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nently rounded half and an upper more flattened mass.The growth involved the scapula, and completely fixed theshoulder-joint, but the whole mass with the scapula movedfreely over the thorax. The skin was not broken, but wastight, and cracked over the posterior part of the growth,where it was of a dark-red colour. The tumour throughoutwas hard and bossed here and there. Its circumference atthe most prominent point was twenty-four inches. Theglands in the axilla and neck were not enlarged. The chestand abdomen were healthy. On July 4th, 1883, Mr. Heathmade an oval incision as for amputating at the shoulder,and, having stripped back the skin, cut upon the positionof the shoulder-joint, and removed the arm, necessarilyleaving a large mass of growth attached to the scapula.The axillary artery was tied with hemp ligature, and theneck of the scapula, with the glenoid cavity and inferiorborder of the bone, was sawn off. Mr. Heath next removedthe scapula, first dividing the clavicle at its outer third, andthen isolating the posterior border of the scapula. Thewound was dressed on the second and fourth days, and thepatient made an uninterruptedly good recovery. The highesttemperature was 104° on the eighth day. He was dischargedon August 30th, being only fifty-nine days in hospital. The

part removed consisted of a large mass of ossifying sarcomasurrounding the upper end of the humerus, and firmly unitedto the scapula and clavicle, the growth extending down thehumerus to the junction of the upper and middle thirds.The scapula itself was but slightly affected, the growthextending backwards for a short distance around the neck ofthe bone and down the axillary border. The growthextended into the subscapularis, teres minor, and, shghtly,the infra-spinatus muscles. The cut end of the clavicle washealthy. Microscopically, the growth was found to be asarcoma of mixed small cells and oval corpuscles, withextensive ossification, in the shape of bony spicules, runningthrough the tumour. In none of the spicules were Haversiancanals to be seen, but lacune were normally developed.Mr. Heath added that since the patient was last seen a smallloose nodule had sprung up near the cicatrix, which he

proposed to remove at once.-Mr. BUTLIN thought that therecurrence, the great extent of the disease, and the generaland micrcscopical characters proved that the growth was ofa malignant nature. The glands were not affected, as wasusual in subperiosteal growths unless they grew directlyinto lymphatic vessels.-Mr. BARWELL had performed a

somewhat similar operation for the late Mr. Hancock. Thegrowth recurred, and was considered to be malignant.

Dr. HENEAGE GIBBES exhibited a number of the differentforms of Putrefactive Bacteria :-A section of DiphtheriticMembrane showing two forms of micrococei, one large ingroups, the other much smaller in masses. A section ofHuman Spleen from a case of Tuberculosis, showing largemicrococei in groups; similar organisms were found in thelungs and liver of this case. Sections from the Livers oftwo Pigs which had died of the Purples or " Red Soldier ";sections of these livers were full of bacteria, but the forms

were quite different in each; in one liver the bacteria con-sisted of short rods not joined together, in the other theywere very long and slender ; section of kidney from one ofthese cases showed the vessels full of a form quite differentfrom those in the liver. Stool from a case of InfantileDiarrhoea, showing organisms very similar to those in thespecimen of rice-water stools sent by Prof. Straus. Verylarge organisms from the stomach in a case of Carcinoma ofthe Pylorus. Spirilla, vibriones, various other forms of bac-terium in chains, and micrococci from putrefying animalmatter in water, were also shown. Section of MesentericGland revealing the so-called Typhoid Bacillus, shownwith a lIT oil immersion x 800. Human Sputum from acase of Tuberculosis; one specimen showed nine differentforms of bacteria, and this with an oil immersion lensmagnifying 600 diameters. These specimens were shown withMessrs. R. and J. Beck’s new pathological microscope,made from Dr. Gibbes’ designs.

CLINICAL SOCIETY OF LONDON.

