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quiry is suggested, What is inflammation ? I mean the causes, not the effects; for the “dolor," "calor," w tamor," et " rubor," however elegant in diction as a definition, express the effects only of inffammation. The remote causes of inflammation are still unknown; and the increased means of diagnosis by the microscope have failed to unveil the mysterious process, or demonstrate a difference between an inflammatory or non-inflammatory morbid deposit. The definitions of Drs. Alison and Bennett, the rival champions, do not enlighten the darkness. The former says, “ Exudation of lymph is essential to almost all changes of structure produced by inflammation.” The latter says, “I understand inflammation to be an exudation of the normal liquor sanguinis.” It is pretty certain that the amount of fibrine is increased in the blood, and that there is a diminution of the red, and an increase of the white corpuscles of the blood.
The proximate cause of inflammation appears to be a relaxed condition of the capillaries, causing them to admit red blood corpuscles, to which they are impervious in their normal condition. However, Wedl, at page 22, says, “ This contraction and dilatation of the lumen of the capillaries is problematical.”
Another important element in this inquiry is, the effect produced on the physico-chemical character of the blood by venesection. There are, however, discrepancies of opinion as to the alteration of the blood consequent on depletion.
Polli states that the fibrine is increased, and that the red globules and albumen are diminished. Andral states that the fibrine is not diminished at once, but that the number of red globules is immediately reduced. Kölliker holds the same opinion. Ancelli states that the fibrine is diminished.
We are thus stopped by these discordant statements at the threshold, and drawn to follow the less attractive, but more useful process of inductive experience.
Until recently, venesection was universally, and by many is still, considered the “ sheet anchor” in the treatment of “ Penetrating wounds of the chest”, in order to arrest a dreaded train of pneumonic symptoms. Stromeyer, in his writings on the Danish War, expresses regret that Dr. Schwartz should hold the opinion that bleeding is not always necessary in lung wounds. This observation may fairly apply to the case of Hannihan, reported by Dr. McLeod in the Edinburgh Monthly Journal, vol. ii, page 192. The experience of the late Mr. Guthrie induced him to practise, and strongly advocate, large and repeated venesections in all cases of “Penetrating wounds of the chest”. In this opinion he derives support from more recent writers. Mr. Erichsen, at page 316, says " the most experienced surgeons are unanimous in their opinions that at this stage of the injury the patient's safety lies in full and repeated venesections.” Sir Astley Cooper says, “it (bleeding) is, in fact, the only chance left of saving the patient from suffocation, although stimulants are required to counteract its effects.” Bransby Cooper, at page 102 of his Lectures on Surgery, says: “ Under all circumstances of wounds of the chest, the great desideratum is to diminish the quantity of blood sent to the lungs; this object is obtained by bleeding, which must be freely employed, repeating it to the utmost so long as blood is coughed up, and the dyspnæa urgent, even to the verge of danger from its use.” Dr. Ballingall writes still more strongly at page 317: “ The surgeon's object must be to diminish, as far as consistent with life, the quantity of the circulating fluid.”
Illustrative of the undue influence of these opinions, may be given the case of Private John Dolan, related at page 64 of the Director General's Report. Both pleuritic cavities were opened. The surgeon says: “ Bleeding was not adopted in this case, on account of the weakness of the pulse and anæmic appearance of the patient.” Here we have actually a surgeon, of superior judgment, who deems it necessary, almost, to apologise for not doing, according to routine, a murderous act.
In again referring to Dr. McLeod's “notes," I have pleasure in saying that, although his opinion is at variance with my own, he having been upon the spot, any observations from him demand attentive consideration. I may observe, that as the doctor's care was not particularly devoted to
swounds of the chest," his illustrative facts cannot be numerous. He says, at page 237: “But, I think, it was very generally observed, that those cases did best in which early, active and repeated bleedings were had recourse to.” Nevertheless, a case reported by him at page 241, in his own practice, gives no favourable proof of the benefit of depletion. No signs of acute pneumonia are stated to have been present; the solidified state of the lung was the consequence of pressure from fluid. In a case published by Mr. Hole, in the British Medical Journal, of the 7th of August, 1858, venesection is highly lauded, because recovery took place; whereas, the only proof given that the substance of the lung was wounded was the fact " that air escaped with every expiration, thereby clearly indicating the passage of the ball through the lung”; the rationale of the treatment is consequently erroneous. Three cases are related by Mr. Mackay, of 2nd Battalion of the Royals, vol. i of the Edinburgh Medical Journal, page 924. It is more than doubtful whether the lung was wounded in the case of Duffy; the urgent dyspnea, which was supposed to require venesection, was caused by the emphysema acting mechanically upon the walls of the thorax; fortunately the patient did not suffer by the loss of forty-eight ounces of blood. The termination of the case of Mulreahey not being given, no conclusion is derived from it. The case of Sweenly is clear. The lung was wounded ; the repeated bleedings did not prevent a fatal issue.
To pursue this subject, pleuritis and pneumonia are generally considered to follow penetrating wounds of the chest. In proof of this, a recent writer, Mr. Erichsen, says, at page 298, “ Pneumonia is an invariable sequence of a wounded lung"; and again, in same page, “ Traumatic pneumonia resembles, in all its symptoms, auscul. tatory as well as general, the idiopathic form of the disease. There is the same crepitation, dulness on percussion, and absence of respiratory murmur, as hepatisation advances, with rusty sputa, much tinged with blood in the early stages. It differs, however, from the idiopathic form of the disease, in having a less tendency to diffuse itself throughout the lung, in being limited to the injured side alone, and in more frequently terminating in abscess, which, however, is often dependent on the lodgment of some foreign body in the substance of the lung.” Dr. Watson, on the other hand, says that there is “ a marked difference between fevers and common inflammation occurring in a previously healthy person. In fevers, the blood is primarily diseased. In inflammation, it is the part inflamed which gradually spreads infection through the general mass of the blood; and this contamination we prevent, or limit, if we can arrest the inflammation.”— Watson, Monthly Journal of Medicine, vol. ii, p. 1087.
This argument, admitting the difference alluded to, will not apply in the case of wounds, if, as al