Blood Basics > Early Practices
A Brief History of Bloodletting
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.
Barber-surgeons develop
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.
Scientific community reacts to phlebotomy
In 1885 bloodletting in London had fallen into disfavor.3 At this time it was thought that disease represented a depressant effect to be overcome. Since bloodletting aggravated depression, its usefulness was limited to the treatment of local inflammations. "The year 1830 and subsequent years were marked by the epidemic visitations of cholera and of influenza. These diseases were characterized by extreme depression. If antiphlogistic measures were adopted, they proved failures, and taught the physician that bloodletting was not the universal panacea it was supposed to be."3 Bloodletting reached its high point in the United States by the end of the eighteenth and very early nineteenth centuries. Benjamin Rush, M.D., used it extensively during the yellow-fever epidemic in Philadelphia in 1793. In 1799 Dr. Rush treated George Washington for acute laryngitis by use of heavy bleeding; Washington died some 24 hours later.
The foregoing concepts of bloodletting came under increasing attack after 1850. The credit for undermining the antiphlogistic doctrine of treatment of inflammation in general, and of pneumonia in particular, belongs to Josef Skoda, M.D., and Josef Dietl, M.D., in Vienna; and to Pierre Charles Louis, M.D., Grissolle, M.D., August Chomel, M.D., and Gabriel Andral, M.D., in Paris.6 By the mid-nineteenth century Hughes Bennet, M.D., professor of medicine at the University of Edinburgh, is quoted by Watson and Condie5 as saying, "The principles on which bloodletting and antiphlogistic remedies have hitherto been practiced are opposed to sound pathology." The tide against bloodletting had begun. Oliver Wendell Holmes, M.D. (1809 to 1894), said, "The lancet was the magician's wand of the dark ages of medicine." Once the concept of microorganisms as the causative factor in disease was understood, the quest for cure of disease was redirected. The swelling, redness, and fever became secondary factors to be resolved.
A tradition of several thousand years dies hard. Austin Flint, M.D.,7 in 1881 gave the following advice:
A great change has taken place with respect to bloodletting in the treatment of acute inflammations. This measure was formerly thought to be highly important, and was rarely omitted. It is now considered by many as seldom, if ever, called for. The infrequent use of the lancet now, contrasted with its frequent use forty years ago, constitutes one of the most striking of the changes in the practice of medicine which have occurred during this period. It can hardly be doubted that this measure was formerly adopted too indiscriminately, and often employed too largely, but the natural tendency being to pass from one extreme to another, the utility of blood letting in certain cases, at the present time, is perhaps not sufficiently appreciated.As late as 1920, Osler and McCrae8 gave the following information regarding bloodletting in pneumonia:
We employed it much more than we did a few years ago, but more often late in the disease than early. To bleed at the very onset in robust, healthy individuals in whom disease sets in with great intensity and high fever is good practice. Late in the course marked dilatation of the right heart is the common indication. The quantity of blood removed must be decided by the effect; small amounts are often sufficient.Methods of bloodletting
The following quotation comes from the DICTIONARY OF PRACTICAL SURGERY of 18869:
Bloodletting is said to be general when blood is taken from a vein or artery so that the amount in the vascular system is materially diminished as shown by diminution on the tension of the blood vessels: it is termed local when, by means of leeches, cupping, or scarification, blood is taken in smaller quantities, with a view of relieving limited congestion and vascular tension. It may be safely said that in these two methods the surgeon possesses the means of treating, in a powerful and beneficial manner, those acute inflammations and engorgements of certain important organs and serous membranes associated with hard pulse, great pain, and distress occurring from injury in persons of healthy constitutions.Bloodletting can therefore be listed under the following headings:
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I. General bloodletting
A. Venesection
B. Arteriotomy
II. Local bloodletting
A. Scarification with wet cupping
B. Leeches
Bloodletting by venesection was the method most commonly used; instruments used included lancets and fleams. A thumb lancet is a small, sharp-pointed, two-edged surgical instrument which was the principal instrument used for phlebotomy in human beings. ... The lancets, several of which might be contained in a special case, had either tortoise shell, ivory, or pearl folding guards. The cases were often made of silver or tortoise shell, and resembled a pocket cigarette lighter in size and shape ... which the physician usually carried in his waistcoat pocket.
