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as a dernier ressort two ounces (fluid) of a solution ofsulphate of soda (two ounces to the pint) at 100°F. wasslowly injected into the loose cellular tissue of the axilla,where it formed a large swelling. It was very rapidlyabsorbed and the child became better, took some peptonisedmilk, and at 8 P.M. was quite conscious and taking hisnourishment well. At midnight he was very restless, butless blanched. Pulse 180, quite perceptible at wrist. Thefeet and legs were now enclosed in a thick covering ofcotton-wool, the bandages reapplied, and one minim oftincture of opium given. Temperature 1020.

Twenty-fifth day.-Passed a restless night, sleeping atintervals. The pulse is full, bounding, and hard, 176. Hetakes his food well. Temperature 103°. The wound looksrather red; dressed with iodoform. On removing thecoverings from the extremities, the toes of the right footwere found to be almost black, and colder than the sur-rounding parts. Some bullæ had also appeared on thedorsum of the foot and ankle, and there was no sensibilityin these parts. Warm cotton-wool was applied.During the next few days there was continued improve-

ment. The wound kept sweet and looked healthy. Thetoes recovered in great measure, only about half of theterminal phalanx of each drying up, and a line of demarca-tion forming between this and the recovered portion.On the thirtieth day, at 7 A.M., some oozing took place

from the wound, which at once stopped on the applicationof cold, and was at first thought to have occurred fromsome granulations; but four hours later a sudden gush ofdark venous blood took place, and, on exploring, the veinwas found in part bared, but the bleeding point could notbe determined. The hæmorrhage recurred three timeswithin the next twenty-four hours (plugs being employedto arrest it each time), and at 4 P.M. on the thirty-first day,during a fourth attack, Mr. Wright made a careful examina-tion, and found a small opening in the sheath of the veinfrom which the blood escaped; this he enlarged, and, twopoints of haemorrhage becoming evident, he ligatured thevein above and below these, but immediately afterwards theblood flowed from a perforation still higher up, and heapplied a third ligature above this. The tissues of the veinwere soft and friable, tearing away in the forceps.At midnight on the thirty-second day haemorrhage again

occurred, and this time from a part of the vessel lying sohigh up and deep in the neck as to be inaccessible to liga-ture. It was at this time noted that the child had completeparalysis of the left upper limb and paresis of the left leg.He could not shut his left eye. Sensibility was also im-paired on the left side. The intercostal muscles and dia-phragm acted equally, and the pupils were equal andreacted readily. He had remained in a condition of greatprostration since the venous haemorrhage commenced.

Thirty-third day.-Purpuric spots appeared on the rightear and cheek; he now, for the first time, absolutely refusednourishment, and nutrient enemata were given. He graduallybecame weaker, and died on the thirty-fourth day of thedisease.Necropsy.-There was general bloodlessness of the organs,

which appeared otherwise healthy. The blood was pale, andthe spleen enlarged (weighed three ounces). The brain wasanæmic. No emboli were found. The thoracic viscera andstructures on the right side of the neck were removeden masse, and on subsequent dissection presented thefollowing characters :-The carotid artery, from the seatof ligature up to the point of bifurcation, had entirelydisappeared, and the walls of the remaining upper partwere so thinned and soft as to tear like wet tissue paperwhen seized with the forceps. Below the ligature the vesselwas filled with clot. The vein was in a similar softenedcondition and had four perforations, one of these almostimmediately above the highest ligature and beneath a gland.The sheath, which had disappeared both from vein andartery from a little below the point of carotid ligature to thebifurcation, was saparated from the vessels above and belowthese points, and in the anterior mediastinum, immediatelyover the pericardium, was expanded into a small cavitycontaining thin purulent fluid.

