THE AMERICAN MEDICAL RECORDER. VOL. III.] OCTOBER, 1820. [NO IV. ON THE MODUS OPERANDI OF BLOODLETTING. Observations on the .Modus Operandi of Blood-letting; with an in- quiry into the propriety of abstracting Blood from different parts of the body, according to the nature and seat of the Disease. By Henry W. Ducachet, M. D. of New York. IT has been said, with great truth, that the practice of medi- cine is regulated by fashion. This observation has, in no in- stance, been more remarkably verified, than in the subject of which we are to treat. There was a time, when the different parts of the body from which blood was to be drawn, were de- signated with the most scrupulous minuteness ; and prescribed in a tone of authority and decision, which repressed the rashness of the most presumptuous innovators. The ancient physicians as- signed to each part, and to almost every disease, its appropriate vein. Thus, in affections of the parts below the clavicle, the basilic vein was selected. The cephalic was opened in diseases of the head and face; and the median was chosen when the parts both above and below the clavicle, were involved in the disease. Vol. Ill-3 0 462 'Observations on Blood-letting. In like manner, the occipital, the temporal, and the frontal veins, were selected, according as the different parts of the head might be disordered. In diseases of the eyes, peculiar virtue was as- cribed to bleeding in the vein between the thumb and the index finger; and that between the little and the ring fingers, was sup- posed to have some peculiar connexion with the spleen. The ranular vein was opened for the cure of quinsies, and inflamma- tions of the ear; and the saphena, in cases of suppressed men- ses. In nephritis and stone, they chose a vein on the calf of the leg; and for the cure of barrenness, a small branch behind the ear. But it was impossible that rules, so evidently dictated by caprice, should long be held in veneration. Practice too, neces- sarily changes, and adapts itself to prevailing theories. So that the places which were selected by the physicians of one age, were denounced by those of the next. But it was not until the disco- very of the circulation, that it was thought a matter of indiffer- ence from what part blood might be drawn. When physicians became acquainted with the fact, that the whole mass of blood circulated through the system, and that the route was accom- plished in the short space of about three minutes and a half;* they began to imagine that no part could be affected by blood- letting, in whatever situation it might be performed, unless by participating with the system in the general consequences of the evacuation. The rules respecting the different situations to be preferred in certain cases, were very soon disregarded; and were observed, so far only as they might comport with the convenience of the operator, or the whim of the patient. At the present time, blood is seldom abstracted from any part but the arm; and so universal is the impression that the effects of blood-letting are not influenced by the situation in which it is per- formed, that bleeding in the foot, or on one side in preference to • There is a difference of opinion on this point among physiologists, as they vary in their computations of the quantity of blood in the body. Some make it not more than 8 lbs. and others estimate it at 100. But allowing the quantity to be 35 lbs. and that two ounces are emitted from the heart of an ordinary man at each pulsation, the time taken up in performing the circu- lation will be exactly 3 minutes and 44 seconds. Observations on Blood-letting. 463 another, is looked upon as indicative of superstition, or of blind attachment to antiquated notions. It cannot be denied that bleed- ing, even as practised in the present day, is an eminently useful remedy. But is it not a fact, that it sometimes proves injurious in cases where the abstraction of blood is clearly indicated? And could not the same beneficial effects be produced more speedily and effectually by a much smaller loss of blood, were the opera- tion performed in different situations, according to the seat of the disorder? It is, I am convinced, in consequence of overlooking the advantages of this practice, that we find it necessary to ab- stract such enormous quantities of blood in diseases which, we read with astonishment, were formerly cured by comparatively moderate bleedings; that convalescence is so often a tedious pro- cess, protracted far beyond the period in which nature herself can have accomplished a cure, and perfectly re-established health; and that patients may so frequently, with more propriety, be said to have escaped from the hands of the physician, than to have been cured of their diseases. It is intended, in the following essay, to take a view of the effects of blood-letting generally; to point out its particular opera- tion when performed upon different parts; and to attempt to shew, that there are certain cases, in which it is proper to ab- stract blood from certain situations in preference to others. First, then, of the action of blood-letting in general. On the application of the ligature to a limb, the progress of the blood is retarded in the superficial