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Home , Bloodletting, Geoffrey Keynes, Vis medicatrix naturae

J R Coll Physicians Edinb 2014; 44:72–7 Paper http://dx.doi.org/10.4997/JRCPE.2014.117 © 2014 Royal College of Physicians of Edinburgh

The demise of DP Thomas Retired Haematologist, , UK

ABSTRACT Bloodletting was a practice favoured by doctors and barber-surgeons Correspondence to DP Thomas for many centuries, and is now, perhaps surprisingly, still employed for a few The Old Barn North Green specific indications. The effectiveness of bloodletting for treating such as Kirtlington Oxford was convincingly challenged in the mid-nineteenth century, but OX5 3JZ, UK medical conservatism ensured the practice continued well into the twentieth century. As late as 1942, a famous medical textbook considered bloodletting e-mail [email protected] appropriate treatment for pneumonia.

KEYWORDS Bloodletting, lancets, pneumonia, , transfusion

DECLARATIONS OF INTERESTS No conflicts of interest declared.

THE HISTORY OF BLOODLETTING

Bloodletting, the taking of from a patient with therapeutic intent, was a practice carried out over millennia.1 Ancient Greek vases depict a physician performing bloodletting, and and both recommended the practice. The rationale for bloodletting, in so far as it had any, was based on the ancient belief of the existence of four humours, namely blood, phlegm, black bile and yellow bile, and that an imbalance of any of these could lead to illness. Various instruments were used to remove blood from the superficial , from simple syringes or lancets, to spring-loaded lancets, fleams (Figure 1) and multi-bladed scarificators. The amount of blood removed depended on the condition of the FIGURE 2 A seventeenth century Flemish painting by Jan patient, as well as the practice of the doctor, and varied Horemans showing a barber-surgeon with his young assistant from relatively small amounts to litres of blood over a woman, while the attending physician examines her several days. urine. Image courtesy of the Wellcome Library, London.

Galen (129–200) believed that blood was the dominant humour, and therefore an excess of this humour was treated by bloodletting and purging. The dominance of Galen’s theories in the ancient world was such that his teachings prevailed for many centuries, as did the practice of bloodletting. By medieval times, bloodletting was usually carried out by a barber-surgeon; the red and white of the barber’s pole is a reminder of their earlier role, with the red standing for blood, white for bandages or tourniquet and the pole itself for the stick grasped by the patient to assist in dilating the arm veins. In a well-known painting (Figure 2), the Flemish artist Jan Horemans (1682–1759) depicted a barber- surgeon bleeding a female patient, with his young assistant collecting the blood in a bowl (an example can be seen in Figure 3) while an accompanying physician examines the patient’s urine. This was a commonplace HISTORY FIGURE 1 A brass-handled three-bladed fleam, with original scene that would have changed little over the centuries. leather case, early nineteenth century. Image from author’s When one of the world’s leading medical journals, The collection. Lancet, was founded in the 1820s, its title reflected the

