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.jpg) Bloodletting in 1860 | |
| MeSH | D001815 |
Bloodletting (orblood-letting) is the deliberate withdrawal ofblood from a patient to prevent or cure illness and disease. Bloodletting, whether by a physician or byleeches, was based on an ancient system ofmedicine in which blood and other bodily fluids were regarded as "humors" that had to remain in proper balance to maintain health. It was the most common medical practice performed by surgeons fromantiquity until the late 19th century, a span of over 2,000 years.[1] In Europe, the practice continued to be relatively common until the end of the 19th century.[2] The practice has been abandoned by modern-style medicine for all except a few very specificmedical conditions.[3] In the beginning of the 19th century, studies had begun to show the harmful effects of bloodletting.[4]
The modern termphlebotomy refers to the drawing of blood for laboratory analysis orblood transfusion.[5]Therapeutic phlebotomy refers to the drawing of a unit of blood in specific cases likehemochromatosis,polycythemia vera,porphyria cutanea tarda, etc., to reduce the number of red blood cells.[6][7] The traditional medical practice of bloodletting is considered apseudoscience,[8] though the method is still commonly used in forms ofalternative medicine.
Passages from theEbers Papyrus may indicate that bloodletting by scarification was an accepted practice inAncient Egypt.[9][10][11]Egyptian burials have been reported to contain bloodletting instruments.[12]According to some accounts, the Egyptians based the idea on their observations of thehippopotamus,[13] confusing itsred secretions with blood and believing that it scratched itself to relieve distress.[14][15]
In Greece, bloodletting was in use in the 5th century BC during the lifetime ofHippocrates, who mentions this practice but generally relied ondietary techniques.[16]Erasistratus, however, theorized that many diseases were caused by plethoras, or overabundances, in the blood and advised that these plethoras be treated, initially, byexercise,sweating, reduced food intake, and vomiting.[17] But his studentHerophilus supported bloodletting.[18] A contemporary Greek physician, Archagathus, one of the first to practice in Rome, also believed in the value of bloodletting.[citation needed]
"Bleeding" a patient to health was modeled on the process ofmenstruation. Hippocrates believed that menstruation functioned to "purge women of bad humours". During theRoman Empire, the Greek physicianGalen, who subscribed to the teachings of Hippocrates, advocatedphysician-initiated bloodletting.[19]
The popularity of bloodletting in the classical Mediterranean world was reinforced by the ideas of Galen, after he discovered that not onlyveins but alsoarteries were filled with blood, not air as was commonly believed at the time.[20][21] There were two key concepts in his system of bloodletting. The first was that blood was created and then used up; it did notcirculate, and so it could "stagnate" in the extremities. The second was thathumoral balance was the basis of illness or health, the four humours being blood, phlegm, black bile, and yellow bile, relating to the four Greekclassical elements of air, water, earth, and fire respectively. 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 anemetic to induce vomiting, or adiuretic 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. "Do-it-yourself" bleeding instructions following these systems were developed.[22] 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 orvenous, and distant or close to the area of the body affected. He linked differentblood vessels with differentorgans, according to their supposed drainage. For example, the vein in the right hand would be let forliver problems and the vein in the left hand for problems with thespleen. The more severe the disease, the more blood would be let. Fevers required copious amounts of bloodletting.
TheTalmud recommended a specific day of the week and days of the month for bloodletting in theShabbat tractate.[23] During medieval times bleeding charts were common, showing specific bleeding sites on the body in alignment with the planets and zodiacs.[22]Islamic medical authors also advised bloodletting, particularly for fevers. It was practised according to seasons and certain phases of theMoon in thelunar calendar. The practice was probably passed by the Greeks with the translation of ancient texts toArabic and is different thanbloodletting by cuppingmentioned in thetraditions ofMuhammad. When Muslim theories became known in theLatin-speaking countries ofEurope, bloodletting became more widespread. Together withcautery, it was central toArabic surgery; the key textsKitab al-Qanun and especiallyAl-Tasrif li-man 'ajaza 'an al-ta'lif both recommended it. It was also known inAyurvedic medicine, described in theSusruta Samhita.
