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not dwell upon them. But, as I pointed out before, h2amor-rhage is mostly secondary,-that is to say, it occurs only whenthe clot which had plugged up the vessels falls off. Now thissecondary haemorrhage is very dangerous in most cases, andoften kills the patient in a few minutes; but we shall dreadthis complication still more when we recollect that a suddenand fatal gush of blood may take place when we least thinkof it, and without any premonitory symptom. This fact hasnaturally led surgeons to inquire whether it would not beadvisable, in those cases where we suspect that a large arteryhas been wounded, to use a prophylactic compression on thecourse of the vessel, by means of a tourniquet. I do not ap-prove of this method, for if the compression is powerfulenough completely to stop the circulation through thevessel, it may give rise to gangrene; and we know thatgunshot wounds are, by their very nature, sufficiently ex-posed to sphacelus, so that it would be hardly justifiable tomake the patient run an additional risk. If, on the otherhand, the compressive force is not sufficient to obliterate thevessel, it is quite useless, and hurtful besides, on account ofthe pain which it occasions.

Bloodletting.-Abstraction of blood, both locally and gene-rally, have been strongly recommended by a great number ofsurgeons, especially by those who do not advocate the practiceof incisions. Venesection has been employed by some prac-titioners immediately after the receipt of the injury, andrepeated several times over, with a view of obviating localinflammation and general reaction. These measures, gentle-men, are very advisable within certain limits; but they maybe fraught with much danger-nay, they may rapidly bringon a fatal issue, if not applied with prudence and moderation;for when the patient arrives at the suppurative stage, if hehave been weakened by bleeding, he will not be able to bearthe drain of suppuration, and you are aware that in gunshotwounds the suppurative process, along with the eliminationof the sloughs, cannot be prevented, and are inevitable; weshould therefore husband the strength of our patient, and notbleed him too much. You must not, in fact, have recourse tovenesection merely because your patient is labouring under agunshot wound, but you should be guided by the usual indi-cations for the abstraction of blood. Thus it will beadvisable to bleed immediately after the wound has been in-flicted, when the latter involves parts abundantly providedwith cellular tissue, if the patient is plethoric, and above all,if the wound has penetrated a splanchnic cavity. Bleedingmav also be used in a later stage if the reaction is too violent.or if the inflammatory fever is too intense. Local bleedinghas likewise been extensively used in cases of gunshot wounds,by means of the cupping-glasses or leeches. When cuppingwas resorted to, it was employed to answer two ends. Theglasses were applied on the wound itself, the margin of thelatter having previously been slightly scarified. This was in-tended to pump up and draw out the poison, just as it is nowdone with wounds really and truly poisonous, or with thoseresulting from the bites of snakes. This mode of applyingcupping-glasses is now quite abandoned, as the idea that gun-shot wounds are venomous is entirely given up. This practiceis, however, not bad in itself, since there is really, as I haveshown, a sort of poison generated in most gunshot injuries.As for myself, I do not use cupping at all;’ I prefer injections,which are much better calculated to cleanse the wounds, bywashing away all those putrid substances which might provenoxious to the economy. The other end which was held inview when cupping-glasses were applied in the ordinarymanner, was to control the pretty intense inflammationwhich sometimes springs up around the wound; but thescarificator, as well as the exhausted glasses, are too pain-ful in such cases, and they may advantageously be re-

placed by leeches. But you must notice that the latterare not advisable, except the inflammation be consider-able ; and there is no doubt that Dupuytren was quiteright when he condemned, in strong terms, the abuseto which the application of leeches was carried. Lisfrancused to apply them five or six times consecutively aroundgunshot wounds, not because there was any particular in-dication for such a course, but from principle, and a priori,in order, as he said, to combat the likelihood of distention inthe part, and to render incisions unnecessary. To convinceyourselves that this was bad practice, you should rememberthat distention and strangulation in the track of a gunshotwound are very rare; not one of the wounded we have in thehouse offered us any example of such symptoms, and thoseupon whom I performed amputation were equally exemptfrom it. I prescribed leeches for one of these patients only,not because there was distention, but on account of the in-

