On the Proper Administration of Blood-Letting, for the Prevention and Cure of Disease, (London, 1840) by Henry Clutterbuck, M.D., Member of the Royal College of Physicians.[Excerpts]

From the Preface:

"The Series of Lectures contained in this work were delivered, from time to time, by the Author, to his Pupils at the General Dispensary, and have recently appeared in the pages of the Medical Gazette. They are now with considerable additions, submitted to the judgment of his professional brethren, as the result of long experience, in a field of no small extent."

From Lecture I. General Observations on Blood-letting.

"We are now, gentlemen, approaching a subject of paramount interest and importance - one which merits, and I doubt not will receive, your closest attention. I mean, the use of blood-letting, as well for the prevention, as the removal of disease. From the earliest times this remedy has been extensively employed; and at no period, perhaps, has it been held in higher estimation, or more frequently resorted to, than in the present day: one might naturally expect, therefore, that a pretty general agreement in opinion would found among practitioners with regard to it. This, however, is far from being the case; opinions are still vague and unsettled on the subject, and, in some respects, contradictory; while the merits of the practice, as far as I am able to judge, are by no means justly or sufficiently appreciated. I know of no greater service that could be rendered to the healing art, and consequently, to society at large, than the assigning, with tolerable certainty and precision, the various circumstances that ought to influence us in the use of this herculean remedy."

"The importance of blood-letting , as a medicinal agent, in comparison with other means of cure, is shown in various respects...it is the least equivocal of remedies: its good effects, when properly administered, are, in most cases, so immediate and striking as not to be mistaken...In short, blood-letting is a remedy which, when judiciously employed, it is hardly possible to estimate too highly."

From Lecture II. History of Blood-letting.

"Like most other branches of the healing art, its origin is involved in impenetrable darkness. It is certain, however, that the practice is of great antiquity, and was in general use long before the time of Hippocrates, the earliest writer on medicine whose works have reached us, and who flourished considerably more than 2000 years ago. Hippocrates appears, from his various writings, to have been familiarly acquainted with phlebotomy, or venesection, and also scarification, both with and without cupping." "Aretaeus was very friendly to blood-letting, but he preferred, in general, small and repeated bleedings to large ones, which he considered to be dangerous." "Celsus, equally remarkable for the elegance of his style, and his intimate acquaintance with the whole art of medicine as it existed in his time, was a great friend to blood-letting, and appears to have possessed an extensive and critical knowledge of the subjects. He advises it in many cases in which his predecessors had forbidden its use, as in infants and in old person, and also during pregnancy..." "Galen attached himself chiefly to Hippocrates as his guide, whose system he laboured to re-establish and bring to perfection, in opposition to the prevailing sects of the time...Galen appears to be the first that mentioned the absolute quantity of blood necessary to be taken on different occasions: neither Hippocrates, Celsus, nor any preceding writer, taking any notice of this. In ordinary cases, the largest quantity mentioned by Galen did not exceed a pound and a half: the smallest, seven or eight ounces. He held that on certain occasions, blood might be properly taken till the patient fainted; and he mentions, as an extraordinary circumstance, that he had drawn from the same individual fifty-four ounces in the space of a single day. This was done at the commencement of an acute fever, where the patient was of a plethoric habit, and the blood in a state of great commotion. He limits this mode of practice, however, to the cases just mentioned; and as a caution against the general use of it in this way, he observes, that he saw two person die in consequence of its adoption." "Paracelsus, the prince and prototype of quacks, though far more learned and illustrious than the modern race to whom we are accustomed to apply this designation...appears to have employed blood-letting, as well as other means of cure, thought the particular views with which he used it are not stated."

From Lecture IV. On the Medicinal Use of Blood-letting in general: with the Theory of its Operation.

"Blood-letting may be considered in three points of view--as curative, as palliative, and as preventive; and in all these respects it is important.

When the circulation of the blood was first discovered, it was expected, and not without reason, that the mode of acting, as well as the effects, of blood-letting, would be clearly understood: but it turned out far otherwise; insomuch that it is a matter of doubt whether the subject did not become involved in greater obscurity than before. The effects of blood-letting were judged of upon mechanical and hydraulic principles; as if the blood were moving in inanimate, or, at least, in simply elastic tubes. The contractility of the vessels, a vital property, and nearly allied to muscularity, if not identical with it, was wholly overlooked, although, without reference to this, it is impossible to comprehend a variety of phenomena that present themselves in the movement and distribution of the blood."

