationsi which arise during its progress, did not

present any very marked peculiarity requir-ing special notice, except those whichoccurred in the thoracic and abdominalcavities. These complications, besidesthose I have just mentioned, were the cere-bral and gastro-enteric. The former werethe less severe of the two; the gastric andgastro-enteric being very much so at differ-ent periods in the course of the disease.These latter, however, were much subduedabout a fortnight before the death of thepatient, and, ten days before this event, hadnearly disappeared; the vomiting and diar-rhoea having ceased, and the tongue becomeclean, and free from its aphthous appearance.I mention these circumstances as evidenceof the progress towards a cure of the gastro-enteric complication, because we foundhardly a trace of any morbid alteration ofthe gastro-intestinal mucous membrane afterdeath to enable us to account for thesymptoms which indicated the inflammatorycharacter of the disease with which it wasaffected for a period of several weeks. Thepain in the region of the stomach on slightpressure ; the frequent vomiting ; red, dry,chapped tongue,with aphthous exudation anddiarrhoea, were the symptoms which accom-panied the presence of this inflammatoryaffection of the digestive mucous membrane,and were not subdued till after a consider-able time, by leeching, repeated blistering,and the use of hydrocyanic acid. The se-

verity of the symptoms was, I believe, dis-proportioned to that of the inflammation ofthe mucous membrane, on account of thenervous and highly-irritable temperament ofthe patient. And this is a circumstancewhich ought always to be taken into con-sideration in estimating the influence of anyorganic lesion in the production of those

symptoms or modifications of function towhich it may give rise. In this way wemay explain more satisfactorily the almosthealthy appearance of the digestive mucousmembrane, so soon after the subsidence ofthe symptoms, which were observed in thiscase.

Let me now direct your attention to thepathological conditions observed in the

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chest after death, premising these by ageneral view of the signs which we ob-served during life, as indicating the exist-ence of typhoid pneumonia.The first physical sign of the chest affec-

tion was observed on the 13th March, thefourteenth day of the fever, and consistedchiefly in roughness of the respiratory mur-mur. The fever was then severe ; therewas great agitation and restlessness ; headvery hot and painful; intolerance of light,and slight delirium, and the pulse 136.Two days after the signs of pneumonia weremanifest in the left lung, which, posteriorly,was dull on percussion, with bronchial re-

piration, and absence of vesicular respira-tion : and there was puerile respiration inboth lungs anteriorly, but most marked inthe right lung. During the eight. or tendays that followed the bronchial respirationand bronchophony became marked, and verycharacteristic; they were, indeed, so much sothat they might be said to be perfect, par-ticularly at the lower angle of the leftscapula, although they were not confinedto this part of the left side. There was alsoheard, by Mr. Taylor, at the lowest part ofthe chest, bronchial respiration, but it wasof a different character, such, viz., as occursin small-sized tubes. In the upper part ofthe chest, posteriorly, the respiration wasaudible, and percussion less dull (if notnatural) than elsewhere, for a considerabletime after the chest symptoms supervened.At a later period, however, the percussionbecame dull at the upper part of the chestposteriorly. The respiration was natural orpuerile, and the percussion clear up to thetime of death at the upper part of the chestanteriorlv.At no period of the disease was oegophony

heard by me, nor by Mr. Taylor, whoexamined the patient frequently; nor wasthere observed any other sign of pleuriticeffusion until the day on which the patientdied, when Mr. Taylor perceived that theribs rose and fell during respiration on theright side only ; but there was no bulgingof the left side, and no filling up of the in-tercostal spaces.Had the patient been examined with

greater care or more frequently,-for I wasalways loath to disturb her, never raisingher up after the first examination, but al-ways examined her as she lay in bed, some-times employing percussion only, at othersauscultation, as the one or the other wasmost convenient,-we might, perhaps, havedetected the effusion. I say we mightperhaps have done so, for I believe that wewere not deceived in our diagnosis as to theexistence of pneumonia at the commence-ment of the attack. That pneumonia didexist has been shown by the state of the leftlung found after death. A considerableportion of the inferior lobe presented tracesof pneumonia; the pulmonary tissue was

consolidated, of a pale yellow-grey colour,easily broken down into a pulpy substance,containing puriform matter. That the in-flammation of this, the inferior lobe, tookplace at the commencement of the attack Ifeel certain, from the pathological fact thatcompression of the pulmonary tissue, suchas that occasioned by effusion into thecavity of the pleura, has seldom been knownto give rise to, or be followed by, pneumonia.The existence of pneumonia, therefore, Iconsider as certainly to have occurred atthe commencement as the physical signs bywhich it was recognised by us.But there was also pleurisy with effusion,

and of the existence of this we were notaware till after death, nor perceived anysign of it till the day on which the patientdied. How is this to be accounted for?As the chest was examined with care at thecommencement of the disease, and as oego.phony, the characteristic sign of pleurisywith effusion, in the early stage, was notheard, it is more than probable that no suchmorbid condition then existed ; that thephysical signs then heard were those ofpneumonia alone ; or that pneumonia wasthe principal disease, and pleurisy, if pre-sent, a complication, but without effusion,even of coagulable lymph, the presence ofwhich should have given rise to the frictionsound, which, like œgophony, was notheard. Independently of the absence ofthose physical signs which accompany theearly stage of pleurisy with effusion, thosesigns were also absent which generally ac-company the advanced stages of the disease;viz., enlargement of the affected side, thebulging out of the intercostal spaces, thedisplacement of the diaphragm, medias-tinum, and heart. The immobility of theaffected side was the only sign, as I havealready stated, which we observed at theclose of the fatal termination of the disease.There is no difficulty, however, in explain-ing the absence of the former of these signs,viz., increased bulk and displacement,which was, no doubt, owing to the quantityof the effusion not being sufficient to pro-duce these changes. With regard, however,to the early signs of the pleuritic effusion,they were either overlooked by us, or,which is more probable, were so modifiedby the previous existence of the pneumoniaas not to be distinguished from those ofpneumonia, which were so marked in thiscase. And this difficulty was increased bythe form of the pneumonia, which, from thecommencement of the seizure, we regardedas of the typhoid kind.

