Bounds must be placed to the quantity of blood taken even when the remedy is most strongly called for. it must be remembered that morbid changes often happen in the course of the disease, which time and a certain amount of energy are required to repair. if the strength is exhausted by bleeding, recklessly employed, there may be danger that the system may be unable to pass through the processes requisite for the restoration of health. The inflammation itself may have been conquered, but the patient may die in the arms of victory. Thus, in pneumonia, there is generally consolidation of large portions of the lungs; in pleurisy often very copious elimination into the cavity of fibrin and serous liquid; and strength must be reserved to accomplish the removal, or proper disposal of these abnormal products. Suppuration and ulceration are often inevitable, as the result of a particular inflammation. When this is ascertained, though bleeding may still be indicated to lessen the amount of the approaching evils, care must be taken to leave the resources of the system so far unimpaired that it may finally surmount them. An example of this we frequently have in dysentery.

In deciding as to the quantity of blood to be taken in any case, from the character of the pulse, we must bear in mind the influence upon it of hypertrophy of the heart, and not be led astray by a strength and fulness which may be owing to this cause, and which often continues, through great debility, almost to the very close of life.

After as much blood has been taken from the arm as may seem advisable, or in cases in which, from the mildness of the disease, the previously debilitated state of the system, or the advanced stage, it may not be considered proper to use the lancet at all, local bleeding may frequently be employed with the happiest effects. it will often completely subvert the inflammation, even after it has resisted copious general depletion.

In some cases of inflammation, even of a dangerous character, the state of general debility, the depraved condition of the blood, or the depressing influence of some poisonous agency upon the system may be such as wholly to preclude the lancet. This sometimes happens even in cases in which the patient may have been in good health previously to the attack; as in typhous pneumonia, malignant erysipelas, etc. But it is more frequent when the inflammation supervenes upon a low disease, as pneumonia coming on in the advanced stage of enteric or typhoid fever. in such cases as these, local depletion is often of incalculable importance. The inflammation may be just sufficient, if unabated, to destroy the patient, and a slight influence may be sufficient to turn the scale in his favour. Exactly such an influence is often obtained from the loss of a few ounces of blood from the neighbourhood of the inflamed part, when no other measure will afford it. I have seen this too frequently to permit me to have any doubt upon the point. Cups or leeches should be used in such cases, even though it may be necessary to stimulate internally. As much blood should be taken as the strength will permit; but scarcely any amount is so small as to be incapable of good. One or two fluidounces lost will, I believe, sometimes save life. This is particularly the case in the congestive attacks, resembling pneumonia, coming on in low fevers. The patient will be extremely prostrate, his pulse feeble, his skin cool, his respiration difficult, and his colour venous in consequence of the blood passing unchanged through the lungs, or not passing them in sufficient quantity. After the application of two or three wet cups in such cases, and a few dry ones, I have seen the whole aspect of the patient changed as by a charm. The lungs throw off their weight, the blood circulates through them again, the dark colour of the surface disappears, and the pulse regains some activity; though the conjoint aid of carbonate of ammonia, wine-whey, etc. is necessary to. sustain the circulatory and respiratory processes.

In chronic inflammation, general bleeding should be used very sparingly. There are now and then cases which permit and even require it; but the quantity taken should be less than in the acute; and, generally speaking, local bleeding is much preferable. This may often be employed with great advantage, and may be repeated from time to time in the same case.

In all cases of inflammation, the presence of a decided buffy coat upon the blood offers, so far as it goes, a favourable indication for the further use of the lancet; unless there may be reason to think that it has resulted from anaemia. Frequent bleedings often induce this very condition; and great care must be taken not to mistake the buffy coat thus induced for a sign of inflammation, and a proof of the necessity of further bleeding. This appearance is owing to an excess of fibrin over the red corpuscles. if these have their normal proportion, then the buffy coat indicates inflammation; if they are very deficient, and the fibrin is thus brought into excess, it offers no such proof, and should not be considered as favouring the use of the lancet.

Excessive bleeding, as before explained, by inducing anaemia, may favour the production of hypertrophy and dilatation of the heart. Now, it may sometimes be a question whether the danger should be incurred, in order to save an organ threatened with serious injury from inflammation. Should the organ be a vital one there can be no doubt as to the proper measure. Life must be saved at present, whatever may be the risk in the future. But where it is of less than vital importance, the question is not so easy of solution. When a young practitioner, I had a case of inflammation of the eye, affecting the anterior chamber, which was one-third filled with an opaque puruloid matter. I had bled the patient as much as I dared to do, but without amending the condition of the eye. I then called in the counsel of one of the most eminent medical men of those times. He advised a constant repetition of the bleeding; and it was carried so far that, at last, the blood came from the arm almost like dirty reddish dish-water; and the coagulum formed was reduced to extremely small dimensions. The eye was saved; and the patient after a time recovered tolerable health, though long suffering from very troublesome palpitations of the heart. Some years afterwards, death suddenly occurred; and, though I had no opportunity of making a post-mortem examination, I have little doubt that cardiac disease was the cause. With my present views, I should prefer the risk of the destruction of the eye to that of the greater evil.