TABLE ILLUSTRATING THE VARIOUS SAGES OF SUPPURATIVE FEVER AND THEIR DURATION IN THE ABOVE TWENTY CASES. Nature of the Original Disease. Stage of Invasion. Typhoid Stage. Catheter was passed on Pulmonary symptoms appeared} Set in on June 14. Stage of Incubation. CASE I. Retention of urine. { June 9 on Rigors occurred on April 12. Secondary hæmorrhage and a } Pyrexia felt on May 26. Rigors occurred on July 4. Countenance anxious on July 1. Not marked. XI. Wound into knee-joint. XII. Chronic pyæmia. Unknown. Amputated on November 6. Rigors set in on November 11. Amputated on May 6. CHAPTER V. ON THE PROGRESS OF SUPPURATIVE FEVER. THE ordinary course pursued by this fever has been for the most part indicated in the remarks on the symptoms of this disease. Besides referring briefly to these, it will be advantageous to notice certain complications which occasionally accompany this affection, and likewise the sequela which sometimes occur after convalescence has commenced. The Stages of Suppurative Fever.-The symptomatology of suppurative fever points to certain stages, which are generally more or less well defined. These stages resemble those of other fevers in being characterised by certain symptoms, in bearing a certain relation to time, and in observing a definite succession. Four stages may be described: The Stage of Incubation; The Stage of Invasion; It will be observed that no mention is made of the crisis, which in other fevers is a most important point. As yet a sufficient amount of observation on the progress of suppurative fever has not been collected to enable us to define such a period as the crisis. No doubt by-and-by this point will be more clearly settled, and, in the meantime, we must speak of convalescence as following the typhoid stage of suppurative fever, without any limit between the two stages being detectable. The twenty cases I have before reported are arranged in the preceding table, p. 136, with the view of showing the succession and the duration of these four stages. The incubative stage of suppurative fever is a latent indefinite period, which doubtless exists, but cannot be specified. In the case of contagious fevers, data, pointing to certain media of contagion, or to the existing action of certain epidemic influences, can be employed as fixed points, from which to reckon the commencement of the stage of incubation. In suppurative fever there are no such fixed circumstances from which to calculate. This fever is not contagious, and, though sometimes prevalent, cannot be strictly spoken of as epidemic. As to the duration, then, of the incubative stage of suppurative fever, and as to the symptoms which characterise it, nothing definite can be stated at present. An attack of suppurative fever may be dated most correctly from the occurrence of the first rigors; or, when this symptom is absent, from the time at which depression of spirits, or any of the other premonitory symptoms before narrated occur. As has been before remarked, pyæmia and puerperal fever generally set in on the fourth or fifth day after an operation, injury, or delivery. In fifteen among the twenty cases I have quoted, as seen in the preceding table, rigors were experienced, and this symptom served to fix the stage of invasion. In two instances the history of the cases was too indefinite to enable us to specify the stages of the fever; and among the remaining three cases the stage of invasion was marked in one by pulmonary symptoms, in another by pyrexia, while in the third case an anxiety of expression first betrayed the change for the worse which had taken place in the patient. The accession, then, of suppurative fever is indicated generally by rigors, followed by increased temperature of the skin, profuse perspirations, and thirst. This pyrexial condition has scarcely passed off, when the patient is attacked with bronchitis or pneumonia. The appetite is rarely affected at this stage of the fever, and for a few days (three to ten days) after the commencement of this stage, the constitution is apparently not affected. The patient complains of cough, restlessness at night, rigors at intervals, and of profuse perspirations; but in other respects he appears to be pretty well, when suddenly the typhoid stage sets in. The typhoid stage is characterised by extreme prostration, low muttering delirium, and by more or less unconsciousness; by the dusky-yellow (pyæmic) discoloration of the skin and conjunctivæ; by disinclination to food; by the purulent odour of the breath, and by the formation of secondary abscesses. Locally, this stage is marked by a sloughy inactive condition of the wound, and is accompanied by an ichorous, fœtid discharge. What this condition is due to we are unable at present to state. Whether the typhoid symptoms are owing to the retention of urea in the system, decomposed and eliminated as carbonate of ammonia, which is supposed to be the case in typhus; or whether they are ascribable to the presence in the blood of sul phuretted hydrogen, or of some other gas, or of some foreign substance generated by the suppurative process in the viscera or in the wound,-requires to be determined by further research. That the systemic infection has not a local origin, but that the changes in the blood, which induce the typhoid symptoms, commence in the lungs either in consequence of deficient oxydation of the blood, caused by the pneumonic hepatisation of the pulmonary tissue, or in consequence of some specific agent developed in the contents of the secondary pulmonary abscesses,—will, I think, be acknowledged by all. Pus, as such, has nothing to do with inducing suppurative fever, nor do its liquid contents produce this condition; but it is probable that some catalytic process is excited by purulent fluid in contact with imperfectly oxygenised blood. When the typhoid symptoms advance rapidly, the discharge is profuse and the prostration extreme, death taking place in from three days to a week after the commencement of this stage. As regards convalescence, the symptoms which mark a return to health are developed very gradually. An improved appetite and better spirits are generally the first signs of amendment. In Case XVII., the only instance of recovery which I have cited, convalescence set in on the fourteenth day after the commencement of the typhoid condition. On careful observation of cases of recovery from suppurative fever, it will be found, I believe, that the stage of convalescence, like the other stages of this fever, exhibits a periodical character, i.e, that it commences generally at dates corresponding to weekly periods. For example, in Case III. secondary hæmorrhage and rigors occurred on the fifteenth day after |