Bloodletting 64196 222254022 2008-06-28T10:21:41Z Javierme 574348 /* External links */ commons {{dablink|For the Concrete Blonde album, see [[Bloodletting (album)]]. For the Overkill album, see [[Bloodletting (Overkill album)]]}} [[Image:Iatros.jpg|right|framed|Ancient Greek painting in a vase, showing a physician (iatros) bleeding a patient.]] '''Bloodletting''' (or '''blood-letting''', in modern medicine referred to as '''phlebotomy''') was a tremendously popular [[medicine|medical]] practice from antiquity up to the late 19th century, a time span of almost 2,000 years. Bloodletting involves the withdrawal of often considerable quantities of [[blood]] from a patient in the hopeful belief that this would cure or prevent a great many illnesses and [[disease]]s. The practice, of unproven efficacy, has been abandoned for all except a few very specific [[Bloodletting#Phlebotomy|conditions]]. It is conceivable that historically, in the absence of other treatments for [[hypertension]], bloodletting could sometimes have had a beneficial effect in temporarily reducing [[blood pressure]] by a reduction in blood volume. However since hypertension is almost always [[asymptomatic]] and thus undiagnosable without modern methods, this effect was unintentional. In the overwhelming majority of cases, however, the historical use of bloodletting has been downright harmful to the patient. The logic of bloodletting was based in the theory of the [[four humours]]. According to this theory, a mystical equilibrium between several bodily fluids maintains human life. Excess blood, thus would disturb the balance and result in illness. Today the term "phlebotomy" refers to the drawing of blood for laboratory analysis or [[blood transfusion]] (see [[Phlebotomy (modern)]]). Therapeutic phlebotomy refers to the drawing of a unit of blood in specific cases like [[hemochromatosis]], [[polycythemia vera]], [[porphyria cutanea tarda]] etc., to reduce the amount of red blood cells. ==In the ancient world== [[Image:Bloodletting 276px.jpg|right|framed|[[Hans von Gersdorff]], ''Feldbuch der Wundarznei'', 1517 &mdash; Points for blood-letting]] Bloodletting is one of the oldest medical practices, having been practiced among diverse ancient peoples, including the [[Mesopotamia]]ns, the [[Egypt]]ians, the [[Greece|Greeks]], the [[Mayans]], and the [[Aztecs]]. In Greece, bloodletting was in use around the time of [[Hippocrates]], who mentions bloodletting but in general relied on [[Dieting|dietary techniques]]. [[Erasistratus]], however, theorized that many diseases were caused by ''plethoras'', or overabundances, in the blood, and advised that these plethoras be treated, initially, by [[exercise]], [[sweat]]ing, reduced food intake, and [[vomit]]ing. [[Herophilus]] advocated bloodletting. [[Archagathus]], one of the first Greek physicians to practice in [[Roman Republic|Rome]], practiced bloodletting extensively and gained a most sanguinary reputation. "Bleeding" a patient to health was modeled on the process of menstruation. Hippocrates believed that menstruation functioned to "purge women of bad humors." Galen of Rome, a student of Hippocrates, began physician-initiated blood-letting. <ref>Elsimar M. Coutinho, ''Is Menstruation Obsolete?'',Oxford University Press 1999</ref><ref>See Wikipedia Article [[http://en.wikipedia.org/wiki/Elsimar_M._Coutinho]]</ref> The popularity of bloodletting in Greece was reinforced by the ideas of [[Galen]], after he discovered the [[vein]]s and [[artery|arteries]] were filled with blood, not [[Earth's atmosphere|air]] as was commonly believed at the time. There were two key concepts in his system of bloodletting. The first was that blood was created and then used up, it did not [[Circulation (physiology)|circulate]] and so it could 'stagnate' in the extremities. The second was that humoral balance was the basis of illness or health, [[the four humours]] being blood, phlegm, black bile, and yellow bile, relating to the four Greek [[classical element]]s of air, water, earth and fire. Galen believed that blood was the dominant humour and the one in most need of control. In order to balance the humours, a [[physician]] would either remove 'excess' blood (plethora) from the patient or give them an [[emetic]] to induce vomiting, or a [[diuretic]] to induce urination. Galen created a complex system of how much blood should be removed based on the patient's age, constitution, the season, the