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secutive cases of tertiary eruption found evidence cf primarychancre absent in 20 per cent.Henry H-, aged twenty-five, seaman, six weeks before

admission fell down the hold of a ship, a distance of aboutfifteen feet, on to a cargo of copper ore. He alighted onboth his feet, and then fell backwards on to both buttocks.He "fainted away" at the time of the accident, but soonrecovered consciousness. He then found that he had injuredhis left knee ; the joint was swollen and bruised. For thishe was treated by splinting and rest in bed for four weeks.He shortly afterwards came to the Seamen’s Hospital, withthe joint still swollen and walking with a limp. Martin’selastic bandage was applied, and the effusion graduallysubsided. The patient had a small tumour of the upperlip, which he was anxious to have removed. He stated hehad had a similar one taken away four years previously.Ether was given, and the growth, which proved to be afibroma undergoing myxomatous degeneration, was cut

away. About five days after this the patient complainedof pain and numbness along the back of the neck and inboth arms. These symptoms were first observed abouteight weeks after the accident and two weeks after hisadmission. He suffered also from indigestion and pain afterfood. There were no motor symptoms of any kind. Thenumbness had extended in a fortnight’s time to the right sideof the thorax and abdomen; otherwise there was no changein his condition; so he remained for another month, whenhe complained of diplopia. The right external rectusmuscle was found to be paralysed; no other muscle wasaffected. The pupils, slightly dilated, responded to thestimulus of light. Ophthalmoscopic examination showedthe fundus of the eye to be normal. Sensation in the arms,right side of thorax, and abdomen was still impaired; ankle-clonus on both sides was well marked. The reflexes werenormal. He was able to walk in the dark, and could feel theground well. His gait, however, was peculiar. Some threedays later the left external rectus became paralysed, but noother ocular muscle was affected. He vehemently deniedall history of syphilis, nor was there any evidence of it abouthim. In spite of this, he was put on iodide of potassium andperchloride of mercury. The doses were increased, and theiodide pushed until its physiological effects were well marked.Improvement under this treatment was slow, but wellsustained. The right external rectus (the first affected)recovered before its fellow; the numbness of the arms andright side of the chest and abdomen gradually decreasedand disappeared, except in the left little finger, and thisrecovered after his discharge. When he was up and aboutagain, the ankle-clonus was soon no longer to be detected.He had been on specific treatment for three months beforehis final recovery. When last seen as an out-patient, hewas perfectly well. He was still, under advice, continuinga mild course of specific treatment.Renzarks by Mr. TURNER.-I believe this to have been a

case of syphilitic pachymeningitis, in which the posteriornerve roots were chiefly involved, and in which injury, andpossibly some slight haemorrhage, had made the partssusceptible to the syphilitic poison. The affection of theexternal recti alone of the ocular muscles, and the effects ofanti-syphilitic treatment, make the diagnosis almost a

certainty. It is lucky for the patient that his symptomsdeveloped while he was in hospital, and he thus had theadvantage of early treatment. In time, no doubt, theanterior roots, as well as the posterior and other cranialnerves than the sixth pair, would have been affected.PERIPHLEBITIC GUMMA FOLLOWING INJURY ; REMOVAL OF

BLOOD-CLOT FROM FEMORAL VEIN ; REMARKS.

(Under the care of Mr. G. R. TURNER. ) This is also a case in which latent syphilis formed a most

important element in the production of the local condition,and in which it manifested itself by definite and charac-teristic ulceration after some time, other than specifictreatment proving useless. It is in the experience of mostsurgeons that wounds, whether accidentally received or

inflicted by the surgeon, occasionally change in character,and, instead of following the normal course and heal-ing, exhibit a tendency to enlarge and spread byulceration, which only yields to what are called anti-syphilitic remedies. Although this fact is generallyrecognised, we have known the want of its recognitionproductive of serious consequences. The removal of a

blood-clot from the common femoral vein is a curiosity insurgery

Joseph L——, aged thirty-one, seaman, was admitted onDec. 12th, 1887. Six months previously he had contracteda chancre, but this had been followed by no secondarysymptoms ; there was, however, a vague history of a rashsome long time ago. On Dec. lst his left thigh began toswell and become painful, and he could feel a hard cord (hecalled it the nerve) extending from the inner side of theknee up to the groin. He was at sea at the time, andcontinued at his work for two days, but then had to lie up.In June, 1887, he had met with an accident, falling downthe hold of a ship on to his left hip and buttock. Had neversuffered from gout.On admission, he presented a hard mass of indurated

glands in the left groin, extending below Poupart’s liga-ment, the skin in this situation being red, tender, andswollen. There was very slight oedema of the thigh. Thegeneral appearance of the parts suggested a suppuratingbubo. Beyond some glandular enlargement there was notrace of syphilis about him.The apparent bubo burst shortly after admission, dis-