veins. The consequence is, that they become distended, and contain a greater quantity of blood than they did before. The distention commences at the part to which the ligature is applied, and gradually extends along the canal of these veins. As they become engorged, the resistance to the ac- tion of theii*arteries also is increased. The action of the heart continuing as yet the same, these arterial branches too, become distended with blood; and, finally, this fulness is communicated to the great arterial trunk from which they arise. Besides, as the return of blood is interrupted in these veins, the vena cava into which they ultimately terminate, is deprived of that portion of blood which is retained in them; and also of the vis a tergo which 464 Observations on Blood-letting. they, or their arteries, might supply. So that in the cava also, the return of the blood to the heart, is retarded; and, of neces- sity, the internal veins, which accompany the arteries of the limb, become distended also. But there is another circumstance which contributes to this effect. It has been very satisfactorily proved, that in addition to its propulsive power, the heart performs the office of a suction-pump, by means of the alternate contraction and relaxation of its parietes.* Now it is certain, that this contrac- tion will be in proportion to the stimulus applied to the cavities of the heart; and that the consequent relaxation will be in propor- tion to this contraction. But we have seen that a considerable quantity of blood is prevented from returning to the heart, by the ligature around the limb. It is evident then, that the suction power of the heart must be diminished; and the inevitable con- sequence must be, an accumulation in the cava. It will doubt- less occur to the reader, that this diminution of the suction pow- er of the heart, ought to affect both cavae equally. But it must be remembered, that the cava connected with the veins of the limb upon which the ligature is applied, has another power ope- rating upon it whereby the return of the blood through it is im- peded; and that the two streams of blood poured by the cavas into the right auricle, are, in some degree, antagonizing forces. * This doctrine was first advanced by Dr. Andrew Wilson, in a work which he published in London, in the year 1774, and entitled " Inquiry into the moving powers employed in the circulation of the blood and it has since been ably illustrated and established by Dr. Carson of Li verpool, who published a work on the same subject, in the year 1815. The idea is now adopted and approved by most physiologists. Indeed, without its admission, it is impos- sible to account for the circulation itself: for, considering the quantity of blood, the length of its course, and the various obstacles to its progress, it is very improbable that the propulsive force of the heart alone is sufficient; and it is granted on all sides, that the veins are destitute ofirany very consi- derable contractile power. Without granting this suction influence of the heart, the use of its valves becomes a mystery ; it will be impossible to say why a vein collapses above a ligature which obliterates the continuity of its calibre ; or why a punctured vein will not bleed when a ligature is not appli- ed. A very good exposition of this principle, may be seen in a note by Dr. Elliotson to Blumenbach's "Institutions of Physiology." See Warner's Phi- ladelphia edition of 1817, p. 68. I am indebted to his remarks for the sub- stance of this note. Observations on Blood-letting. 465 Such being the state of the parts, it is obvious that the limb contains more blood than it did before the application of the bandage; and that the proportion of blood in other parts of the body, must be diminished.* This is what the ancient physicians meant by derivation, and revulsion. But as they had not the be- nefit of a knowledge of the circulation, they had no very precise idea of the manner in which derivation or revulsion was pro- duced; and used the former term to denote the afflux of blood to the limb itself, and the latter to express their indistinct notion of its abstraction from other parts of the system. Hence it is, that we find them so inconsistent and contradictory on this subject. But to return. The vein is now opened: but this does not ma- terially affect the condition of the limb. The interruption to the return of the blood continues; and, of course, its consequences re- main. So that, although the vein which is opened is less turgid, the other vessels are not evacuated. It is evident then, that the quantity of blood which is abstracted, does not immediately affect the state of the limb; but that it contains as much blood, or very nearly so, as it did before the orifice was made. The evacua- tion then, must be at the expense of the other parts of the sys- tem; and the limb itself can be affected, only by the general dimi- nution of the circulating mass. The obvious effects of blood-letting are, then: first, a diminu- tion of the general quantity of blood; secondly, an accumulation in the part upon which the operation is performed; and, thirdly, a consequent abstraction, or revulsion, of it from all the other parts * I had almost finished this essay, when, in consulting Van Swieten's Com- mentaries for another purpose, I accidentally met with the following passage, which so entirely coincides with the view I have here taken of the action of the ligature. Boerhaave had, in the aphorism upon which the commentary is written, advised ligatures to be applied to the legs in apoplexy : and upon the passage the commentator remarks, "ligaturx autem artuum tales, ut ve- nas comprimant, arterias non adeo, utpote profundius sitas plerumque, et mi- nus facile comprimendas, efficiunt, ut magna copia humorum colligatur in artubus; cum arterix admittant, venx vero pressx reditum ad cor impedi- ant; hinc longe minori copia urgebitur caput." Comment. §. 