Bloodletting Over the Centuries
Gilbert R. Seigworth, M.D.
Vestal, New York
Director, Obstetrics and Gynecology, Upstate Medical Student Program, and Active Staff, Charles S. Wilson Memorial Hospital, Johnson City; and Active Staff, Obstetrics and Gynecology, Ideal Hospital, Endicott.
Bloodletting is a procedure that was performed to help alleviate the ills of mankind. For an operation with a 3,000-year history, bloodletting has attracted little attention in recent historic accounts of medicine. Bloodletting began with the Egyptians of the River Nile one thousand years B.C., and the tradition spread to the Greeks and Romans; its popularity continued throughout the Middle Ages. It reached its zenith during the beginning of the nineteenth century, but had virtually died as a therapeutic tool by the end of that century.
The custom of bloodletting as practiced over the centuries might seem repulsive to the modern practitioner of medicine. However, the physician and his treatment must be judged in the light of the contemporary theory of disease. Primitive man looked on disease as a curse cast on him by an evil spirit; his treatment consisted of driving out the demon that possessed him. Neolithic man of the late Stone Age used flint tools for trepanning the skull as a method for releasing the demon; the logic of the treatment was sound, but the premise on which it was based was wrong. The premise was that the evil spirit of disease was contained within the skull and could be drawn out. In much the same way as trepanning allowed demons to escape from the head, bloodletting was supposed to facilitate the release of evil spirits from elsewhere in the body. Later use of bloodletting in hypertension, apoplexy, dropsy, and nervous disorders had a more physiologic explanation.
The story of bloodletting is intertwined in the mysterious fabric of medical lore; it originated from magic and religious ceremonies. The physician and priest were one and the same since disease was thought to be caused by supernatural causes. Witch doctors and sorcerers were called on to drive out the evil spirits and demons. Bloodletting was a method for cleansing the body of ill-defined impurities and excess fluid. The early instruments included thorns, pointed sticks and bones, sharp pieces of flint or shell, and even sharply pointed shark's teeth. Miniature bow and arrow devices for bloodletting have been found in South America and New Guinea. A small bloodletting instrument resembling a crossbow was once used in Greece and Malta. Wall paintings dating from 1400 B.C. depict the use of leeches for drawing blood from human beings.
Four body humors
Prior to the time of Hippocrates (460 to 377 B.C.), all illness was attributed to one disease with variable symptoms. Careful clinical observations by Hippocrates led to the recognition of specific disease states with identifying symptoms. It was during this time that the concept of body humors developed. The four fluid substances of the body were blood, phlegm, yellow bile, and black bile. Health depended on the proper balance of these humors. Bloodletting was, therefore, a method used for adjusting on of the four body humors to proper balance. This clinical concept led to the decline in the doctrine of evil spirits in disease.
It was thought that blood carried the vital force of the body and was the seat of the soul; body weakness and insanity were ascribed to a defect in this vital fluid. Blood spurting from fallen gladiators was drunk with the hope that it would transfer strength to the recipient. Caspar Bartholin, M.D., (1655 to 1738) described an epileptic girl at Breslau who drank the blood of a cat. The girl, so the report goes, became endowed with the characteristics of a cat. She climbed on the roofs of houses and imitated the manner of a cat by jumping, scratching, and howling. Not content with that, she would sit for hours gazing into a hole in the floor.
Surgery during the four centuries from 1100 to 1500 A.D. was a very crude business. The barber-surgeon developed during these years after a church edict by the Council of Tours in 1163 A.D. prevented monks and priests from continuing the custom of bloodletting. The council said, "The church abhors bloodletting." The barbers began to lance veins and abscesses as well as to perform amputations of arms and legs. The red-and-white barber pole designated a barber who did surgery as well as haircutting. The educated physicians avoided surgery during these years. This was to set the stage for later conflict when surgery became a respectable method of treatment. The Barber-Surgeon Company existed officially in England until 1744. However, barbers and surgeons had a clear separation of function for many years before that. The transition of surgery from disrespect to prominence was led by the French master barber-surgeon Ambroise Paré (1510 to 1590) who is considered the father of surgery.
