I am presenting this paper in three sections, much would have presented at medical school in the 1830:
- The brief theory of bloodletting and bleeding
- Exposition of the practical application of bloodletting and bleeding
- A survey of historical and contemporary application of bloodletting and bleeding and the legends which surround this medical treatment
The brief theory of bloodletting and bleeding
For thousands of years, physicians relied heavily on a single treatment for hysteria, heart disease and just about every other malady: bloodletting. The theory behind the practice changed often over time, but the practice itself remained much the same — with doctors often bleeding patients until they were weak, pale and, sometimes, unconscious. In the beginning in Asia and the Mideast, patients were bled to release demons and bad energy. Later, in ancient Greece, they were bled to restore the body’s balance of fluids, and even later, in medieval and Renaissance Europe, they were bled to reduce inflammation — by then thought to be at the root of all disease.
The idea of bloodletting centres around Hippocrates’s theory of the four humors. He postulated this concept in Greece in 230 BCE, and it stuck around up through the 19th century CE. Hippocrates believed that the human body was made up of four humors: black bile, phlegm, yellow bile, and blood. When someone was sick, one or more of their humors was out of alignment, and the only way to fix the issue was by removing some of the humor. So, for example, if the illness had to do with the blood, then bloodletting was in order.
The four humors were aligned to the seasons, a particular organ, and the elements: black bile equalled winter, earth, and the spleen; the presence of phlegm aligned with autumn, water, and the brain; yellow bile was summer, fire, and the gall bladder; and blood was springtime, air, and the heart. The weather conditions during those seasons helped diagnose the problem and the solution. If someone had a fever and was sweating a lot, then they had too much blood in their bodies.
The practice of bloodletting seemed logical when the foundation of all medical treatment was based on the four body humors: blood, phlegm, yellow bile, and black bile. Health was thought to be restored by purging, starving, vomiting or bloodletting.
Before the modern era medicine was based on concepts first delineated by ancient Greek physicians, such as Hippocrates and Galen. These principles were distilled into the holistic medicine (treatment of the entire body or constitution) practiced in the Georgian and Regency eras. Human health was a situation where the patient’s constitution was balanced between “weakness” and “plethora.” In modern use, the word plethora means “a large amount, or many,” but in medical terminology it meant an excess of heat, blood, body fluids, etc. Plethora was diagnosed in conditions where the patient became more red, warm or swollen, and might include fevers, localised infections such as cellulitis (where affected areas of skin become red and swollen), inflammatory arthritis (such as gout), and pregnancy (where the skin is typically more pink and warm than usual because of the increased blood volume). Weakness, on the other hand, was any condition that would make the patient paler, thinner or weaker: blood loss, fainting, chills, or wasting diseases.
The treatment of plethora included changes in diet to avoid anything which was thought to be “heating”, and generally meant anything red, rich or fatty, or stimulating. Foods to be avoided included red meat, eggs, spices, and “stimulants” such as wine, coffee, and tea. “Cooling” foods were encouraged, such as fruits and vegetables, and simply prepared white meats, such as chicken and fish, and bland foods such as gruel (a sort of runny cereal made by boiling oats or other grain in milk or water). In addition, physicians would take blood from patients to directly remove the “excess” blood that was engorging their bodies and causing them to be red and hot. This treatment would be likely to help patients with gout, where there is an excess of uric acid in the blood. This results in red, hot joints, most commonly in the big toe and the knee.
Fever was a common medical problem because of the lack of antibiotics and vaccinations (except for smallpox vaccination, which was widespread by the Regency era).With this theory of health and disease states, bleeding a patient who was hot and feverish to decrease the fever made perfect sense to pre-modern practitioners. Ironically, bloodletting was often used after gunshot wounds to prevent a fever from the almost inevitable wound infection which resulted from having the ball and bits of clothing fibers implanted in the body. One wonders how many gunshot accidents resulted in death because the surgeon finished off the patient after the bleeding from the wound stopped.
Pregnancy was considered to be a plethoric condition and women in this “interesting condition” were often given “cooling” diets to promote health. Because these would include plenty of fruits and vegetables, it would often improve constipation, which is common in pregnancy, and was taken as encouragement that the diet was working as it should. Fortunately for the health of the patients and their infants, most women did not follow these diets as strictly as their physicians would have liked. Women who had a history of miscarriage or infertility would be more likely to rigorously follow the suggestions of their physician, and to change physicians if their condition did not improve to find one whose care they liked better.