Remarks.—Although sloughing into the internal carotidfrom the throat is comparatively common in scarlet fever,there are very few cases recorded where the haemorrhagehas occurred from without. Among others, Dr. Kennedy inhis account of the epidemic in Dublin 1834-42 reports threecases, in two of which the vein alone was opened into, andin the third there was no post-mortem. In the latter and

one of the other cases the blood escaped from an openingwhich had been made into an abscess some days previously;in the remaining case a large slough formed, dissecting outglands, muscles, and bloodvessels. Fatal haemorrhage throughthe external auditory meatus has occurred several times, asrecorded by Graves, Professor Porter, and Dr. P. J. Hynesrand in one such case the. child recovered after the carotidhad been ligatured by Mr. Bennett May. It would seemthat the destructive processes leading to this perforation ofthe vessels are of two kin&. In the one, the peri-glandularcellulitis and abscess is followed by softening and dissolutionof the tissues (colliquative necrosis). In the other, largesloughs form and separate, laying bare many of the deeperstructures; but, generally speaking, the vessels, and moreparticularly the arteries, are the last to be destroyed, andseveral times complete recovery has ensued where thesheath of the carotid and the internal jugular has been exposedwithout the occurrence of haemorrhage.

NEWCASTLE-ON-TYNE INFIRMARY.LARGE LOOSE CARTILAGE SUCCESSFULLY EXTRACTED FROMTHE KNEE-JOINT OF A PATIENT AGED EIGHTY YEARS.

(Under the care of Mr. FREDERICK PAGE.)M. G-, a woman aged eighty, was admitted into the

infirmary on Nov. 5th, 1885, with the following history.For the last five or six years she had suffered from pain inthe left knee-joint, and was aware of a loose body in itwhich she was able to push from one part of the joint toanother. On Nov. 1st she fell upon her knee. Considerablepain and swelling of the joint followed, and for this she wasadmitted into the hospital. The limb was kept at rest on aMacIntyre splint.

Dec. 15th.—All inflammation having subsided, a free in-cision was made into the joint under carbolic acid spray,and a loose cartilage extracted. The cartilage was peculiarin appearance, not unlike a flat oxalate of lime calculus. In

length it measured 2 in., in breadth 1 in., and in. in thick-ness. It weighed 250 grains. The wound healed kindly.29th.-The patient was able to move about the ward

readily.The case is interesting from the age of the patient, and

from the size and peculiar appearance of the loose body.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

Enteric Fever at Suakim.

AN ordinary meeting of this Society was held on Tuesdaylast, Dr. George Johnson, F.R.S., President, in the chair,Drs. Robert Maguire, Harrington Sainsbury, John McDonagh,and Messrs. C. H. Golding Bird, and B. Wainewright wereelected Fellows of the Society.

Dr. J. E. SQUIRE read a paper on Enteric Fever at Suakim,with some cases of Malarial Enteric or Typho-malarial Fever.By the courtesy of the medical officers of the Suakim FieldForce, the author was entrusted with the charge of adivision of the Base Hospital at Suakim, and was thus enabledto see much of the fever which occurred among the troops.The analysis of nearly eighty cases shows that, though thelarge majority-about seventy-were of the ordinary entericfever type, as verified in two cases by necropsies, some wereso modified by climatic causes as to merit the designation ofmalarial enteric. Two or three showed stronger evidence ofmalaria. One of these, believed to be enteric during life,was found post mortem, after four weeks’ illness, to haveno specific enteric lesions at all; to this class of cases theterm " typho-malaria" might be restricted. In two ofthe fatal cases hasmorrhagic effusions occurred under theconjunctivæ or in some parts of the skin; these cases werenot due to scurvy, the diet of the troops being varied with

! fresh meat and vegetables. Typhus was unknown in the. force. Diarrhoea was a prominent symptom in all the cases.

