Bloodletting

, Field book of wound medicine, 1517 Passages from the Ebers Papyrus may indicate that bloodletting by scarification was an accepted practice in Ancient Egypt. Egyptian burials have been reported to contain bloodletting instruments. According to some accounts, the Egyptians based the idea on their observations of the hippopotamus, confusing its red secretions with blood and believing that it scratched itself to relieve distress. In Greece, bloodletting was in use in the 5th century BC during the lifetime of Hippocrates, who mentions this practice but generally relied on dietary techniques. Erasistratus, however, theorized that many diseases were caused by plethoras, or overabundances, in the blood and advised that these plethoras be treated, initially, by exercise, sweating, reduced food intake, and vomiting. But his student Herophilus supported bloodletting. A contemporary Greek physician, Archagathus, one of the first to practice in Rome, also believed in the value of bloodletting. "Bleeding" a patient to health was modeled on the process of menstruation. Hippocrates believed that menstruation functioned to "purge women of bad humors". During the Roman Empire, the Greek physician Galen, who subscribed to the teachings of Hippocrates, advocated physician-initiated bloodletting. The popularity of bloodletting in the classical Mediterranean world was reinforced by the ideas of Galen, after he discovered that not only veins but also arteries were filled with blood, not air as was commonly believed at the time. There were two key concepts in his system of bloodletting. The first was that blood was created and then used up; it did not circulate, and so it could "stagnate" in the extremities. The second was that humoral balance was the basis of illness or health, the four humors being blood, phlegm, black bile, and yellow bile, relating to the four Greek classical elements of air, water, earth, and fire respectively. Galen believed that blood was the dominant humor and the one in most need of control. In order to balance the humors, a physician would either remove "excess" blood (plethora) from the patient or give them an emetic to induce vomiting, or a diuretic to induce urination. Galen created a complex system of how much blood should be removed based on the patient's age, constitution, the season, the weather and the place. "Do-it-yourself" bleeding instructions following these systems were developed. Symptoms of plethora were believed to include fever, apoplexy, and headache. The blood to be let was of a specific nature determined by the disease: either arterial or venous, and distant or close to the area of the body affected. He linked different blood vessels with different organs, according to their supposed drainage. For example, the vein in the right hand would be let for liver problems and the vein in the left hand for problems with the spleen. The more severe the disease, the more blood would be let. Fevers required copious amounts of bloodletting. == Middle Ages ==

The Talmud recommended a specific day of the week and days of the month for bloodletting in the Shabbat tractate. During medieval times bleeding charts were common, showing specific bleeding sites on the body in alignment with the planets and zodiacs. Islamic medical authors also advised bloodletting, particularly for fevers. It was practised according to seasons and certain phases of the Moon in the lunar calendar. The practice was probably passed by the Greeks with the translation of ancient texts to Arabic and is different than bloodletting by cupping mentioned in the traditions of Muhammad. When Muslim theories became known in the Latin-speaking countries of Europe, bloodletting became more widespread. Together with cautery, it was central to Arabic surgery; the key texts Kitab al-Qanun and especially '' both recommended it. It was also known in Ayurvedic medicine, described in the Susruta Samhita''. ==Use in the 1600s through the 19th century==

Bloodletting became a main technique of heroic medicine, a traumatic and destructive collection of medical practices that emerged in the 18th century. and Louis was dogged by the sanguinary Broussais, who could recommend leeches fifty at a time. Some physicians resisted Louis' work because they "were not prepared to discard therapies 'validated by both tradition and their own experience on account of somebody else's numbers'." During this era, bloodletting was used to treat almost every disease. One British medical text recommended bloodletting for acne, asthma, cancer, cholera, coma, convulsions, diabetes, epilepsy, gangrene, gout, herpes, indigestion, insanity, jaundice, leprosy, ophthalmia, 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 customary to remove a quantity of blood equal to the amount believed to circulate in the limb that was to be removed. There were also theories that bloodletting would cure "heartsickness" and "heartbreak". A French physician, Jacques Ferrand wrote a book in 1623 on the uses of bloodletting to cure a broken heart. He recommended bloodletting to the point of heart failure (literal). Leeches became especially popular in the early 19th century. In the 1830s, the French imported about 40 million leeches a year for medical purposes, and in the next decade, England imported 6 million leeches a year from France alone. Through the early decades of the century, hundreds of millions of leeches were used by physicians throughout Europe. Bloodletting was also popular in the young United States of America, where Benjamin Rush (a signatory of the Declaration of Independence) saw the state of the arteries as the key to disease, recommending levels of bloodletting that were high even for the time. George Washington asked to be bled heavily after he developed a throat infection from weather exposure. Within a ten-hour period, a total of 124–126 ounces (3.75 liters) of blood was withdrawn prior to his death from a throat infection in 1799. One reason for the continued popularity of bloodletting (and purging) was that, while anatomical knowledge, surgical and diagnostic skills increased tremendously in Europe from the 17th century, the key to curing disease remained elusive, and the underlying belief was that it was better to give any treatment than nothing at all. The psychological benefit of bloodletting to the patient (a placebo effect) may sometimes have outweighed the physiological problems it caused. Bloodletting slowly lost favour during the 19th century, after French physician Dr. Pierre Louis conducted an experiment in which he studied the effect of bloodletting on pneumonia patients. Barbara Ehrenreich and Deirdre English write that the popularity of bloodletting and heroic medicine in general was because of a need to justify medical billing. Traditional healing techniques had been mostly practiced by women within a non-commercial family or village setting. As male doctors suppressed these techniques, they found it difficult to quantify various "amounts" of healing to charge for, and difficult to convince patients to pay for it. Because bloodletting seemed active and dramatic, it helped convince patients the doctor had something tangible to sell. ==Controversy and use into the 20th century==