Astrology played an important role in the physician's practice during the fourteenth and fifteenth centuries. Bloodletting as well as surgery in general was regulated by the signs of the zodiac, and the planets had to be in a proper relationship. A phlebotomy table (1480 A.D.) spelled out the relationship of every part of the body to the signs of the zodiac. Bloodletting was performed at specific times for specific parts of the body.1
Indications for venesection
Venesection was the most common method of general bloodletting. The specific indications have varied over the years. The following translation from Old English is advice given by Ambroise Paré in a 1634 text.2
But blood is let by opening a vein for five respects: the first to lessen the abundance of blood, as in plethoric bodies, and those troubled with plentitude. The second is for diversion, or revulsion, as when a vein of the right arm is opened to stay the bleeding of the left nostril. The third is to allure or draw down, as when the vein is opened in the ankle to draw down the menstrual flow in women. The fourth is for alteration or introduction of another quality, as when in sharp fevers we open a vein to breathe out that blood which is heated in vessels, and cooling the residue which remains behind. The fifth is to prevent imminent disease, as in the spring and autumn we draw blood by opening a vein in such as are subject to spitting of blood, quinsy, pleurisy, falling sickness, apoplexy, madness, gout, or in such as are wounded, for to prevent the inflammation which is to be feared. Before bloodletting, if there be any excrement in the guts, they shall be evacuated by a gentle clyster, or suppository, lest the mesenteric veins should thence draw unto them any impurity.
In the early nineteenth century adults with good health from the country districts of England were bled as regularly as they went to market;3 this was considered to be preventive medicine. In earlier times specific veins were described as heart veins, breast veins, and head veins. Buchan's4 DOMESTIC MEDICINE discussed this in the 1784 edition. Buchan realized that since systemic blood made a full circuit, little significance should be placed on the site chosen for venesection. The median basilic vein was the site most frequently used.
The term antiphlogistic means to counteract inflammation. Redness, heat, and swelling were considered the abnormal responses to be treated. With infection, the formation of laudable pus was thought to be an essential part of healing. It was not appreciated that these responses represented an attempt by the body to counteract bacterial infection; this discovery came later. Our current efforts to treat cancer without understanding the underlying etiologic factors will someday no doubt appear just as illogical. Bloodletting counteracted the redness, heat, and swelling by relieving the vascular congestion. The following quotation comes from Watson and Condie's5 PRACTICE OF PHYSIC in 1858.
The main object of general blood letting is to diminish the whole quantity of blood in the system, and thus to lessen the force of the heart's action. The object of local bleeding is, in most instances, that of emptying the gorged and loaded capillaries of the inflammed part. Sometimes the blood is thus taken directly from the turgid vessels themselves; more often, I fancy, topical bloodletting produces its effect by diverting the flow of blood from the affected part, and giving it a new direction, and so indirectly relieving the inflammatory congestion.
Watson goes on to state, "I cannot too strongly inculcate the precept that in order to extinguish or check acute inflammation, you must above all bleed early." An indication for bleeding in acute inflammation was a hard pulse of 90 to 120 beats per minute, which was measured by the resistance that the pulse of the artery made to the pressure of the examiner's fingers. Rapid bleeding by venesection with the patient standing was advised. It was surmised that the early onset of faintness and softness of pulse was beneficial. Slow bleeding with the patient supine led to more blood loss before the soft pulse and faintness developed, which was thought to be undesirable. Blood losses averaged 16 to 30 oz. Sufficient bleeding had occurred when the fever subsided, the pulse had become soft, or suppuration had developed.
Variations of the concept of body balance persisted until the end of the nineteenth century. Most physicians of that century believed that illness was due to either an excess or deficiency of some body product. Cathartics were used to reduce an over-excited nervous system by cleansing the bowels. Diuretics were used to restore systemic balance. Tonics were used to stimulate a depressed nervous system. Bloodletting allowed the physician to reduce body fluids and decrease body temperature. The febrile patient with a full pulse, red skin, and agitated state could be rendered pale and cool. The physician concluded that this represented clinical improvement.
"Bloodletting Over the Centuries" by Gilbert R. Seigworth, M.D. From the NEW YORK STATE JOURNAL OF MEDICINE (December, 1980): 2022-2028. Reprinted by permission of the Medical Society of the State of New York.