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By Danielle Wheadon and Lidya Tekeste
Working together

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Description
Ancient wisdom is when someone believes something is a fact based on the fact that it was believed in ancient times. Even if science has disproven a belief, people will still believe in it because they think the ancients had more knowledge than we do, even though it is illogical to think this way.

Connection
This article goes through a thorough history of bloodletting: the act of withdrawing blood from an infected patient's body to drain the disease with it. The article goes through the origin, methods of bloodletting, how physicians at the time felt about the act, how physicians tested the efficacy of the act, and the presence of bloodletting in today's society and why some countries still use it.

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With a history spanning at least 3000 years, bloodletting has only recently-in the late 19th century-been discredited as a treatment for most ailments.

The practice of bloodletting began around 3000 years ago with the Egyptians, then continued with the Greeks and Romans, the Arabs and Asians, then spread through Europe during the Middle Ages and the Renaissance. It reached its peak in Europe in the 19th century but subsequently declined and today in Western medicine is used only for a few select conditions.

Humors, Hippocrates, and Galen
To appreciate the rationale for bloodletting one must first understand the paradigm of disease 2300 years ago in the time of Hippocrates (~460-370 BC). He believed that existence was represented by the four basic elements-earth, air, fire, and water-which in humans were related to the four basic humors: blood, phlegm, black bile, yellow bile.

Each humor was centred in a particular organ-brain, lung, spleen, and gall bladder-and related to a particular personality type-sanguine, phlegmatic, melancholic, and choleric.[ 1]

Being ill meant having an imbalance of the four humors. Therefore treatment consisted of removing an amount of the excessive humor by various means such as bloodletting, purging, catharsis, diuresis, and so on. By the 1st century bloodletting was already a common treatment, but when Galen of Pergamum (129-200 AD) declared blood as the most dominant humor, the practice of venesection gained even greater importance.[ 2]

Galen was able to propagate his ideas through the force of personality and the power of the pen; his total written output exceeds two million words. He had an extraordinary effect on medical practice and his teaching persisted for many centuries. His ideas and writings were disseminated by several physicians in the Middle Ages when bloodletting became accepted as the standard treatment for many conditions.

Methods of bloodletting
Bloodletting was divided into a generalized method done by venesection and arteriotomy, and a localized method done by scarification with cupping and leeches. Venesection was the most common procedure and usually involved the median cubital vein at the elbow, but many different veins could be used. The main instruments for this technique were called lancets and fleams.[ 3]

Thumb lancets were small sharp-pointed, two-edged instruments often with an ivory or tortoise shell case that the physician could carry in his pocket. Fleams were usually devices with multiple, variably sized blades that folded into a case like a pocketknife.

Localized bloodletting often involved scarification, which meant scraping the skin with a cube-shaped brass box containing multiple small knives, followed by cupping, which involved placing a dome-shaped glass over the skin and extracting the air by suction or prior heating.[ 4]

Leeches used for bloodletting usually involved the medicinal leech, Hirudo medicinalis. At each feeding a leech can ingest about 5 to 10 ml of blood, almost 10 times its own weight. The use of leeches was greatly influenced by Dr François Broussais (1772-1838), a Parisian physician who claimed that all fevers were due to specific organ inflammation. He was a great proponent of leech therapy along with aggressive bloodletting. He believed in placing leeches over the organ of the body that was deemed to be inflamed.[ 5]

his therapy was very popular in Europe in the 1830s, especially France, where 5 to 6 million leeches per year were used in Paris alone and about 35 million in the country as a whole. By the late 1800s, however, enthusiasm for leech therapy had waned, but leeches are still used today in select situations.

Famous bleedings
When Charles II (1630-1685) suffered a seizure he was immediately treated with 16 ounces of bloodletting from the left arm followed by another 8 ounces from cupping.[ 6] Then he endured a vigorous regimen of emetics, enemas, purgatives, and mustard plasters followed by more bleeding from the jugular veins. He had more seizures and received further treatment with herbs and quinine. In total he had about 24 ounces of blood taken before he died.

After riding in snowy weather, George Washington (1732-1799) developed a fever and respiratory distress. Under the care of his three physicians he had copious amounts of blood drawn, blisterings, emetics, and laxatives. He died the next night of what has been diagnosed retrospectively as epiglottitis and shock.[ 6] His medical treatment aroused significant controversy, particularly the bloodletting.