Thrombosis of Vena Cava.—Charcot’s Joint Disease.—Dis-location of Semilunar Cartilage.1 ,J

THE ordinary meeting of this Society was held on Friday,February 22nd, Sir Andrew Clark, Bart., President, in thechair. The number of living specimens shown was a decidedfeature of the proceedings; the keen interest which was

excited by this clinical display affords abundant evidence ofthe partiality of the members for practical medicine andsurgery.Dr. MANSELL MOULLIN brought forward a case of

Thrombosis of the Inferior Vena Cava. The patient, a managed thirty-five, was admitted into the London Hospital inAugust, 1883, for varicose veins and ulceration of the left lowerextremity. He was employed as a paper-hanger, and had beena trumpeter in the army. There was no history of syphilisor gout. A year and nine months before admission he felldown a staircase on to his back, cutting his right leg severelyand falling with his loins across the hand-rail. From theeffects of this accident he was confined to bed for five weeks,his right leg, the one injured, becoming much swollen.While in bed, three weeks after his fall, he noticed that theveins in the lower part of the abdomen were enlarged, andfrom that time they have gone on gradually increasingin size and spreading in extent up to the present time.There does not appear to have been at any time either generalanasarca or hematuria. On admission it was noticed atonce that the abdomen was covered with great clusters oftortuous veins, which might be divided into three maingroups-two on the left side, the one having its origin inScarpa’s triangle, and the other just above the crest of theilium ; and the third oa the right, behind, some four inchesto the right of the vertebral column ; and from these maingroups great coils of enormously distended veins stretchedupwards, gradually diminishing in size as they reached thethorax and could pour their contents into the superiorepigastric, intercostals, and long thoracic veins. The rightepigastric was but slightly enlarged in comparison, butin this, as in all the rest, the currrent was upwardsin direction. The left limb was so swollen as only tobe lifted with difficulty ; the right, six inches less incircumference, was almost normal. In the abdomen was alarge ill-defined mass lying in front of the vertebral column,most prominent opposite the umbilicus, and running down tothe right of this a line along which pulsation and a systolicthrill and bruit could easily be ascertained. Besides this, inthe large left lumbar cluster were a continuous thrill and anexceedingly loud bruit. There were no signs of aneurism,the pulsation in the abdomen being distinctly non.expansile;the lungs were emphysematous ; the heart slightly enlargedand the aorta dilated ; there were no haemorrhoids, or vari-cocele to any extent, or albuminuria. The diagnosis madewas that of thrombosis of the inferior vena cava, with a clotextending down through the left iliacs to the femoral on thatside, the ill-defined tumour in the abdomen being theplugged inferior cava, with swollen and cedematous tissueround it, the line of pulsation corresponding to some largeabdominal vessel, probably the superior mesenteric dis.placed to one side. The thrombus could never have ex-tended above the renal veins, but there is no evidence toshow whether it originated in a small trunk and spreadtill it involved the cava, ceasing where the renal veins

poured in a large current or started in the cava itself. Thereis, however, little doubt, from the time of its occurrence, thatit must be directly connected with the accident. Referencewas made to a case published by Robin, in which violentexertion while in a stooping position produced the sameresult, and to other cases, which tended to show that com-plete obstruction of the inferior cava need not of itself causeappreciable enlargement of the external veins or much oedema.-The PRESIDENT inquired whether the urine was normal.If it were so, it was surprising when the great extent of’theaffection of the veins was borne in mind.-Dr. MANSELLMouLLIN said that he had not examined the urine for threemonths, but it was healthy at that time.

Mr. R. CLEMENT LUCAS read a paper on Charoot’s JointDisease attacking the Right Elbow and Foot. The patient,a man aged thirty-nine, came under notice last autumn, andwas at that time exhibited at the Society. His father diedof heavy drinking and consumption. His mother was stillliving, but suffered from dropsy and asthma. He was one ofnine children, seven of whom were living. One brother wasa cripple from paralysis of right side from birth, but lived to beforty. The patient denied having had syphilis, and there wasno history of fits or insanity in the family. He had been muchexposed, as a hawker, to wet and cold, and had drunkfreely. About four or five years ago he became subjectto rheumatic pains. He had had neither girdle-pains norgastric crises. For twelve or eighteen months he hadhad occasional numbness in his hands, especially theright, and had found a difficulty in buttoning his collar and