I shall only further remark, with regardto this complicated affection of the chest,that the pneumonic signs were first observedon the 15th of March, and became more andmore marked during the following eight orten days. It was at this time that the pa-tient complained of pain in the left side, and

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which she stated was increased during in-spiration. It is possible that this was thedate of the pleuritic attack, but after ex-amining the side on two different occasions,we concluded that the pain was superficial,and of a nervous character. This circum-stance leads me to notice the circumscribedperitonitis, and the purulent collectionsfound after death. Of the existence ofthese we had no suspicion during life. Itis true that the patient complained of painin the abdomen, chiefly in the right hypo-chondriac region, on several occasions, andfor the first time on the 12th of April. But

although we examined, several times, theparts to which it was referred, we did notthink that it depended on peritonitis ; onthe contrary, we felt persuaded that it wasof the same nervous character as that com-

plained of when the patient was first ad-mitted, and so common in hysterical females.In this, however, we were altogether de-ceived. Nor is this a very rare occurrence,even in cases where the diagnosis is muchless embarrassing than it was in our case.I know of many examples of peritonitis-of acute peritonitis-occurring without anycomplication, as an idiopathic disease, andin which there was no affection of the brainto obscure the perceptions of the patient,the existence of which was not detected tillafter death. Two cases of this kind havecome to my knowledge within these fewweeks, and were under the care of expe-rienced physicians. And we shall feel theless surprise that peritonitis should occurwithout the usual symptoms by means ofwhich it is detected, if we reflect that in-flammation of other serous membranes, as.the pleura and pericardium, also occurs

under what has been called a latent form,-the existence of which is only discoveredafter death by the presence of the false membranes or adhesions to which it hadgiven rise.

’

Among the morbid appearances foundafter death is mentioned perforation of theintestine and of the diaphragm ; both per-.forations were examples of the effects ofpressure of the confined puriform fluids.The appearance of the perforation of the in-testine clearly showed that it took placefrom without inwards, and the small quan-tity of faecal matter which had escaped, thatit had verv recentlv been effected. That ofthe diaphragm was much more extensive,and had been followed by destruction of apart of the contiguous surface of the spleen.The adhesion of this organ around the per-foration prevented a communication fromtaking place between the cavity of the leftpleura and that of the abdomen.The morbid appearances in this case fur-

nished us with a satisfactory explanation ofthe inflammatory affection of the limb, whichoccurred a short time before the death ofthe patient. We found the external iliac

and femoral veins involved in the diseasewhich occupied the pelvic cavity. The in-flammation of the peritoneum in this situa-tion had extended to these vessels, and, asis usually the case in phlebitis, had effectedtheir obliteration by the coagulation of theblood, which existed in the state of fibrinousclots, adhering to the parietes of the vessels.Had the patient lived the organisation ofthese would probably have followed, thevessels would have been permanently obli-terated, and the life of the limb preserved bythe formation of a collateral circulation,traces of which were already observed inthe enlarged subcutaneous veias of thethigh.

I may observe here, that had we not wit-nessed the occurrence of the phlebitis fromits commencement in this case, and traced itto the local cause which I have named, wemight have been led into the error of ascrib-ing the puriform collections found in theabdomen and pleura to the phlebitis, andconsidered them as examples of those puru.lent deposits which so frequently follow asconsequences of this disease.With regard to the treatment of this very

complicated case I have very little to say.In all such cases antiphlogistic measurescan only be employed with a verv cautiousand sparing hand. The debilitated condi-tion of our patient before the acute attack,and the early typhoid symptoms of the fever,rendered bloodletting altogether inadmissi-ble, except by means of moderate cuppingand leeching; and this was only had re-course to with the view to relieve the moreurgent local symptoms which accompaniedthe cerebral and gastric complications, thelatter of which we endeavoured to subduechieny by blisters. The pulmonary compli-cation we combatted by the administrationof the tartarised antimony, which we wereobliged to employ in small doses, partlyowing to the weak state of the patient, andpartly from the irritable state of the stomachand bowels, and which forced us to lay itaside several times.

Notwithstanding these means, and theemulovment. at as earlv a period as nossible.of such nourishment and tonics as the patientcould support, she only rallied on one ortwo occasions for a few days. The extentof disease found after death fully accountedfor the progressive aggravation of the case,and its fatal termination.

We cannot but feel regret at not havingobtained a more accurate knowledge of someof the complications to which I have alluded;whilst at the same time I do not believe thatany modification of the treatment which aknowledge of them might have suggested,

would, under the circumstances in whichour patient was placed, have afforded addi.

tional means of security against a fatalresult.