Warring physicians
The practice of bloodletting aroused deep emotions in both practitioners and detractors, with intense argument about the benefit and harm of venesection. Drs Benjamin Rush, William Alison, and Hughes Bennett exemplify this conflict.

Dr Benjamin Rush (1745-1813) was one of the most controversial physicians in his time. He was arrogant and paternalistic but dedicated to eradicating illness wherever he saw it. He worked tirelessly during the yellow fever epidemics in Philadelphia in 1793 and 1797 and devoted much time to the problem of mental illness.[ 7]

Unfortunately he had a very simplistic view of disease and thought that all febrile illnesses were due to an "irregular convulsive action of the blood vessels." Therefore in his mind all therapy was directed at dampening down this vascular overexcitement. He was a great proponent of "depletion therapy," which meant aggressive bloodletting and vigorous purging.

He was known to remove extraordinary amounts of blood and often bled patients several times. "It frequently strangles a fever... imparts strength to the body... renders the pulse more frequent when it is preternaturally slow... renders the bowels, when costive, more easily moved by purging physic... removes or lessens pain in every part of the body, and more especially the head... removes or lessens the burning heat of the skin, and the burning heat of the stomach..."[ 8]

In addition he held a firm belief in his calomel purgatives, which were loaded with mercury and which he called "the Samson of medicine." In numerous articles he boldly proclaimed the benefits of his therapy.

He aroused both extremely positive and negative reactions in those around him, including many physicians. Some doctors referred to his practices as "murderous" and his prescribed doses as "fit for a horse." He had a long-running feud with his college of physicians, which forced him to resign, and his application to the faculty of Columbia Medical School in New York was denied. However, Rush Medical College in Chicago was named in his honor and gained its charter in 1837.

At the Edinburgh School of Medicine Dr William Alison (1790-1859) and Dr Hughes Bennett (1812-1875) were a study in contrasts. The former was a dignified old-timer and strong believer in bloodletting, while the latter was an arrogant newcomer and resolute debunker of bloodletting. Whereas Dr Alison followed the old tradition of clinical experience and empirical observation, Dr Bennett believed in the new methods of pathology and physiology supported by the microscope and the stethoscope.[ 9]

Central to their debate was the observation that the improved outcome of patients with pneumonia paralleled the decreased usage of bloodletting. While Dr Alison ascribed this to a "change in type" of illness which had gone from sthenic (strong) to asthenic (weak), Dr Bennett believed it due to diminished use of a dangerous therapy.

Both were implacable in their point of view, thereby underlining the significant gap between their beliefs in empirical observation versus scientific verification. Dr Bennett had the advantage of the latest techniques and "grounded his rejection of bloodletting on pathologic concepts of inflammation and pneumonia derived from microscopic studies of inflamed tissues."[ 9]

The tide turns
In Paris Dr Pierre Louis (1787-1872) was another scientific-minded physician who wanted to assess the efficacy of bloodletting. He examined the clinical course and outcomes of 77 patients with acute pneumonia taken from his own and hospital records.

He compared the results in patients treated with bloodletting in the early phase versus the late phase of the illness. In his conclusions he did not condemn bloodletting but concluded that the effect of this procedure "was actually much less than has been commonly believed."[ 10]

Subsequent studies by Pasteur, Koch, Virchow, and others confirmed the validity of the new scientific methods, and the use of bloodletting gradually diminished to a few select conditions.

Bloodletting today
Today phlebotomy therapy is primarily used in Western medicine for a few conditions such as hemochromatosis, polycythemia vera, and porphyria cutanea tarda.[ 11]

Hemochromatosis is a genetic disorder of iron metabolism leading to abnormal iron accumulation in liver, pancreas, heart, pituitary, joints, and skin. It is treated with periodic phlebotomy to maintain ferritin levels at a reasonable level so as to minimize further iron deposition.

Polycythemia vera is a stem cell bone marrow disorder leading to overproduction of red blood cells and variable overproduction of white blood cells and platelets. Its treatment includes phlebotomy to reduce the red blood cell mass and decrease the chance of dangerous clots.

Porphyria cutanea tarda is a group of disorders of heme metabolism with an associated abnormality in iron metabolism. Phlebotomy is also used to decrease iron levels and prevent accumulation in various organs.