Instruments known as spring lancets,10 spring fleams,11 or schnappers were introduced in Germany about 1680. ... Bennion12 labeled them single-bladed scarificators; they are spring loaded, and are constructed with a brass or white metal handle, and vary from 5 to 8 cm. in length. Pressure on a release lever allows the lancet to spring forward and penetrate the skin and vein. Small spring lancets were used for human beings; large ones were used for domestic animals such as the horse. The small, manually controlled thumb lancet was preferred by the physician; the spring lancet was used more by the laity. The spring lancet was more difficult to control, and the incision in the vein was often either too small or too large. Transfixation of the vein, injury to the tendon or nerve, and accidental arteriotomy were serious complications of the spring lancet.
According to Bailey,13 a fleam is a farrier's tool for letting blood in horses; a farrier is a smith who shoes and doctors horses. The term fleam has been applied to several bloodletting tools including the spring lancet, but should be used principally to indicate a bloodletting instrument with several shafts that fold into a case much like a pocketknife. Each shaft has a different size cutting blade, constructed at right angles to the shaft ...; sometimes the brass handles are decorated with animal horn.
In using the thumb lancet for venesection, the practitioner followed a prescribed set of instructions. The arm of the patient was bound above the elbow with a broad tape tight enough to compress the vein, but not tight enough to diminish the arterial pulse. The blade of the lancet was grasped between the thumb and forefinger, and the hand was steadied by the other three fingers. The lancet was then introduced into the vein in an oblique direction until blood rose up at the point. The front edge of the lancet was then pulled up in as straight a line as possible to make the skin wound the same size as that in the vein. The thumb of the left hand which was compressing the vein distally was removed, and the blood was allowed to flow into a bowl for measurement. Care was taken to avoid transfixation of the vein, accidental arteriotomy, or injury to the nerve or tendon. The spurting blood was caught in various types of vessels. Barber's shaving bowls were sometimes used. ... Soon after 1500 A.D., the design of the bowl was changed to include a semicircular notch in the rim.14 The notch allowed the bowl to be pressed against the skin of the neck or antecubital fossa. When sufficient blood had been withdrawn, the tourniquet was removed and the wound was dressed with dry lint (shredded linen) and a roller bandage.
Venesection was used to treat horses as well as man. In 1825 White15 stated, "In almost all the internal diseases of horses bleeding is the essential remedy; and the earlier and more freely it is employed the more effectual will it generally be found." "Bleed 'em White," as he became known, indicated his liberal views on bloodletting. The horse was bled most often from the jugular vein of the neck; a small lancet was used for small veins, but a fleam was preferred for the large veins. The preference for the fleam was its rapid introduction before the horse could pull free. Except in expert hands, the lancet was slightly slower and caused considerable skin pain before the incision could be made in the vein; by this time the horse would be out of control. The blade of the fleam was held against the long axis of the jugular vein, and the fleam handle was struck with the bottom of the fist to drive it through the skin and vein wall. As in human beings, rapid bleeding to a state of faintness was thought to be the proper technique. An instrument known as a blood-stick, a small club of hardwood usually weighted at one end with lead, was sometimes substituted for the rapid stroke of the hand.16
General bloodletting by arteriotomy
Arteriotomy was said to be indicated when there was a relative emptiness of the veins and an overfullness of the larger arteries. In comparison to venesection, the operation was infrequently performed.
