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Bloodletting represents the folly of the past, the sorcery and the misguided physiology that we now proudly say marked the dark ages of medicine - or did it (1)? In fact, bloodletting has a place in medicine today and a history that is worthy of review.

The Four Humors

The traditionally held "Father of Medicine" was the Greek physician Hippocrates (460-370 BC), who taught medicine on the island of Cos. One of his major precepts was the rule of harmony, the theory that all body systems were in balance and that disease resulted from an imbalance. Galen (130-201 AD) was the physician to Marcus Aurelius and became the heir to Hippocrates and one of the most influential physicians of all times. He taught the importance of maintaining balance between the four bodily fluids, or "humors" (2): blood, phlegm, yellow bile, and black bile. Each fluid was associated with a specific personality characteristic. Blood was associated with a sanguine personality, that is laughter, music, and a passionate disposition. Someone with a phlegmatic personality was sluggish and dull, while yellow bile represented an individual quick to anger or choleric (cholera meaning yellow as in yellow fever). Lastly, black bile represented a melancholic or depressed personality, melan meaning black. It was the job of the physician to restore harmony in those four humors by the use of emetics, cathartics, purgatives, and by bloodletting. Bleeding was used to reduce excess circulation, to slow the pulse, and to "reduce irritation", all felt to be the cause of inflammation. Dr. Benjamin Rush, a signer of the Declaration of Independence, was a major figure in colonial American medicine and was an important proponent of bleeding, though unfortunately he mistakenly thought that the body held 12 instead of 6 quarts. Shortly before his death, George Washington was bled 4 ‡ quarts in 24 hours for an infected throat and died not long after (3).

Early transfusion was based on the notion that giving blood would help balance the humors (4,5). On June 15, 1667, Jean Davis replaced part of a patient's blood with sheep's blood though the patient died and Dr. Davis was subsequently accused of murder. Transfusion was set back until the 19th century, well before blood typing was understood.

The First Bloodletting Technique

Leeches were used for bleeding by Syrian physicians as early as 100 BC. Hirudo Medicinalis were imported to the United States from Europe and have suction cups at both ends. On the "business end" are 3 sharp teeth and hirudin, which is an anticoagulant that is now being investigated for use in some medical procedures. The leeches were placed on the patient and drank their fill, to be used again several days later after being stored in glass (6) or very fancy porcelain jars (7,8). Leeches could be directed to small areas such as the mouth, ear, or vagina, by placing them in a small receptacle called a "leech tube" (9). Toward the end of the 19th century, technology began to take over and artificial leeches were manufactured which drew blood essentially the same way (10).

1) Scenes of the Practice of Medicine, 15th century

Bloodletting, which was normally venous, was arterial in this depiction. Galen is "long robbed" and supervises the procedure by others.

2) Galen's Four Humors

Clockwise from upper left: a) blood - passionate and sanguine, b) phlegm - sluggish and dull, c) black bile - melancholic and depressed and d) yellow bile - choleric and quick to anger.

3) "George Washington in His Last Illness" (Ca 1800)

Drs. Craik and Brown bled President Washington for an infected throat prior to his death. Note one of the doctors monitoring the effects of bleeding by a change in the pulse.

4-5) Bleeding and Transfusion

A patient has his "humors" rebalanced by bleeding and replacement with sheep's blood in "Armanentarium Chirugiae" (1693), by Ioannis Sculteti. Blood transfusion is illustrated in this Harper's Weekly magazine, July 4, 1874.

6) Glass Leech Jar

This large jar stored leeches in the pharmacy or doctor's office. Muslin covered the jar to prevent the leeches from climbing out. These containers are not to be confused with apothecary candy jars.

7-8) Large Leech Jars, Mid 19th Century

Illustrated here are wonderful porcelain containers that stored leeches when they were not in use. The first is a Staffordshire leech jar by Samuel Alcock and Co., Ca 1840. They are rare because they are so fragile.

9) Leech and Leech Tube

This leech is larger than the one that would be used medically. The glass container would be used to direct a small leech.

10 Heurteloup's Artificial Leech

Mechanical leeches were made the latter part of the 19th century and functioned the same way as the real thing, though maintenance was obviously easier.

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1) Bloodletting, 15th Century

2) Galen's Four Humors

3) G. Washington After Being Bled

4) Bleeding and Transfusion

6) Glass Leech Jar

7) Porcelain Leech Jar

9) Leech and Leech Tube

10) Artificial Leech