Object of the month: Letting blood

25 April 2012

Feeling unwell? Perhaps you’re suffering from a surfeit of blood? William Birnie investigates the curiously long history of a cure that usually left the patient feeling worse.

 Jan Baptist Lambrechts: A surgeon preparing to let blood by cupping, his apprentice. Wellcome Images

Jan Baptist Lambrechts: A surgeon preparing to let blood by cupping. Wellcome Images

Molière’s dictum that ‘nearly all men die of their remedies, and not of their illnesses’ seems a deadly accurate one for the procedure of bloodletting. Although perplexing for us in 2012 to consider it was ever felt to be advantageous, there are compelling reasons why accomplished men felt bloodletting beneficial to human health.

Bloodletting, a type of ancient therapy based upon a specific concept of disease, began with the ancient Egyptians around 1000 BCE. Spanning antiquity, the custom continued throughout the Middle Ages and ultimately reached its apex at the beginning of the 19th century. Nevertheless, by the end of that century its use as a therapeutic tool had virtually died out.

Previous to the time of Greek physician Hippocrates (460–377 BCE) it was felt that all illness was due to one disease, with varying symptoms. Observations by Hippocrates led to recognition of specific disease states and to the development of the body humours theory. The practice was thought to purge the body and restore balance to these humours, which were linked to the classical Greek elements and comprised of blood, phlegm, black bile and yellow bile.

The health of the body (the microcosm) was determined by the balance of these humours, just as the state of the world (the macrocosm) was determined by the four elements of earth, air, water and fire. This perhaps somewhat simplistic view of body humours was later formalized into four qualities (warm, cold, moist, and dry) and also the four seasons. For example, black bile was cold and dry, phlegm was associated with winter, and yellow bile was coupled with fire: too much fire made your temperament choleric.

Of all these humours, blood (air, spring, warm and moist) was the principal one that needed the most management. It was believed blood could stagnate in the body’s extremities and as a consequence, bloodletting was used to prevent and treat many illnesses. The seeds of Galen’s ideas can be found in the Hippocratic Corpus, but they had grown into something far more cogent by the time of Galen. His discovery that veins and arteries are full of blood, and not air as was previously supposed, meant a complex system developed regarding the best time to blood let. How much blood was to be removed depended on a number of things: proximity to the affected area, geographical location, weather, and, reassuringly, the patient’s age and constitution. Sessions of bloodletting would often not stop until the patient began to swoon, with fainting seen as the natural conclusion of the treatment.

In discussing the followers of Greek philosopher Chrysippus and physician Erasistratus and their reasons for opposing bloodletting, Galen expressed their dissatisfaction in terms of bloodletting’s harmful side-effects rather than the practice itself. Interestingly, the principle of bloodletting itself was not seen as wrong by these followers; it just had to be administered correctly, with excessive bloodletting deemed murder. Other practical objections included cutting an artery instead of a vein, an inability to stop the bleeding and the occurrence of cases where the patient never woke up. As mentioned earlier, bloodletting was a certain type of therapy, one based on the patient as a being very distinct from the disease.

A number of techniques and devices were used during its practical application. One early technique required a vein to be cut (venesection) with either a knife or a lancet. In our Medicine Man gallery we have a number of these devices including a scarificator (not to be confused with the body modification technique), a bleeding bowl and a cupping set. One of the scarificators in Medicine Man is multi-bladed and contained within a box. A spring mechanism releases the blades, which would rapidly disappear after an incision had been made. Cupping was a later approach that required the use of heated cups, with the heated air inside creating a vacuum and thus encouraging blood to flow. This appliance was often used in association with the concealed scarificator previously mentioned (those in Medicine Man are part of a set).

The leech was also established as a reliable means of venesection, and is particularly revealing in how its uses were phrased. Using the leech to bleed a patient was markedly advantageous for those considered to have ‘delicate constitutions’. Read into that what you will.

The idea of the Greek humours in relation to bloodletting fell out of use as more was discovered and understood about the body. In a clear demarcation of their roles, physicians would recommend the treatment of bloodletting, while barbers would perform it. English physician William Harvey (1578–1657) disproved many of the theories underpinning the practice of bleeding with his publications on the circulatory system, yet he was resolute that bleeding had a salutary effect:  ‘vitiated states and plethora of the blood, are causes of a whole host of diseases; and the timely evacuation of a certain quantity of the fluid frequently delivers patients from, very dangerous diseases, and even from imminent death. In the same measure as blood is detracted, therefore, under certain circumstances, it may be said that life and health are added’.

Although many of his contemporaries ignored the consequences of such findings, and continued to bleed patients, doubts began to creep in to the hypothesis of blood acting as the vital force of the body, seat of the soul, with all weakness and insanity attributed to a defect in this fluid. By the 19th century, doubts were quite vocal, with Scottish physician Dr John Bennett writing in 1855 that he doubted whether bleeding a patient from the arm would do anything except reduce their strength and impede their recovery.

Although falling in and out of favour throughout the ages, with bloodletting virtually dismissed as quackery with the beginning of the 20th century, attachment to the practice persisted by some. For example, Sir William Osler recommended it in his 1923 publication Principles and Practice of Medicine. Now that the practice is no longer used as the therapeutic tool it once was, parallels can still be drawn, and it is intriguing to note that the amount taken during blood donation today (just under 500ml) was the amount usually removed during bloodletting’s heyday.

In writing about the practice, which she described as killing in two fashions, in the court of Louis XIV, Nancy Mitford was explicit when she stated: ‘After being bled the patient always felt much worse, and this was considered an excellent sign. The Comte de Toulouse, having bravely endured the operation for stone, was bled four times in twenty-four hours. Strong and young, he recovered. Twenty-six years later he received the same treatment for the same complaint, and died.’

Need I say more?

William Birnie is a Visitor Services Assistant at Wellcome Collection. You can contact him at w.birnie@wellcome.ac.uk.