Arteriotomy was most often performed on the superficial temporal artery or one of its branches. The vessel was partially cut through by a single transverse incision; when adequate blood was removed, the artery was completely severed so that the ends might contract and thus arrest the hemorrhage. A compress of dry lint was applied to the wound along with a tight roller bandage.
Local bleeding by scarification and wet cupping
Cupping may be wet or dry. Dry cupping is the application of a suction cup over an area of intact skin. The idea was to draw underlying blood and fluid away from the area of inflammation to the surface of the skin. This method relieved the congestion from the inflamed area, but did not remove fluid from the body. An early explanation by Paré2 is as follows: "For (as Celsus saith) a cupping glass where it is fastened on, if the skin be first scarified, draws forth blood, but if it be whole, then it draws spirit."
The cupping devices were most often dome-shaped glasses. ... Bailey13 defines a cupping glass as "a sort of glass vial applied to the fleshy part of the body to draw out corrupt blood and windy matter." This same dictionary uses cucurbitula as a synonym for cupping glass. The word is derived from Latin curcurbita meaning a gourd, or made in the shape of a gourd. It is interesting to note that small gourds were actually used as cupping devices for drawing blood. There were several ways to create suction in the cupping glass. One was to heat the air in the glass before application to the skin; as the air cooled, a suction developed. Another way was to attach a brass syringe to the glass cup to produce suction. However, the heated cupping glasses remained the favorite method. Some cups were made from the hollowed, distal portion of an animal's horn called cupping horns. A hole, which was used for mouth suction, was made in the pointed end. Once suction was established, the hole was plugged with wax. Such devices were described by Paré.2
Wet cupping involved scarification of the skin so that blood and fluid could be extracted. Most of the scarificators were cube-shaped, brass boxes containing multiple small knives operated by a spring mechanism. ... The scarificators, some of which were cylindric in shape, contained from 1 to 20 blades; however, most had 12 small knives. An early nineteenth-century bloodletting set contained cupping glasses, scarificator, and spirit heater. ...
The following method for wet cupping was described by Druitt in 1860.17 The equipment included a scarificator, cupping glasses, torch, spirits of wine, lighted candle, hot water, and sponge. The skin was sponged with warm water to increase the vascularity. A towel was used to dry the skin, after which a small torch, soaked in spirits of wine, was set on fire. The burning torch was introduced into the cupping glass for one second, and the cupping glass was then applied to the intact skin. As soon as the skin became red and swollen, the cup was removed by insinuating the fingernail under its edge. The spring-loaded scarificator was then placed on the prepared skin, and, with the release of the spring, 12 small lancets perforated the skin. The cupping glass was reheated and reapplied. After 3 to 5 ounces of blood had been extracted, the cup was removed and the wound was dressed with lint and plaster. Several precautions were given. To avoid burning the patient's skin, the edges of the cupping glass were not to be heated. If the scarificator blades were set too deeply, the fat protruded through the skin incision and prevented the flow of blood. The direction of the incision was to correspond to the course of the muscular fibers.
Local bleeding by use of leeches
The word leech comes from an Old English word "laece" meaning physician. In 1668 the veterinarian was known as a horse-leech. The spelling later became leech and was used to name a worm used in bloodletting. The leech belongs to the class "Hirudinea" and phylum "Annelida." The technical name for the medicinal leech is "Hirudo medicinalis." Leeches release an anticoagulant known as hiruden, and are found in many parts of the world including North America, Sweden, and Portugal. The Swedish leeches were said to draw four times the blood an American leech could extract. The leeches were stored in special porcelain jars with perforated lids, which contained spring water and were kept in a cool place. ...
An instrument known as an artificial leech was used for the over-sensitive patient who objected to live leeches; the device consisted of a pointed lancet inside a glass syringe cylinder or "sucker."
