Saturday, April 27, 2013

History of Bloodletting

A Brief History of Bloodletting Essay:

A Brief History of Bloodletting
On July 13, 1824 a French sergeant was stabbed through the chest while engaged in single combat, within minutes he had fainted from blood loss. He was rushed to a local hospital and was immediately bled about 20 ounces or almost a liter of blood to prevent inflammation. During the night doctors bled him another 10 ounces and then 5 more times again within the next 14 hours. Half of the sergeant’s blood supply was removed from his body. These bleedings continued this way over the next few days. When inflammation began to show doctors administered 32 leeches to the most sensitive part of the wound. A combination of bleedings and “leechings” the patient was fully recovered and discharged by October. His doctor wrote that he lost a total of 4.8 liters due to bleedings and approximately 1.8 liters from the application of leeches. With the 19th Century standards this task, although as absurd as it sounds had been completely normal.
The body contains about 5 liters of blood. Blood is obviously vital to a human’s survival and excessive blood loss can lead to shock and death. However; throughout history losing blood was considered beneficial to ones health. Dating back 3,000 years bloodletting has been a procedure that was performed to help alleviate nearly all ailments. First depictions of bloodletting specifically for a medical use began with the Ancient Egyptians in the year 1,000 B.C. then spread to the Greeks and Romans, continuing through the Middle Ages and then having it’s hay day in the early 19th century. Pre-Columbian Mesoamerica bloodletting was believed to serve a very different purpose. Mayan priests and rulers used stone implements to pierce their tongues, lips, genitals and other soft body parts, offering their blood in sacrifice to their gods. Blood loss also allowed individuals to enter trance-like states in which they reportedly experienced visions of deities or their ancestors.
The custom of bloodletting is an ancient idea corresponding with the theory of disease. Primitive man looked at disease as a curse cast upon him by evil spirits. Treatment was initially meant to remove these “demon spirits” of disease from the possessed individual. Flint tools were used for trepanning the skull, the source of disease, in hopes of extracting and allowing the demons to escape from the head. It developed from magic and religious ceremonies, where physician and priest essentially went hand and hand and truly believed that disease was the result of supernatural causes. Extracting blood was a method for cleansing the body of ill-defined impurities and excess fluid.  Along with flint tools, early instruments included thorns, sticks and bones, sharp shells, and even sharks teeth, and around 1400 B.C. wall paintings depicted leeches drawing blood from humans.
Still thinking about the theories of disease being perceived a supernatural happening, Hippocrates a Greek physician and philosopher who had been credited as “the father of medicine” had dismissed the idea of illness being cured by superstitious practices or by spirits or the gods. He had a more rational, for the time, approach to medical treatment based on observations of his patients. In his theory of medicine an effective treatment considered the state of the patient as a whole. Diet, sleep, work, and exercise were all important factors that could affect the balance of the forces in the body. He came up with the idea that the body is made up of 4 types of “humours” that corresponded with the elements and seasons; blood, phlegm, black bile and yellow bile. Disease was caused when these 4 fluids were out of balance. Characteristics of each humour included:
Blood – was associated with the season of Spring, the element of air and it was believed to possess warm qualities. The personality traits that corresponded to this humor were courage, hope and lust. Blood was usually tied to the healthy functioning of the liver. Patients that were diagnosed with an overabundance of blood would be called sanguine or optimistic.

Black Bile - was associated with the season of Autumn, the element of earth and it was considered to be comprised of cold and dry qualities. The levels of black bile in the body determined an individual’s state of melancholy. Melancholic patients possessed high levels of black bile and were believed to suffer from sleeplessness, irritability, and depression.

Phlegm – was associated with the season of Winter, the element of water and it was linked to the healthy functioning of the brain and lungs. The cold and moist properties of this humor were believed to produce calm and unemotional behavior in patients. Patients that were diagnosed with an overabundance of phlegm were called phlegmatic or apathetic.

Yellow Bile – was associated with the season of Summer, the element of fire and warm and dry properties. Yellow bile was necessary for the healthy functioning of the gall bladder. Patients diagnosed with too much yellow bile in their system would be labeled as choleric and would most likely suffer from the effects of a very bad temper.
He believed that bloodletting would eliminate imbalance within these fluids and the patient would be cured.
 With this new theory established another Greek physician Galen studied Hippocrates methods and advocated the humeral theory. He also based his theories on close observation and examination of patients, paying particular attention to the patient’s pulse.  He also debunked a popular belief that arteries were filled with blood and not air. Galen based his work on 2 concepts.  That blood did not circulate and stayed motionless in the body until it went stagnant or was let out and agreeing with the idea of the balance of the humours. He mapped out the blood vessels of the body and would cut his patients in different areas depending on what region would help the specific ailment. For example, the right hand was cut and drained to treat liver problems. Also during the Fall and Winter months it was more effective to cut a patient on their left side and the right side in the Spring and Summer months.  As well as presenting a guideline of how much blood should be removed based on the person’s age, health, the season, the weather and geography. Commonly he would drain 16-30 ounces 1 to 4 pints of blood. The rule of thumb was that most physicians would drain until the patient became faint for it was a sign the treatment was working and they would stop.
Later on bloodletting was used to treat almost every disease.  It was recommended for acne, asthma, cancer, cholera, coma, convulsions, diabetes, epilepsy, insanity, jaundice, leprosy, 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 common to remove a quantity of blood equal to the amount believed to circulate in the limb that was to be removed. Variations of the concept of balancing the humours 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 so other methods such as laxatives 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.
Monks and priests became the authority on providing medical services such as bloodletting. Surgery was still a crude and avoided task so many people turned to the church for help. But in 1163 the church and the Council of Tours forbade monks and priest from practicing bloodletting because it was deemed as sacrilegious to be handling blood. This ban lead to the interesting practice of the barber surgeon profession. Instead of clergymen barbers would perform medical services as well as cosmetic services of shaving and hair styling. The barber pole we see adapted today began from the custom of bloodletting. The instruments they would commonly used during the procedure included a staff for the patient to grasp to stimulate the veins in the arm, a basin to hold leeches and catch blood and linen bandages. After the operation was complete the bandages would be hung outside of the staff. The image we see today is inspired by this. The spiraling white stripe, the tourniquet or bandages, the red spiral represents the color of blood or the occasional blue stripe the veins, and the pole itself represents the staff the patient would grip.

