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by day. Soon after the commencement of his illness he consulted a Norwegian surgeon, who prescribed an ointment which discoloured the skin and did not benefit him.

On admission, the left knee-joint was greatly swelled and very painful, and fluctuation was felt below the patella. The thigh was twice its normal size and very tender on pressure, especially in its lower third, where deep-seated fluctuation was felt. The left ankle and foot were oedematous. He was very weak, but he exhibited no symptoms of organic visceral disease. Hot fomentations were applied over the affected joint, and the limb was kept elevated.

By the use of these means the oedema disappeared in a few days, but the size of the thigh and of the joint had not diminished. His appetite and general health were improved, and he suffered little pain.

On May 1 the patient's constitutional state was much better; but behind the diseased knee there was a sudden increase of swelling and distinct fluctuation to be felt. An incision was, accordingly, made into the sheath of muscles on the outer aspect of the thigh, just above the knee-joint, and this evacuated a large quantity of pus and of venous blood. Amputation through the lower third of the thigh was performed at once, as it was evident that the popliteal vein had given way. After sawing through the femur at the usual point, it was found to be still further diseased; and more of the bone was removed. Suppuration was found extending along the thigh close to the femur above the point where it had been divided last. No reactionary hæmorrhage occurred. On dissection, a small ulcerated opening was discovered on the outer aspect of the

popliteal vein, and the tissues of the popliteal sheath were found thickened and matted together. The medullary structure of the femur was disintegrated, and macerated by unhealthy and very fœtid pus.

The patient improved daily after the operation. He gained flesh and was in good spirits. The stump healed well, and the discharge from it was healthy and profuse. The treatment consisted of nourishing diet, with tonics and large quantities of wine and brandy. Occasionally an opiate was given at night. The ligatures separated at the normal period.

On May 11 the patient was observed to have a bed

sore.

He had a rigor two days later, and next day the wound looked sluggish and discharged less. Rigors occurred daily, and were followed by pyrexia.

On May 16 his face was flushed, and his appetite for food was impaired. His lips were parched. He had slight cough. The discharge from the stump was scanty in amount.

On the ensuing day the patient became very delirious, and tossed about. Although he had received an opiate at bed-time he had been very restless during the night. His tongue was dry and brown, and his teeth covered with sordes. The dusky-yellow pyæmic tinge was well developed, and his breath had a sweet and hay-like odour. The wound was sloughy and sluggish, discharging a scanty amount of bluish-green and very fœtid pus. He died on the evening of the following day. Pathological Appearances.-The body exhibited the characteristic dusky-yellow hue of suppurative fever.

On opening the thorax its cavities were found to contain a considerable amount of seropurulent fluid;

but there was a smaller quantity of it on the right than on the left side. Both layers of the pleuræ on either side were covered with lymph at their lower part; and both lungs contained numerous secondary abscesses in all stages of development. The lower part of the left lung was firmly adherent through old pleuritic exudation. There was some yellowish serum in the pericardial cavity, and firm coagula in the heart.

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The liver was somewhat enlarged, but not discoloured. There were several spots of extravasation distributed through the hepatic substance. The spleen was larger than normal, pulpy, and contained pigment. The kidneys were somewhat flabby. No secondary abscesses were found in the abdomen.

On dissecting the stump, the periosteum, as far as the lesser trochanter, was greatly thickened. The end of the femur was necrosed. Secondary abscesses, containing greenish fœtid pus, were observed in close proximity to the blood-vessels along about half the length of the

thigh; but they did not communicate with the bloodvessels.

Remarks. There are many note-worthy points presented by this case. The primary disease was evidently acute necrosis of the femur, which soon involved the neighbouring knee-joint, For some days after the patient's admission into hospital he improved greatly, till a sudden swelling behind the knee-joint led to the suspicion of hæmorrhage taking place among the deepseated soft tissues of the limb. An exploratory incision proved the surmise to be correct; and dissection after amputation revealed an ulcerated orifice on the outer aspect of the popliteal vein communicating with the interior of that vessel. This lesion is of interest on account of its rarity, but still more so when viewed in relation to the origin of suppurative fever. The osteomyelitis of the femur, present in this instance, leads to the inquiry, whether the suppurative fever which followed is to be ascribed to the introduction into the system of morbid matter through the vein, or to its imbibition by the medulla of the bone, or to both combined. The ordinary sequence of phlebitis to osteomyelitis was not observed in this case; and the symptoms exhibited lead rather to the conclusion that these forms of unhealthy inflammation were not the sources of systemic infection. Even though the limb was amputated, the untoward sequela of suppurative fever supervened, confirming my remarks on Professor Fayrer's proposal of curing pyæmia by amputation, to be found in a subsequent chapter, under the title of the "Treatment of Suppurative Fever."

CHAPTER IV.

SYMPTOMATOLOGY OF SUPPURATIVE FEVER.

LIKE most non-contagious fevers, suppurative fever presents a chronic and an acute form. Chronic pyæmia is most commonly met with in connection with such medical affections as typhus and scarlet fever, empyema, rheumatism, dysentery, &c.; while acute pyæmia generally succeeds surgical operations and injuries, and parturition.

Examining carefully the symptoms presented by these two forms of the disease, they meet us as general and local phenomena. The constitutional or general symptoms which characterise suppurative fever in its acute form, or as a consequence of surgical wounds and affections, are best considered analytically, as follows:

The Physiognomy.-The face is often flushed. This flushing is general and of a reddish hue; sometimes there is great pallor, and sometimes alternate flushing and pallor. The countenance is anxious; but there is no particular characteristic expression, like that in peritonitis or apnoea. Occasionally the patient is depressed he anticipates from the very outset of the disease a fatal issue. As the fever progresses the features become pinched, haggard, and care-worn. During sleep

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