1025. In another passage, he refers to Galen as recommending ligatures (vincula) to the lower extremities, in cases of headach. Aph, 396. The efficacy of this practice I have repeatedly experienced. 466 Observations on Blood-letting. of the system. But venaesection has another important effect. It slackens, or represses, the momentum of the circulation. In whatever manner this effect may be produced; whether it be the result of the diminished quantity of blood, or of any peculiar operation upon the cerebral system; whether it be the consequence of the more tardy circulation of the blood through the lungs, or the effect of all these causes combined; it matters not. The fact has been established by the experiments of Dr. Hales,* and many later physiologists. As this effect of blood-letting does not concern the doctrine which we are about to advance, it would not have been thus particularly noticed, but that it may be ad- duced in objection to the positions laid down above. It may be contended, that, as the force of the circulation is abated in pro- portion to the loss of blood; the accumulation which we describ- ed as taking place in the arteries, cannot occur. But it must be observed, that this effect of blood-letting is not immediate; that it is not perceptible until the evacuation has been consider- able; that it is, frequently, not produced until after the operation; and that it is, sometimes, not observed at all. And further, it could not affect our position, even should the objection be admit- ted in its fullest extent, and without any exceptions or qualifica- tions. For the same diminution of the vis a tergo, which affects the action of the arteries, will proportionably affect the transmis- sion of the blood by the veins. II. Secondly, we come to apply the doctrine to particular cases. Upon the application of a ligature to the arm, the fol- lowing changes take place in the state of the limb. The super- ficial veins, the basilic, the cephalic, and the median and its branches, become distended with blood. This plethora extends to their inosculations with the extreme arteries of the limb, and * The sovereign control which blood-letting exercises over the force of the circulation, is shewn by the following experiment of Dr. Hales. He opened the vessels of living animals, adapted glass tubes to their orifices, and observed to what height the blood rose in the tubes at each systole of the heart: he then drew from the animals different quantities of blood, and observed the force of the heart diminish, in proportion as the blood was abstracted. Hales' Hamastaticks Observations on Blood-letting. 467 finally affects the arteries themselves. The accumulation pro- gresses, until the main trunk of the limb, the brachial artery, becomes unusually full. Nor will it be confined here : it will extend to the axillary and subclavian portions of this trunk, to the arteria innominata, and to every branch that is given off by them. Now it is obvious, that in proportion as the limb contains an unusual quantity of blood, the other parts of the body will con- tain less. This is the reason why the pain and dyspnoea of pneumonia, will sometimes be relieved before the orifice is made. And it is upon this principle alone that we can explain the fact noticed by Dr. Sydenham, that although the blood flows ever so fast, yet if it trickles down the arm in bleeding, its abstraction is less serviceable than when it streams horizontally from the vein.* Its not streaming from the orifice, results from the bandage being either too tight, or too loose. In the first case, the influx of blood into the limb, is prevented by the compression of the main artery which supplies it; and, in the second, the derivation can be but small, because the interruption to the return of blood by the super- ficial veins, is not complete. From this view of the operation of blood-letting in the arm, it may be concluded, that it may be employed whenever a mere eva- cuation of blood is required; as in cases of mere plethora, unat- tended with local congestion, and without any destruction of the balance of the circulation. It is here resorted to as a mere eva- cuant. 