weather and the place. Symptoms of plethora were believed to include [[fever]], [[apoplexy]], and [[headache]]. The blood to be let was of a specific nature determined by the disease: either arterial or [[venous blood|venous]], and distant or close to the area of the body affected. He linked different [[blood vessel]]s with different [[Organ (anatomy)|organ]]s, according to their supposed drainage. For example, the vein in the right hand would be let for [[liver]] problems and the vein in the left hand for problems with the [[spleen]]. The more severe the disease, the more blood would be let. Fevers required copious amounts of bloodletting. The [[Talmud]] recommended a specific day of the week and days of the month for bloodletting, and similar rules, though less codified, can be found among [[Christianity|Christian]] writings advising which [[saint's day|saints' days]] were favourable for bloodletting. [[Islamic medicine|Islamic medical authors]] too advised bloodletting, particularly for fevers. The practice was probably passed to them by the Greeks; when Islamic theories became known in the [[Latin]]-speaking countries of [[Europe]], bloodletting became more widespread. Together with [[cautery]] it was central to [[Arab]]ic surgery; the key texts ''[[The Canon of Medicine|Kitab al-Qanum]]'' and especially ''[[Al-Tasrif|Al-Tasrif li-man 'ajaza 'an al-ta'lif]]'' both recommended it. It was also known in [[Ayurveda|Ayurvedic]] medicine, described in the ''Susruta Samhita''. ==In the 2nd millennium== [[Image:4 transfusion.jpg|left|thumb|300px|[[Ioannis Sculteti]], ''Armamentium Chirugiae'', 1693 &mdash; Diagrammed transfusion of [[sheep]]'s blood]] Even after the humoral system fell into disuse, the practice was continued by [[surgery|surgeon]]s and [[Barber surgeon|barber-surgeons]]. Though the bloodletting was often ''recommended'' by [[physician]]s, it was carried out by barbers. This [[division of labour]] led to the distinction between physicians and surgeons. The [[Barber's pole|red-and-white-striped pole]] of the [[Barbershop (hair)|barbershop]], still in use today, is derived from this practice: the red represents the blood being drawn, the white represents the [[tourniquet]] used, and the pole itself represents the [[stick]] squeezed in the patient's hand to [[dilation|dilate]] the veins. Bloodletting was used to 'treat' a wide range of diseases, becoming a standard treatment for almost every ailment, and was practiced [[prophylaxis|prophylactic]]ally as well as therapeutically. [[Image:Blood letting machine.jpg|right|thumb|100px|Scarificator]] [[Image:Blood letting machine mechanism.jpg|right|thumb|100px|Scarificator mechanism]] [[Image:Bloodletting showing depth adjustment.jpg|right|thumb|100px|Scarificator, showing depth adjustment bar]] [[Image:Bloodletting depth adjustment.jpg|right|thumb|100px|Diagram of scarificator, showing depth adjustment]] The practice continued throughout the [[Middle Ages]] but began to be questioned in the 16th century, particularly in northern Europe and the [[Netherlands]]. In [[France]], the court and university physicians advocated frequent phlebotomy. In [[England]], the efficacy of bloodletting was hotly debated<ref>[http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=2260507&pageindex=1#page British Medical Journal: Blood-letting], page 283, [[March 18]] [[1871]], retrieved on [[March 21]] [[2008]]</ref>, declining throughout the 18th century, and briefly revived for treating [[tropical fever]]s in the 19th century. At right are three photos and a diagram of a 19<sup>th</sup> century bloodletting device called a scarificator. It has a spring loaded mechanism with gears that snaps the blades out through slits in the front cover and back in, in a circular motion. The case is cast brass and the mechanism and blades steel. One knife bar gear has slipped teeth, turning the blades in a different direction than those on the other bars. The last photo and the diagram show the depth adjustment bar at the back and sides. A number of different methods were employed. The most common was ''phlebotomy'' or ''venesection'' (often called "breathing a vein"), in which blood was drawn from one or more of the larger external veins, such as those in the forearm or neck. In ''arteriotomy'' an artery was punctured, although generally only in the temples. In ''scarification'' (not to be confused with [[scarification]], a method of body modification) the "superficial" vessels were attacked, often using a syringe, a spring-loaded [[lancet]], or a glass cup that contained heated air, producing a [[vacuum]] within. A scarificator is a bloodletting tool used primarily in [[19th century medicine]]. [[Leech]]es could also be used. The withdrawal of so much blood as to induce [[syncope]] (fainting) was considered beneficial, and many sessions would only end when the patient began to swoon. [[William Harvey]] disproved the basis of the practice in 1628, and the introduction of [[Evidence-based medicine|scientific medicine]], ''la méthode numérique'', allowed [[Pierre Charles Alexandre Louis]] to demonstrate that phlebotomy was entirely ineffective in the treatment of [[pneumonia]] and various fevers in the 1830s. Nevertheless, in 1840 a lecturer at the [[Royal College of Physicians]] would still state that "blood-letting is a remedy which, when judiciously employed, it is hardly possible to estimate too highly" and Louis was dogged by the sanguinary [[François-Joseph-Victor Broussais|Broussais]], who could recommend leeches fifty at a time. Bloodletting was used to treat almost every disease. One British medical text recommended bloodletting for acne, asthma, cancer, cholera, coma, convulsions, diabetes, epilepsy, gangrene, gout, herpes, indigestion, insanity, jaundice, leprosy, ophthalmia, plague, pneumonia, scurvy, smallpox, stroke, tetanus, tuberculosis, and for some one hundred other diseases. Bloodletting was even used to treat most forms of hemorrhaging such as nosebleed, excessive menstruation, or hemorrhoidal bleeding. Before surgery or at the onset of childbirth, blood was removed to prevent inflammation. Before amputation it was customary to remove a quantity of blood equal to the amount believed to circulate in the limb that was to be removed.<ref>Carter (2005) p6</ref> Leeches became especially popular in the early nineteenth century. Through the 1830s the French imported about forty million leeches a year for medical purposes, and in the next decade, England imported six million leeches a year from France alone. Through the early decades of the century, hundreds of millions of leeches were used by physicians throughout Europe.<ref>Carter (2005) p7</ref> <div class="boilerplate metadata" id="attention" style="background-color: #FFFCE6; margin: 0 2.5%; padding: 0 10px; border: 1px solid #aaa;"> One typical course of medical treatment began the morning of [[13 July]] [[1824]]. A French sergeant was stabbed through the chest while engaged in single combat; within minutes he fainted from loss of blood. Arriving at the local hospital he was immediately bled twenty ounces (570 ml) "to prevent inflammation". During the night he was bled another 24 ounces (680 ml). Early next morning the chief surgeon bled the patient another 10 ounces (285 ml); during the next 14 hours he was bled five more times. Medical attendants thus intentionally removed more than half of the patient's normal blood supply - in addition to the initial blood loss which caused the sergeant to faint. Bleedings continued over the next several days. By 29 July the wound had become inflamed. The physician applied 32 leeches to the most sensitive part of the wound. Over the next three days there were more bleedings and a total of 40 more leeches. The sergeant recovered and was discharged on 3 October. His physician wrote that "by the large quantity of blood lost, amounting to 170 ounces [nearly eleven pints] (4.8 liters), besides that drawn by the application of leeches [perhaps another two pints] (1.1 liter), the life of the patient was preserved". By ninteenth-century standards, thirteen pints of blood taken over the space of a month was a large but not an exceptional quantity. The medical literature of the period contains many similar accounts-some successful, some not.