In the last 25 years leech therapy has made a comeback in the area of microsurgery and reimplantation surgery. Hirudo medicinalis can secrete several biologically active substances including hyaluronidase, fibrinase, proteinase inhibitors, and hirudin, an anticoagulant.

The leech can help reduce venous congestion and prevent tissue necrosis. In this way it can be used in the postoperative care of skin grafts and reimplanted fingers, ears, and toes. Because of concern regarding secondary infections a "mechanical leech" has been developed at the University of Wisconsin.[ 12]

Why did it persist?
We may wonder why the practice of bloodletting persisted for so long, especially when discoveries by Vesalius and Harvey in the 16th and 17th centuries exposed the significant errors of Galenic anatomy and physiology. However as Kerridge and Lowe have stated, "that bloodletting survived for so long is not an intellectual anomaly-it resulted from the dynamic interaction of social, economic, and intellectual pressures, a process that continues to determine medical practice."[ 9]

With our present understanding of pathophysiology we might be tempted to laugh at such methods of therapy. But what will physicians think of our current medical practice 100 years from now? They may be astonished at our overuse of antibiotics, our tendency to polypharmacy, and the bluntness of treatments like radiation and chemotherapy.

In the future we can anticipate that with further advances in medical knowledge our diagnoses will become more refined and our treatments less invasive. We can hope that medical research will proceed unhampered by commercial pressures and unfettered by political ideology. And if we truly believe that we can move closer to the pure goal of scientific truth.

References

1. Magner LN. A History of Medicine. New York: Marcel Dekker, Inc; 1992:66-74.
2. Magner LN. A History of Medicine. New York: Marcel Dekker, Inc; 1992:86-96.
3. McCormic S. Blood and magic-the evolution of phlebotomy. www.associatedcontent.com/article/959576/blood_and_magic_the_evolution_of_phlebotomy.html?cat=37 (accessed 4 April 2009).
4. Seigworth GS. Bloodletting Over the Centuries. New York State Journal of Medicine 1980;Dec:2022-2028. www.pbs.org/wnet/redgold/basics/bloodlettinghistory.html (accessed 4 April 2009).
5. Adams SL. The medicinal leech. Ann Intern Med 1988;109:399-405.
6. Parapia LA. History of bloodletting by phlebotomy. Brit J Haemat 2008;143:490-495.
7. North RL. Benjamin Rush, MD: Assassin or beloved healer? Proc Bayl Univ Med Cent 2000;13:45-49.
8. Rush B. A Defence of Blood-letting, as a Remedy for Certain Diseases. In: Medical Inquiries and Observations. Vol 4. Philadelphia, PA; 1815. Available online at: Arnebeck B. Benjamin Rush's A Defence of Blood-letting, as a Remedy for Certain Diseases. www.bobarnebeck/defence.html (accessed 4 April 2009).
9. Kerridge IH, Lowe M. Bloodletting: The story of a therapeutic technique. Med J Aust 1995;163:631-633.
10. Morabia A. P.C.A. Louis and the birth of clinical epidemiology. Clin Epidemiol 1996;49:1327-1333.
11. Lee GR, Foerster J, Lukens J, et al. Wintrobe's Clinical Hematology. 10th ed. Baltimore, MD: Williams & Wilkins; 1999:1063,1079,1539.
12. Whitaker IS, Rao J, Izadi D, et al. Historical Article: Hirudo medicinalis: Ancient origins of, and trends in the use of medicinal leeches throughout history. Br J Oral Maxillofac Surg 2004;42:133-137.

Dr Greenstone is a family physician in Surrey, BC.

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With a history spanning at least 3000 years, bloodletting has only recently-in the late 19th century-been discredited as a treatment for most ailments. The practice of bloodletting began around 3000 years ago with the Egyptians, then continued with the Greeks and Romans, the Arabs and Asians, then spread through Europe during the Middle Ages and the Renaissance.

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Description
Proof by verbosity is when someone provides so much evidence and information at one time that it distracts the person who is fighting against the other person's point, that their claim must be true, even if the evidence they are providing is not backed up by anything.

Connection:
An example of proof by verbosity is healing water, as there is no evidence that the water actually carries powerful energies to cleanse people from their stresses, however many believe they work. Above, is a website which goes through some places on Earth where bodies of water have been dubbed "healing" in which people may visit day to day.