Bloodletting became a main technique ofheroic medicine, a traumatic and destructive collection of medical practices that emerged in the 18th century.[24]
Even after the humoral system fell into disuse, the practice was continued bysurgeons andbarber-surgeons. Though the bloodletting was oftenrecommended by physicians, it was carried out by barbers. This led to the distinction between physicians and surgeons. Thered-and-white-striped pole of thebarbershop, still in use today, is derived from this practice: the red symbolizes blood while the white symbolizes the bandages. Bloodletting was used to "treat" a wide range of diseases, becoming a standard treatment for almost every ailment, and was practicedprophylactically as well as therapeutically.
A number of different methods were employed. The most common wasphlebotomy, orvenesection (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. Inarteriotomy, an artery was punctured, although generally only in the temples. Inscarification (not to be confused withscarification, a method of body modification), the "superficial" vessels were attacked, often using a syringe, a spring-loadedlancet, or a glass cup that contained heated air, producing avacuum within (seefire cupping). There was also a specific bloodletting tool called ascarificator, used primarily in 19th century medicine. 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.
Leeches could also be used. The withdrawal of so much blood as to inducesyncope (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,[2] and the introduction ofscientific medicine,la méthode numérique, allowedPierre Charles Alexandre Louis to demonstrate that phlebotomy was entirely ineffective in the treatment ofpneumonia and various fevers in the 1830s. Nevertheless, in 1838, a lecturer at theRoyal College of Physicians would still state that "blood-letting is a remedy which, when judiciously employed, it is hardly possible to estimate too highly",[25] and Louis was dogged by the sanguinaryBroussais, who could recommend leeches fifty at a time. Some physicians resisted Louis' work because they "were not prepared to discard therapies 'validated by both tradition and their own experience on account of somebody else's numbers'."[26]
During this era, 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.[27]
There were also theories that bloodletting would cure "heartsickness" and "heartbreak". A French physician,Jacques Ferrand wrote a book in 1623 on the uses of bloodletting to cure a broken heart. He recommended bloodletting to the point of heart failure (literal).[28]
Leeches became especially popular in the early 19th century. In the 1830s, the French imported about 40 million leeches a year for medical purposes, and in the next decade, England imported 6 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.[29]
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 the 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 liters), the life of the patient was preserved". By nineteenth-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.[30]
Bloodletting was also popular in the young United States of America, whereBenjamin Rush (a signatory of theDeclaration of Independence) saw the state of the arteries as the key to disease, recommending levels of bloodletting that were high even for the time.George Washington asked to be bled heavily after he developed a throat infection from weather exposure. Within a ten-hour period, a total of 124–126ounces (3.75 liters) of blood was withdrawn prior to his death from a throat infection in 1799.[31]
One reason for the continued popularity of bloodletting (and purging) was that, whileanatomical 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 (aplacebo effect) may sometimes have outweighed the physiological problems it caused. Bloodletting slowly lost favour during the 19th century, after French physician Dr. Pierre Louis conducted an experiment in which he studied the effect of bloodletting on pneumonia patients.[32] A number of other ineffective or harmful treatments were available as placebos—mesmerism, various processes involving the new technology of electricity, many potions, tonics, and elixirs. Yet, bloodletting persisted during the 19th century partly because it was readily available to people of any socioeconomic status.[33]
Barbara Ehrenreich andDeirdre English write that the popularity of bloodletting and heroic medicine in general was because of a need to justify medical billing. Traditional healing techniques had been mostly practiced by women within a non-commercial family or village setting. As male doctors suppressed these techniques, they found it difficult to quantify various "amounts" of healing to charge for, and difficult to convince patients to pay for it. Because bloodletting seemed active and dramatic, it helped convince patients the doctor had something tangible to sell.[24]