flammation which sprang up around the wound. We must,in fact, beware of carrying the abstraction of blood, by meansof leeches, too far; they depress the organism as well asgeneral bleeding, and when the patient, thus weakened, reachesthe suppurative period, we find the pus unhealthly, sanious,and scanty; colliquative diarrhaea sets in, and soon carrieshim off. To sum up, then, it may be said, that no absoluteor general rule can be framed for the treatment of gunshotwounds. We should use incisions when the parts are actuallyover-distended and strangulated, which complications happenvery rarely; we should have recourse to local or generalabstraction of blood when bleeding is clearly indicated, andwe must finally do nothing a priori, or to satisfy any in-geniously contrived theories.

Hospital Reports.HOTEL DIEU, ORLEANS.

Vertical Dislocation of the Patella.THis is the twelfth vertical luxation of the rotula hitherto

recorded. It happened to a man of sixty, who fell under acab and got his legs entangled in the wheel. When raised,he could not stand upright, and M. Debron found the limb,half an hour after the accident, in the following state:-Theknee flexed to within a third of the right angle ; a slightabrasion, extending from the calf of the leg to the spot where,in the normal state, the inner border of the patella is situ-ated ; extension incomplete and painful; the anterior aspectof the joint very prominent, on account of the patella beingplaced with its inner border against the condyles, and itsouter margin under the skin; its anterior aspect turned in-wards, posterior or articular outwards; the skin depressed oneither side of the projecting edge; the ligamentum patellmon the stretch and drawn a little outwards, and the patella im-movable. M. Debron reduced this vertical external luxationin the following manner, according to the principles laid downby Valentin:-One assistant holding the thigh, another heldthe leg, and raised the heel so as to extend the leg upon thethigh, the latter being flexed upon the pelvis. The patientbeing placed upon a low bed, says M. Debron, I took mystation on the external side of the knee, and whilst supportingthe posterior aspect of the joint with my left arm, I forciblypushed the patella inwards with the palm of my right hand,flattening it, at the same time, against the external condyles;the bone, by a single continued effort, snapped back into itsplace. I then gave directions to have the limb placed on aninclined plane, and soothing compresses to be applied to thejoint. One month afterwards the cure was complete. If thetwelve cases of this peculiar luxation, says M. Debron, beexamined, there will be found seven vertical external, (theanterior surface of the patella turned inwards,) and five ver-tical internal, (the same anterior surface turned outwa1’ds.)In these twelve cases, reduction has been particularly difficultor impossible five times; three times reduction has kept amedium between a degree of ease and much difficulty; andfour times only it has been easy. Amongst the very difficultcases, three had been produced by external violence actingdirectly on the patella; in the medium cases, two were owingto external causes, and four to muscular action. In the easilyreduced cases, three were caused by external violence, andone by muscular power. One case remains doubtful. Themost important question referring to this unusual luxation, isto determine which mode of reduction is the most effectual.The choice lies between the method of Valentin and that ofCoze, or the manner of reduction advised by Mr. HerbertMayo, which has lately been re-introduced by M. Malgaigne.The choice is not of much importance in a practical point ofview, for they are both alike easy and harmless, and can evenbe employed one after the other, if necessary. Still the twomethods rest upon theories directly opposed to each other;for the first argues upon the slackening of the muscles con-nected with the patella, and the second upon the tension ofthe same. The obstacles in the way of the vertical reductionare-1. The tension and dragging of the tendons inserted inthe patella-namely, the tendon of the quadriceps above, andthe ligamentum patellaa below; 2. the sinking of the borderof the patella, which becomes posterior, into the superiorcondyloid depression (as M. Malgaigne calls it) ; 3. the ten-sion of the partly torn capsular ligament, which, in themanner of a rope, keeps down the patella very tightly in itsvicious position. M. Debron, in an able paper (recently pub-lished), examines successively every one of these three causes;

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and without altogether denying that the super-condyloid de-pression may have some share in the fixation of the bone, hebelieves that the importance of the part which this depressionplays in these luxations has been much exaggerated, and thatthe tension of the lateral portions of the half-torn capsularligament has a chief influence in rendering reduction dif-ficult.