The following paragraph is a translation of the Old English from the 1634 text of Ambroise Paré.2
In those parts of the body whereto cupping-glasses and horns cannot be applied, to those leeches may for the most part be put, as to the fundament to open the coat of the haemorrhoid veins, to the mouth of the womb, the gums, lips, nose, fingers. After the leech being filled with blood shall fall off, if the disease require a large evacuation of blood, and the part affected may endure it, cupping-glasses, or horns, or other leeches shall be substituted. If the leeches be handled with the bare hand, they are angered, and become so stomachfull as that they will not bite; wherefore you shall hold them in a white and clean linen cloth, and apply them to the skin being first lightly scarified, or besmeared with the blood of some other creature, for thus they will take hold of the flesh, together with the skin more greedily and fully. To cause them to fall off, you shall put some powder of Aloes, salt or ashes upon their heads. If any desire to know how much blood they have drawn, let him sprinkle them with salt made into powder, as soon as they are come off, for thus they will vomit up what blood soever they have sucked. If you desire they should suck more blood than they are able to contain, cut off their tails as they suck, for thus they will make no end of sucking, for that it runs out as they suck it. The leeches by sucking draw the blood not only from the affected part whereto they are applied, but also from the adjacent and distant parts. Also sometimes the part bleeds a good while after the leeches be fallen away, which happens not by scarification after the application of cupping-glasses or horns. If you cannot stop the bleeding after the falling away of the leeches, then press the half of a bean upon the wound, until it stick of itself, for thus it will stay; also a burnt rag may be fitly applyed with a little bolster and fit ligature.The application of leeches was described by William Bennett in 1886.9The leech was removed from water and dried in a soft towel for 30 minutes before use. The skin of the affected area was sponged with warm water to increase the flow of blood to that part. Milk, or milk and sugar, was applied to the skin to encourage the leech to attach. The small end of the leech was held between the thumb and index finger, and the leech was placed against the desired area of skin. If several leeches were needed, they were placed in a teacup or wine glass which was then inverted over the skin. For application of a leech inside a body cavity such as the vagina, a leech-glass was used. Into this test-tube shaped cylinder of glass, a leech was placed and directed to the desired location. A rolled tube of paper served the same purpose. When leeching in the immediate vicinity of an orifice, the use of a plug of cotton wool was advised to prevent the leech from escaping through the opening. Thomas18 cautioned that this should be done when placing leeches on the cervix for the treatment of amenorrhea. A quotation from his text is as follows:
Three or four large leeches, or a sufficient number of small ones, to take from three to five ounces of blood, may be applied in the following manner: A cylindrical speculum, of sufficient size to contain the entire vaginal portion of the cervix, being passed and the part thoroughly cleansed, a small pledget of cotton, to which a thread has been attached for removal, should be placed within the os, so as to prevent the entrance of the leeches to the cavity above. A few slight punctures, sufficient to cause a flow of blood, should then be made in the cervix, and all leeches to be employed thrown in, and the speculum filled at its extremity by a dossil of cotton pushed toward the bleeding surface. The speculum should be watched until they cease sucking, for if left for a very short time, even with the mouth of the instrument filled with cotton, they will escape. After their removal all clots of blood should be removed by a sponge or a rod wrapped with cotton, the speculum withdrawn, a large sponge squeezed out of warm water placed over the vulva, and the patient directed to remain perfectly quiet.Leeches usually fell off when they became engorged with blood. If not, salt, snuff, or vinegar was applied to discourage their hold. The bleeding was arrested by pressure, a drop of perchloride of iron, a suture, or cautery with a red hot needle.