2. It may be employed in all cases where it is desira*ble to produce a general effect upon the system, without reference to its operation upon any particular part. Thus, it may be used in sim- ple synocha, in the treatment of certain kinds of convulsions, and in those cases in which it is desirable to induce a general relaxa- tion, for the purpose of returning a hernia, or reducing dislocated limbs. * At vero animadvertendum est, quod si sanguis e secta vena non recto flumine versus horizontem prosiliat, sed per cutem repens perpendiculariter dimanet, utut celeri se proripiat gradu, non jeger ab istiusmodi sanguinis mis- sione perinde levatur, ac si modo primum descripto fluat. Sect. VI. cap.iii. 468 Observations on Blood-letting. 3. It will follow too from the view we have taken, that bleed' ing from the arm is to be preferred in diseases of the lower extre- mities, in inflammations of the abdominal and pelvic viscera, in uterine haemorrhages, in pneumonic affections, and in those cases where the opposite extremity, or the integuments of the opposite side, may be involved in inflammation. It will be observed that I am particular in designating the integuments of the opposite side, because I believe it to be immaterial from which side blood is drawn in peripneumony, or pleurisy. This point, however, was, at one time, the subject of very acrimonious contention. While the dogmas of the Arabian physicians prevailed in the schools, it was the universal practice, notwithstanding the authority of Hip- pocrates and Galen to the contrary, to draw blood, in pleurisy, from the arm of the opposite side. In the year 1514, the cele- brated Brissot, with the zeal and pertinacity of a reformer, pub- licly protested against this practice; and contended, that the operation should be performed on the side affected. He met with great opposition; but, in consequence of the distinguished success which, it is said, attended his practice, he procured many adhe- rents. He shortly after went to Portugal, where he engaged in controversy on this subject with the king's physician. The dis- pute was referred to the Academy of Salamanca, whose decision procured an edict prohibiting any person from bleeding in pleu- risy on the side affected. Charles V. of Spain, was shortly after prevailed upon to issue his royal denunciation against the doctrine of Brissot.* 4. It will appear also, that blood-letting from the arm is not * The reader may not be aware that there is high authority for giving a preference to one side rather than the other. The learned Van Swieten says, " videtur ilia sententia, quae venae sectioncm in brachio lateris affecii suadet, tutissima esse." Dr. Sydenham advises bleeding in pleurisy on the affected side. Sect. vi. chap. 3. Dr. Cullen says, " bleeding will be per- formed with most advantage in the arm of the side most affected." Tirst Lines, § 362. And Dr. Wilson Philip, though he speaks with great indiffer- ence, seems to think that the preference is not altogether groundless. Wil- son on Fevers, vol. ii. p. 192. Notwithstanding, I'have never observed any difference of effect in this case; nor can 1 conceive any reason why there should be any. Observations on Blood-letting. 469 advisable in congestions and inflammations of the brain; because the arteries by which it is supplied, necessarily participate in the derivation which is effected. The older surgeons strenuously pro- hibited blood-letting in the right arm in these cases, while they allowed that it might occasionally be advantageous when perform- ed in the left. This remarkable precept will not appear so in- consistent and absurd as it has been thought, when we consider that the left carotid artery arises immediately from the aorta, and consequently undergoes some degree of revulsion when the ope- ration is performed on the left arm; but that, as the right carotid and subclavian arise from a common trunk, and the vertebral ar- tery is given off by the latter, they must all be involved in the de- rivation produced in the extremity of that side. They had, no doubt, observed a difference in the effects of bleeding in these cases; and, although unable to account for it, were led by experi- ence to regulate their practice accordingly. Since taking this view of the subject, I have repeatedly endeavoured to observe this difference of effect in the operation of blood-letting; and it is a matter of uniform experience vvith me, that fainting is induced by bleeding in the left arm much more readily than in the right. The rationale of this fact is easy. A certain degree of tension is in- dispensable to preserve the energy of the brain; and a constant communication of this energy, is necessary to maintain the vigour of the heart's action. Hence nature has contrived a peculiar con- formation of that organ, thereby to retard the passage of the blood through its vessels; and hence profuse haemorrhages, or artificial evacuations of blood, by taking off that ftilness and tension, occa- sion syncope.* Nothing is more common in the operation of phlebotomy; and it can generally be prevented in these cases, by a recumbent posture. It is evidently by diminishing this neces- sary tension of the brain, that tapping and delivery induce deli- quium. In these instances, a change takes place in the distribu- tion of the blood; so that a larger portion of it is derived into other parts of the sanguiferous system, and there occurs a propor- * See Cullen's First Lincs, Vol. II. § 1170, for an ingenious exposition of this theory of syncope Vol. III.