Bloodletting gradually declined in popularity over the course of the 19th century, becoming rather uncommon in most places, before its validity was thoroughly debated. In the medical community of Edinburgh, bloodletting was abandoned in practice before it was challenged in theory, a contradiction highlighted by physician-physiologist John Hughes Bennett. Authorities such as Austin Flint I, Hiram Corson, and William Osler became prominent supporters of bloodletting in the 1880s and onwards, disputing Bennett's premise that bloodletting had fallen into disuse because it did not work. These advocates framed bloodletting as an orthodox medical practice, to be used in spite of its general unpopularity. Some physicians considered bloodletting useful for a more limited range of purposes, such as to "clear out" infected or weakened blood or its ability to "cause hæmorrhages to cease"—as evidenced in a call for a "fair trial for blood-letting as a remedy" in 1871. Some researchers used statistical methods for evaluating treatment effectiveness to discourage bloodletting. But at the same time, publications by Philip Pye-Smith and others defended bloodletting on scientific grounds. The textbook was originally written by Sir William Osler and continued to be published in new editions under new authors following Osler's death in 1919. Bloodletting was once thought to reduce inflammation, boost immunity, and improve circulation by aiding in the detoxification of the blood circulating throughout the body. Over time, however, bloodletting's harmful impacts made the practice a less preferable form of medicine. Not only was bloodletting generally ineffective, it also commonly led to significant blood loss. High loss of blood made patients highly susceptible to infection/sepsis or the formation of a hematoma. Additionally, bloodletting also caused anemia, leading the patient to feel weak, tired, or even go unconscious. The harmful effects did not stop there; in severe cases, bloodletting had the potential to cause deadly hypovolemic shock. As the medical world advanced, these deadly effects made the practice of bloodletting fade in popularity. ==Therapeutic phlebotomy==

Therapeutic phlebotomy is used today in the treatment of a few diseases, including hemochromatosis, sickle cell disease, porphyria cutanea tarda, nonalcoholic fatty liver disease, and polycythemia. It is practiced by specifically trained practitioners in hospitals using modern techniques and a relatively safe procedure that depletes iron stores in the body. However, in the case of hemochromatosis, bloodletting (by venipuncture) has become the mainstay treatment option. Therapeutic phlebotomy is a cost effective way to remove excess iron in blood for patients that have hemochromatosis. ==Cross-cultural bloodletting==

Therapeutic uses of bloodletting were reported in 60 distinct cultures/ethnic groups in the HRAF database, present in all inhabited continents. Bloodletting has also been reported in 15 of the 60 cultures in the probability sample files (PSF) list. The PSF is a subset of eHRAF data that includes only one culture from each of 60 macro-culture areas around the world. The prevalence of bloodletting in PSF controls for pseudo-replication linked to common ancestry, suggesting that bloodletting has independently emerged many times. Bloodletting is varied in its practices cross-culturally, for example, in native Alaskan culture bloodletting was practiced for different indications, using different tools, on different body areas, by different people, and it was explained by different medical theories. According to Helena Miton et al.'s But out of 14 cultures with detailed bloodletting descriptions, there was no evidence of bloodletting being used to cure witchcraft-related ailments, while bloodletting was recorded as a cure for ailments of other origins. The Azande culture has been recorded to believe that bloodletting does not work to cure human-related witchcraft ailments. • Bloodletting is usually administered directly to the affected area, e.g. if the patient has a headache, a cut is made on the forehead. Out of 14 cultures with information on the localization of bloodletting, 11 at least sometimes removed blood from the affected area, while 3 specifically removed blood from a different area from the area in pain. Europe is the only continent with more instances of non-colocalized than colocalized bloodletting. In a transmission chain experiment done on people living in the US through Amazon Mechanical Turk, stories about bloodletting in a non-affected area were much more likely to transition into stories about bloodletting being administered near the area in pain than vice versa. This suggests that colocalized bloodletting could be a cultural attractor and is more likely to be culturally transmitted, even among people in the US who are likely more familiar with non-colocalized bloodletting. Bloodletting as a concept is thought to be a cultural attractor, or an intrinsically attractive / culturally transmissible concept. This could explain bloodletting's independent cross-cultural emergence and common cross-cultural traits. ==See also==

• • Carter, K. Codell (2012). The Decline of Therapeutic Bloodletting and the Collapse of Traditional Medicine. New Brunswick & London: Transaction Publishers. . • {{cite book ==Further reading==