<ref> Carter (2005) pp7-8 </ref> </div> Bloodletting was also popular in the young [[United States of America]], where [[Benjamin Rush]] (a signatory of the [[United States Declaration of Independence|Declaration of Independence]]) saw the state of the arteries as the key to disease, recommending levels of blood-letting that were high, even for the time. [[George Washington]] was treated in this manner following a [[horseback riding]] accident: almost 4 [[pound (mass)|pounds]] (1.7 [[litre]]s) of blood was withdrawn, contributing to his death by [[throat]] [[infection]] in 1799. One reason for the continued popularity of bloodletting (and purging) was that, while [[anatomy|anatomical]] knowledge, surgical and diagnostic skills increased tremendously in Europe from the 17th century, the key to curing disease remained elusive and the underlying belief was that it was better to give any treatment than nothing at all. The psychological benefit of bloodletting to the patient (a [[placebo effect]]) may sometimes have outweighed the physiological problems it caused. Bloodletting slowly lost favour during the 19th century, but a number of other ineffective or harmful treatments were available as placebos&mdash;[[mesmerism]], various processes involving the new technology of [[electricity]], many potions, tonics, and elixirs. In the absence of other treatments bloodletting actually is beneficial in some circumstance, including the fluid overload of heart failure, and possibly simply to reduce blood pressure. In other cases, such as those involving agitation, the reduction in blood pressure might appear beneficial due to the sedative effect. In 1844 [[Joseph Pancoast]] listed the advantages of bloodletting in "A Treatise on Operative Surgery". Not all of these reasons are outrageous nowadays: :The opening of the superficial vessels for the purpose of extracting blood constitutes one of the most common operations of the practitioner. The principal results, which we effect by it, are 1st. The diminution of the mass of the blood, by which the overloaded [[capillary]] or larger [[blood vessel|vessels]] of some affected part may be relieved; 2. The modification of the force and frequency of the heart's action; 3. A change in the composition of the blood, rendering it less stimulating; the proportion of [[blood plasma|serum]] becoming increased after bleeding, in consequence of its being reproduced with greater facility than the other elements of the blood; 4. The production of [[fainting|syncope]], for the purpose of effecting a sudden general relaxation of the system; and, 5. The derivation, or drawing as it is alleged, of the force of the circulation from some of the [[internal organ]]s, towards the open outlet of the superficial vessel. These indications may be fulfilled by opening either a vein or an artery. ==Phlebotomy== Today it is well-established that bloodletting is not effective for most diseases. Indeed it is mostly harmful, since it can weaken the patient and facilitate infections. Bloodletting is used today in the treatment of a few diseases, including [[hemochromatosis]] and [[polycythemia]]; however these rare diseases were unknown and undiagnosable before the advent of scientific medicine. It is practiced by specifically trained practitioners in [[hospital]]s, using modern techniques. In most cases, phlebotomy now refers to the removal of ''small'' quantities of blood for the purpose of performing [[blood tests]]. For more details on this subject, see [[Phlebotomy (modern)]]. ==See also== *[[Hijama]] *[[Fire cupping]] *[[Alternative medicine]] *[[Bloodstopping]] *[[Blood donation]] *[[Hematology]] *[[History of medicine]] *[[Trepanation]] *[[Humorism]] *[[Fleams]] ==External links== {{commonscat|Bloodletting}} *[http://www.library.ucla.edu/libraries/biomed/his/blood/ UCLA Biomedical Library selection on bloodletting] *[http://www.medicalantiques.com/medical/Scarifications_and_Bleeder_Medical_Antiques.htm Medical Antiques: Scarification and Bleeding] *[http://www.phisick.com/zphleb.htm Pictures of antique bloodletting instruments] *[http://www.pbs.org/wnet/redgold/basics/bloodletting.html PBS's "Red Gold: The Story of Blood"] *[http://www.mtn.org/quack/devices/phlebo.htm Bloodletting devices and scarificator] *[http://www.alllancets.com Huge collection of antique bloodletting instruments] ==References== <references/> ==Books cited== {{cite book | last = Carter | first = K. Codell | coauthors = Barbara R. Carter | title = Childbed fever. A scientific biography of Ignaz Semmelweis | publisher = Transaction Publishers | date = February 1, 2005 | isbn = 978-1412804677 }} [[Category:Blood]] [[Category:History of medicine]] [[Category:Medical tests]] [[Category:Medical treatments]] [[Category:Traditional medicine]] [[da:Åreladning]] [[de:Aderlass]] [[es:Sangría (sanguínea)]] [[fr:Saignée (médecine)]] [[gl:Flebotomía]] [[it:Salasso]] [[he:הקזת דם]] [[nl:Aderlaten]] [[ja:瀉血]] [[no:Årelating]] [[pl:Puszczanie krwi]] [[pt:Flebotomia]] [[ru:Кровопускание]] [[fi:Suoneniskentä]] [[sv:Åderlåtning]]