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in walking in the dark. Eight or nine months ago he hadan attack of double vision, which lasted only about a

week, He occasionally felt giddy when starting to work inthe morning, but was unconscious of any defect in walking.About two years ago his right elbow became enlarged, butnot very painful He sought advice, and was treated withblue ointment. He had continued to work with this arm eversince. A few weeks before being seen his right foot becamesomewhat suddenly enlarged, red, and painful, and it was onthis account that he came under observation. The swellingextended from the malleoli to the bases of the metatarsalbones, and occupied the doraum and sides of the tarsus.It was neither codematous nor tender, but he sufferred fromaching pain beneath the head of the astragalus, especiallyafter walking. The right elbow-joint presented a remark-able deformity. On the back of the ulna, two inches fromthe tip of the olecranon, was a rounded projection about thesize of half a Tangerine orange, two inches in diameterand bony at the base. Between the head of the radius andthe olecranon was another projection, sharp, prominent, andbony, apparently growing from the radius, and anotherprominence continuous with this between the head of theradius and the external condyle. These latter projectionsabsolutely prevented all pronation and supination. A smalloutgrowth sprangfrom the inner side of the olecranon, and pro-jected beneath the internal condyle. In front of the joint,just external to the tendon of the biceps, was a roundedswelling an inch and a half in diameter, covered by muscles.Flexion of the elbow could be carried to the normal limit,but extension was arrested at an angle of 150°. The jointwas free from pain. It measured about two and a halfinches more in circumference than the other. The signs oflocomotor ataxy were as follows :—He was unsteady whenhis eyes were closed; if told to touch his nose with his eyesshut he often missed the mark ; he had difficulty in walkingin the dark and in buttoning his shirt collar. His pupilswere not contracted, but unequal, and insensitive to light ;the patella reflexes were entirely absent. Mr. Lucasalluded to the liability there was of these cases beingmistaken for osteo-arthritis. He thought it rare for thejoint affection to be in advance of the ordinary sym-ptoms of ataxy. More generally the paralytic symptomshad existed some time before the joints suffered. Sur-geons had been blamed for not recognisiug the disease.The symptoms he thought were sufficiently distinct, butthe disease was not common among surgical out-patients.-The PRESIDENT said there was an apparent discrepancyin the report as to the presence of pain. Was there anyeruption at any time ?-Mr. CLEMENT LUCAS said the footoccasioned some inconvenience in walking. The elbow wasalmost painless. There was no eruption.-Dr. BUZZARDsaid that the case illustrated how such cases were over-

looked, for even Mr. Lucas had not detected the nature ofthis case when first examined. In those instances where theataxic gait was wantin, the dependence of the joint affec-tion on "locomotor ataxia " might not occur to some surgeons.He related the case of a man with Charcot’s disease of theright shoulder where the gait showed nothing abnormal, andwhich had not been recognised, though it had passed throughthe hands of at least one, and probably two, hospitalsurgeons. So he still thought a good many of thesecases were overlooked. This man had no ataxy ofthe legs; but he was a cabinetmaker, and his handi-craft was impaired, for he could not saw in a straightline or hit a nail with precision ; there was, in fact,incoordination of the movements of the upper limbs. Ex-amination also detected paresis of muscles supplied by theright oculo-motor nerve. "Rheumatic" pains and numbnessof the extremities of the fingers were also present. The jointswelling had appeared suddenly, and had been much greaterthan when he first saw the case. There was a " scraunching "feeling on moving the joint, but no luxation had occurred,and no bony outgrowths were to be felt. In Mr. Lucas’scase there was much bony growth about the ulna and radius,and no large amount of fluid in the joint. The destructiveprocess as regards the ligaments seemed not to have takenplace to its usual extent, hence there was not that oppor-tunity for attrition and wearing away of the bones. It wasa remarkable characteristic that the ligaments suffered firstof all in some cases, so we had an extraordinary laxity ofthe articulations. The ankle might turn in and nearly touchthe ground in such cases. With regard to the seat of thelesion, he was now more strongly inclined to think thatsome connexion existed between the medulla obiongata

