tions, which become purulent, sub-periosteal abscess generally remains confined to the portion of the limb in which it commenced. If it affect other parts of the same limb, it does not do so by direct propagation, but by distinct simultaneous or successive attacks, generally, too, leaving the joints uninjured.

Prognosis.-This must be looked upon as a very serious affection, not that it directly menaces life, or even the loss of the limb; but because-let it go on as well as possible-confinement to bed for months must take place, and there is always a risk of the various complications which suppuration in contact with bone may give rise to. The gravity of the affection is, however, more than ordinarily dependent upon the mode in which treatment is carried out. If active and well comprehended, the most alarming symptoms may be dissipated; while when put feebly into force, death may result in either the primary or consecutive periods. The unhealthy condition of the patient's constitution, frequently the subject of scrofulous diathesis, is an unfavourable element in the prognosis. Five out of the eleven cases employed for the construction of this memoir have died, surgical interference in several having, however, only been sought for at too late a period to be of any service.

Treatment. In a general manner this may be said to consist in-1. The employment of prompt incision; 2. The insertion of a Y-shaped canula, or a perforated seton; 3. At a later period the injection of acidulated douches; 4. Resort to amputation when the rapidity of the accident or the debility of the patient prevents further temporizing; and 5. The employment of various operative manoeuvres when the sequestrum is too solid to yield to the acidulated douches. The opening and counter-openings must always be sufficient for the free discharge of the pus, but should not be excessive. Such discharge cannot, however, be secured by merely making apertures, the large putrid surface requiring also abundant washing out by water, freely injected by means of a pump or syringe. In the author's practice, this is indeed adopted in all abscesses, as the means of freeing their cavities from the pus, which he regards as acting like a foreign body. At a latter period acidulated douches are substituted, M. Chassaignac preferring the hydrochloric acid to any other, and commencing with the proportion of two grammes to a litre of distilled water, afterwards increasing the strength. For the purpose of facilitating the free discharge of pus from these and other abscesses, he employs what he elsewhere calls "drainage," by means of vulcanized caoutchouc tubes. Taking one of these, of the size of a quill, and from 12 to 15 centimetres in length, the extremity which is to enter the wound is cut into the shape of the reed of a flute. The other end is slit into two, and when the tube has been introduced, these two branches are turned back over the surface of the skin, and secured by plaster. In this way the canula takes the form of a T or a Y. When a counteropening has been made, the canula is replaced by the perforated seton, which establishes a permeable uninterrupted channel from one incision to the other.

II. On the Treatment of Varices and Hæmorrhoids by Injection of the Perchloride of Iron. By M. DESGRANGES.--This is the successful essay for a prize upon the above subject offered by the Society. The author doubts the applicability of the treatment to hæmorrhoids; and the following are the conclusions (founded upon 19 cases) he comes to with respect to the employment of the remedy for varices:

"1. The injection of the perchloride of iron into the veins is an innocent but an extremely delicate operation, that requires every care of the surgeon with respect to precautions and manual procedures. If well performed, the consequences are simple and easily managed. 2. Baumé's solution at 30 degs. is the best adapted for varix. 3. Two drops suffice for the coagulation of the blood contained in the largest varicose lobules. To inject more would be both dangerous and useless. 4. The injection must not be made unless blood issuing from the canula proves that we have entered a vein. 5. Only one injection should be made at a time; an interval being then allowed, and a spot next selected as remote as possible from the last injection. 6. We may, exceptionally, throw in an injection into each leg, when the two

are subjects of varix, on the same day, if the patient is in good health. 7. We must pursue the varices as long as the veins are penetrable; so that the mean duration of treatment cannot be assigned. 8. As regards the pain, the accidents, and results of the operation, injection is preferable to other means of treatment. 9. The obliterated vein always remains impermeable to the blood; but we are unable as yet to pronounce on the curative value of this treatment. 10. The injection exerts the most excellent effect on the varicose ulcers, changing their nature, and giving rise to their rapid cicatrization." (p. 409.)

III. On Amputation at the Ankle Joint. By M. VERNEUIL.-The conclusions stated in this paper are chiefly based upon the examination of several stumps, which its author has made at a considerable period after the operations have been performed. One of the rules he lays down from having observed osteitis set up when the malleoli were left entire, is that they should be always more or less excised. Pressure on pointed eminences like these, may indeed give rise to the formation of adventitious bursæ, but such serous sacs easily pass into a state of inflammation. Another rule, applicable in the author's opinion to many other amputations, is couched in these words

"Whenever the extremity of a stump is destined to support a direct continuous pressure, procedures by flaps are to be rejected, if the inflexion of these will place the great nervous trunks in such a position that their terminal enlargement would have to support such pressure; such procedures being, however, allowable on the condition of excising to a certain extent the nervous trunks that may give rise to these inconveniences." (p. 443.)