____

ON

INFLAMMATION AND ABSCESSOF THE

UTERINE APPENDAGES (OVARIES, FALLOPIANTUBES, AND CELLULAR TISSUE) IN THENON-PUERPERAL CONDITION.

BY J. HENRY BENNET, M.D., PHYSICIAN-ACCOUCHEUR TO THE WESTERN GENERAL DISPENSARY, ETC.

(Read before the Medico-Chirurgical Society, January 25th, 1848.)

FROM the writings of Paulus aegineta and others, it is evident that pelvic inflammation and abscess in the female, itssymptoms and sequelae, were known to the ancients. Notonly does Paulus gineta—himself a compiler from Aetius andother older writers-distinctly mention the manner in whichpus formed in the pelvic cavity finds its way to the exteriorby the perforation of the rectum, vagina, or bladder; but healso enters into many curious details respecting treatment,describing the process for opening the abscess by the vagina-an operation which has only latterly been revived. The an-cients do not, however, appear to have had a correct idea ofthe origin and nature of these abscesses, which they describeas abscesses of the uterus. They evidently thought that theuterus itself was the seat of inflammation, and the sourcewhence the pus came.The Arabians merely copied the classical writers on this as

on most other subjects connected with uterine pathology,making no addition to the information contained in the worksof the latter.In the seventeenth and eighteenth centuries, when what

may be termed the revival of midwifery and uterine pathologytook place, the attention of practitioners was directed to thisimportant class of diseases by Guillemeau, Mauriceau, andmore especially by Puzos. The two former thought, with theancients, that the abscesses proceeded from the uterus, butPuzos recognised the fact of their generally originating iu the 1lateral ligaments of that organ. His more correct ideas re-specting pelvic inflammation in the female were, however,disfigured by a fanciful theory as to its origin, which he attri-buted to the metastatic deposit of milk. This singular theorywas adopted, however, for a long period, by all who wrote onthe subject, amongst whom we may name Planchon, VanSwieten, Leuret, Raulin, Antoine Petit, Gastelier, &c., andwas only dispelled by the accurate anatomical investigationswhich characterized the commencement of the present cen-tnrv-

Pelvic inflammation, both in the male and female, has at-tracted much attention in France during the last thirty years,and its history has been elucidated by various writers, amongstwhom I may name,—Dance, Husson, Boivin, Baudelocque,Meniere, Andral, Dupuytren, Grisolle, Velpeau, Bourdon,Verjus, and Marchal de Calvi. This last writer published in1844 an interesting monograph, which may be said to containa good analysis of the existing state of knowledge on the con-tinent with reference to pelvic inflammation generally. ’

In our own country, pelvic inflammation, and especially thatform of the disease which develops itself in the uterine ap-pendages, and which is connected by all authors with thepuerperal state, has attracted much less notice. It isscarcely, if at all, alluded to in the principal monographs onthe diseases of females, although isolated cases of inflam-mation and abscess of the ovaries and Fallopian tubes aredescribed or referred to. Nor does our periodical literaturecontain much information on the subject, with the exception,however, of the interesting articles of Dr. Doherty and Dr.Churchill in the Dublin MedicalJournal for 1843-4, on inflam-mation and abscess of the uterine appendages, and that pub-lished in 1844 in the Guy’s Hospital Reports, by Dr. Lever,under the head of" Cases of Pelvic Inflammation occurringafter Delivery."Although so much has been written abroad, of late years, on

phlegmonous inflammation of the uterine appendages, thereis still an ample field for investigation. Indeed, I may safelysay, that notwithstanding all the efforts that have been madeto elucidate it, the disease is yet but very partially under-

