No. 323.

LONDON, SATURDAY, NOVEMBER 7. [1829-30.

LECTURES ON SURGERY,

MEDICAL AND OPERATIVE,

DELIVERED AT

St. Bartholomew’s Hospitals

BY MR. LAWRENCE.

LECTURE VI.

Causes and Efects of Inflammation.WnEx speaking to you, Gentlemen, in thelast lecture, of the varieties of inflammatoryprocess, I fear, that in the attempt to con-clude the subject within the period of onehour, I may not have explained myself sofully on all the points as I should havewished. I spoke to you of the various effectswhich inflammation produces, but I do notknow that I enumerated them completely ;I now, therefore, recapitulate what I thenstated.

It is difficult to give an exact descriptionof all the stages which are included betweenthe first deviation from a condition of health Iand the more striking effects of disease.But I endeavoured to enumerate the variousresults of the process, nearly in the follow-ing terms :-Irritation, or Disorder.-This, in respect

to internal organs, is evinced simply by analteration of functions ; and we cannot ex-actly say whether, under certain disturbancesin them, such actual organic change is pro..duced as would warrant the term inflamma-Mn; but in external parts, we are oftenable to see such a disturbance accompany-ing even slight alteration of the functions.Thus, distension of the vessels of the eyeBB’111 arise from a slight cause ; we shouldLave no means of ascertaining the existenceof a s;milar condition, if it were in an inter-nalorgan. We e sha1l consider irritation, or(1tm&ugrave;.er, then, as the first step in the de-<iat!(m irom health, when anv cause of dis-ease is applied to a part. Vascular con-ges/iO1! u ascertainable after death, when

we find the vessels preternaturally full.H&oelig;morrhage, that is, a breach of some ves-sels, with consequent effusion of blood,which makes its way externally, when therupture takes place upon a membrane hav-ing an external opening. Effusion of se-rum, or of lymph, into the interstices ofparts. Suppuration, ulceration, and gan-grene. We must regard these various cir-cumstances only as modifications of the

inflammatory state. We cannot exactlyassert that all these are simple differencesin degree. We cannot, in that respect, com-pare them to each other, because we findthat differences of texture produce a tend-ency to one form of change rather thananother, without our being able to say thatthe one is either more or less than the other.Hemorrhage, for example, frequently oc-

curs from the surface of mucous membranes;it does not take place from that of serousmembranes. We cannot determine whetherthe disturbance, which produces haemorrhagein mucous membranes, is either greater orless than that which causes effusion oflymph in the serous. Although we havearranged them according to their generaldifferences in degree, we cannot assert, ineach stage of the progress, that that stageis greater than the one which immediatelyprecedes, or less than that which follows,because the difference of organisation causesvarieties in the result that we cannot ac-count for.These are the immediate effects ; of the

more remote results, the chief is indura-tion, or thickening, and hardness, more orless interfering with function. To this isopposed another kind of change, viz., pre.ternatural softening, observable particu-larly in the brain. Induration exhibits itselfunder two forms. In the majority of in-stances, the indurated substance is of awhite appearance, that is, it possesses nogreat number of blood-vessels. But in cer-tain organs, where there is an abundanceof capillaries, a greater redness is produced,and a sort of liver-like colour ; hence theterm hepatisation, employed by the Frenchto denote a red kind of induration.

I should have spoken to you of the varie-Laties inflammation presents in the several

202

textures. When you are informed thatinflammation is augmented action of theblood-vessels-when you learn that the seatof the disturbance is in the capillaries-when you know, at the same time, that thearrangement of these vessels presents differ-ences in each texture and organ, you willbe prepared to conclude, that the inflamma-tory process will have its peculiar charac-ters in each part. In each of the threeclasses of membranes, inflammation exhibitsstriking differences. In mucous membranesit is characterised by great distension of theblood-vessels, with which the surface of suchmembranes is plentifully supplied. Thusgreat increase of redness: a bright scarlettint is one characteristic of inflammation inthis texture; swelling of the membrane isanother. Increased quantity and altered