After passing an unfavourable criticism on M. Pirogoff's operation, M. Verneuil makes the following observations:

"In following out the principle, that we should be as economical as possible of the hard parts in practising mutilations of the hand and foot, the catalogue of the procedures for partial amputation of these two important regions, is increased day by day by new operations, by which an apophysis, an articular extremity, &c., is preserved: The intention is certainly good, and the execution is sometimes crowned with success; but even good principles must not be pushed too far. Thus, for example, this opulence in operative procedures is of scarce any avail in traumatic cases; for in gun-shot wounds and in partial crushing of the hand and foot, experience shows that the best practice consists in leaving the cure to nature, favouring it by continuous irrigation. The surgeon remains a mere spectator of the process, or he contents himself with simply intervening by the excision of certain osseous points, or by the removal of splinters. This practice, so humble, but so fertile in good results, has become so common, that partial amputations of the foot and hand become more and more rare in our hospitals. Operative parsimony, it must be admitted, is sometimes mischievous in organic lesions; and when we have to do with cancer or fibro-plastic tumours of bone, if amputation is considered advisable, we must make large sacrifices of the diseased parts, and cut into those that are healthy, in order to guard as much as possible against local relapse. In necrosis, we should be content in most cases with the removal of the sequestra. When osteitis or caries is present, we often find the disease return in portions of the bone which at the time of the operation concealed the germ of disease. To sum up: the conservative principle pushed to excess, is frequently useless, if not hurtful. It is by keeping the patient in sight for a sufficiently prolonged period, that we may convince ourselves of this; and great would be the mistake to register as cures all those in which the patient quits the hospital after the cicatrizaton of the woand made by the hand of the surgeon." (p.433.)

The following are the general conclusions of the memoir :

"1. Tibio-tarsal amputation is not a very grave operation, as far as the immediate mortality is concerned; 2. Healing is always slow, and on this account the total duration of the consecutive treatment is longer than in most of the major operations; 3. The employment of the stump should be long delayed-in fact, until the flap and the extremity of the bone become sufficiently organized to support pressure. All traces of inflammation must have disappeared in the soft parts, while as regards the hard parts, if the malleoli have been preserved, they should have become in part blunted (émoussées); or, if they have been excised, the bony surfaces should have thoroughly healed. The treatment resorted to in old or commencing osteitis may be employed with advantage for consolidating or favouring the definitive cure. 4. Although

this operation has been practised a great many times (there being perhaps from eighty to one hundred cases on record), it is impossible to know how many examples there are of complete success, understanding by this cases in which the mutilated leg can entirely replace the wooden one: 5. Instances of failure are unfortunately not rare. This may be immediate or distant, the latter being divisible into two forms. Thus, the stump may be irreproachable in its external configurations, and all the tissues forming it may be healthy in appearance, and yet progression may be impossible. In other cases the lesion is appreciable, and the ill result may be attributed to various causes, some of which are treated of in this memoir. Thus, progression may be rendered impossible by the sole fact of the procedure made choice of, or by the development of unforeseen accidents. The anatomical lesions that have been authentically proved are osteitis of the tibia and fibula, changes in the skin of the flap or in the accidental serous bursæ beneath the bony extremities, neuritis of the large nervous trunks, and osteophytes developed within the substance of the flap. As these consecutive accidents may only appear at a very late period, the result of the operation remains long doubtful; and in order that a cure may definitively be stated to have taken place, the stump must have gone through the ordeal of walking and of sufficiently prolonged standing. 6. This criticism does not imply the blame or proscription of the operation; for if many other operations were submitted to a similar examination, many illusions concerning their harmlessness and the benefits derived from them would be discovered; 7. All things taken into account, this amputation may be said to be a good operation in certain cases; but it is one that seems to me susceptible of improvements, among which, I believe, may be placed the excision of the posterior tibial nerve. To the present time, Mr. Jules Roux is the practitioner under whose hands the operation has made most progress, his mode of procedure being decidedly preferable to all others. 8. If surgeons are desirous of obtaining a definitive solution of this question, they should neglect no opportunity of the careful examination of individuals who have undergone the operation, and of very minutely dissecting any stumps that may come under their notice. Detailed observations of this kind will, at a later period, allow of a more complete history being traced." (p.447.)