charged unliealthy-looking pus, but showed no tendency toheal. On Feb. 29th ether was administered, and an incisionmade into the mass in the groin, enlarging the previousopening. A quantity of fibrinous-looking material mixedwith decomposing blood-clot of varying age was removedby manipulating and tearing through the tissues with thefinger. The latter at length came down on what wasevidently a blood-cast of the femoral veinlying comparativelyloose at the bottom of the cavity. This when fresh had allthe appearance of a vessel itself filled with a decolourisedfibrinous coagulum separable and distinct from the containingsheath. The latter had the thickness, size, colouring, andconsistence of the common femoral artery, and mighthave been readily mistaken for it but that the branchesdid not correspond with those of that vessel. This blood-cast was removed from the situation of the femoralvein, and the pulsation of the artery to the outer sidewas plainly to be felt. There was no bleeding. Thecavity left was plugged with an aseptic sponge anddusted with iodoform. The patient did well afterwards,and there was no constitutional disturbance. The cavity,however, was slow in filling up, and the wound, some four-teen days after the operation, was seen to be covered with athickish diphtheritic-looking membrane. This was followedby increased swelling and suppuration about the parts, withburrowing of matter. Shortly afterwards, in the early partof April, some fresh ulceration in the neighbourhood of thewound was observed, which slowly spread. The patient wasnow placed on large doses of iodide of potassium and salvolatile. The effect of this increase of the dosage (for he hadalready been taking small doses) was almost magical. Thecavity rapidly filled in, the spread of the ulceration wasstayed, and the parts rapidly healed. The man was keptin the hospital for some time longer, till June 20th, takingthe iodide and mercurial pills. When discharged he wasquite well, with the exception of some thickening at theupper part of the thigh and some slight oedema of it and theleg. Dr. Delepine, of St. George’s Hospital, was kind enoughto examine the blood-clot that was removed, and reportedthat there was no trace of the coat of the vessel.Remarks by Mr. TURNER.-The doubt in this case is

whether syphilis or injury destroyed the coat of the femoralvein. Although from the history of the case it is not abso-lutely certain that the injury induced the inflammation ofand consequent clotting of blood in the vein, it is almostcertain that this was so, and that his syphilis attacked himin this his place of least resistance. The history ofsecondary symptoms was, as is so often found when gum-mata are present, very vague and doubtful. The appear-ance and spreading nature of the ulceration alone pointedto the diagnosis.

HULL ROYAL INFIRMARY.A CASE OF DISLOCATION OF THE WRIST BACKWARDS.

(Under the care of Mr. SHERBURN.)DISLOCATlON of the hand backwards from the lower end

of the radius and ulna is a very rare form of displacement,although at one time it was supposed to be rather common.It is probable that fractures of the lower end of the radiuswith displacement were mistaken for it, as demonstratedby Dupuytren and others. Hamilton1 had only met with

1 Fractures and Dislocations, p. 782.

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one example of this injury, and that was in a man agedseventy-five ; moderate and steady traction in a straightline easily reduced the displacement. He recommends thatno splints or bandages of any kind should be applied unlessa tendency to displacement exists, but that it should betreated by rest and fomentations until all danger frominflammation has passed. We think, however, that nobetter way of procuring rest and relief from pain can bedevised than the judicious application of splints. For thefollowing account we are indebted to Mr. Hosegood, juniorhouse surgeon.On Feb. 8th, R. M-, a boy aged fourteen, was brought

to the infirmary with the history of having fallen twentyfeet from a ladder. The men who were working close bycould give no account of the exact position in which thepatient was when he reached the ground, and of course theboy himself could give none. But as the face, moreespecially on the left side, was a good deal contused, it wassupposed that he fell head foremost with outstretched arms.There were no other severe bruises noticed. The boy com-plained loudly of pain in his left wrist.On examination the following condition was found. The

left hand was markedly displaced backwards from the planeof the forearm, and was somewhat abducted (displaced tothe radial side). The fingers were partially flexed in alltheir joints. At the back of the wrist was the roundedprominence of the displaced carpus. On the anterior aspectthe lower extremities of the radius and ulna were easilyrecognised, as were also the styloid processes of these bones.The relations of the parts were easily made out as at thetime of examination ; no swelling had taken place. Thefollowing measurements were taken, and found to be thesame in both arms-viz., (1) from the tip of the olecranonto the styloid process of the ulna, and (2) from the head ofthe radius to its styloid process. There was no fractureand no displacement of the epiphyses. The diagnosis wasconfirmed by Messrs. Savery and Watson.Reduction.-A porter was told to grasp the upper part of

the forearm, and then Mr. Hosegood tried traction in theaxis of the limb. As this was not successful, he extendedthe wrist and pulled in a direction which formed an angleof nearly 90° with the forearm, and gradually altered theline of traction (flexing the wrist) till it became in thesame line as the long axis of the forearm. At the sametime, and with his other hand, he pressed the displacedcarpus downwards and forwards towards its natural posi-tion. In this way reduction was easy. Straight splintsmch as are used for fracture of the forearm were appliedand worn for three weeks.Result.-The boy has very good movements in the wrist;

nothing abnormal except slight stiffness. There is, how-sver, some uniform thickening of the lower extremity of theadius. The patient was kept in the infirmary for two days,as, of course, he was a good deal shaken by the fall.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY.