quality of the fluid poured out by the mem-.brane-that alteration causing the fluid tohave nearly the appearance of pus, is a fur-ther character. In inflamed serous mem-branes there is no swelling or thickness ;there is none, or hardly any perceptible in-crease of redness. There} is increased ac-tion of the exhalents, which pour out eithera thin whey-like fluid, coagulating lymph,or pus. The coagulable lymph becomingorganised, constitutes bands of adhesion oradventitious membrane covering the in-flamed surface. It is this new formationthat sometimes gives to the membranes theappearance of being thickened; whereas, ifyou remove the deposition, you find thatthe part has its natural thinness. So greatand so essential is the difference betweenthe product of inflammation in the two cases,that you can hardly, by any artificial means,produce in the one instance that which natu-rally takes place in the other. Mr. Huntertried to produce in mucous membrane thesame deposition of lymph that takes placeon serous, but he could not succeed, or suc-ceeded only very partially. You will im-

mediately perceive, when you reflect onwhat the organs are, to which the mucousand serous membranes respectively belong,that if the mucous were liable to the samedeposition of lymph and preternatural adhe-sions, the functions of the parts would becompletely destroyed. Consider what wouldbe the state of the stomach and other partsof the alimentary canal ; these tubes wouldbe completely blocked up by the depositionand the unnatural adhesions which take placein the serous membrane.

In the fibrous membranes, you do not findeither effusion of lymph, or the secretion offluid like pus, but interstitial deposition andthickening of the part.

All textures of the body, when wounded ior divided, will suppurate ; but in inflamma-tions of the various organs from internalcauses, the tendency to this termination va-

: ries greatly. The eeltzclar membrane is pc.ticularly prone to suppuration, but the glan.; dular parts are little susceptible of it. I

fancy it has happened only to very few tohave seen abscess of the kidney or splcen.In these climates it is very rare to see it

l taking place in the liver. Inflammati,nfrequently takes place in the testicle, vetsuppuration of it is by no means common.Suppuration is hardly ever seen, speaking

ieither of spontaneous inflammation, or that, which arises from other causes, in the sub.stance of the muscles, or in the tunics of thestomach or other parts of the alimentarycanal. Mortification takes place easily inthe cellular membrane ; the skin is muchless subject to it. Mortification is muchmore common in external than in internalparts.

I next come to the causes of inflammation,and these include almost all the agenciesthat can affect the human body.

In the first place, inflammation may be ex.cited by all kinds of injuries; whether me.chanical, chemical, or of a mixed nature.It is excited by the infliction of wounds,whether they are incised, lacerated, or con.tused. Inflammation is the consequence,therefore, of surgical operations. It is pro.duced by pressure on the body, whetherexerted externally, or taking place from in.ternal causes, such as the distension or ap.proach to the surface of a tumour or aneu.rism. Inflammation is produced by the ap-plication of strong acids to any of the animaltextures; by pure alkalies, and various otheracrid matters, whether animal or vegetable.Under the former head, we may mentionmorbific poisons. Again, it is produced bythe bites and stings of a variety of insects,and by the bites of rabid animals. It is pro&middot;duced by the application of cold or moisture;and by various atmospherical changes, thenature of which we cannot exactly appre.ciate ; and here we find that some such in.fluences are capable of producing inflamma-tion directly ; thus a current of cold air, par.ticularly if combined with moisture, willcause inflammation of the eye. The same

immediately applied to the mucous mem-brane of the nose, throat, trachea, and air.

passages of the lungs, will cause inflamma-tion of these parts. Again, the applicationof cold or moisture to an external part marbring on inflammation in some internal or.

gan, or in some part remote from the seat ofthe direct application. Thus, if a personget wet in the feet, he may have an attackof catarrh, sore throat, or rheumatism.Cold and moisture, and the various atmo.spherical changes, are thus capable ofinnu-encing indirectly the internal and compara-tively remote parts. An organ may becomeinflamed in consequence of excessive exer-tion in the execution of its natural function,

203

Thus, if the eye be excessively exerted inthe observation of minute objects, inflamma.Mn may be produced in it. Excessivemental exertion will cause disorder in thehead. In the same way, the stomach or in-tesunes, the lungs, or the various other or-gans, may be immediately inflamed, in con-sequence of unnatural exertion in the exe-cution of their ordinary functions.