-3 P 470 Observations on Blood-letting, tionate abstraction from the brain. It is thus also, that we are to explain the syncope consequent upon bleeding. On the removal of the ligature, all obstruction to the free course of the circulation in the limb, is removed. The consequence is, that an instanta- neous afflux of blood takes place to that part; so that the tension of the brain is suddenly affected, and that organ necessarily re- mains in some degree of collapse, until the equilibrium of the circulation is restored.* Now, it is obvious, from the view which has been given of the distribution of the arteries that supply the brain, that the quantity of blood in that organ, will be more readily diminished by abstracting it from the left arm, than by bleeding in the right. 5. It is evident that bleeding from the arm of the side affected, is improper in cases of rheumatism of the intercostal muscles. We are so much accustomed to draw blood from the arm, with- out any reference to the seat of the disease; and, I may add, we are so much in the habit of using this remedy empirically, and without reflecting upon its operation, that this remark may, to many, appear frivolous. But it will not seem so unimportant when it is considered, chat the parts in which this affection is seated are supplied with blood by the thoracic or external mammary arte- ries, which arise from the axillary trunk; and that the vena azy- gos, which receives the blood of the intercostal veins, terminates in the superior cava. It is because this circumstance is not ad- verted to, that it has become almost proverbial, that this disease is not so much benefited by blood-letting as might be expected from its pathology. 6. It is obvious, in short, that blood-letting in the arm is con- tra-indicated, whenever parts are involved which receive their blood from branches of the subclavian, axillary, or brachial ar- teries. But it may be said, that blood-letting in the arm is continually * It is true, that the blood is I'eturning to the heart with equal rapidity; but before it can arrive at the brain, it must perforin the circuit of the pulmonary circulation. I do not remember to have ever seen this remarkable fact ex- plained ; and this is the only explication of it that I can devise. I believe it is the only way in which it can be accounted for. Observations on Blood-letting. 471 resorted to in all those cases in which, agreeably to our theory, it is contra-indicated; and that, notwithstanding, it is frequently attended with signal advantage. This cannot be denied. But if it proves serviceable in these circumstances, it can be only by the evacuation it procures; so that the relief it affords can be neither so complete nor so speedy as it might be, were the opera- tion performed in a more suitable part, and the full benefits of revulsion procured. It would no more be proper to condemn, on this account, the principles advanced, than it would be logical to discard the general rule, that blood-letting is to be performed only in diseases of a sthenic diathesis, because it sometimes proves useful in diseases of an opposite character. III. In treating of bleeding in the foot, it will be sufficient to refer to our remarks on the effects of blood-letting in general; pointing out, however, the peculiarities of this operation. The effects of compression by the ligature, will here be the same as we have seen to take place in the former instance; with the ex- ception, that while blood-letting in the arm is revulsive with re- spect to the opposite limb,* blood-letting in the foot produces de- rivation in both of the lower extremities. For, as the iliac arteries proceed from the same trunk, diverge at the same angle, and are of the same calibre; and as the iliac veins unite to form the infe- rior cava; the derivation which is produced in one extremity, must necessarily affect the other in nearly the same degree. It will be remarked, too, that the derivation in this case is more extensive than in the former; as, from the anatomical connexions of the parts, the pelvic and abdominal viscera necessarily partici- pate in the derivation which is produced. Further, as another peculiarity of bleeding in the foot, it will be kept in view that the extremity is immersed in warm water. * Any one may convince himself of this by a very simple experiment. Apply a bandage to the arm, as in bleeding; and the veins of the other arm will be observed to lessen very remarkably. Upon removing the ligature, the increased flow of blood into this arm will be very sensible. Again, im- merse one leg in warm water, and the veins of the opposite extremity will become turgid. 472 Observations on Blood-letting. The pediiuvium was, no doubt, had recourse to for the purpose of rendering the vein which was to be opened, more perceptible. But this is not the only effect it produces. It is evident that it must greatly add to the derivation created by the ligature, by facilitat- ing the distention of the parietes of the veins, and thus inviting a copious afflux of blood to the limb. This effect of the pediiuvi- um is too remarkable to have escaped the observation of physi- cians; and, accordingly, we find that they have always availed themselves of its advantages in the treatment of diseases. It would be easy to adduce a long list of ancient authors, who laud the virtues of the pediiuvium in the language of enthusiasm. Nor has it been less esteemed by modern physicians. Van Swie- ten informs us, that he had seen an epidemic pleurisy, in which there was a great tendency to the brain; and that he averted this dangerous metastasis by the early use of the warm bath to the feet.