Patients who were pale and weak, such those who were having chills in the early stages of a cold or who had wasting diseases such as tuberculosis, were encouraged to have a “heating” diet and could eat as much red meat and drink as much wine, especially red wine, as they wished to warm an overly cool and weakened constitution. They would also be treated with heating treatments, such as mustard foot baths or mustard plasters to the chest. In this case, of course, bloodletting was not used.
So, infections such as malaria, bacterial wound infections, or influenza (all of which are characterised by fever) would be treated as plethora, while infections such as tuberculosis, which causes chronic cough and gradual wasting, would be treated as weakness.
Exposition of the practical application of bloodletting and bleeding (“how to bloodlet and bleed”)
In ancient times, leeches were sometimes used, but more often people used thorns or sharpened sticks, bones or shells to cut open a vein (a process known as venesection) or to make small incisions in capillaries just below the skin (known as scarification).
Their successors used lancets and fleams — small double-edged blades that came with pocket-sized, often tortoiseshell carrying cases. They used vacuum cups of varying dimensions to draw blood to the surface of the skin and bleeding bowls to catch the fluid, released in amounts from a few ounces to a quart at a time.
Bloodletting was usually done in the veins of the elbows or knees, places where the practitioner could easily reach them. However, there are spots on the body that people believed “needed” to be bled that were too small for bloodletting implements. This is where leeches came in. One early practitioner of leeching therapies, Themison, who lived in Greece from 80-40 BCE, stated that leeches could be placed on the fingers, nose, lips, gums, and – even more horrifyingly – the outer parts of a woman’s womb. These areas of the body are where he believed haemorrhoid veins were located.
In the days before modern medical procedures, leeching blood was seen as a cure for many different ailments, from headaches to sore throats and even to flatulence. Bloodletting, sometimes with leeches, was a practice that consisted of removing blood from the body, thereby restoring a person’s health.
In the decades that followed, physicians began to realize that germs — not an imbalance of fluids — were at the root of cholera, flu and other illnesses. But bloodletting retained a few adherents into the 20th century, and even today some of its wisdom, however faint, is coming to light: Leeches are used to improve circulation and prevent clotting in some surgical patients. In 2004, University of Chicago researchers found that some bacteria rely on iron in blood cells to survive — leading some researchers to conclude that as an attempt to kill bacteria, letting blood out of the body may not have been such a bad idea after all.
Practitioners throughout Europe routinely bled patients who could afford it in efforts to prevent sickness brought on by excess food, weather changes and wounds.
A variety of devices were used to draw blood:
- The lancet was first used before 5th Century B.C. The vein was manually perforated by the practitioner. Many shallow cuts were sometimes made.
- Spring loaded lancets came into use during the early 18th Century. The device was cocked and a “trigger” fired the spring-driven blade into the vein. The fleam was heavily used during the 18th and 19th centuries. Many varieties exist. Sometimes a wooden “fleam stick” was used to hit the back of the blade and drive it into the vein. (Ouch!) The fleam was often used by veterinarians.
- The scarificator, a series of twelve blades, was also in vogue during the 18th Century, This device was cocked and the trigger released spring-driven rotary blades which caused many shallow cuts. The scarificator seems more merciful than the other bloodletting instruments.
By the late 1700s, bloodletting was the treatment of choice in America too — thanks to the efforts of Declaration of Independence signer and physician Benjamin Rush. Rush believed that tension in blood vessels was at the root of disease, turning to bloodletting to treat victims of Philadelphia’s devastating yellow fever outbreak in 1793. He favoured a quart at a time, repeated several times over several days, and claimed the treatment sped his recovery when he contracted the disease.
Later that same decade, George Washington fell ill with laryngitis, and his physicians bled him heavily, one after the other. The president gave up more than two litres of blood during the procedures and died a day later. Historians dispute whether it was the loss of blood or other complications that actually killed him.
A survey of historical and contemporary application of bloodletting and bleeding, and the legends which surround this medical treatment
Until 1163, Catholic priests and monks performed bloodletting procedures on their constituents. However, that year Pope Alexander issued an edict declaring the practice to be barbaric and forbidding any member of the religious clergy from conducting it. Although these priests and monks could still have the procedure done to them if they should get sick, they had to see a barber, surgeon, or doctor just like everyone else
By the time of the Renaissance, blood-letters (often barbers in Europe), had the practice down to a science of sorts. Zodiac charts determined the best times of year for letting blood from different parts of the body. Medical tomes distinguished between diverting blood flow (bleeding the right arm to staunch a bloody left nostril, for example) and encouraging it (bleeding the foot to draw menstrual blood down).