As regards the cases of enteric fever, it would seem that the. disease was imported from Cairo, and that the infection wa&

spread by the air; the use of none but condensed water for

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drinking and cooking purposes excluding water as a meansof transmission. In opposition to the views of some Indianand army medical authorities, the seasoned troops, repre-sented by the East Surrey Regiment from India, wereattacked earlier than those unused to tropical climates, asrepresented by the Guards who came direct from England,and the mortality was not proportionally greater among theyounger soldiers. Cases of enteric fever were admitted intothe Base Hospital soon after it was opened, in March; themalarial cases did not occur till some two months later.Seventy-three temperature charts and some cases in full weregiven in illustration of the points referred to in the paper.-Dr. GEORGE JOHNSON considered that enteric fever couldoriginate from other sources than contaminated water, andmentioned some cases in illustration of its origination fromsewer-gas.—Surgeon-Major MEYERS said at the commence-ment of the campaign he had seen cases of "dysentericdiarrhoea" at the Base Hospital, but this epidemic dis-appeared when the Guards moved to Tambouk. Whethertrue enteric fever was the nature of the majority of casesof febrile illness at Suakim he felt himself in doubt, butwas inclined to think it was not true enteric, and was ratherdisposed to regard dysentery as at the bottom of it, whichwould not be surprising when we bore in mind the sort of.emanations from a soil composed of dry forces and sand, thelatter constituent having no deodorising properties. Rosespots during life and typical ulceration after death were, inhis experience, rarely met with. The peculiarity of manynecorpsies was a remarkable form of extensive sloughinground the ileo-cascal valve, totally different from what hehad seen in enteric fever in this or any other country.-Dr.M-A.B8TON dwelt upon the great influence of age and recentarrival in a tropical or subtropical country in increasing thesusceptibility to enteric fever, and he illustrated this by someforcible figures showing the percentage liability to die ofthis fever of men under twenty-five years of age duringtheir first and second years of service in India, as com-pared with older men of longer service in that country.The amount of enteric fever in a newly-arrived regiment,as compared with a more acclimatised one, showed the samething. The facts came out year after year with a monotonywhich left no room for doubt. And it was the same thing in war;in Afghanistan and Egypt, and in the French Army duringthe campaign in Tunis. As the second case of enteric feveroccurred at Suakim in the Shropshire regiment the day afterthat of the Surrey regiment, it was impossible for the latterto have been the cause of it. It must be remembered thatrecent experience has proved that the incubationary periodcould be prolonged to six or even seven weeks. The casesof fever seen in tropical climates were, in his experience,true enteric fever, presenting its clinical features duringlife and its morbid appearances in fatal cases. As re-gards typho-malarial fever, there was no evidence ofits existence as a new and perfectly distinct disease,although, of course, a malarious subject might be attackedwith typhoid fever and exhibit symptoms of both diseases.-Dr. D. DREWITT had seen cases of fever at Palermo andSicily in which there were definite sets of symptoms;suggesting that we had to deal with a "chemical" unionof typhoid and malarial fevers, rather than with a

mechanical mixture. In Dr. Whipham’s history of theAmerican rebellion there were narratives showing the greatvariety of types of disease that were constructed of theunion of apparently different maladies; any combination oftyphoid, dysentery, and ague being liable to be met with.-Dr. SINCLAIR THOMSON believed that the nature of the soildetermine the form of typhoid of which he distinguishedvarious types; the abdominal and diphtheritic being twochief ones. When water was the source of the poison theabdominal symptoms prevailed; but when sewer gas, then thethroat was more affected and nervous symptoms were pro-minent.—Dr. DoN had had twenty years’experience of typhoidfever, and had written a paper in a Blue-book for 1870 on thesubject. Speaking of typhoid fever in subtropical latitudes,he recognised the civil view which interpreted an outbreakof enteric fever as due to some pre-existing case, and themilitary view which allowed that the disease could originatede novo under certain climatic, dietetic, and like causes. Hebelieved that a nutritive intestinal change preceded theappearance of typhoid fever, and considered that it was justa chance whether this precedent intestinal disease shoulddevelop into typhoid fever or not. He declared emphaticallyhis opinion that enteric fever could originate de novo.- :Brigade Surgeon GRIBBON had medical charge of the Ganges,

.

