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A point not so far mentioned in the correspondence generated by Professor Carter's article (January 2001 RSM, pp. 38-42) is that the therapeutic effect of leeches is due not to the amount of blood ingested but to continued bleeding after their detachment. Their saliva contains the most potent natural anticoagulant known (hirudin) and a histamine-like vasodilator that promotes local bleeding, a local anaesthetic and hyaluronidase that enhances the spread of other salivary secretions into the bite wound1. Blood loss after prolonged use of leeches must be monitored. Leeches must also be prevented from ‘wandering’ or attaching to normal or better perfused tissues.