and this effect on the joints of the body. 110 hadcomo across a great number (more than 50 per cent.)of instances of laryngeal, gastric, or intestinal ait’ec-tions, associated with bone-joint troubles, which tendedto support his views. He said all parts of the spinalcord might be diseased without there being any joint ail’ec-tion. Some sclerosis attacking the vagus "centre" wasprobably the cause of the damage of the nutrition of thebony skeleton in the disease in question. The facts seenin acute rheumatism supported such a hypothesis. The"centre" might possibly be the vaso-motor centre.-Dr.HALE WHITE spoke of a diseased pelvis which he had shownat the Pathological Society, and which Charcot and Fere hadnow pronounced to be an undoubted example of a rare kindof Charcot’s disease. This was the first post-mortem specimenwhich had been exhibited in this country. Some had saidthat the joint disease was not due to a nerve disorder; othershad maintained that if it were due to a nerve lesion, itpresented no peculiarity whatever that might not be explainedby the circumstances of the case. Weir Mitchell had saidit was impossible to distinguish a case of arthritis due tonerve lesion from other forms of joint affections. Cerebral

softening or haemorrhage was sometimes associated withjoint trouble ; these cases might be regarded as forming a con-necting link between the two classes of cases.—Dr. Al/rnAUScould not agree with the "central" hypothesis of Dr. Buzzard.Local lesions of peripheral nerves had been demonstratedto exist in such cases, Peripheral neuritis was of frequentoccurrence in locomotor ataxia. In some cases of severelocomotor ataxia he had found no evidence of anesthesia.He had frequently seen ichthyosis, or herpes, or othercutaneous eruptions in connexion with the disease.-Dr.BUZZARD said that in one case Charcot had found theanterior horns of the spinal cord healthy, and also the peri-pheral nerves ; so there was one case at least in which thehypothesis of peripheral neuritis did not obtain. -Dr.MoxoN had seen a great deal of locomotor ataxia, and thenotion of the frequency of the joint affection ran counter tohis experience. He would like to know whether the affec-tion was truly peculiar and special to ataxic patients.Before we asserted this we ought to have in our mind’s eyethe proportion of ataxies to the whole population as well asthe proportion of cases of chronic rheumatic arthritis. Itcould not be said that ataxies had immunity from thesufferings of the rest of humanity. It was fully possible forlocomotor ataxia and chronic rheumatic arthritis to put across upon one another when they happened to coexist.He had met with cases of gastric crises indistinguishablefrom those of locomotor ataxia, and chiefly of nocturnaloccurrence, in governesses and pupil teachers. In that over-scrutinised disease, locomotor ataxia, it was the fashion foreverything that happened to a patientaffiicted with it to be saidto possess an epiphenomenon. He could not accept such views.Dr. Buzzard’s centre in the medulla seemed to be a verywonderful Secretary of State for the Bone Department. -ThePRESIDENT said that he had seen cases of curious jointaffection associated with symptoms of chronic cerebraldisease.-Mr. CLEMENT LUCAS said that his case had muchexostosis and was exceptional. The disease was quiteunlike any case of osteo-arthritis he was in the habit ofseeing. He felt sure that the malady was an entirelydistinct and peculiar disease of the joints.

Mr. NOBLE SMITH read notes of a case of Dislocation ofone of the Semilunar Flhro.cartilages of the Knee.Joint.The left knee was first injured sixteen years ago by a fall.Great pain was felt, and while being carried home thepatient was upset, the knee again twisted, and the intensapain immediately relieved. This history was considered ascharacteristic of displacement of one of the cartilages. Thepatient was unable to move for many months, rest and localapplications being prescribed. After nine months walkingwas recommenced. The subsequent history was that of

repeated injury from trivial causes and a continued state ofweakness of the joint, with discomfort or pain during move-ment. The same kind of treatment was always prescribed,and in the course of weeks or months after each accident thepatient would gradually recover sufficiently to be able toget about again, but always with difliculty. On Nov. lltb,1882, this patient was first seen by Mr. Noble Smith. Astiff knee-cap was being worn, and any locomotion was verydifficult. Rest as complete as possible had lately beenagain recommended, and the advice was being carefullyfollowed. The knee was slightly flexed, and could notbe moved without pain. The internal cartilage of tho