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True Stories of Transformation from Near-Death Experiences

Join the extraordinary Witnessing Heaven series and take an unforgettable journey through the stories of real people, just like you, who took a miraculous journey to heaven and back. Some of the books in the series are:

Book 1: Heavenly Encounters

Book 2: Messages from Heaven

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Book 5: A Choir of Angels

Book 6: Scenes from Heaven

Book 7: A Joy Like No Other

Book 8: A Glorious Light

You can join the series and save $2 per book, or you can purchase each book individually.

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True Stories of Transformation from Near-Death Experiences Join the extraordinary Witnessing Heaven series and take an unforgettable journey through the stories of real people, just like you, who took a miraculous journey to heaven and back.

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Description:
When individuals remember items that support our beliefs and forget things that don't, this occurs.

Connection: When hospital staff thinks days with a full moon are busier than days without a full moon, they are exhibiting confirmation bias. Although it has been demonstrated that days with full moons are just as busy as days without full moons, people like to look for patterns in everything, therefore they only remember the busy days during a full moon. This is connected to patternicity.

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Description:
Mystical energy is a person who asserts they have attained, or feel they have the potential to achieve, insight into secrets that are beyond the scope of conventional human understanding, such as through direct communion with the divine or instantaneous intuition when in a state of spiritual ecstasy.

Connection:
Kundalini, also known as "the yoga of awareness," strengthens your body and frees energy stored at the base of your spine while opening your heart. Breath is the main emphasis of kundalini yoga. It attempts to develop a person's creative spiritual potential so they can uphold moral standards, speak the truth, and concentrate on empathy in order to help and heal others.

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A local Reiki practitioner claims on her website that her clients receive “spiritual universal energy” during one of her therapeutic sessions. Indeed, one of the published testimonials is from a client who claims the practitioner could “connect to [her] energy almost instantaneously” and she could feel her moving from chakra to chakra, “connecting all the pieces.” In order to explain why I dismiss these claims about “spiritual universal energy”, I feel like I have to properly define energy, but achieving that turns out to be a lot like trying to capture water in your fist. It’s very slippery and you end up making a mess. Physicists are the accountants of the natural world I learned about energy in school but, to write this piece, I decided to seek out textbooks, videos and articles that had wrestled with clearly explaining what actual energy is from a scientific point of view. Many of the definitions felt like cop-outs, like the fact that it’s the ability to do work, the latter being the movement of an object against an opposing force. That is accurate but it feels like sleight-of-hand: what is this “ability” to do work? What does it look like? What does it even smell like? I doubt there exists a truly satisfying definition of energy out there. If there is, I haven’t found it. The best encapsulation of it I heard came from the Science Asylum YouTube channel. Energy is a weird, abstract property of the universe. It’s not a flash of light, it’s not a mystical heat, it’s not a series of tiny balls filled with universe juice. It’s a number. And in a closed system, like our universe, that number can be tracked by an accountant. Imagine having a million dollars in the bank (ain’t that nice?) and never receiving a single cent more or spending any of it. But you can put some of it in a special account called “kinetic energy” (that’s tied to movement) and the rest in a different account called “potential energy” (tied to the possibility of movement). And you can keep moving the money around between these two accounts but it will always add up to a million. Energy is like that. In a closed system, energy is never created, never destroyed, only transferred or transformed. The Rube Goldberg machine of our body Some forms of energy are easier to visualize than others. The energy of a falling apple can be imagined as coming from the gravity field around our planet. The apple falls because the Earth’s gravity draws it toward the ground. But what about the food energy of that apple? Where in the fruit is the sustaining energy our body needs? An apple contains molecules known as sugars. In our digestive tract, these sugars are broken down into a very simple one, glucose. We all know glucose holds energy we can use, but where in this ring of carbon, oxygen and hydrogen is it? Glucose gets broken down into smaller molecules and, in the process (and to simplify the fascinating biochemistry quite a bit), two molecules of ATP emerge. These ATP molecules are key. They each have a tail of three identical groups called phosphates. That last phosphate can be broken off and sent to bind to a different molecule. That, right there, is energy. It’s not the phosphate itself, but its transfer from one molecule to another, allowing for a cascade of chemical events to take place which grant us the ability to move and to stay alive. Can mystical energies really be felt? Actual energy, like gravity and the energy contained in food, is studied by scientists and its properties can be discovered, leading to predictions. But to come back to the “spiritual universal energy” of our local Reiki practitioner, the word “energy” can be mangled and appropriated. Many alternative medicine practitioners believe in a form of energy—alternatively called qi, prana or universal energy—that our body has and that they can manipulate, with no evidence of its existence. That doesn’t stop them from claiming they can feel it, unblock it, or balance it. But there is no evidence for the existence of this form of energy, and actual evidence that its believers can’t even feel it. A nine-year-old girl, Emily Rosa, working with her parents and Dr. Stephen Barrett (who runs Quackwatch), designed an experiment in the late 1990s to test whether practitioners of therapeutic touch could actually detect the mysterious energy field they claimed surrounded the human body and which they said they could “repattern”. Fine, Rosa said: if that’s the case, you should be able to do it blind. So the practitioners were each sat in front of a large screen with cutouts at the bottom so they could slide their hands underneath it. Rosa hovered her hand over either the left or right hand of the practitioner. Said practitioner had to feel the little girl’s energy and say over which of their hand was Rosa’s own hand. This was repeated several times with a total of 21 practitioners, and the end result was that they might as well have flipped a coin. They simply could not feel Rosa’s energy over their open hand, despite their claims. There is real energy all around us, potential and kinetic energy scientists can measure, harness, and manipulate. But because of energy’s slippery nature—it’s a mathematical property of stuff, not a glowing orb—and because of our intuitions and wishful thinking, it’s a concept that lends itself well to pseudoscience. Trying to manipulate this non-scientific, mystical energy turns out to be, well, a waste of energy. Take-home message: - Energy cannot be easily defined, as it is not a thing so much as a number, a property that objects have in our universe - Because of the abstract nature of energy, it has been used by many believers in alternative therapies but we should be skeptical of claims of the existence of “non-scientific” energies @CrackedScience Want to comment on this article? Visit our Facebook Page!

