A young healthy man, aged 26, was admitted into Hospital on the evening of the 7th November. I saw him early on the morning of the 8th, and decided to operate at once, as the diagnosis was obvious, and the man was rapidly becoming moribund. On opening the peritoneal cavity a large quantity of fluid containing pus and several faecal concretions escaped. The appendix was gangrenous and had perforated. The abdomen was thoroughly washed out with hot saline and a rubber drain inserted. For many days he was desperately ill, but he gradually improved, pain became less, tongue, which had been like a burnt chip, became moist, and he felt fit to get up when I last saw him on the eighth day after the operation.

I was then absent from the Hospital for three days, owing to illness, and was thunderstruck when I saw in the morning paper on the 12th day that he was dead. He had been seen by the Medical Superintendent the previous evening, and was feeling and looking so well that Dr. Ewart put him down for a liberal diet for the following day.

The nurse in charge reports that he slept until 3.25 a.m., when his breathing suddenly became embarrassed, he lost consciousness, and perspired profusely. He asked if he had had a faint, and said that he felt very weak. After an interval of a few minutes his breathing again became much louder, pupils dilated. Temp., 97° Fahr.; pulse, uncountable. These attacks occurred at intervals of a few minutes, and he died shortly before 4 a.m. For the last ten minutes he had been getting more cyanosed, and was unconscious.

I regret that I did not see the partial post-mortem that was made, but the Assistant House Surgeon reported about 3 oz. or 4 oz. of a brownish fluid in the peritoneal cavity, so that it would seem that the peritoneum had come off the victor in its phagocytic contest. There was a patent foramen ovale, and all the cavities were filled with blood. By some curious oversight the lungs were not examined. This malformation had never been suspected in him, as he was always so strong and healthy, although a brother of his suffered in the same way. I find it impossible to believe that this had anything whatever to do with his death.

To my mind, a much more likely explanation is that he had thrombosis of a large vein in the abdomen, and died of pulmonary embolism. The patent foramen ovale would account for the cavities on both aides of the heart being full of blood.