            Respected physicians and surgeons advocated the practice and would prescribe it to their most esteemed patients. Such as Marie-Antoinette, she wasn’t shy to the benefits of a healthy dose of bloodletting. While giving birth to her first daughter in 1778 she fainted and her physician was quick to this lancet to perform a snappy bloodletting cure. Another famous case was of George Washington around his death in 1799. He had caught a nasty throat infection and called upon his doctor to administer the normal treatment of bloodletting to cure his illness faster, he was a strong supporter so he wouldn’t have questioned the procedure. However his doctors may have in fact killed him. They ended up draining over half of his blood supply in 24 hours, a shocking 9 ounces or 4 liters of blood.
            The tools and procedures used to perform bloodletting included fleams, which were various sized blades folded into a case like pocketknife for opening veins. Lancets, which were sharp two edged scalpel like instruments. Scarification by a scarifyer that was a device that resembled at cube shaped brass box that contained several small spring loaded knives that would be followed by “cupping” where a dome shaped glass would be heated up and placed over the skin by way of suction. The scarifyer would agitate and cut the veins so the cupping could extract more blood from the wound. And finally of course leeches.
            The medical leech or Hirudo medicinalis, can grow up to 20 centimeters and are normally greenish brown. They commonly have a thin red stripe down the front. They have 2 suckers one at each end. The back sucker is mainly used for leverage and the frontal sucker containing the jaw and teeth is where it feeds. Medical leeches have 3 jaws that look like little saws that consist of 100 sharp teeth to latch onto the host. The incision mark leaves an upside y shape on the host. After biting they inject and secret anesthetics in their saliva and suck out the blood. They can consume up to ten times their body weight in a single meal with 5 to 15 milliliters on average. They can also live up to a year between feeding.  They were applied to any area of the body that instruments could or could not cut, some tied a string around the leech when entering the mouth so it could be retrieved easier or not get lost in patients lungs. It was said that it was common for over 100 leeches to be applied to a single patient over a few days. 
During the 19th century popularity of bloodletting especially using the leeching method was at its high point it was often referred to as “leechamania”. At the end of the 1700s leeches were a low-priced commodity. However, by the turn of the century the growing medicinal use of leeches and their scarcity due to overuse would drive the cost up 300%. It was most popular in Europe especially France with the help of Dr. Francois Broussais, a Parisian physician who claimed all fevers were due to specific organ inflammation. He was a great supporter of the leech therapy along with aggressive bloodletting. He thought placing leeches over the organ of the body that was inflamed would cure his patients without a doubt. This form of therapy became so popular around the 1830’s France used around 5 to 6 million leeches per year in Paris alone. France imported more than 42 million for the whole country in one year.
The cultivation of leeches by leech farmers or medical facilities became a booming industry, and the import of leeches also increased rapidly during this time. With this high demand a botched market of the leech trade began to arise. Importers from America would gather diseased and emaciated horses and walk them through swamps to collect maximum amounts of leeches, while the leeches were useless and infected salesmen would still market the leeches. Many fraudulent and ineffective leeches were often bought and sold. When they were in short supply, creative techniques were developed to extend the use of a single leech. Such as immersing the leech in vinegar or applying salt to its mouth would cause the animals to disgorge, allowing them to be reused. Bdellatomy, or cutting open a leech’s digestive tract, would allow leeches to continuously consume blood without limit. Another interesting fact is the ceramic leech jars that were primarily manufactured in England. Many physicians and pharmacists would collect and have elaborate and ornate leech jars to indicate the high value of the leech during the 19th century. They were adorned with elaborate and elegant designs and would have holes cut into the lid for ventilation for the leeches to survive.
There were obvious flaws and many physicians questioned the procedure such as Pierre Charles Alexandre Louis to demonstrate that it 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 when an appropriate dosage of bloodletting was introduced was effective. Louis’s findings were put up against Broussais, who could recommend leeches fifty at a time. It got to the point where by the 1870’s bloodletting was so popular among patients that, although medical use of the practice was declining, many patients had to be convinced not to be bled when they fell ill. This placebo affect became dangerous but by the late 1800’s enthusiasm for leech therapy had worn off. Developments in other procedures and the discovery of antibiotics in the 1920’s had made leeches obsolete. Leeches are still used today in select situations. Surgeons who do plastic and reconstructive surgery find leeches valuable when regrafting amputated appendages. Once found beneficial for the amount of blood they could withdraw, leeches are useful now for the anticlotting agent hirudin, contained in their saliva, which keeps blood flowing freely during these procedures. When looking back and criticizing the absurdity of bloodletting, society today could look at our own extreme medical practices such as chemotherapy and future generations would find this dangerous and illogical which is something to think about. Medicine is constantly improving and changing due to our new understandings and developments of the body.

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"Science Museum. Brought to Life: Exploring the History of Medicine." Leech Jar, England, 1831-1859. N.p., n.d. Web. 21 April 2013.

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