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Description:
when speakers sidestep the primary point by bringing up unrelated topics

Connection:
The mother in the picture is attempting to divert her daughter's attention away from the main topic of discussion by telling her that they have a tasty treat at home.

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Description: attempting to explain something we don't really comprehend.

Connection:  Crop circle are anything that can be regarded as inexplicable. Because it is unclear where they originated from, many people assume they are aliens. The problem with this way of thinking is that there isn't any solid proof that aliens are involved. Despite the fact that it is unknown where they come from, it is not a good idea to draw any conclusions before considering all the options. Even so, there is a chance that this mysterious occurrence was caused by aliens, but there are other possibilities as well, and nothing should be ruled out until there is sufficient proof to verify whatever the reason is.

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Description: how people's minds automatically search for patterns in everything they do

Connection: A good example of patternicity is the elephant rock on the island, which is basically a rock that some people think looks like an elephant. This is due to the fact that the human brain is wired to detect patterns wherever it goes, even when there are none. The mind's limitations force us to look for a pattern in this enormous rock even when there is none, and despite there being no significance to these rocks, people nevertheless perceive an elephant.

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9. Reason For Belief 3 - Emotional Connection

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9. Reason For Belief 3 - Emotional Connection

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Description
Having an emotional connection can make humans want to believe something that may not be logical or provide reason enough to be true. However, even though it may be clear to outsiders that it would be illogical to believe in something that is being said, the person with the emotional connection will not see it that way.

Connection
An example of emotional connection are psychic mediums. Mediums are people who claim they can speak to the dead. The video above is a clip from TLC show 'Long Island Medium' in which a psychic medium connects with people to talk to them about their lost loved ones. Even though many people are skeptical of mediums, the emotional connection when someone talks about what someone who's passed away wants to say to their living loved ones, it is very believable to people who are grieving.

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In 15 Years This Has Never Happened | Long Island Medium

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Define Problem:

The problem is that bloodletting does not rid disease efficiently from the human body.

Gather Information:

The source is a published website. It is the British Colombia Medical Journal and has a credible author who is a medical doctor.

Evaluate Evidence:

This is a credible source with a credible author. It is not for or against bloodletting and provides an informative read with scientific evidence. It very clearly identifies the theory behind bloodletting and provides evidence as to why it may not be the best option nowadays.

