The possible effects of iron loss from bloodletting on mortality from pneumonia in the nineteenth century

OBJECTIVE

To estimate iron losses and disease severity following 19th century bloodletting in patients with pneumonia.

STUDY DESIGN AND SETTING

Benefits of bloodletting in pneumonia patients were contested during the 19th century. Although large blood volumes during infection were removed there was no systematic data collection assessing efficacy and knowledge of iron composition of blood was rudimentary. This observational analysis of historical data quantifies iron losses in pneumonia cases in relation to disease severity.

RESULTS

Based on one detailed case series average blood volume removed for survivors was 830 mL (range 114-2272 mL), and mean recovery times were shorter in patients bled within 2 days of illness (P < 0.001). Average iron removed was 446 mg with phlebotomy done ≤2 days of illness presentation and 347 mg after >2 days of illness (P = 0.012). Across several European hospitals average case fatality in pneumonia patients receiving phlebotomy was higher than in those treated without phlebotomy (19.9% vs. 12.8%, OR 1.55, 95% CI 1.38-1.74, P < 0.001).

CONCLUSION

Variable efficacy for bloodletting could at least in part be explained by altered iron status.

Pierre-Charles-Alexandre Louis and the Evaluation of Bloodletting

Additional material for this article is available from The James Lind Library website [ www.jameslindlibrary.org ] where this paper was previously published.

[Treatment by bloodletting in the past and present]

INTRODUCTION

Therapeutic bloodletting has been practiced at least 3000 years as one of the most frequent methods of treatment in general, whose value was not questioned until the 19th century, when it was gradually abandoned in Western medicine, while it is still practiced in Arabic and traditional Chinese medicine.

CONTENT

In modern medicine bloodletting is practiced for very few indications. Its concept was modeled on the process of menstrual bleeding, for which it was believed to"purge women of bad humours. "Thus, bloodletting was based more on the belief that it helps in the reestablishment of proper balance of body "humours" than on the opinion that it serves to remove excessive amount of blood as well as to remove toxic "pneumas" that accumulate in human body. It was indicated for almost all known diseases, even in the presence of severe anemia. Bloodletting was carried out by scarification with cupping, by phlebotomies (venesections), rarely by arteriotomies, using specific instruments called lancets, as well as leeches. In different periods of history bloodletting was practiced by priests, doctors, barbers, and even by amateurs. In most cases, between one half of liter and two liters of blood used to be removed. Bloodletting was harmful to vast majority of patients and in some of them it is believed that it was either fatal or that it strongly contributed to such outcome. In the 20th century in the "Western"medicine bloodletting was still practiced in the treatment of hypertension and in severe cardiac insufficiency and pulmonary edema, but these indications were later abandoned.

CONCLUSION

Bloodletting is still indicated for a few indications such as polycythemia, haemochromatosis, and porphyria cutanea tarda, while leeches are still used in plastic surgery, replantation and other reconstructive surgery, and very rarely for other specific indications.

Lady Brilliana Harley (1598-1643): Her medicines and her doctors

Lady Brilliana Harley was the redoubtable chatelaine of Brampton Bryan Castle in Herefordshire during the mid-seventeenth century. Her many letters reveal much about the medications which she dispensed to her family and about the family's medical attendants. Whenever possible the Harleys preferred to consult university-educated physicians rather than the local apothecary or surgeon. These physicians are all known from other sources but Brilliana's letters add to what is known of their provincial practices. In particular, they reveal their willingness to undertake blood-letting, often thought to be the province of the more lowly surgeon, and they emphasise the great distances travelled by these practitioners and the difficulties faced by two of them during the Civil War.

Treatment of the Man: Galen's Preventive Medicine in the De Sanitate Tuenda

Ideally in Galen's model of preventive medicine, the patient does not become a patient at all but remains a healthy person able to maintain his or her health without need of either medicines or other therapies. This chapter is divided into four sections, Galen's ideal patient; less than ideal patients; patients in old age; and patients whose nature is inclined to a bad mixture of humours, and so in need of medication. In all four categories, even those where medical recommendations such as blood-letting are recommended, Galen offers an option based on hygieine, or the art of maintaining good health. Galen's aim in de sanitate tuenda is to ensure that a well-educated person can lead a healthy life by learning what does harm and what benefits him or her. The chapter explores the extent to which the patient can really be independent of the doctor, and the interesting balance between nature and urban life which constitutes good health in Galenic thought.