Comment
Phlebotomy still goes on. Blood removal is a recognized treatment of polycythemia and hemochromatosis. Exchange transfusions are used in hemolytic disease of the newborn. The phlebotomist makes his daily rounds in hospitals and physicians' offices around the world. Now bloodletting is used primarily for diagnosis rather than for treatment, and the lancet and fleam have been replaced by the syringe and needle. Blood loss for diagnostic testing in modern hospitals can be considerable. With some philosophic reflection, one might wonder whether or not the loss of blood could have any therapeutic benefit. Does the acute withdrawal of blood stimulate the defense mechanisms of the body? The body is known to respond more promptly to acute blood loss than to chronic loss of small amounts. It seems hard to believe that the many educated observers over the centuries were completely wrong in their assessment of clinical improvement following bloodletting. Whether bloodletting represents treatment or mistreatment continues to depend on the evolution of our ideas as to the basic causes of disease. Perhaps some day a rational explanation for the popularity of bloodletting will be found. A closing quotation from the year 1935 by Randolph6 seems appropriate. "With alternating periods of excess and moderation it is about the only remedy that has held its own throughout our history."
Summary
An occasional glance into our medical past can provide a refreshing interlude in our present-day practice of medicine. Medicine has many important roots in our cultural past. One of our medical roots is entwined in the history of bloodletting, the changing therapeutic uses of which follow the evolution of man's concept of disease. The tools of bloodletting include the lancet, fleam, scarificator, cupping-glass, and leech. These instruments have joined the ranks of interesting nostalgia and deserve to be remembered as part of colorful medical heritage.
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References
1. Thornwald, J.: SCIENCE AND SECRETS OF EARLY MEDICINE, New York, Harcourt, Brace and World, Inc., 1963, p. 152.
2. Johnson, T.: THE WORKES OF THAT FAMOUS CHIRURGION AMBROSE PARÉY (PARÉ), London, printed by T. Cotes and R. Young, 1634, p. 692.
3. Quain, R.: A DICTIONARY OF MEDICINE, London, Longmans, Green, and Company, 1885, p. 111.
4. Buchan, W.: "Domestic Medicine," London, printed for W. Strahan, T. Cahill in THE STRAND, and J. Balfour and W. Creech, at Edinburgh, 1784, p. 623.
5. Watson, T., and Condie, D.: WATSON'S PRACTICE OF PHYSIC, Philadelphia, Pennsylvania, Blanchard and Lea, 1858, p. 167.
6. Randolph, B.: "The blood letting controversy in the nineteenth century," ANN M. HIST. 7: 177 (1935).
7. Flint, A.: PRACTICE OF MEDICINE, Philadelphia, Pennsylvania, Henry C. Lea's Son and Company, 1881, p. 133.
8. Osler, W., and McCrae, T.: THE PRINCIPLES AND PRACTICE OF MEDICINE, New York and London, D. Appleton and Company, 1920, p. 102.
9. Heath, C.: DICTIONARY OF PRACTICAL SURGERY, London, Smith, Elder, and Company, 1886, p.162.
10. SURGICAL INSTRUMENTS, New York, George Tiemann and Company, 1889, p. 115.
11. Bell, B.: A SYSTEM OF SURGERY, Edinburgh, printed for Charles Elliot, 1790, p. 42.
12. Bennion, E.: ANTIQUE MEDICAL INSTRUMENTS, London, Philip Wilson Publishers Ltd., 1979, p.49.
13. Bailey, N.: ENGLISH DICTIONARY, London, printed for R. Warf, A. Ward, J. and P. Knapton, and T. Longman, 1742.
14. Abel, A.: "Bloodletting. Barber-surgeons' shaving and bleeding bowls," J.A.M.A. 214: 900 (1970).
15. White, J.: THE VETERINARY ART, London, printed for Longman, Hurst, Rees, Orme, Brown, and Green, 1825, p. 296.
16. Clark, J.: A TREATISE ON THE PREVENTION OF DISEASES INCIDENTAL TO HORSES, Edinburgh, printed by the author, 1790, p. 202.
17. Druitt, R.: MODERN SURGERY, Philadelphia, Pennsylvania, Blanchard and Lea, 1860, p. 602.
18. Thomas, T.: DISEASES OF WOMEN, Philadelphia, Pennsylvania, Henry C. Lea's Son and Company, 1880, p. 333.
"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.