Recognize Assumptions, Emotions, Biases:

There is not a lot of bias in this article. The article is not for or against bloodletting but provides evidence for both. There may be some bias in favour of not using bloodletting nowadays as it is an old practice that was used when there was nothing else. With the advancement in technology and medicine today, there is always going to be bias in favour of the scientific evidence.

Synthesize Evidence, Identify Alternatives:

Nowadays, there are better alternatives to bloodletting like erythrocytapheresis - which is an exchange/transfer of bad blood cells from the body with good blood cells from a donor, there is chelation therapy - which is a therapy in which chelation agents are injected into the bloodstream to bond with the heavy metals in the body to then remove them, and there is also modern phlebotomy - which is the same thing as bloodletting but with more precautions.

Select Best Alternative:

I believe that erythrocytapheresis is the best alternative to bloodletting as it replaces bad blood with good blood immediately to achieve the same effect as bloodletting without actually having to drain blood. This would provide the least harmful effect to a person overall.

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With a history spanning at least 3000 years, bloodletting has only recently-in the late 19th century-been discredited as a treatment for most ailments.

The practice of bloodletting began around 3000 years ago with the Egyptians, then continued with the Greeks and Romans, the Arabs and Asians, then spread through Europe during the Middle Ages and the Renaissance. It reached its peak in Europe in the 19th century but subsequently declined and today in Western medicine is used only for a few select conditions.

Humors, Hippocrates, and Galen
To appreciate the rationale for bloodletting one must first understand the paradigm of disease 2300 years ago in the time of Hippocrates (~460-370 BC). He believed that existence was represented by the four basic elements-earth, air, fire, and water-which in humans were related to the four basic humors: blood, phlegm, black bile, yellow bile.

Each humor was centred in a particular organ-brain, lung, spleen, and gall bladder-and related to a particular personality type-sanguine, phlegmatic, melancholic, and choleric.[ 1]

Being ill meant having an imbalance of the four humors. Therefore treatment consisted of removing an amount of the excessive humor by various means such as bloodletting, purging, catharsis, diuresis, and so on. By the 1st century bloodletting was already a common treatment, but when Galen of Pergamum (129-200 AD) declared blood as the most dominant humor, the practice of venesection gained even greater importance.[ 2]

Galen was able to propagate his ideas through the force of personality and the power of the pen; his total written output exceeds two million words. He had an extraordinary effect on medical practice and his teaching persisted for many centuries. His ideas and writings were disseminated by several physicians in the Middle Ages when bloodletting became accepted as the standard treatment for many conditions.

Methods of bloodletting
Bloodletting was divided into a generalized method done by venesection and arteriotomy, and a localized method done by scarification with cupping and leeches. Venesection was the most common procedure and usually involved the median cubital vein at the elbow, but many different veins could be used. The main instruments for this technique were called lancets and fleams.[ 3]

Thumb lancets were small sharp-pointed, two-edged instruments often with an ivory or tortoise shell case that the physician could carry in his pocket. Fleams were usually devices with multiple, variably sized blades that folded into a case like a pocketknife.

Localized bloodletting often involved scarification, which meant scraping the skin with a cube-shaped brass box containing multiple small knives, followed by cupping, which involved placing a dome-shaped glass over the skin and extracting the air by suction or prior heating.[ 4]

Leeches used for bloodletting usually involved the medicinal leech, Hirudo medicinalis. At each feeding a leech can ingest about 5 to 10 ml of blood, almost 10 times its own weight. The use of leeches was greatly influenced by Dr François Broussais (1772-1838), a Parisian physician who claimed that all fevers were due to specific organ inflammation. He was a great proponent of leech therapy along with aggressive bloodletting. He believed in placing leeches over the organ of the body that was deemed to be inflamed.[ 5]

his therapy was very popular in Europe in the 1830s, especially France, where 5 to 6 million leeches per year were used in Paris alone and about 35 million in the country as a whole. By the late 1800s, however, enthusiasm for leech therapy had waned, but leeches are still used today in select situations.

Famous bleedings
When Charles II (1630-1685) suffered a seizure he was immediately treated with 16 ounces of bloodletting from the left arm followed by another 8 ounces from cupping.[ 6] Then he endured a vigorous regimen of emetics, enemas, purgatives, and mustard plasters followed by more bleeding from the jugular veins. He had more seizures and received further treatment with herbs and quinine. In total he had about 24 ounces of blood taken before he died.