Dr Robert Robertson (1742-1829): Fever Specialist and Philosopher-Experimenter in the Treatment of Fevers with Peruvian Bark in the Latter Eighteenth-century Royal Navy

The life and works of Dr Robert Robertson are reviewed set against the background of the extant British management of fevers during the latter 18th-century. Commencing in 1769, using the febrifuge Peruvian bark (cortex Peruvianus; Jesuit's Powder), he experimented and tested Peruvian bark mono-therapy protocols in the tropics in the cure and prevention of intermittent fever (predominantly malaria). His later work also showed the benefit of the bark in the acute care of developed continuous fevers (largely Ship Fever due to Epidemic Louse-borne Typhus Fever) in both the Temperate and Torrid Zones. In the realm of comparative statistics Robertson first demonstrated the safety and effectiveness of bark therapy against the dangerous depleting processes of the antiphlogistic regimen. He was the first to alert the Admiralty to the efficacy of bark in both the cure of acute fevers as well as a prophylactic in the tropics, and signalled the dangers of bloodletting in treating fevers of the tropics. He authored 13 books devoted to fevers outlining his theory of Febrile Infection and its treatment. The essay concludes with his role as the Physician-in-Charge of the Royal Hospital, Greenwich over a 28-year period, as an acknowledged expert in the small British group of 18th-century fever specialists.

Rhazes and an Early Case With Possible Hypertensive or Reversible Encephalopathy

In one of Rhazes' medical treatises, Tales and Stories of Patients, descriptions, medical manifestations, and treatment approaches of 34 patients were mentioned. Among those, an epileptic patient with a florid face and congested veins was cured by performing venesection on his saphenous and basilic veins. Signs and symptoms of the case might correspond to hypertensive or reversible encephalopathy.

Classic Maya bloodletting and the cultural evolution of religious rituals: quantifying patterns of variation in hieroglyphic texts

Religious rituals that are painful or highly stressful are hypothesized to be costly signs of commitment essential for the evolution of complex society. Yet few studies have investigated how such extreme ritual practices were culturally transmitted in past societies. Here, we report the first study to analyze temporal and spatial variation in bloodletting rituals recorded in Classic Maya (ca. 250-900 CE) hieroglyphic texts. We also identify the sociopolitical contexts most closely associated with these ancient recorded rituals. Sampling an extensive record of 2,480 hieroglyphic texts, this study identifies every recorded instance of the logographic sign for the word ch'ahb' that is associated with ritual bloodletting. We show that documented rituals exhibit low frequency whose occurrence cannot be predicted by spatial location. Conversely, network ties better capture the distribution of bloodletting rituals across the southern Maya region. Our results indicate that bloodletting rituals by Maya nobles were not uniformly recorded, but were typically documented in association with antagonistic statements and may have signaled royal commitments among connected polities.

History of the leech trade in Ireland, 1750-1915: microcosm of a global commodity

In the nineteenth century the medicinal leech Hirudo medicinalis evolved into a lucrative commodity in great demand throughout the western world. In less than a century its trade became big business by any measure, involving tens of millions of animals shipped to every inhabited continent. In this context Ireland is particularly instructive in that it was the first country in Europe to exhaust its supply of native leeches. Concomitantly, it was also the first country to import leeches from abroad, as early as 1750. Being an island with manageable border controls, and a clearly definable medical market, Ireland serves superbly as a microcosm of the leech as a worldwide commodity. Being a relative small country it is possible for the first time to gain a balanced perspective of various economic factors underlying this trade, including supply and demand, exploitation of natural resources, and an evolving network of competitive traders. This paper addresses these and other aspects of the leech trade in Ireland. The principal, and unexpected, finding of this paper is that leeches were unequivocally very expensive in Ireland and became a significant drain on hospital budgets. As such, they found little use amongst the Irish poor. An estimate of several million leeches were imported into Ireland in the nineteenth century, a practice which continued into the twentieth. They were imported initially from Wales and then from France following the defeat of Napoleon, but the bulk came ultimately from Hamburg, via importers in England.