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left kneo was felt to project slightly beyond the upperborder of the tibia. Upou pressure being applied to thisprotrusion while the leg was flexed and extended repea,tedly,the cartilage was felt to slip back, after which the patientwalked round the room quite naturally, and felt a relief whichhad only once been experienced since the first occurrence ofthe accident. A pad was strapped over the place wherethe cartilage had protruded. During the next few weeksthere was a tendency to relapse, but by perseverancewith the treatment the joint was gradually worked intoa natural condition. An apparatus iwas made which,while it permitted flexion and extension of the leg, pre-vented lateral motion and twisting. Walking exercise wasrecommended from the first, provided no pain was felt.This patient has remained quite well up to December,1883. Several similar cases had been met with by Mr. Smith.This displacement, which was first described and theappropriate treatment devised by Mr. Hey of Leeds, isto be distinguished from inflammatory disorders and the

presence of loose cartilages. The variety of the con-

ditions which may occur are described by Hamilton.Bonnet of Lyons experimented upon a dead body, andproduced displacement of the inner cartilage, and sub-sequently reduced the dislocation by extension. The expe-riment was frequently repeated with a similar result.-- Mr. HOWARD MARSH said the apparatus mentioned byMr. Smith was devised by Sir James Paget. The internalsemilunar cartilage was said to be more commonly displacedthan the external cartilage, which was also commonlyaffected. Mr. Godlee had shown a case in which the internalcartilage was lodged in the intercondyloid notch of thefemur. Cases of displacement of the external cartilagewhich had become crumpled up behind the femur, andcases of displacement of the external cartilage in frontof the femur, were also mentioned. We must suppose eitherthat there was great relaxation of their attachments or elseabsolute tearing away from their attachments. Casesoccurred in football where the kicking leg missed the ball.The case related by Mr. Brodhurst showed how a loose bodyappeared in the knee which turned out to be the posteriortwo-thirds of the lacerated external semilunar cartilage. Itwould appear that the femur overshot the cartilage, and sothe joint became locked. The mechanical treatment wassingulttrly successful; he had now used the clamp in at leastthirty cases with success.

Dr. Tvsoy of Folkestone related a case of the affectionin which an elastic knee-cap had not been successful. Theadoption of the tailor’s posture, which flexed and rotated thelimb outwards, succeeded in restoring the extended positionot the limb. He was glad to have heard of the properinstrument.-Mr. CLEMENT LUCAS referred to cases inwhich the semilunar cartilage had become displaced on theouter side. Two examples of this were narrated. -.!BIr.NOBLE SMITH said that in all his cases it was the internalcartilage. The sudden movement forwards and nothing tostop it was the cause of displacement. His apparatus com-bined the action of both the instruments devised by SirJames Paget.A committee, composed of Drs. Moxon, Douglas Powell,

Frederick Tayfor, and Fowler, was formed to report on Dr.Kingston Fowler’s case of pulmonary regurgitation.

Several living specimens were shown :-Mr. MorrantBctker showed a case of Anomalous Affection of CertainBones and Joints ; Dr. Buzzard, a case of Charcot’s JointDisease ; Dr. Stephen Mackenzie, a case of Excessive S weat-ing of the Upper Half of the Body of a Man; Mr. Symouds,a case of Congenital Hypertrophy of one Leg and Prepuce ;Dr. Kingston Fowler, a case of Pulmonary Rugurgitation ;Mr. Clement Lucas, a case of Excision of the Patella ; Mr.Rickman J. Godlee, a case of Nodules on the Finger.

MEDICAL SOCIETY OF LONDON.