72 HISTORY

5 73 Strong man man Strong 3 Benjamin Rush 3 Charles II (1630– 2 The demise of bloodletting of demise The Cobbett was not alone in 4 3 In my early days, bleeding was very frequently very bleeding was frequently days, early In my in the people were and to in this hospital; resorted just request, their own be bled at to coming habit of and it their teeth drawn, to have apply now as they students. the for practice good be to thought was I began by drawing a small quantity at a time. The time. a quantity at small a drawing by I began upon the and its effects of the blood, appearance Never efficacy. and safety satisfied me of its system felt I now as did I experience such sublime joy before It remedies. of my in contemplating the success The life. all the toils and studies of my me for repaid the triumph was ... formidable this of conquest of .principle a of Hospital, describing his experience of bloodletting in 1879 Hospital, an intriguing insight into mid-Victorian practices: provides illustrates the depth of his convictions regarding the the regarding illustrates the depth of his convictions value of this treatment: salutarya is of dangers the of reminder approach Rush’s traditional methods, in the value of held beliefs sincerely evidence-based a critical, and highlights the need for at that time Even of treatment. of all assessment forms main his One of methods. Rush’s of critics were there William Cobbett (1763– was the Englishman opponents the wrote in Philadelphia stay a during who 1835), to indeed when quack ominous ‘The times are couplet: quack cries purge and bleed’. is Byron Lord during his last illness, his scepticism: as ‘the lancet, that to his physician said to have reputed the lance’. people than killed more had knows, he well Norwichand Norfolk the at physician consultant A The fervour with which physicians in earlier times earlier times in with which physicians The fervour seems extraordinary out bloodletting carried today. Medical of the Paris Dean (1601–1672), Guy Patin ‘fluxion’ of the chest, a for 12 times bled his wife Faculty, and himself , a continuing for his son 20 times ‘cold in the head’. a for times seven and General George a stroke, 1685) was bled following throat severe a from suffering (1732–1799), Washington hours. of a few times in a matter bled four was infection, has been variously him from taken The amount of blood pints. nine and five between at estimated his constitution could not withstand even though he was, and it seems the misguided effortshis physicians, of hastened his end. such treatment likely and American physician distinguished a (1746–1813), was Independence, of the Declaration of signer that bleeding his patients was the best convinced undoubtedly he was graduate, An Edinburgh treatment. the teachings by influenced during his time in Scotland who William Cullen (1710–1790), physician of the great nervousused bloodletting to deplete the , During caused disease. he believed, imbalance of which, in 1793 Rush epidemic in Philadelphia fever the yellow passage The following bled and purged his patients. 72–7 : 44 2014; 2014; A set of lancets with tortoise shell handles and a A bleeding bowl. Image courtesy of the Museum A bleeding bowl.

FIGURE 4 FIGURE Alastair Image courtesy of Dr c.1820. carryingsilver case, Mowat. FIGURE 3 FIGURE College of Surgeons of Edinburgh of the Royal J R Coll Physicians Edinb Coll Physicians J R © 2014 RCPE While cynics might say modern hospital phlebotomists modern hospital phlebotomists While cynics might say taken laboratory blood for testing have withdrawing supposedly of practice time-honoured the role, the over out well bloodletting was in fact carried therapeutic century. into the twentieth fact that a lancet was considered an indispensable item an indispensable item fact that a lancet was considered Today, 4). (Figure doctors medical equipment for of such as haemo- specific indications, a few apart from bloodletting is and polycythaemia, chromatosis But long discarded. as an obsolete treatment, regarded come to an end? just when did the practice finally DP Thomas