[Discussions on history of the bloodletting therapy overseas]

To introduce the origin, development and theoretical source of the bloodletting therapy overseas. The bloodletting therapy, which was based on Hippocrates's four fluid theories, had the therapeutical effect and therefor spread abroad. Many people not only thought this therapy was benefit, but also let out blood regularly. During the medieval Europ, the bloodletting therapy reached its top, which was caused by the part-time job of barber. It was questioned when spreading in the America. After that, as the development of the other medical method, the disadvantage was exposed. With several clinical mistherapies, it faded away from the stage of history. The recent research shows that the normative bloodletting therapy could treat some diseases.

[Reinforcing and reducing method of bloodletting therapy]

Through review and analysis on description of bloodletting therapy in ancient medical classics, it is found that bloodletting therapy can be classified as two categories of reinforcing and reducing. And the classification is related with many factors such as the quantity of blood, apparatus selected, depth of acupuncture, points selected and physical conditions, etc. Bloodletting therapy is not confined only in excessive syndromes, it is also applied to the treatment of complicated syndrome of excess and deficiency as well as deficiency syndrome with excessive manifestations and deficiency syndrome.

[The study on the establishment of acupuncture]

In ancient china, four famous literatures, Huang Di Nei Jing, Nan Jing, Ben Cao, Shang Han Lun appeared, which made the foundation of oriental medicine. Huang Di Nei Jing, the book of acupuncture, is the most essential literature among these four litertures. So the question asking the identity of oriental medicine can be turned into the question about the identity of acupuncture. The investigation into origin will not be the only way to study of identity but one of the most attractive means. So we can answer with the study of origin to the question about identity. Acupuncture is comprised of theories like jing mai, qi xue and technical factors like moxibustion, bian which is like present operating knife. To trace the origin of acupuncture, we must investigate not only technical factors but also theories. But it will be impossible to trace every theories underlying the acupuncture in this small thesis. This is the reason that I restricted my attention to the principle of preventive medicine, regimen. Before the excavation of Mawangdui, the belief that acupuncture started long ago before Han period had been generally accepted. But there was not any proof proving the presence of acupuncture in the excavated literatures representing the Han period medicine. This fact announced that we must draw the time of establishment of acupuncture back after the Mawangdui literature buried in B.C. 168. But we can find the proof of the presence of acupuncture just before B.C. 168 in Shiji written by Si Mi Qian. Through these facts and inferences that we got until now, we can reach a conclusion that acupuncture would have appeared around 190-176 when Chun Yu Yi was practicing as a doctor. As you know, in the Mawangdui literature, what was associated with jing mai was moxibustion. But at the same time, moxibustion was being used just as the experience medicine technique without theory. So the moxibustion would has been about to be associated with jing mai theory in Mawangdui period. The word zhen jiu, the acupuncture and moxibustion, means there was a way to reconcile two techniques. It was by assuming bu and handing xie over to acupuncture that moxa can coexist with acupuncture. bian is used for infection treatment more than bloodletting tool in ancient china. but there is a bridge between acupuncture with bian. Acupuncture inherited its appearance from bian. It is generally believed that blood-letting is commonly developed in the classic east and west medicine. But the blood-letting could be harmonious with the old chinese belief that vitality must be retained in the body? No. The blood-letting is not generally practiced in ancient china. We can scarcely find the evidence of blood-letting in the ancient literature now in hand except Huang Di Nei Jing. Blood-Letting widened its territory in ancient chinese medicine with the help of the medical version of wuweierwubuwei principle which means 'not do anything, then everything does'. But soon lost its territory. Even in the Huang Di Nei Jing, We can find its disappearance. What is the reason? For its disharmony with chinese life idea, 'not lose essence'. Acupuncture replaced the blood-letting. It was the response of the ancient chinese healers to the regimen spirit and harmonious with chinese life view. Regimen spirit, the medical version of 'wuweierwubuwei' does not pursue cure after being ill but defense before disease. Acupuncture, meeting the demands of time, appeared in pre-han period as the association with jingmai theory which may be developed in regimen field, inheritence of moxa's esperience, and the shape of bian.