Bloodletting gradually declined in popularity over the course of the 19th century, becoming rather uncommon in most places, before its validity was thoroughly debated. In the medical community ofEdinburgh, bloodletting was abandoned in practice before it was challenged in theory, a contradiction highlighted by physician-physiologistJohn Hughes Bennett.[34] Authorities such asAustin Flint I, Hiram Corson, andWilliam Osler became prominent supporters of bloodletting in the 1880s and onwards, disputing Bennett's premise that bloodletting had fallen into disuse because it did not work. These advocates framed bloodletting as an orthodox medical practice, to be used in spite of its general unpopularity.[35] Some physicians considered bloodletting useful for a more limited range of purposes, such as to "clear out" infected or weakened blood or its ability to "causehæmorrhages to cease"—as evidenced in a call for a "fair trial for blood-letting as a remedy" in 1871.[36]
Some researchers usedstatistical methods for evaluating treatment effectiveness to discourage bloodletting.[32] But at the same time, publications byPhilip Pye-Smith and others defended bloodletting on scientific grounds.[35]
Bloodletting persisted into the 20th century and was recommended in the 1923 edition of the textbookThe Principles and Practice of Medicine.[37] The textbook was originally written by Sir William Osler and continued to be published in new editions under new authors following Osler's death in 1919.[38]
Bloodletting was once thought to reduce inflammation, boost immunity, and improve circulation by aiding in the detoxification of the blood circulating throughout the body.[39] Over time, however, bloodletting's harmful impacts made the practice a less preferable form of medicine. Not only was bloodletting generally ineffective, it also commonly led to significant blood loss. High loss of blood made patients highly susceptible to infection/sepsis or the formation of ahematoma.[40] Additionally, bloodletting also causedanemia, leading the patient to feel weak, tired, or even go unconscious. The harmful effects did not stop there; in severe cases, bloodletting had the potential to cause deadlyhypovolemic shock.[41] As the medical world advanced, these deadly effects made the practice of bloodletting fade in popularity.
Therapeutic phlebotomy is used today in the treatment of a few diseases, includinghemochromatosis,sickle cell disease,porphyria cutanea tarda,nonalcoholic fatty liver disease, andpolycythemia.[42][43] It is practiced by specifically trained practitioners in hospitals using modern techniques and a relatively safe procedure that depletes iron stores in the body.[44] In most cases,phlebotomy now refers to the removal ofsmall quantities of blood fordiagnostic purposes and is an important procedure in the U.S.. According to an academic article posted in theJournal of Infusion Nursing with data published in 2010, the primary use of phlebotomy is to take blood that would be reinfused back into a person (blood donation).[45] However, in the case ofhemochromatosis, bloodletting (byvenipuncture) has become the mainstay treatment option.[46][47] Therapeutic phlebotomy is a cost effective way to remove excess iron in blood for patients that havehemochromatosis.[44]
Therapeutic uses of bloodletting were reported in 60 distinct cultures/ethnic groups in theHRAF database, present in all inhabited continents. Bloodletting has also been reported in 15 of the 60 cultures in theprobability sample files (PSF) list.[48] The PSF is a subset ofeHRAF data that includes only one culture from each of 60 macro-culture areas around the world. The prevalence of bloodletting in PSF controls for pseudo-replication linked to common ancestry, suggesting that bloodletting has independently emerged many times. Bloodletting is varied in its practices cross-culturally, for example, in native Alaskan culture bloodletting was practiced for different indications, using different tools, on different body areas, by different people, and it was explained by different medical theories.[49]
According to Helena Miton et al.'s[48] analysis of theHRAF database and other sources, there are several cross-cultural patterns in bloodletting.
In atransmission chain experiment done on people living in the US throughAmazon Mechanical Turk, stories about bloodletting in a non-affected area were much more likely to transition into stories about bloodletting being administered near the area in pain than vice versa.[48] This suggests that colocalized bloodletting could be acultural attractor and is more likely to be culturally transmitted, even among people in the US who are likely more familiar with non-colocalized bloodletting.
Bloodletting as a concept is thought to be a cultural attractor, or an intrinsically attractive / culturally transmissible concept. This could explain bloodletting's independent cross-cultural emergence and common cross-cultural traits.[48]
{{cite book}}: CS1 maint: others (link){{cite book}}: CS1 maint: others (link)Arguing that it was the physician's obligation to be active and to intervene when necessary, bloodletting proponents explicitly contrasted themselves with advocates of expectant treatment, whom they portrayed as passive, timid, and unwilling to do what was necessary to save their patients.
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