After riding in snowy weather, George Washington (1732-1799) developed a fever and respiratory distress. Under the care of his three physicians he had copious amounts of blood drawn, blisterings, emetics, and laxatives. He died the next night of what has been diagnosed retrospectively as epiglottitis and shock.[ 6] His medical treatment aroused significant controversy, particularly the bloodletting.

Warring physicians
The practice of bloodletting aroused deep emotions in both practitioners and detractors, with intense argument about the benefit and harm of venesection. Drs Benjamin Rush, William Alison, and Hughes Bennett exemplify this conflict.

Dr Benjamin Rush (1745-1813) was one of the most controversial physicians in his time. He was arrogant and paternalistic but dedicated to eradicating illness wherever he saw it. He worked tirelessly during the yellow fever epidemics in Philadelphia in 1793 and 1797 and devoted much time to the problem of mental illness.[ 7]

Unfortunately he had a very simplistic view of disease and thought that all febrile illnesses were due to an "irregular convulsive action of the blood vessels." Therefore in his mind all therapy was directed at dampening down this vascular overexcitement. He was a great proponent of "depletion therapy," which meant aggressive bloodletting and vigorous purging.

He was known to remove extraordinary amounts of blood and often bled patients several times. "It frequently strangles a fever... imparts strength to the body... renders the pulse more frequent when it is preternaturally slow... renders the bowels, when costive, more easily moved by purging physic... removes or lessens pain in every part of the body, and more especially the head... removes or lessens the burning heat of the skin, and the burning heat of the stomach..."[ 8]

In addition he held a firm belief in his calomel purgatives, which were loaded with mercury and which he called "the Samson of medicine." In numerous articles he boldly proclaimed the benefits of his therapy.

He aroused both extremely positive and negative reactions in those around him, including many physicians. Some doctors referred to his practices as "murderous" and his prescribed doses as "fit for a horse." He had a long-running feud with his college of physicians, which forced him to resign, and his application to the faculty of Columbia Medical School in New York was denied. However, Rush Medical College in Chicago was named in his honor and gained its charter in 1837.

At the Edinburgh School of Medicine Dr William Alison (1790-1859) and Dr Hughes Bennett (1812-1875) were a study in contrasts. The former was a dignified old-timer and strong believer in bloodletting, while the latter was an arrogant newcomer and resolute debunker of bloodletting. Whereas Dr Alison followed the old tradition of clinical experience and empirical observation, Dr Bennett believed in the new methods of pathology and physiology supported by the microscope and the stethoscope.[ 9]

Central to their debate was the observation that the improved outcome of patients with pneumonia paralleled the decreased usage of bloodletting. While Dr Alison ascribed this to a "change in type" of illness which had gone from sthenic (strong) to asthenic (weak), Dr Bennett believed it due to diminished use of a dangerous therapy.

Both were implacable in their point of view, thereby underlining the significant gap between their beliefs in empirical observation versus scientific verification. Dr Bennett had the advantage of the latest techniques and "grounded his rejection of bloodletting on pathologic concepts of inflammation and pneumonia derived from microscopic studies of inflamed tissues."[ 9]

The tide turns
In Paris Dr Pierre Louis (1787-1872) was another scientific-minded physician who wanted to assess the efficacy of bloodletting. He examined the clinical course and outcomes of 77 patients with acute pneumonia taken from his own and hospital records.

He compared the results in patients treated with bloodletting in the early phase versus the late phase of the illness. In his conclusions he did not condemn bloodletting but concluded that the effect of this procedure "was actually much less than has been commonly believed."[ 10]

Subsequent studies by Pasteur, Koch, Virchow, and others confirmed the validity of the new scientific methods, and the use of bloodletting gradually diminished to a few select conditions.

Bloodletting today
Today phlebotomy therapy is primarily used in Western medicine for a few conditions such as hemochromatosis, polycythemia vera, and porphyria cutanea tarda.[ 11]

Hemochromatosis is a genetic disorder of iron metabolism leading to abnormal iron accumulation in liver, pancreas, heart, pituitary, joints, and skin. It is treated with periodic phlebotomy to maintain ferritin levels at a reasonable level so as to minimize further iron deposition.

