In Acute Inflammation, especially of Serous Membranes, the practice of general blood-letting, advocated in the first edition of this work (1854), has undergone considerable modification, and it is now generally admitted that the indiscriminate and repeated use of the lancet not only fails to "cut short an inflammation," as was formerly thought it could, but that the practice is, on the whole, not only useless, but injurious. Various explanations have been offered to account for this change of practice. By one class it has been affirmed that of late years there has been a change in the type of inflammatory disease, the present type having assumed a more asthenic character than that which formerly prevailed. The subject has been ably reviewed in all its bearings by Dr. Markham,* in his Gulstonian Lectures for 1864; and he adduces evidence to show that the change of practice is due, not to any change of type in disease, but to our better scientific knowledge, to advances in animal chemistry and physiology, and partly to the observation of the ill effects of blood-letting, as practised in the early part of the present century. In perusing the statements of those who condemn blood-letting, it should be remembered that their observations have almost invariably been made in the hospitals of large cities, where the inhabitants, especially that class who apply to hospitals for relief, are already debilitated by residence in overcrowded, ill-ventilated apartments, with the further depressing concomitants of bad and scanty food, and insufficient clothing; and it may admit of a question, how far conclusions drawn from this class are applicable to strong, plethoric residents in country districts who have been subjected to none of those debilitating influences which must always, more or less, bear upon the inhabitants of large towns. That blood-letting is a remedy of great power, for good or evil, as it is judiciously or injudiciously employed, - that by its aid we can reduce the force and frequency of the heart and circulation more certainly and speedily than by any other one single measure, - that by it we can, as shown by Andral (ante), alter the composition of the blood, reducing to a minimum the amount of fibrine and globules in the circulating fluid, - that by its aid we can often afford immediate relief to urgent symptoms, as in great obstructions of the respiratory and circulatory systems, - that it is capable of effecting these ends, there can be no doubt; and it is to be feared, with the prejudice which at present exists against blood-letting, there is danger of going to the other extreme, and of too much neglecting, if not altogether abandoning a remedial measure which, applied judiciously in proper cases, may be productive of the best effects. Taking Dr. Markham as the exponent of the most recent views on this subject, we shall cite a few short passages from his admirable Gulstonian Lectures, already quoted. "VenAesection," he remarks, " is not a remedy for inflammation, but a remedy for the accidents which accompany or rather arise out of certain inflammations and non-inflammatory diseases, - viz., those inflammations and diseases which are accompanied with obstructions of the cardiac and pulmonary functions. It is, therefore, of service only in those inflammations which are attended with such obstructions." "In local Inflammations, the direct abstraction of blood (by leeches, &c.) acts immediately upon the seat of inflammation; its benefits are sure and immediate also, and, as usually practised, its influence over the system generally is scarcely perceptible. VenAesection, on the other hand, has no such influence over the local inflammation, but a very powerful one over the system at large. It acts only through the influence which it exercises indirectly over the inflammation. The good effects of direct abstraction of blood are positive and manifest, and admitted by all, and they are obtained at a small cost to the system at large." " In all those cases of internal 1nflammations in which there is a direct capillary connection between the skin and internal inflamed part (this applies to Pleuritis, Peritonitis, &c), the local abstraction of blood (by leeches, &c.) is of manifest service, just as we see it to be in external inflammations; but in all those inflammations in which there is no such capillary communication, the benefits of the local abstraction of blood are neither so clear nor positively ascertained." Still, even in these latter cases, local blood-letting is often found of service, and it may very fairly be suggested whether any good effected by leeches, &c, and local irritation of the skin over these internal inflammations, may not be ascribed to the excitement of the reflex action of the vaso-motor nerves producing contraction of the inflamed capillaries." For a further detail of these views, and the practice which results from them, the reader cannot do better than consult for himself Dr. Mark-ham's Gulstonian Lectures.
* British Med. Journ., April, May, and June 1SC4.