’

The causes of inflammation now mention.ed, admit of being divided into two classes:some of them, such as external injuries, orthe application of chemical substances or

morbific animal poisons, will produce inflam-mation wherever they are inflicted. Theycertainly and necessarily produce it in somedegree; it may be more or less. Supposewe take the case of a surgical operation. Ifthe operation be performed on a person whohas been carefully prepared for it, and who is,in other respects, healthy, only a slight de-gree of inflammation would be the conse-

quence ; but if the individual should be un-healthy, or if no pains should have been takento place him under favourable circumstances,a very considerable degree of inflammationwill be produced. If you extract a cataractfrom an individual in a healthy condition ofbody, and whom you have carefully preparedfor It, perhaps you will have hardly any per-ceptible inflammation at all; but if the opera-tion be performed in a person of gouty habit,arthritic inflammation may come on, and evenfrustrate the intention of the operator. IIit is performed on a person of plethoric habit,without means having been adopted to pre.pare him, an attack of common idflammatioiimay be the result, and which may have thesame effect.The other causes, that is, cold, moisture,

various atmospheric changes, and excessiveexertion, do not act invariably ; for they willproduce inflammation only under certaincircumstances. If many persons are ex-

posed to cold, with rain, sleet, or snow, thegreater part will not suffer any injuriousconsequences ; but perhaps one may have asore throat, another an attack of catarrh, anda third an attack of rheumatism. A largenumber of individuals may sit down to afeast, and perhaps one out of the numberwill experience an attack of apoplexy, or ofpalsy. A person in good health may receivea shght blow on the foot, without any fur-ther inconvenience than slight pain at themoment; a similar accident in another, maycause an attack of gout.Thus we have to consider not merely the

causes, but the state of the individual towhom they are applied ; and this brings us tothe cistmction I have already pointed outbetween the direct or immediate, and theremote or predisposing causes.The direct or immediate, in many in.

aividuals, will not produce disease, unless

the individual shall have been prepared forits action, by the effect of the remote or

predisposing cause.Under the head of remote, or predis-

posing causes to inflammation or diseases ofany kind, we may enumerate the naturalpeculiarities of organisation which belong toindividuals. All mankind are not construct-ed alike. There are differences in organisa-tion ; there are consequent differences inthe functions executed by the organs, andhence the state of health, which is a state ofexertion in the functions of all the organs,will present a variety in each individual. Ifwe look throughout the whole of the worksof nature, we see that it appears to be herobject everywhere to produce variety. Na-ture, if we may personify her, seems to havenothing of the quaker taste ; she takes nodelight in uniformity of colour or shape.(Laughter.) She has not thought fit to cutout all mankind by one pattern. There are,in fact, varieties in the organisation andfunction of every part ; varieties that arecommon to a considerable number of indi.viduals, and they being arranged and classedtogether, constitute what physiologists havetermed differences of temperament or con-stitution ; that is, the predominance of cer-tain particular organs, or systems of organs,in certain individuals. The sanguineous,the nervous, the lymphatic, and the bilioustemperaments. In the first, the circulating ;in the second, the nervous; in the third,the absorbent ; and, in the fourth, the ali-men-tary, chylopoietic, or digestive systems,seem to be predominant. These differencesof temperament or constitution have beenrecognised from the remotest times, and. nodoubt, such differences are founded innature. There are other differences whichbelong to individuals, and these are calledidiosyncrasies. This is a Greek term, whichmeans-peculiar mixture. Now we see

that there is, in fact, a something peculiarin each individual; we find this more par-ticularly traceable in some individuals, bythe effects of external applications. Wesee a particular sort of medicine or food pro-duce a certain condition in one person,which it does not in another. There aresome in whom we find it difficult to affectthe system with mercury ; there are others,whom a grain, or two grains, of blue pill willsalivate. Another law of nature is, that

organised beings produce by generationnew beings like themselves, otherwise spe-cies and races would not be preserved ; andthe law by which new beings partake of thecharacter of those who give them birth, ex-tends to the differences of temperament.Thus it happens that different dispositionsare inherent in different families, just likeparticular forms of features.We come, in the next place, in consider*

204

ing the circumstances which give predispo-sition to certain diseases, to consider what 1are called morbid differences; these ap-proach nearer to the state of disease than the edifferences of temperament mentioned,though it would not be very easy to draw aline of distinction between them. Of mor-bid, I may mention scrofula, gout, and rheu.matism ; these, in some measure, depend onnatural and original differences of constitu.tion, and are transmitted hereditarily ; butin other instances they are produced byexternal agencies. An individual who maybe supposed to be born healthy, may havea morbid disposition to disease, which maybe either hereditary or acquired. It is tothis the technical name of diathesis is ap-plied. A scrofulous disposition, or scrofu-lous diathesis; a rheumatic or gouty dispo-sition, or rheumatic or gouty diathesis-these are equivalent terms. Age and se.r,in some instances, give a particular disposi-tion to certain diseases. Climates havecertainly a marked influence in disposing todisease. Atmospherical heat disposes to

inflammation, and particularly to that of theskin. Erysipelas is a very common andserious occurrence in hot countries. Theliver is very liable to be affected by hightemperature. Thus, though abscess of thisorgan is rare in this country, yet nothing ismore common than such an affection in