When I was in practice in the country, my American hospitals, he concluded that bloodletting did was visited on Sunday mornings, in spring and not improve survival.12,13 The work of Hughes Bennett, autumn, by a number of labouring people, who paid like that of Louis before him, was distinguished by a their shilling each to be bled; sometimes five or six careful epidemiological approach, with results based on were going at the same time, and I never knew any group comparisons. While this approach would not of them take harm from the loss of blood – indeed, meet modern standards for controlled clinical trials they considered themselves all the better for it, and (they simply compared mortality rates retrospectively would have it done.6 in different wards or hospitals), detailed records of their patients enabled them to assess survival rates. For Even though this physician agreed that bloodletting was example, in a series of 105 consecutive cases of simple, less commonly employed than before, he claimed there uncomplicated pneumonia treated by him without was still a place for it in certain diseases: ‘But there is bloodletting over 18 years at Edinburgh Royal Infirmary, one form of disease which is peculiarly under the Hughes Bennett reported no deaths in his patients as influence of bleeding as a remedy, and if treated in its a result of pneumonia.12,13 These results were in marked early stage or onset, is cured by it very speedily and contrast to his detailed analysis of patients at the same satisfactorily… I allude to idiopathic pleurisy’.6 hospital ‘when upwards of one-third of all patients affected with pneumonia died who entered during a In his Gulstonian Lecture to the Royal College of period of ten years when bleeding and an antiphlogistic Physicians, London in 1864, Dr WO Markham (1818– treatment was universally practised’. Hughes Bennett 1891), a physician to St Mary’s Hospital in London, concluded that ‘supporting and restoring (not made a plea for the judicious use of bloodletting in stimulating) the nutritive powers of the system, and certain conditions, deploring that venesection was avoiding all weakening remedies (low diet, bleeding, carried out less frequently than before. He claimed that tartar emetic, narcotics, etc.) ought to constitute the ‘bloodletting, rightly applied, is now, as it ever has been, practice in pneumonia’.12,13 a good remedy in disease’.7 John Haddon, a physician from Hawick, wrote in 1915: ’Our grandfathers used to This iconoclastic approach led to the famous bloodletting be bled every spring, and I have heard… tell of the row dispute of the 1850s. The traditional view of its value of patients waiting to be bled. Languid and lazy before was upheld by William Pulteney Alison (1790–1859), being bled, they felt as if their youth were renewed by recently retired from the Chair of Physic at Edinburgh the bleeding.’8 University.14 Hughes Bennett, a generation younger than Alison, and recently returned from studying in Paris and While bloodletting had been standard treatment for Berlin, strongly believed in the value of pathology and centuries, by the early eighteenth century there were the microscopic study of disease. His whole approach, some physicians who opposed excessive bloodletting. including the use of statistics, was based on a more One of the best known physicians in London, John scientific study of disease. One of the theories prevalent Radcliffe (1652–1714), preferred to apply blisters.9 His in the mid-nineteenth century was that a change had preference for the and opposition occurred in the nature of inflammatory diseases in the to bloodletting may well have enhanced his reputation. sthenic type of patient as compared to those who were He left his considerable fortune to Oxford University asthenic. The argument was made that prior to the where his name is commemorated by several buildings, introduction of rail travel and cramped city living, including the main teaching hospital. In France, François patients were more robust, and their symptoms Broussais (1771–1838) believed that nature had no demanded depletive or antiphlogistic therapy, such as healing power and disease had to be aborted by active bloodletting.15 As the century progressed, and with it measures. To this end, he applied leeches over the more modern conditions, patients became more asthenic whole body, and was a fervent advocate of bloodletting. with diminished energy, and were less able to withstand However, during the second half of the nineteenth bloodletting. They therefore needed nourishment, such century scepticism grew of the value of bloodletting. as with beef tea and alcohol. The claim was that the Broussais’ views were challenged by Pierre Louis effect of town life, as opposed to country living, had led (1787–1872), often considered the founder of medical to a change in the constitution of the human body, and statistics. Louis took a strong stand in favour of facts hence the need to alter the type of treatment. In and figures, as opposed to ‘sterile’ theorising,10,11 and addition, much of this dispute centred on the confusion concluded that for most patients there was no attending the concept of – was inflammation convincing evidence supporting bloodletting. This a disease or a symptom of disease? The distinction approach was reinforced by John Hughes Bennett between septic and aseptic inflammation was not (1812–1875), whose views on bloodletting and its lack appreciated at the time. Bloodletting was the chief HISTORY of efficacy triggered a great controversy on the topic in remedy against inflammation in the so-called antiphlogistic Edinburgh. In an impressive statistical analysis of regimen indicated for sthenic patients, whereas it was survival rates following pneumonia in European and considered inadvisable in asthenic patients.15,16

74 J R Coll Physicians Edinb 2014; 44:72–7 © 2014 RCPE HISTORY 75 While While 23 21 But what is even But what is even 22 Hale-White reminded Hale-White reminded The demise of bloodletting of demise The 24 At this meeting, the distinguished distinguished the meeting, this At

The indications upon which most of the 24 Before Louis’s iconoclastic paper on bleeding in bleeding in on paper iconoclastic Louis’s Before almost as been regarded have it would pneumonia We without venesection. a patient criminal to treat ago, years did a few than we more it much employ bleed To than early. often late in the disease but more is individuals… healthy verythe at in robust onset dilatation Late in the course marked practice. good The right heartthe of indication. the common is the be decided by must quantity of blood removed sufficient. often are amounts small effect; frequency of bloodletting. Another speaker at this at this Another speaker of bloodletting. frequency Wilcox, William Sir physician, well-known a meeting, of cases: classes in five indicated venesection considered heatstroke convulsions; the heart; right-sided dilation of or drowning from and violent asphyxia polycythaemia; the therefore, times, modern in relatively Even hanging. suitable a considered were bloodletting for indications medical meeting in London. a at discussion topic for this was at a time before the general availability of of the general availability this was at a time before It seems available. sulpha drugs were penicillin, a as late as the 1940s, that if, to conclude reasonable recommended medicine of textbook leading the practice was not pneumonia, bloodletting for century. the twentieth into abolished until well of Society Royal the at in London held meeting a At it venesection, the subject of April 1927 on Medicine in be employed not should that the procedure agreed was especially pressure, blood low and anaemias on chronic in the elderly. and polycythaemia were agree to appeared group the chronic among certainof high cases with conditions associated lividity and acute and group, it was that agreed also was It heartright dilatation. sunstroke. beneficial in William Hale-White (1857–1949) Sir physician ‘eighty place taken had discussion the if that commented people would hundred several previously or ninety years since every in London, in the afternoon been bled have was days health in those his after looked who person and autumn’. spring bled every with charged was the audience that in 1840 a doctor with pneumonia, patient a bleed failing to for malpractice in the change had been a great there but subsequently for comments: the following are In the same edition a in hospital the into come who ‘[P]atients emphysema, great with lividity and urgent dyspnoea of state And should be bled freely…’. of the veins engorgement and asphyxia, intense with cases the ‘[I]n sun-stroke: for free minutes, few a in place take may death which in biographer As his latest bleeding should be practised.’ ‘blind spot’ on a Osler had Michael Bliss commented, the supposed value of bloodletting. death, after Osler’s 23 years is that, remarkable more the fourteenth first edition, after the and 50 years not changed the edition of his textbook (1942) had advice about bleeding patients with pneumonia.