‘’reat7iteat of Enteric Fever by Cold.THE papers and discussion on the treatment of enteric

fever by cold were brought to a close at a late hour on

Monday last, Sir Joseph Fayrer, President, in the chair.Dr. FREDERICK TAYLOR contributed the results of the

Treatment of Euteric Fever by the application of cold aspractised at Guy’s Hospital. The method employed hadbeen-(l) The bath at 70° or 75° F. ; (2) sponging with ice-coldwater ; (3) the wet pack, with ice-cold water; (4) the

application of ice-bags in the ftxille, ; (5) Leiter’s coils oftubing for the continuous How of water. As the cases wereunder different physicians, the treatment was not preciselythe same in all instances ; the majority were treated by thebath, but many cases had also sponging or other coldapplication, and in others the sponging or other methodwas alone used. The cases were considered together,because all these methods effect a decided reduction of

temperature. As a rule, the temperature was taken everythree hours, and the patient was bathed when the tempera-ture was found to be 103° or more. In some cases 101°was taken as the standard. In estimating the results of thetreatment, the mortality, the complications and seque],T,including relapses, and the general effect upon the patient’simmediate comfort were considered. During the precedingten years, 1874 to 1883, 440 cases of enteric fever had beentreated at Guy’s Hospital, of which 78 were fatal, giving apercentage of 17’7. The mortality varied from year to

year, being low in 1874, 1875, and 1876, very high in 1879and 1880, and about the average in 1882 and 1883. Ofthese cases, 100 were submitted to some kind of coolingtreatment, by bath, cold sponging, or ice-pack; and of these27 were fatal. This greatly increased mortality was partlyexplained by the cases treated by cooling measures includ.ing a much larger proportion of severe cases. The influenceof the bath on the cause of death did not seem to be verystriking, the proportion of cases in which perforation andperitonitis occurred being very nearly the same in those treatedby cold as in the total number of cases; but the proportionof deaths by haemorrhage was somewhat greater. Againstthe large mortality amongst the bathed cases, it is importantto notice that many cases were submitted to these measuresvery late in the illness, and many were only partially treated.The mortality in 49 cases treated on or before the tenth daywas 20’4 per cent., in 50 cases treated after the tenth day itwas 30 per cent., in 30 cases treated on or before the seventhday it was 1C ’6 per cent., while in 69 cases treated after theseventh day it was 28’9 per cent. Then, again, of the fatalcases, in four-fifths the treatment was began after the seventhday. As to the frequency of the baths, only 9 cases had asmany as ten baths ; of these 2 died, and only 12 had as manyas ten cold spongings, of these three died. It was con.stantly observed that the effect of the bath was greater thanthat of sponging, and the relative mortality indicated thesame. Of 28 cases sponged only, 6 died, or 21’4 per cent. ;of 45 cases bathed only, 9 died, or 20 per cent. Of these 45cases, the deaths occurred amongst those who had fewestbaths; the 11 cas°s who had more than five baths allrecovered. It was not found that the bath had any strikingeffect upon complications, with the one exception of haemor.rhage, as illustrated by the fatal case. Thirteen cases hadhaemorrhage, but in the majority of these it was obviouslyunconnected with the use of the bath. The bath did notappear to aggravate bronchitis, or increase the tendency torelapses, or lead to other complications. The immediateeffect of the bith was to lessen delirium, induce sleep, andgenerally improve the condition of the patient for the time.Dr. Taylor concluded that though the bare figures did notshow to the advantage of the bath, it was clear that in pro.portion as the patients came early under treatment and werethoroughly treated, the results were better. After somegeneral remarks on the use of the bath Dr. Taylor recordeda case which happened at the Evelina Hospital, in whichoccurred the complication of pulmonary haemorrhage, towhich Dr. Coupland had drawn attention. -Sir JOSEPHFAYRER said that he had received a letter from Surgeon-General Townsend, C.B., which told how among the hillpeople in India the poor women had to take their babieswith them to work wrapped in cloths; the quietude of thechildren was attained by keeping their heads constantlybathed in a cooling stream of water, such treatment inducedsleep, and no ill consequences ever resulted from its employ.ment.-Dr. CAYLEY first pointed out that much of what hadbeen brought forward was not antipyretic treatment; bythorough antipyretic treatment was meant the employmentof means for reducing the temperature from the first, andcontinuously throughout the course of the case. The failureof heart and respiratory power, which so much tended toproduce collapse of the lungs, of which Dr. Bristowe hadbeen so frequently frightened, was really much less fre-quent in cases treated systematically with cold. He furthercriticised Dr. Bristowe’s remarks. Was it more scientific touse a chemical balance or to infer from muscular impres-sions, or was the microscope of no value because some