Europeans who visit the East or West In-dies. The yellow fever, a dreadful scourgein those countries, owes its origin to the highdegree of atmospheric temperature. It issaid, that in some of those places, if Fahren.heit’s thermometer remains steady at 80&deg; forfour or five or six weeks, the yellow feverwill invariably occur.Now I have thus far considered inflamma-

tion as the result of causes acting directlyon the organs that are the seat of such dis-order ; that is, I have considered what wemay call accidental inflammations&mdash;inflam-mations that arise directly from causes im-

mediately applied. But in many instanceswe cannot trace the application of any causeto the affected organ : this is the case witha great number of internal inflammations;such are called spontaneous inflammations.By this we do not mean to assert, that theinflammation actually arises ofitself, only thatit takes place without an apparent adequatecause. We see in children inflammation ofthe brain, leading to effusion of fluid iuto theventricles, or 7iydi-oce ,p)zaliis; we see in-flammation of the arachnoid coat and piamater in the adult, producing various affec-tions of the head, and, many times, mentalderangement. Inflammation may occur inthe liver or stomach&mdash;erysipelas may attackthe face-the synovial membrane of a jointmay become inflamed, or a joint generally.Thus inflammatory affections may occur

either in internal or external orgaM, wherewe cannot trace the application to those

organs of any causes capable of producingdisease ; hence we have established thehead of spontaneous, in contradistinction toaccidental inflammation.Now though we cannot in many of these

cases trace the application of local causes tothe seat of disease, we can often discern theremote or predisposing circumstance, whichwe may consider to have had an influence in

originating the disease. We find these re-mote or predisposing causes also actuallycapable of leading to the occurrence of acci-dental inflammation.The most powerful and general of the

predisposing causes, whether of spontaneousor of accidental inflammation, undoubtedlyis what is called, in common language, ful.ness of habit, or what we technically callplethora of the system, that is, an unhealthycondition of the frame, produced by takinginto the body an excessive quantity of newmaterials, by indulgence in the pleasures ofthe table, by eating and drinking too much.The natural supply of the frame requires,that a certain quantity of new materialshould be introduced into it, but persons arein the habit of taking perhaps, twice orthree times the quantity the natural wantsof the economy require ; hence arises a stateof repletion ; the digestive organs are over.loaded, and a state of repletion occurs in thesanguiferous system, which receives the newmatter from the digestive organs. Personscommit errors with respect to diet, not onlyin quantity, but in quality, and both theseare chiefly observed in two articles, that is,animal food and fermented liquors. It is,perhaps, rather difficult to determine whatis the minimum of supply that will keep thebody in a healthy or proper state ; but wehave facts from which we conclude, that amuch smaller quantity is sufficient for that

purpose than persons are in the habit of

taking. There is a celebrated example ofthis, which has been frequently cited inthis theatre, that of Cornaro, a Venetiannobleman. He had been in the habit of

indulging, like the rest of mankind, till hearrived at about the age of -10 years. Hethen lost his health, and became the subjectof serious and various ailments. ’He in vaininvoked the aid of the medical art. He

then undertook his own case, and resolvedto try what he could do by starvation. Bypractising a system of rigid abstinence, in ashort time he got rid of all the symptoms hehad been troubled with. He continued to

pursue this course of abstinence until hearrived at nearly a hundred years of age,leading a very active life, in the full enjoy.ment of all his powers, bodily and mental,and holding important offices in the state,

