In treating of Inflammation generally (ante), we have seen that amongst the cases in which the utility of blood-letting, general or local, is still recognised, are those in which obstructions of an inflammatory or non-inflammatory nature are present: hence in Pleuritis and Pneumonia, and in a minor degree in Acute Bronchitis, depletion by the lancet or leeches and cupping may be productive of benefit; but care is necessary in the selection of cases, especially in large cities where danger of inducing an adynamic state is ever to be borne in mind. Where a doubt exists, local depletion should be preferred to general blood-letting. With regard to Pneumonia, Dr. Bennett* gives the following judicious directions: - " If we are called," he says, "to a case at a very early period, before exudation is poured out, and before dulness, as its physical sign, is characterised, but when, notwithstanding, there have been rigors, embarrassment of respiration, more or less pain in the side, and commencing crepitation, then bleeding will often cut the disease short. This state of matters is rarely seen in public hospitals. When, on the other hand, there is perfect dulness over the lung, increased vocal resonance, and rusty sputum, then exudation blocks up the air-cells, and can only be got rid of by that exudation being transformed into pus, and excreted by the natural passages. In such a case, bleeding checks the vital powers necessary for these transformations, and, as a general rule, if the disease be not fatal, will delay the recovery. " I believe," he adds," this to be the cause of so much mortality from Pneumonia in hospitals, where bleeding is largely practised; for, in general, individuals affected do not enter until the third or fourth day, when the lung is already hepatized." In the Pneumonia of Children, venAesection has been advised, particularly by Mauthner,t of Vienna, who advises its vigorous employment at an early stage, and even in the advanced stages. Excepting in the first stage, however, it is not usually regarded either as safe or expedient; and even then, abstraction of blood by leeches is preferable to general blood-letting.

* Med. Gaz., July 20, 1849.

3009. In Acute Laryngitis, if blood-letting is to be advantageous, it must be employed early and copiously. " When," observes Dr. Watson, "there is high inflammatory fever present, and the skin is hot, the pulse firm and full, the cheeks red, and the lips florid, you may bleed your patient with decision and advantage. But if his powers are beginning to sink under the poisonous influence of imperfectly aerated blood, if his skin be cold or even cool, his face pale or leaden, his lips blue, his pulse small and feeble, his mind wavering, you will do no good by blood-letting; nay, you will increase the debility which already exists, and hasten the fatal catastrophe." Leeches or blisters to the throat are objectionable; cupping at the nape of the neck may sometimes be useful. If these and other remedies fail, tracheotomy must be employed, in order to save the patient's life.

3010. In Croup, bleeding may be employed when the patient is strong and plethoric, and is seen at the outset of the disease. Abstraction of blood by venAesection or cupping, in the case of older children, and by leeches in the case of infants, should be practised whenever the symptoms are violent, and there is much fever, and the patient is seen within a few hours after the commencement of the symptoms. The relief which is given by this measure, under such circumstances, is often so decided that no doubt can remain of its usefulness and propriety. (Dr. Watson *) Dr. Copland, however, thinks, with the majority of medical men, that blood-letting, by cupping between the shoulders, or at the nape of the neck, or leeches to the top of the sternum, is preferable to venAesection; and he states that the loss of little more than an ounce or an ounce and a half for each year of the patient's age can well be borne, whilst nausea is kept up by an emetic previously administered.

* Edin. Monthly Journ., Aug. 1850. Ibid., Feb. 1850.

Lectures, vol. i. p. 816.