* The celebrated Dr. Whytt, in his invaluable work on nervous dis- orders, relates several interesting cases in proof of the excellence of warm pediluvia in fevers attended with delirium; and declares, that " he had saved more patients who appeared to be in great danger, in the delirious state of fever, by this means, than by any other remedy."! It is recommended in phrenitis and other affec- tions of the head, by almost every practical author, both ancient and modern; and its efficacy in restoring the menses and recall- ing suppressed lochia, is a matter of popular notoriety. It is unnecessary to extend our remarks on the action of warm pediluvia, as it is sufficiently manifest from the view we have ta- ken of their operation, and of their employment in diseases, that they exert a powerful impression upon the system; and that their beneficial effects are wholly ascribable to the derivation and re- vulsion they procure. It must be obvious, then, that, indepen- dently of every other consideration which can give it an ad van- * Memini me quandoque talem pleuritidis epidemics speciem vidisse, cui morbo, nisi ab initio jam balneis pedum, &c.prospiceretur, familiaris erat in phrenitidem primis etiam diebus mutatio. Comment, in § 772. f Observations on the nature, causes, and cure of those disorders which have commonly been called Nervous, Hypochondriac, or Hysteric, &c. &c. Edin- burgh, 1775. 8vo. p. 446-458. Observations on Blood-letting. 473 tage over blood-letting in the arm, bleeding in the foot must, in many cases, be the preferable practice. 1. I conclude, that it is to be preferred in apoplexy, in phre- nitis, and in all other cases where it is desirable to relieve the brain by the detraction of blood.* 2. It is to be preferred in affections of the upper extremities, in diseases of the throat, in haemorrhages from the nose,f &c. 3. It is to be preferred in suppressions of the menses. Whatever differences of opinion there may be respecting the na- ture and the proximate cause of the menstrual evacuation, there is but one indication for restoring it when suppressed; and that is, to excite the action of the uterine vessels. This indication may be fulfilled, by imparting to them a certain degree of tone; or by inducing a local plethora in the organ, which will be adequate to overcome the constriction of their exhalent mouths. I would not be understood to convey the idea, that this accumulation does, by its mechanical distention, break down the obstructions that may exist in the uterus, or force a passage for the blood by the rup- ture of the vessels: I believe, however, that a certain degree of fulness and tension, is necessary to excite in the organ that action whereby the menstrual function is performed. And, accordingly, all the emmenagogues that are usually prescribed with the vague idea of their specific virtue in propelling the catamenia by some peculiar action upon the womb, are conducive to this end in pro - portion to the derivation which they create in that organ. Per- haps I would not expose myself to contradiction, were I to de- clare, that not a single article of this class has any immediate ac- * In apoplexy, Boerhaave recommends ligatures to the lower extremities. Aph. 1025. In phrenitis, he says, " vense sectio instituenda larga-in pede, &c.-pedtlzivia applicanda," &c. Aph. 781. And Van Swieten explains the operation of the baths thus: " his enim laxantur vasa partium inferiorum. Versus hxc loca major copia humorumducitur, adeoque a superioribus revul- sio fit." Comment, in Aph. 781. Dr. Rotheram, in his note to Dr. Cullen's chapter on Phrenitis, advises " large bleedings on the lotver extremities." Cullen's First Lines, § 295. Chap. IV. Dr. Lind recommends blood-letting in the foot in the commencement of some tropical fevers, in which there is pain in the head. On Hot Climates, p. 178. f In epistaxis, immersing the feet in warm water will arrest the hemor- rhage, when plugs, and ice, and bleeding from the arm, have totally failed. 474 Observations on Blood-letting lion upon the womb itself;* and that this organ is affected only by sympathising in the action which they excite, or by partici- pating in the derivation which they procure, in the neighbouring parts. If we examine the operation of any of the principal em- menagogues; whether it be calomel, aloes, scammony, or any other drastic; whether it be savin, cantharides, or hellebore; we shall find that its principal and immediate action is confined to some neighbouring organ, and that it determines an afflux of blood to that part. It is exactly upon this principle that Corvin sartf found leeches to the pudenda so serviceable in provoking the menses, and that Dr. Chapmanj: has applied blisters to the thighs with such signal success.