, being in fact a character of considerable im-

205

portance in Venice. He has left behindhim a small book, entitled, " Praises of aSober Life;" and in that he states of himselfwhat I have mentioned, and says, that hisdiet consisted of twelve ounces of solid foodand fourteen of liquid. per diem; that wouldbe four ounces of solid food taken threetimes a day. He states, that this system ofabstinence was so necessary to the enjoy-ment of his health, that when he exceededthe twelve ounces and took fourteen, he im&middot;

mediately became hot and feverish, and feltthe necessity of going back to his formerquantity. I was very well acquainted witha lady, the mother of a numerous family,always robust, healthy, and capable of tak-ing plenty of exercise. She lived verycarefuliv never taking more than a singleglass of wine a day, and seldom that, withabout half the quantity of food that personsordinarily take. She, however, was occa-

aionally subject to disease, and that was ofan inflammatory nature (erysipelas), thoughshe lived in this abstemious way. At anadvanced period of life she experienced de.termination of blood to the head, which re-quired active treatment for a considerabletimf.That the quantity of animal food and fer-

mented liquor persons take, and suppose tobe necessary, is by no means so, may beunderstood from a variety of circumstances.I was myself acquainted with a lady, who,from a kind of whim, began to live on vege-table diet. She was in good health, and itwas not necessary at all for her to give upher ordinary habits of life. She took a fancy,however, to live in this way, and on dis-tilled water, and, in point of fact, she didlive on fruit and vegetables, without tastinganimal substance, except the milk she tookin her tea, for several years. I never knewa more active person ; she made nothing ofwalking ten miles, and could walk twenty.She was a very little, sprightly-made woman.She bore two children during the time Iknew her, and suckled them for about twelvemonths each, but never took any thing what.ever beyond what I have stated to you. Shenever drank any thing stronger than tea.

In London we have the opportunity ofobserving the effects of habits contrary tothese. Persons who follow laborious occu.pations here, such as porters, coal-heavers,draymen, and a variety of individuals whofollow the more laborious avocations in Lon-dan, do eat and drink most enormously.&mdash;Laughter.) A great number of them passthrough this hospital, and give us the oppor-tirlity of seeing their habits. As for two ortLree pots of porter a day, that is scarcely amouthful.&mdash;(Laughter.) You really wouldLtrdtyheliete, that many of these personsdrink eight, ten, twelve, or fourteen quartsoi porter a day, filling up the intervals with

glasses of gin (continued laughter) ; and

really take animal food in proportions thatwould perfectly astonish you ! Now theseare individuals formed for robustness andlong life ; they are strong men, who comefrom the country, and who, if they took onlymoderate care of themselves, might reachold age, with full possession of their bodilypowers, but they very seldom come to anything near it; we see a great many of themout here. Their habits of excess predisposethem to inflammation; they suffer from dis-ease of the liver, stomach, lungs, heart, &c.Thus most of them, if their lives are notcut short by some accidental injury, whichgenerally leads to most severe inflammation,die of dropsy about the age of fifty. I re-member having been called to a very fine,hearty, young fellow, one of Whitbread’sdraymen, under thirty years of age ; he wasquite a picture of strength ; he had merelygrazed his leg against the iron hoop of a butt.He did not think much of the accident, andwent about his occupation ; but soon hisleg began to be painful; it became muchmore troublesome, and within forty-eighthours after he met with the injury I sawhim. The whole of his leg was then enor-mously swelled ; it was livid, black, blue,and the limb mortified up to his very body,and merely from the occurrence of this slightaccident.You will readily understand, that the

effect produced by an erroneous system ofdiet must be very considerable, for the causeof disease is incessantly applied. Per-sons eat and drink day after day, and yearafter year. When you inquire into a person’shabits, probably he will tell you that he isvery moderate, only taking three or fourglasses of wine a day. In the first instance,that does seem to be very moderate, but youmust multiply that three or four by 365, toascertain what he takes in the course of the

year, and then you will find that an enor-mous quantity of alcohol has been taken intothe system. This state of unnatural reple-tion, in the first place, seems to be attendedwith rather an improved state of health ; theperson seems to be ruddy, cheerful, andhealthy, but after a certain length of time,a condition of the body is produced whichapproaches to disease : there is a preterna-tural fulness of pulse, a disposition to heat,and thirst on exertion. Such an individuallives on the brink of disease ; a slight im-pulse is sufficient to destroy the balance andpush him over.With respect to the state of plethora in

those cases, the accuracy of that expressionhas been doubted. It has been questionedwhether the vessels contain more blood insuch cases, and it is difficult to determine.We do not know what the natural, regular,or normal quantity of blood is in a person