10 17 18

19 in 1915, a consulting a in 1915, . In the first edition in in edition first the In . 72–7 : 44 Perhaps even more surprising more even Perhaps 20 2014; 2014; BritishMedical Journal may save life. To be of serviceof be done be it should To life. save may to thirty twenty of from the abstraction early… beneficial. way is in every of blood ounces During the first five decades of this centuryof decades During the first five the last the during but much, too bled profession Pneumonia certainly little. too bled have we decades venesection in which a timely is one of the diseases J R Coll Physicians Edinb Coll Physicians J R © 2014 RCPE at the very onset in robust, healthy individuals in whom individuals healthy verythe at in robust, onset is, intensity and high fever sets in with the disease great practice’. a good I believe, the as late as advice following the is eyes modern to his textbook: 1930 edition of Ten years later, he was still advocating the removal of removal the he was still advocating later, years Ten bleed ‘To of pneumonia: part as blood of the treatment Principles and Practice of Medicine of PrinciplesPractice and Osler wrote: 1892, convinced that general bloodletting is the remedy for for remedy the is bloodletting general that convinced (due to poison gas) those cases of traumatic bronchitis further a fuller trial’. and be given it should and several listed (1849–1919) Osler William Sir bloodletting in his famous textbook indications for Similarly, Louis had also concluded there were useful were there concluded also Louis had Similarly, cases. severe for but only of bloodletting, effects comment that bloodletting at the Humphry’s However, was occurs’ ‘scarcely centurynineteenth the of end the letter to a In in Scotland. even premature, somewhat the of editor ‘I am Infirmary Royal at the Edinburgh surgeon wrote: ‘either the over-use in the past must have been wrong been wrong have must in the past ‘either the over-use both, Probably be so. or the total disuse in the present altered so been have cannot constitution human the for concluded He change.’ justify the to as period in that that in some cases ‘the opinion is gaining ground that advantage’. with to resorted be may venesection about bloodletting continued throughout the latter half throughout continued bloodletting about into the indeed well and of the nineteenth century, Surgery of , at In 1895 the Professor twentieth. (1820–1896) at a meeting of the Sir George Humphrey ‘went bloodletting that claimed Society, Medical Oxford occurs to the practitioner scarcely it now and suddenly on to say But he also went of treatment’. as a means and treating disease, involving both laboratoryboth involving disease, treating and However, observations of results. and statistical analysis that of more came into conflict with this approach their own on rely to clinicianswho continued traditional Despite on clinical observation. solely based experience, controversy the treatment, the of scepticism growing From today’s perspective, perhaps the most surprising the most perhaps perspective, today’s From Hughes and Louis of work pioneering the of aspect to was profession medical the slow how was Bennett to the in relation especially evidence, accept their strong attempting Hughes Bennett was of pneumonia. treatment identifying to scientific approach more a introduce to TOO MUCH OR TOO LITTLE? TOO OR MUCH TOO DP Thomas