IV. On the Condition of the Cervix Uteri during the latter Half of Pregnancy. By M. CAZEAUX.-Drs. Costilhes, Boys de Loury, and Bennett, maintain that during the early months of pregnancy ulcerations of the cervix uteri are of great frequency, and exert a powerful influence in the induction of various pathological conditions. M. Cazeaux believes these statements to be greatly exaggerated; and at all events in the latter half of pregnancy, to which his own observations apply, they are not borne out. Examined by the speculum, the mucous membrane of the vulva, the vagina, and the free surface of the os itself, is found of a dark colour, which becomes deeper and deeper, until towards the end of pregnancy it has attained a dark violet. A person unaccustomed to this examination, and especially if he has not previously ascertained the position of the cervix by means of the finger, may have considerable difficulty in engaging this part within the extremity of the instrument, this arising from the anteversion of the body throwing the vaginal extremity backwards.

"As the toucher would lead one to suspect, the modifications presented to the eye by the vaginal portion of the cervix, are very different in primiparous and in multiparous women. In both, the cervix is of a deep violaceous, wine-lees colour; but in the primipara, this is pretty uniform throughout its whole extent. The external orifice, the lips of which are much softened, is in general more or less rounded; but although it is larger than in the unimpregnated state, it admits of the penetration of the eye with difficulty, even when the valves of the speculum are considerably expanded. The circumference of the os, and the free portion of the cervix, rarely exhibit any traces of ulceration, but it is common enough to observe series of cherry red granulations, true fleshy vegetations, varying in size from a pin's head to a large pea, which bleed on the slightest contact. In the woman who has borne a certain number of children, the cervix is in general much more voluminous, so that there is some difficulty in completely embracing it by the speculum. The lips of the os seem divided into several fragments, this segmentation, the result of lacerations that have occurred during former deliveries, rendering it very irregular. In consequence of these numerous solutions of continuity, the orifice is much larger and much more easily dilatable, so that the eye is enabled with ease to explore all the cavity of the cervix. The walls of this cavity are very unequal, and present irregular series of fungous projections, separated by more or less deep depressions. Some of these prominences are transparent, being probably due to hypertrophied follicles, but others resemble true flabby (mollasses) vegetations. Sometimes these are covered by a protective

epithelium, but it is not unusual for them to be deprived of this, and then to bleed upon the slightest touch. It is especially within the furrows which separate them, that more or less deep linear ulcerations are often observed. These ulcerations sometimes so increase in size as to occupy a pretty considerable surface, and then they are easily seen; but generally they are hidden in the depths of the anfractuosities, and in order to perceive them, after well cleansing the surface, we must put the cervix on the stretch by opening the instrument widely. I have very often met with these ulcers in multiparous women, and I believe that I am within the truth when I say that I have observed them in seven-eighths of the cases, confining this statement to the last third of pregnancy. Supposing that a singular chance has not favoured my researches for a long time past, it is probable that what I describe here is the normal condition, and should not be considered as a pathological state, but simply as a consequence of the progress of gestation. Resembling in this respect the deep colour, the tumefaction, the ramollissement, and the almost fungous condition of the walls of the cervix, which are proper to pregnancy, and in no wise influence its progress, these ulcerations have the same origin, and should be considered as the result of excessive congestion. I believe that they are of no more importance. I am especially convinced of their innocence, and believe that all treatment of them is much more mischievous than useful. . .. . If I am not mistaken, then, and if the peculiarities I have been describing belong to pregnancy, and are only an exaggeration of the modifications of the structure and the vascularity of the parietes of the uterus, this condition should disappear with the cause that gave rise to it. Like vomiting, varices, hæmorrhoids, and all the sympathetic disturbances of pregnancy, it should cease with this. And that is precisely what takes place, and we may lay down as a rule, that no traces remain five or six weeks after delivery; the ulcerations which we sometimes meet with in women recently delivered, do not, in fact, present the same appearances, and generally are referrible to another origin." (pp. 453-456.)

The statements made by Boys de Loury, Bennett, and others, as to the frequency with which abortion and various puerperal diseases are produced by ulcerations occurring at an early period of pregnancy, are so discordant with the observations the author himself has made, that he cannot but tax them with exaggeration. It is of importance to distinguish between ulcerations that have preceded pregnancy, and have persisted and increased since its occurrence, from those which have only become developed subsequently to the formation of the germ. The former, becoming irritated under the influence of exertion, and espe cially by excessive coition, may easily induce the contractility of the body of the uterus, and bring about premature expulsion. But the latter, in the author's opinion, rarely exercise a similar influence; so that however proper treatment may be in the one case, it does not seem called for in the other. He also doubts the justice of Bennett's statement, that these ulcers are a frequent cause of obstinate vomiting in pregnancy; and since he has been in the habit of treating this affection by the application of belladonna to the cervix, he has had the opportu nity of examining four primiparæ, reduced by it to the last stage of marasmus, in whom the cervix remained perfectly healthy.