206

We have no means of ascertaining, in a par-ticular case, how much blood is in the sys-tem, therefore we want data for comparison.We cannot say whether an individual in thestate I have mentioned, has more blood inhis vessels than he has at another period ;yet we find in many of those individuals,that there is an unnatural fulness andstrength of pulse. It is excited by the

slightest exertion. When we take bloodfrom them, it frequently presents the ap-pearance which characterises blood drawnfrom persons labouring under inflammationit is buffed and cupped, so that whetherthe quantity is greater or not, at all eventswe can determine that such individuals arein an unhealthy state. They are in a statevery similar to that of females, in whommenstruation is suppressed, where you willhave flushed countenance, pain of head, andheat of the surface ; or to that of females inwhom menstruation has not occurred at thetime it ought. It is a similar state to thatwhich occurs in persons where old ulcershave been rapidly healed. For my own

part I am inclined to think, that there is anincreased quantity of blood in the system;that the expression of plethora applied insuch cases is literally true. I remember a

person coming under my care with cataract,for the purpose of undergoing the operation.He was a man between 40 and .50 years ofage. When I asked him how he was in his

general health, he said, perfectly well. Buthe had an enormous head, with a particularlylarge face, and that of a very deep brownishor sort of red colour; in fact, the appearanceindicated that state of the capillary system,which I did not like in a person about to

undergo such an operation. This led meinto further inquiries, and I found that hehad been in the habit of taking an inordinatequantity of animal food and fermentedliquor. He had a full, strong, and hardpulse, and there were other circumstances,in the state of his tongue, digestive organs,and so forth, which proved, though he saidhe was in a healthy state, that he was in acondition very far from it ; in that conditionin which I felt perfectly satisfied, if I per-formed the operation, inflammation of adestructive kind would be the result. 1 didnot operate for ten days or a fortnight after-wards. In that time I took 120 ounces ofblood from him, and did not conceive it safeto operate without doing so. If be had nothad more blood in his veins than ordinary, Ithink he would not have admitted of thattreatment. He was prevented from takingfermented liquor and solid animal food ; at

the end of that period, I can assure you helooked quite a different person (laughter) ;but I brought him to a state in which theoperation could be safely performed, and,indeed, it succeeded most perfectly.

ST. THOMAS’S HOSPITAL.

ABSTRACT OF A CLINICAL LECTURE

BY

DR. ELLIOTSON.

FEVER.

DR. ELLIOTSON had mentioned his inten.tion, at his last lecture, of making morbidanatomy the subject of the clinical lecture,whenever he should have an opportunity ;but, as no examination had taken placeduring the week (Dr. E. having lost only onepatient since the commencement of the

season), he should, this morning, bring be.fore them two cases of the common con.tinued fever of this town, both which oc.curred in individuals of about the same age.The first was that of John Guinn, a youngman, aged nineteen, from a place at Shore.ditch, called Castle Court. There was noone ill in the neighbourhood excepting him.self, as far as he knew ; but he had beenmuch exposed to wet and cold lately in thestreets, and was attacked ten days beforeadmission with a cough, pain in his head,sickness, shivering, and a feeling of loss ofpower; complains of pain, on pressure, atthe epigastrium. There is great heat ofskin, and thirst. Pulse 72, full; tonguevery much coated in the centre, and red atthe edges and tip ; bowels open from medi.cine ; slight expectoration ; countenancethat of fever. Ordered

Hyd. submur., gr. vj., statim et cras mane;Slops only for diet.On the following day, the bowels had not

been opened ; there was great heat of skin;had slept ill; pulse quick, strong, and full;and there was pain on pressure at thescrobiculus cordis. Ordered

Olei ricini, 3vi. statim.Hirud., xviij., scrobic. cordis.Hydrargyri submu2-iatis, gr.vj. crasmane.Cold or tepid ablution whenever he is hot.

Under this treatment he quickly recovered.The second case was that of Anne Buller,

xtat. 17, who was attacked ten days beforeadmission with rigors, followed by ex.

treme heat, and some thirst, and constantpain in the head, with evening exacerba.tions, for the first few days. Five days agopain came on in the abdomen, back, andlimbs, with great sense of weakness, andhas continued ever since. She was then

bled, and has been taking, she says, largequantities of purgative medicine. The painnow is principaliy of head, epigastrium, andright hypochondrium, with some pain in theleft hypochondrium, and generally over thewhole abdomen ; great tenderness of the epi-