In correspondence following the report of this meeting, MODERN the physiologist RJS McDowall made the point, as an experimentalist, that following venesection ‘contraction of The general decline in bloodletting had certainly the peripheral vessels to keep up the arterial pressure... become established by , which ironically brought about a profound fall of venous pressure which is heralded the era of modern blood transfusion. Although relatively lasting and which must be of enormous value in there had been many attempts over the centuries to relieving the right side of the heart.25 F Parkes Weber, treat patients by transfusing blood from animals to man another well-known physician, in a letter to the editor, and man to man, it was only after the identification of commented that his father, when in Bonn, Germany, blood groups early in the twentieth century,27,28 and the around 1850, was asked to show Sir James Young Simpson discovery of the effectiveness of citrate as an (1811–1870) around his clinic. Simpson claimed that anticoagulant,29 that blood transfusion became a venesection for the treatment of pneumonia had been practical and reliable treatment. The life-saving value of completely abandoned in Edinburgh. When he asked what blood transfusion was amply demonstrated during this would happen if a patient in Bonn died without being bled, war, and the experience was instrumental in persuading he was told that the assistant who had attended the case surgeons of its value for blood loss following acute would be waylaid and unmercifully beaten.26 Simpson was trauma.30,31 Sir Geoffrey Keynes (1887–1982), a pioneer Professor of Obstetrics in Edinburgh University, and his of blood transfusion following his experience as a comment may well have been accurate for the obstetricians, surgeon on the Western Front in World War I, published but was manifestly not true for some of the physicians. Sir the first British textbook on blood transfusion in George Humphrey, a surgeon, made a similar claim in the 1922.32 By the 1920s doctors were more likely to 1890s that venesection had been virtually abandoned.17 transfuse blood than bleed their patients. Perhaps venesection was abandoned earlier among surgeons and obstetricians than by physicians. CONCLUSION LEECHES In the days when doctors had little in the way of effective treatment, and there was a need to be seen to be doing The application of leeches () has a something to treat the patient, the effect of history at least as long as bloodletting. Their use was bloodletting should not be underestimated. This is particularly favoured in the nineteenth century, to the probably also true for other practices long discarded by extent that several million leeches were employed in Paris mainstream Western medicine, such as blisters and hospitals every year. As late as the 1950s in at least one purging. However, when such an astute clinical observer London teaching hospital, leeches were kept in the as believed that venesection was helpful in hospital pharmacy and used occasionally. As a houseman some patients it would perhaps be unwise to assume the to a cardiologist there in 1955, I was instructed to apply reputed benefits were simply the result of a placebo leeches to a patient with pericarditis. My chief at the time effect. Even Louis, while deprecating the widespread thought it appropriate to maintain some of the old practice of bloodletting, concluded there were useful customs, and he believed leeches were effective in effects, but only for narrow and specific indications.10 An relieving the pain of pericarditis. I was reluctant to editorial in the British Medical Journal in 1871 made a plea challenge him, even though I had spent a previous summer for a ‘fair trial for bloodletting as a remedy’;33 it would be as a medical student working with Archie Cochrane impossible today to carry out a controlled clinical trial (1909–1988), who had inspired me with the spirit of to settle the issue. healthy scepticism towards some current clinical practices. Cochrane’s approach eventually developed into the It is difficult to state definitively when bloodletting for modern concept of evidence-based medicine, celebrated conditions such as pneumonia finally ceased in Western today by the many Cochrane centres established around medicine, and the practice still persists in some North the world. He would certainly have been bemused had he African countries today.1 While the indications are that known one of his students was instructed to apply the practice continued sporadically in the West until the leeches in 1955. However, leeches have had something of 1940s, the arrival of antibiotics for the treatment of a renaissance in recent years, being used in micro- and pneumonia would have ended the need for any such plastic surgery for removal of localised collections of non-specific treatment. By then, the modern era of blood, as opposed to any systemic effect. For example, evidence-based medicine was dawning, and bloodletting they are used to treat venous congestion if it occurs in had been consigned to the dustbin of discarded plastic surgery flaps or on reattached digits. It is relatively treatments. In years to come it is a safe prediction that easy to restore arterial blood flow, but more difficult to some, if not many, of our current practices will be establish venous drainage, and congestion can easily looked on with similar disbelief, so perhaps we should HISTORY jeopardize a successful outcome. The application of a not be too critical of our medical predecessors. to the affected part can have a beneficial effect by removing congested venous blood.

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