During the medieval era, barbers helped doctors out by performing bloodletting procedures on their own; after all, they had sharp implements. The traditional barber pole comes from this practice –their white and red stripes stand for the bandages (white) and the blood (red) of the procedure. Supposedly, these poles resemble the bloody white towels that barbers would display outside their storefronts. Although barber poles in the U.S. occasionally have blue on them, as well, the additional colour is viewed by some as the colour of the veins that the barbers would open. Over time, barbers (particularly those in England) were forbidden from conducting bloodletting on their clients, but for several centuries, their jobs were closely related to surgeons.
Bloodletting came to the U. S. on the Mayflower. The practice reached unbelievable heights in the 18th and early 19th centuries. The first U.S. president, George Washington, died from a throat infection in 1799 after being drained of nine pints of blood within 24 hours. The draining of 16-30 ounces (one to four pints) of blood was typical. Blood was often caught in a shallow bowl. When the patient became faint, the “treatment” was stopped. Bleeding was often encouraged over large areas of the body by multiple incisions. By the end of the 19th century (1875-1900), phlebotomy was declared quackery.
Today, bloodletting is used to treat hemochromatosis (an inherited problem which causes the storage of too much iron, damaging the liver), polycythemia vera (excess red blood cell production, which can increase the risk of stroke), and porphyria. An interesting historical side note to this treatment was the condition of the Prince Regent and his father, King George III. The king is well known for the periods of insanity from which he suffered, which eventually became permanent and required that the Prince of Wales become Regent. A number of medical historians believe that King George III suffered from a form of porphyria, an inherited disease in which the patient lacks one of the enzymes required to break down haemoglobin into smaller molecules which can then be excreted by the kidneys. The major symptoms of hereditary porphyrias are abdominal pain and psychiatric symptoms. The treatment for porphyria, still used today, is to remove blood from patients on a regular basis until they are slightly anaemic and thereby decrease the number of porphyrins in their blood. This treatment is done at blood centre and is just like donating blood, except that the blood removed is discarded. The Prince Regent had a long history of various types of illness, including frequent abdominal pain, and he was a great believer in bloodletting, having it done whenever he felt unwell. His symptoms might have been from his unrestrained eating and drinking, but if they were an indication of porphyria, his enthusiasm for having his blood let might have prevented him from developing the severe mental symptoms from which his father suffered.
The Institute for Tradition Medicine online extols the therapeutic benefits of “bleeding points”:
Peripheral blood-letting today is mainly carried out at the fingers and toes. At the tips of the toes, for example, are the qiduan points, located 0.1 cun behind the nails. These are said to be useful for emergency treatment for stroke or for numbness of the toes, also for redness, swelling, and pain of the instep of the foot.
When the actual history of acupuncture, bloodletting, cupping, and similar techniques are investigated we find that there are many modern myths about these practices. One myth is that there were completely different traditions in the various cultures, especially East and West. In reality, these were only cultural variations on the same themes – restoring balance and flow to blood and life energy in accordance to some astrological principles.
Acupuncture was originally a form of bloodletting – the “needles” were really lances and the acupuncture points locations over veins to be opened. Chi, or the Chinese concept of the life force, was believed to be partly in the blood, and bloodletting could be used to free the flow of chi. This was closely related to the Galenic concept of using bloodletting to free the flow of static blood in the tissue.
There is also evidence of direct cultural contact – not just reinventing the same concepts. For example, the iceman is the frozen remains of a 5200 year old man found in the Alp. He was covered with tattoos of points and lines over traditional acupuncture points. This was probably an example of therapeutic tattooing – the tattoos themselves were meant to be therapeutic. There are also needle punctures at some of these points. Think about the implications of a person living near the Alps (what is now Europe) 5,200 years ago being tattooed over what later were known as acupuncture points.
It is further a myth that what we know today as acupuncture or cupping was developed in line with their modern incarnations. In reality, these techniques were just variations of bloodletting and were very deliberately and fairly recently distanced from their bloodletting roots to make them more acceptable.
And finally it is a myth that bloodletting itself has been eliminated from traditional practice. It survives in muted form in various traditions.
What do we conclude from this paper?
- Bloodletting and bleeding have been very dynamic and sometimes misunderstood and misdirected forms of healthcare.
- Bloodletting and bleeding have variously been restoratives, palliatives, medicines and merely universal remedies with both physical and mental restorative powers.
- Bloodletting and bleeding seem to have a place in contemporary healthcare.
- Many of the myths are universal truths of medicine and healthcare.
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