From Lecture V. On the different Modes of Blood-letting

"Different methods are in use for taking away blood from the system, for therapeutic purposes; as, 1st by phlebotomy, or venesection, where the blood is drawn from one or more of the larger external veins that are conveniently situated for the purpose; 2dly, by arteriotomy, or the puncture of an artery, which is sometimes resorted to; 3dly, by scarification of the superficial vessels, with or without the aid of the syringe, or cupping-glass; 4thly, by leeches, which are likewise in frequent use. These different modes of abstracting blood from the system have their respective advantages and disadvantages, which require discussion, the one mode being often applicable, where the others are less appropriate."

1. "Venesection, or phlebotomy.--The various purposes of blood-letting, as a medicinal agent, are, upon the whole, much more effectually answered by venesection, than by any of the other modes of drawing blood. If, for instance, the object be to take away blood so rapidly as to make a great and sudden impression on the system, with the view of producing actual syncope or fainting, for any particular purpose, venesection is the most sure and effectual means we possess of so doing. If, on the other hand, we be desirous of obtaining a large quantity of blood, in order to produce a more lasting effect, without inducing syncope,-- in this, as well as in the former case, venesection is still the preferable mode; because it is almost always in our power to regulate the velocity with which the blood flows from a vein; at the same time that we are pretty sure of obtaining the desired quantity. By dexterously opening one or more of the larger external veins, either in the upper or lower extremities, or in the neck, (the external jugulars, which are both large in size, and of ready access), it is in general an easy matter to obtain blood, both in quantity, and with all the rapidity, that can be required."
2. "Arteriotomy.-- There are but few places where an artery can be safely opened, or, at least, where the opening would not be followed by more or less of inconvenience. The temples, inddeed, are almost the only part where arteriomtomis now practised; and here the branches of the artery are in general so small in size, as to make it by no means an easy matter, at all times, to obtain blood in quantity sufficient for our purpose; and still less in the way that is required to make a sudden and general impression on the system; while, in order to restrain the bleeding after the operation, it is often necessary to have recourse to so much compression of the external vessels of the head, as is likely to distrub in some degree the circulation of the brain."
3. "Scarification, with aid of the syringe, or cupping-glasses, ranks next to venesection, in point of efficiency, though still greatly inferior to it as a general remedy; because it is seldom that the blood can be so quickly obtained by mode of drawing, as to produce a sudden effect, for the purpose of counter impression, in urgent cases of disease, though a sufficient quantity of blood may often thus be procured for ulterior and more durable objects." Simple scarification is sometimes practiced with advantage, as a topical remedy, on parts where the vessels run superficially, and are easy of access. As, for example. in the tonsils, and other parts within the mouth; the inner nostrils. It is not altogether foreign to our purpose to remark here, that cupping without scarification or dry cupping, as it is termed, is an agent of no small importance, and applicable in many instances where loss of blood is objectionable. It acts powerfully as a counter-irritant; as is proved by the pain attending the operation, and by the increase of action it excites in the vessels of the part, and to some distance around. Dry-cupping alone is a useful means of producing counter-irritation on a variety of occasions, and is less resorted to than it deserves to be."
4. "Leeches, furnish another mode of drawing blood that has its advantages, as being applicable on some occasions, where other means cannot be conveniently resorted to. Generally speaking, however, as in regard to the other modes of local or topical bleeding, the blood drawn by leeches is discharged too slowly to have much effect on the general system, in the way of counter-impression. Infants, however, are sometimes quickly and powerfully affected, even to fainting, by the application of two or three leeches, which, so far, in them, may answer the purpose of general blood-letting, producing all the effect of venesection in the adult. There is one objection, however, to the use of leeches in children, which deserves attention; namely, the terror they sometimes occasion, with a continuance of angry feelings for an hour or two, while the operation lasts. This is a cause of aggravation in many brain affections of children, where the sensibility and irritability of the system are already greatly in excess. In such cases, therefore, scarifiction with cupping is often preferable to leeches; and, still more, venesection, if it be practicable, as it often is, either in the arm or neck. By this, not only is the irritation here spoken of avoided, but the disease itself more effectually relieved."