and had no doubt whatever that the disease was entericfever, for he saw characteristic ulcerations in some necropsies.Most of the cases on board were convalescent; some hadbeen sent with the diagnosis of "remittent fever," "heatapoplexy," and the like, but he believed they were reallyenteric also. Suakim was not, in his opinion, a malariallocality; northerly winds tend to empty the harbour andsoutherly winds to fill it, but there was no actual tide;stenches arose during the prevalence of northerly winds.The first case on the Ganges occurred in one of the orderlies,curiously enough, and only convalescent patients were thenabroad; the orderly had been ashore a few times, but hisdietetic and hygienic arrangements aboard were sound.-Dr. BROADBENT said the paper was valuable for the discus-sion that it had raised, and when coordinated with the largerset of observations of Dr. Marston was still more valuable.The fact of the occurrence of enteric fever at certain agesand on recent arrival in a country teaches nothing as to thespecific or non-specific nature of the disease. He felt con-vinced that there was some other fever met with in tropicaland sub-tropical climates, and distinct from, though simula-ting to a certain extent, the course of typhoid fever. Thesecond tropical fever could hardly be enteric fever modifiedby climatic and other conditions. Experience has shownthat we require some distinct name to express this secondaffection, and " typho-malarial" was perhaps the best one thatcould be discovered for a fever which was even more proteanthan enteric fever in its clinical course. Reference wasmade to a history in which five officers figured, and had beenunder the same conditions in Malta; of these, three developedan illness soon after-one was said to have subacute rheu-matism, another enteric fever, which lasted three monthsand ran an irregular course; the third case came under Dr.Broadbent’s own care, and it had nothing in common withenteric fever, if we except the fact of protracted high feverwith some intermissions. He said that Murchison in his Indianexperience had remarked on the protracted duration of thehigh temperatures of these cases, which resembled in nothingthe pyrexia of enteric fever. He considered that it was verynecessary to differentiate these fevers,which are still confused,for the typho-malarial form departs in the most complete wayfrom enteric fever, being really a distinct fever that simulatestyphold fever only to a very limited extent. - Dr. I3R,nrEconsidered that an epidemic limited to a few individuals inthe community attacked was evidence of the typhoidnature of the illness; the appearance of the " typhoidtongue" on the third or fourth day he regarded as of con-siderable diagnostic significance.-Dr. SQUIRE, in replysaid he was glad to hear Dr. Broadbent express the opinionthat there were two distinct diseases to deal with, for itoncurred with his view stated in the paper.

MEDICAL SOCIETY OF LONDON.

Subperiosteal Resectionjor Acute Necrosis.-CerebralAbscess and Empyema.

AN ordinary meeting of this Society was held on Mondaylast, Dr. W. M. Ord, President, in the chair.Mr. BERNARD PiTTS read a paper on Subperiosteal

Resection for Acute Necrosis, and exhibited a living specimenof the first case, which was that of a girl aged fifteen,who was admitted to St. Thomas’s Hospital on Nov. 25th,1882, with swelling of the lower end of right tibia. For oneweek the swelling and pain had been present, and an incisionwas made above the ankle, a quantity of matter escaping.At the time of admission the girl was in a prostrate con-dition, with a temperature of 102°. The incision wasfreely enlarged and the limb placed on a Neville’s splint.The patient steadily lost ground, and on Dec. 16th, or thirty-five days from the beginning of the disease, an operationwas performed, in which the lower two-thirds of the tibiaand ankle-joint were exposed. The lower half of the tibiawas found to benecrosed, with separation at the lower epiphy-sial line ; the epiphysis was almost entirely destroyed, a mereshell of bone representing the external malleolus remaining;the upper surface of the astragalus had lost its cartilage,and was granulating. There was a line of separation at theupper end of the necrosis; this fact decided Mr. Pitts totry to save the limb, which it was till then thought requiredamputation to save life. The tibia was sawn through alittle above the line of demarcation, so that three-fifths of