Polycythemia vera is a stem cell bone marrow disorder leading to overproduction of red blood cells and variable overproduction of white blood cells and platelets. Its treatment includes phlebotomy to reduce the red blood cell mass and decrease the chance of dangerous clots.

Porphyria cutanea tarda is a group of disorders of heme metabolism with an associated abnormality in iron metabolism. Phlebotomy is also used to decrease iron levels and prevent accumulation in various organs.

In the last 25 years leech therapy has made a comeback in the area of microsurgery and reimplantation surgery. Hirudo medicinalis can secrete several biologically active substances including hyaluronidase, fibrinase, proteinase inhibitors, and hirudin, an anticoagulant.

The leech can help reduce venous congestion and prevent tissue necrosis. In this way it can be used in the postoperative care of skin grafts and reimplanted fingers, ears, and toes. Because of concern regarding secondary infections a "mechanical leech" has been developed at the University of Wisconsin.[ 12]

Why did it persist?
We may wonder why the practice of bloodletting persisted for so long, especially when discoveries by Vesalius and Harvey in the 16th and 17th centuries exposed the significant errors of Galenic anatomy and physiology. However as Kerridge and Lowe have stated, "that bloodletting survived for so long is not an intellectual anomaly-it resulted from the dynamic interaction of social, economic, and intellectual pressures, a process that continues to determine medical practice."[ 9]

With our present understanding of pathophysiology we might be tempted to laugh at such methods of therapy. But what will physicians think of our current medical practice 100 years from now? They may be astonished at our overuse of antibiotics, our tendency to polypharmacy, and the bluntness of treatments like radiation and chemotherapy.

In the future we can anticipate that with further advances in medical knowledge our diagnoses will become more refined and our treatments less invasive. We can hope that medical research will proceed unhampered by commercial pressures and unfettered by political ideology. And if we truly believe that we can move closer to the pure goal of scientific truth.

References

1. Magner LN. A History of Medicine. New York: Marcel Dekker, Inc; 1992:66-74.
2. Magner LN. A History of Medicine. New York: Marcel Dekker, Inc; 1992:86-96.
3. McCormic S. Blood and magic-the evolution of phlebotomy. www.associatedcontent.com/article/959576/blood_and_magic_the_evolution_of_phlebotomy.html?cat=37 (accessed 4 April 2009).
4. Seigworth GS. Bloodletting Over the Centuries. New York State Journal of Medicine 1980;Dec:2022-2028. www.pbs.org/wnet/redgold/basics/bloodlettinghistory.html (accessed 4 April 2009).
5. Adams SL. The medicinal leech. Ann Intern Med 1988;109:399-405.
6. Parapia LA. History of bloodletting by phlebotomy. Brit J Haemat 2008;143:490-495.
7. North RL. Benjamin Rush, MD: Assassin or beloved healer? Proc Bayl Univ Med Cent 2000;13:45-49.
8. Rush B. A Defence of Blood-letting, as a Remedy for Certain Diseases. In: Medical Inquiries and Observations. Vol 4. Philadelphia, PA; 1815. Available online at: Arnebeck B. Benjamin Rush's A Defence of Blood-letting, as a Remedy for Certain Diseases. www.bobarnebeck/defence.html (accessed 4 April 2009).
9. Kerridge IH, Lowe M. Bloodletting: The story of a therapeutic technique. Med J Aust 1995;163:631-633.
10. Morabia A. P.C.A. Louis and the birth of clinical epidemiology. Clin Epidemiol 1996;49:1327-1333.
11. Lee GR, Foerster J, Lukens J, et al. Wintrobe's Clinical Hematology. 10th ed. Baltimore, MD: Williams & Wilkins; 1999:1063,1079,1539.
12. Whitaker IS, Rao J, Izadi D, et al. Historical Article: Hirudo medicinalis: Ancient origins of, and trends in the use of medicinal leeches throughout history. Br J Oral Maxillofac Surg 2004;42:133-137.

Dr Greenstone is a family physician in Surrey, BC.

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With a history spanning at least 3000 years, bloodletting has only recently-in the late 19th century-been discredited as a treatment for most ailments. The practice of bloodletting began around 3000 years ago with the Egyptians, then continued with the Greeks and Romans, the Arabs and Asians, then spread through Europe during the Middle Ages and the Renaissance.