M. Laborie, in his report upon this paper, observes that M. Coffin, drawing his materials from the practice of M. Richet, describes precisely the same fungous ulcerations as those treated of by M. Cazeau; but that he attaches much more importance to their presence, at the same time that he admits that no kind of treatment has been applied with success. Of 7 women examined by M. Laborie himself in M. Cullerier's wards at the Loureine, there was but one who did not exhibit ulcerations. She was a primipara, and had reached the fifth month. Two other primiparæ, exhibiting the ulcers markedly, were three months gone; and the 4 multipare had respectively attained the periods of five, seven and a half, and nine months. In these cases no special means of treatment were adopted, nor is it probable that the ulcerations would have ever been discovered without the use of the speculum.

V. On the Cicatrization of Arteries, and on the Form of Ligature which least exposes to the Danger of Secondary Hamorrhage. By M. NOTTA.-In a thesis published in 1850, M. Notta, deriving them from investigations made on ligatures of arteries applied after amputation, arrived at conclusions which differed

from those announced by Jones, Béclard, Scarpa, and Manec. Thinking that this diffe ence might have arisen from the fact of the investigations of these observers having been conducted on animals, while his own were made on the human subject, he determined to repeat the latter upon animals, and compare the results. The present memoir gives an account of these results, which are confirmatory of those formerly arrived at, and the preparations upon which the conclusions are founded are all deposited in the Musée Dupuytren.

"Authors are by no means agreed as to the primary effects of a simple ligature applied immediately to an artery. According to Amussat, who has, so to say, exaggerated the ideas of Jones upon this point, at the end of some hours the inner coats are found divided, and retracted from half a line to two lines or more above the ligature. There is therefore a space in which the arterial tube consists only of the cellular tunic, with which the base of the coagulum is in contact, and contracts adhesions. According to Guthrie and Manec, the inner and middle coats are not only divided, but are also so recurved inwards as to come into contact at the edge of their section. From this it results that the arterial canal is completely closed by the inner coats, which form a kind of diaphragm interposed between it and the cellular coat-so that the coagulum lies with its base upon the inner coat. In my numerous experiments, made on the horse and dog, I have in vain endeavoured to verify Amussat's assertions; while I have constantly observed the disposition mentioned by Guthrie and Manec, a disposition resembling in every point that which I have described as occurring in

man.

"Immediately after the ligature has been applied, a deposit of fibrin takes place, and adheres to the lips of the divided inner coats, which project more or less into the interior of the vessel. This clot, small at first, increases in size until it fills the artery, with the walls of which it contracts adhesions. These adhesions of the coagulum to the internal coat were misunderstood by Jones and Amussat, merely alluded to in some of Beclard's experiments, and demonstrated by Scarpa and by Manec, who comprehended their importance, but for their explanation erroneously admitted the existence of a layer of plastic lymph. As in man, they are direct, without any intermediate substance, At all events, that is what I have observed in 19 out of 21 cases, comprised between the 3rd and the 122nd day after the operation. In all these preparations an adherent fibrinous clot is seen, and I have always found it impossible to distinguish the layer of plastic lymph spoken of by Manec. In these experiments, as in man, the extent of the adherent portion of the coagulum was always found dependent upon the presence of a collateral vessel, however small the volume of this might be. The twenty-one preparations only offer one exception to this rule. I will merely observe that in those cases in which there is a great distance between the ligature and the first collateral, as in the carotid, the clot, when entirely developed, does not completely fill the artery, the vessel remaining permeable for a space varying from five to ten centimetres between its cardiac extremity and the first collateral. In man, on the other hand, when the coagulum is well developed, it almost always reaches as far as or very close to the first collateral."-(pp. 479-482.)

The formation of a clot at the peripheric end of the vessel is not of constant occurrence. It was absent in 4 of the 21 cases, 3 of these being ligature of the carotid, and 1 of the aorta. In 3 other cases, the coagulum was less developed than that at the cardiac end, being much less adherent. In 8 cases, while almost as large as the cardiac clot, it differed from this in length, density, or adhesion. In 5 cases only no difference was observable in the two coagula. Thus, so far from the shock of the column of blood against the ligature being prejudicial to the formation of the coagulum, it would seem to favour this. This difference only confirms the conclusion already arrived at by the author in his investigations upon the human subject, that the formation of the coagulum is nowise dependent upon inflammation, as arteritis. Guthrie had already shown that the inferior development of the clot in the peripheric extremity of the vessel rendered secondary hæmorrhage from this end more common.

As the coagulum increases in age it contracts and augments in density; but although its adhesion to the inner coat becomes more intimate, it always remains distinct from this, and the most careful examination has never detected the slightest traces of vessels penetrating it. During its contraction, it draws the arterial tumours with it, so that when the vessel is examined four or five months after the