Plastic Operations on Neck and Arms for Deformities ajterBu ns.--Gastro-enterostomy.

AN ordinary meeting of this Society was held on May 14th,Sir Edward Sieveking, President, in the chair.The PRESIDENT said that the Council had appointed a

committee to inquire into the Medical Climatology andBalneology of Great Britain. Dr. Ord was selected as Pre-

sident, and the names of the other members will be announcedshortly.Mr. JOHN CROFT read a paper on Plastic Operations on

the Neck and Arms for severe Cicatricial Deformities afterBurns. The author carefully limited the subject of hispaper to the terms of the title. His particular object wasto advocate the use of large flaps of skin and their trans-plantation in two stages, or at two separate operations. Abrief reference was made to the absence of a historicalaccount of this mode of operating. He first gave a generaldescription of the mode of operating in the five cases onwhich the paper was founded, then a brief narrative of eachcase, and afterwards the conclusions and criticisms whichhe had drawn up. At the first stage of this operation the

strap or bridge of skin, varying in length from nine to sixinches, was to be raised, left attached at each end, andcarefully dressed. At the second stage, when the strapto be transplanted was in a suitable condition, and when thepatient was in a condition to bear the operation, the con-tractions were to be severed, and the transplant moved tothe position which it was permanently to occupy. Detailswere given and suggestions made. The advantages claimedfor this mode of operating were : 1. That risks of sloughingof parts of the transplant were greatly diminished ; thetransplantation being made two or three weeks after thefirst operation. 2. That, instead of being transplantedwhen recently drained of blood and reduced in temperature,the transplant was moved when abundantly vascular andfull of active living plastic material. 3. That this plan hadmanifest advantages over that of transplanting a flap froma distant part of the body. 4. That by this mode largeflaps of skin might be transplanted, provided that this

simple rule be observed: that the length of the strapwhen cut shall not be more than three times thewidth of its base. The author illustrated the paper byphotographs, and the patients were present for inspection.-Mr. BRYANT said that these cases were amongst the mostdifficult in surgery, and though the method Mr. Croft hadproposed was not altogether new, yet there was novelty init. Few probably had used such large straps, for gangrenehad been feared ; but leaving the ends attached guaranteedthe vitality of the flaps. The dissecting up of such wideflaps added somewhat to the gravity of the procedure, onaccount of the exposure to the air of so large a raw surface.He could recall cases in which this method would have beenadvantageous, and he personally felt grateful to Mr. Croftfor bringing forward the subject.-Mr. CROFT laid no claimto originality in the operation, which he had adapted fromthe bi-basal flap operation for ectropion vesicae.Mr. HERBERT PAGE then read a paper on a case of

Gastro-enterostomy, togetherwith a table of the cases hithertorecorded. The patient was a man aged forty-eight, whohad suffered from malignant pyloric obstruction for severalmonths, and who was operated on according to the methodof Wölfler in St. Mary’s Hospital in December, 1887. Hewas much relieved by the operation; he regained hisappetite, and the vomiting, which had been incessant andexhausting before, almost entirely ceased. He lived for

seventy-two days in comparative comfort, but did not gainin weight-a circumstance due, it was believed, to the factdiscovered at the necropsy that the lower end of the ileumhad been sutured to the stomach. Reference was madeto a recent case in which the same accident befellLauenstein, and special remarks were directed to thisuntoward feature and to the necessity of taking suchsteps at the operation as should secure the right pieceof jejunum or upper ileum being chosen. An appendedtable contained in all thirty-eight cases, two of which weresubjected to both pylorectomy and gastro-enterostomyat thesame time. Of thethirty-sixcasesofgastro-enterostomy alone,fifteen were fatal, directly or indirectly as the result of theoperation. Collapse was the most frequent cause of death,and examination of the table showed that those patientsonly were fitted to bear the operation who had not beengreatly exhausted either by vomiting or by extension of thecancerous disease. It was suggested that the use of Senn’sdecalcified bone plates, by doing away with the necessity ofputting in so many sutures, was likely to shorten the timespent over the operation, and that thereby the risk ofdeath from shock might be materially lessened. There hadbeen a steady decline in the rate of mortality. In the firsteighteen cases there were ten deaths, while in the secondeighteen there were five only. In the author’s opinion,gastro-enterostomy was worthy of more attention than ithad hitherto had in this country. In properly selected casesit appeared to him to be an operation distinctly justinahle andone to be recommended, for it was capable of bringing relieffrom the distressing symptoms incidental to pyloric obstruc-tion, and was thereby in all probability the means of prolong-ing life.-Dr. LEES said that the man was not to any greatextent reduced in strength before the operation. He greatlvimproved after it, but did not gain flesh. Compared withanother similar case, he did not think that the operationprolonged the patient’s life, though it made it much morecomfortable. Two lessons were to be learnt from it-tomake certain of the part of the intestine into which theopening should be made, and to lessen the duration of theoperation.-Mr. BARKER said that the time taken to suture