stood. This I believe to be owing to the circumstance, thatup to the present time it has only been studied in relation tothe puerperal condition, with which it is supposed, by theauthors I have named, to be nearly always connected; whereas,in reality, it not unfrequently occurs apart from that state. Itis now more than ten years ago that this fact was pointed outto me by M. Gendrin, the eminent Parisian pathologist, and Ihave since ascertained, to my complete satisfaction, the cor-rectness of his assertion. A careful analysis of all the casesof pelvic inflammation in the female, that I have met with, inrather wide fields of observation, enables me to state, from myown experience, most positively, that the disease is by nomeans uncommon in the non-puerperal state, although gene-rally unrecognised, and confounded with acute metritis, oriliac abscess. I am not aware that this important fact hashitherto been recognised by any author who has written onthe subject in question, the most recent essays on inflam-mation of the lateral ligaments, treating of it as a disease allbut peculiar to the puerperal state. Thus, out of fifty casescollected from various sources, and published by M. Marchal deCalvi, whose work represents the present state of scienceabroad, forty-nine are puerperal. Out of twenty-three casesquoted by Dr. Churchill, twenty-one are puerperal. The caseof Dr. Doherty is puerperal, as also are the nine of Dr. Lever.Owing to inflammation of the uterine appendages having thus

been studied only in its severest form, when it occurs in con-nexion with the puerperal state, the peculiar features whichthe disease presents in its milder or non-puerperal shape havenot yet been described. Thence it is that this form passesunrecognised. Nor can we be surprised, when we considerhow peculiar is the stamp which the puerperal state impresseson all inflammatory diseases that occur under its influence.They all present a peculiar and an unusual intensity, owing, asit is now supposed, in a great measure, to the increased quantityof fibrine contained in the blood. This increased intensity hasbeen more particularly observed with reference to inflamma-tion of the uterus, and is equally observable in that of theorgans connected with it. Thence inflammation of the uterineappendages, occurring after parturition, presents as great adifference from the same disease in the ordinary state of thesystem, as puerperal metritis offers to non-puerperal metritis.

In the puerperal form of the disease, the uterus itself isnearly always considerably implicated; the inflammation ofthe ovaries, Fallopian tubes, or cellular tissue, has a tendencyto extend to the peritonaeum, and to the cellular tissue liningthe pelvic cavity; adhesions to the abdominal parietes, abdo-minal perforations, and even death, not unfrequently occur.In the non-puerperal form, on the contrary, the disease has atendency to limit itself to the tissues primarily attacked;peritonitis, abdominal perforations, and a fatal termination,

beine’ verv rarelv met with.The non-recognition of the milder form of this disease has

been attended with another evil. The less severe cases ofpuerperal inflammation itself are often passed over; and ex-treme cases only being observed and recorded, erroneous im-pressions become prevalent, even with respect to the puerperalform. Thus we find M. Marchal de Calvi giving it as an ascer-tained fact, that the disease is very often fatal, because he findsthirteen fatal cases among the fifty, in reality exceptionalones, which he has collected. Reasoning on the same falsedata, he also comes to the conclusion, that these abscessesopen as often by the abdominal walls as by the rectum orvagina. In both these assertions there can be no doubtthat he is quite in the wrong.In the present paper I purpose treating of inflammation of

the uterine appendages in the non-puerperal state only. Bystudying this affection in a form in which it is infinitely moresimple, and infinitely less complicated with disease of thesurrounding tissues, than when it follows parturition, I hopeto be able to throw some additional light on the disease, inall its forms. Before, however, I proceed any farther, I mustbriefly recal to mind the anatomy of the region in which thedisease of which I am treating occurs.The peritonaeum in the female, after covering the posterior

surface of the bladder, is reflected on the uterus, covers theanterior surface of the body of the uterus, its posterior sur-face, and is then again reflected on the rectum. As it passesfrom the anterior to the posterior wall of the uterus, the peri-tonspum forms two wide folds, which contain between themthe Fallopian tubes, the ovaries, and the round ligaments.The two folds of the peritonaeum, which thus, by their juxta-position, constitute the lateral ligaments, are separated onefrom the other, as also the organs which they contain, bya certain amount of filamentous cellular tissue. This cellulartissue is connected with the extra-peritonseal cellular tissue