§ It was with the view of producing a temporary plethora of the uterus, that Dr. Hamilton proposed compressing the crural arteries by a tourniquet. Had he applied it so as merely to compress the veins, he would more frequently have succeeded. In the experiments of Dr. Home, it seemed evidently to determine to the head.|| But to return to the subject of bleeding in the foot. We have seen that the effect of the ligature to the lower extremity, is to produce a plethora in the iliac arteries; and we know that the womb is supplied with blood principally by branches of the hypo- gastric arteries, which arise from the external iliacs. It is evident, then, that the menstrual discharge will be most readily restored by letting blood from the foot. Nor is this operation entitled to a mere preference. Bleeding in the arm, I believe to be positively injurious in cases of suppression; as, by the revulsion it produces in the uterus, it diminishes the necessary plethora in that organ, and represses that action of its vessels which is indispensable to • I will except the rubia tinctorum, and the ergot, as they have no sensible operation, except what they exhibit upon the womb. But, notwithstanding the encomiums of Dr. Home, the former article has fallen into disrepute; and the emmenagogue virtue of spurred rye is yet a subject of doubt. f On the Heart, &c. + Theurapeutics and Mat. Med. vol. ii. p. 54. § It was formerly a fashionable practice to apply cups to the thighs. Astruc, Maladies des Femmes. Tom. i.p. 195. Friend, Emmenologia. Opera, Vol. I. p. 126. 11 Home's Clinical Expts, and Hist. p. 411. Observations on Blood-letting. 475 restore the suspended function. It would neither be consistent with truth, nor with policy, to declare, that blood-letting in the arm should be prohibited in every case of amenorrhoea. This practice is pursued continually, and often with the most decided success. But this is no objection to the principles I have advanced, or the precepts deduced from them. There are, undoubtedly, in- stances of suppression, in which bleeding from the arm is not only admissible, but absolutely necessary. In those cases in which the retention of the menses would seem to be owing to an inordi- nate engorgement of the uterine vessels; in which there is super- added an inflammatory disposition, or painful tension of the womb; letting blood from the foot would certainly be pernicious, and bleeding in the arm would be indispensable. But with these ex- ceptions, I hold it as a principle established by the soundest patho- logy, that bleeding in the foot only is proper in suppressions of the catamenia.* 4. Blood-letting in the foot is to be practised in suppressions of the lochia. It is unnecessary to dilate here, as the reasons of this preference must be obvious from what has been said respecting the practice in amenorrhoea. It is proper to observe, however, that should suppressed lochia be complicated with an inflamma- tion of the womb, bleeding in the arm is to be preferred. 5. Blood-letting in the foot is contra-indicated in diseases of the lower extremities, in inflammatory affections of the pelvic and abdominal viscera, in uterine hemorrhages, in haemorrhoids, &c. It is necessary to remark, that this operation is not to be excluded entirely in inflammations of the uterus; for when the menses, or the lochia continue in some degree, and there is any probability of restoring the evacuation, it may be resorted to with propriety and advantage.! IV. Bleeding in the jugular vein is not unfrequently practised. It is evident, however, that the compression employed, must pro- duce an accumulation of blood in the brain. This operation can seldom be necessary, as, except in young children and persons of * Home's Clinical Experiments, Histories, &c. p. 419. + Astrnc, Traite des Maladies des Femmes. Tom, iii. p. 56. Paris 1761 476 Observations on Cataract. a very corpulent habit, sufficient blood can always be procured by bleeding in other situations. Yet, as so large a quantity can be abstracted in a short time from this vessel; and, in consequence of the orifice being situated between the bandage and the part affected, a direct detraction of blood is procured; it may doubtless be practised with advantage in many cases of engorgement ol the brain. Perhaps it should be preferred, when it is necessary to obtain very speedy relief. But, I believe, it should seldom take the precedence of bleeding in the foot; as, in the latter operation, in addition to the evacuation, the immense advantage of revulsion is gained. Arteriotomy, or opening the temporal artery, I believe to be perfectly useless. It does indeed afford the benefits of an evacua- tion of blood: but these may be obtained more conveniently, more speedily, and more effectually, by bleeding in the arm or foot. Having completed my remarks on the subject of blood-letting, I commit them to the judgment of the profession, with a firm assu- rance of the truth of my statements, and, I confess, with some confidence in the correctness of my reasoning. Yet I feel a hesi- tancy in advancing opinions, and in recommending modes of prac- tice, so contrary to those which are usually received; sensible of the difficulty of restoring confidence in what is discarded, or of procuring it for what is new. " Res ardua vetustis noritatem dare, novis auctoritatem." Plin.