Re-imagining bleeders: the medical leech in the nineteenth century bloodletting encounter

While some historians have noted the absence of animals in medical history, few have made the animal the central object of their historical gaze. Twenty years ago W.F. Bynum urged medical historians to follow historians of science in paying attention to the role of non-human animals in the material practices of medicine. Yet few have responded to his call. In this paper we again ask the question: what work can the non-human animal achieve for the history of medicine? We do so in the light of the conceptual possibilities opened up by the rapidly emerging field of ‘animal studies’. This interdisciplinary and sophisticated body of work has, in various ways, revealed the value of the ‘animal’ as a tool for exploring the co-constitution of species identity. We asked ourselves, surely, in our present biomedical world, this must be an area that we as medical historians are best placed to comment on; and what better place to start than the well-known, yet surprisingly little-studied, medical leech?

[Discussion on collateral puncture therapy in Japan]

The history of collateral puncture therapy in Japan was traced, the current status and characteristics of collateral puncture therapy in Japan were introduced in this paper. Originated in China, the collateral puncture therapy in Japan combined Japanese knowledge of acupuncture with the theory and practice of bloodletting of Portugal Medicine and Netherlands Medicine. The discussion on the theory and technique of the collateral puncture therapy by Kudo Kunsei became the standard of the collateral puncture therapy in Japan in modern times. Based on this discussion, Tetuo Asami proposed a new theory of the collateral puncture therapy which improved the collateral puncture therapy in Japan. Currently, as a part of Japanese health care system, the collateral puncture therapy with Japanese characteristics is gradually accepted by the medical profession in Japan.

[Origin of three symbols in medicine and surgery]

BACKGROUND

Humans use many ways to communicate with fellow humans. Symbols have been one of these ways. Shamans probably used these in the beginning and adopted other distinctive symbols as they were introduced.

DISCUSSION

The origin, the reason and use of three symbols in medicine and surgery are discussed. Some symbols currently remain the same and others have been modified or have disappeared. The oldest of these three symbols is the staff of Aesculapius, related to the Greek god of medicine and health. Since the 19th century, in some countries the symbol of the medical profession has become the caduceus, but the staff is the natural symbol. The second symbol is the barber pole that was created at the beginning of the Middle Ages. This was the means to locate the office and shop of a barber/surgeon in towns, cities and battlefields. On the other hand, the surgeon made use of the emblem of the union, trade or fraternity to which he belonged, accompanied by the bowl for bloodletting. The third symbol is the wearing of long and short robes that distinguished graduate surgeons from a medical school and the so-called barber/surgeons.

CONCLUSIONS

Symbols facilitate the manner in which to identify the origin or trade of many working people. Some symbols currently remain and others have either been modified or are obsolete, losing their relationship with surgery and medicine.

Change of type as an explanation for the decline of therapeutic bloodletting

In clinical lectures given between 1850 and 1852, William Pultney Alison, a senior Edinburgh physician, reflected on whether therapeutic bloodletting could be useful in some cases of pneumonia but harmful in others. If so, Alison reasoned, a change in the form of the disease-a change of type-could explain why therapeutic bloodletting had been nearly abandoned in treating a disease for which, only a few years earlier, it had been the standard therapy. In response, a young pathologist, John Hughes Bennett, denied that anything like a change of type had occurred and insisted that bloodletting had never been an effective therapy. Over the next two decades, more than forty physicians debated the usefulness of bloodletting and the reasons for its decline. This debate, known as the Edinburgh Bloodletting Controversy, has attracted the attention of contemporary historians. Those who have discussed the debate side with Bennett and give Alison little serious attention. I argue that by examining the texts to determine what the issues really were, we can see that Alison may actually have been right. Moreover, this examination illuminates the practice of bloodletting and reveals one hitherto unrecognized factor that contributed to its decline.

'For the benefit of the people': the Dutch translation of the Fasciculus medicinae, Antwerp 1512

The article deals with the Dutch translation of the Fasciculus medicinae based on the Latin edition, Venice 1495, with the famous woodcuts created in 1494 for the Italian translation of the original Latin edition of 1491. The woodcuts are compared with the Venetian model. New features in the Antwerp edition include the Skeleton and the Zodiac Man, bot originally based on German models. The text also deals with other woodcuts in the Low Countries based on these Venetian illustrations. The Appendices provide a short title catalog of all the editions and translations based on the Venetian edition and a stemma.

The death of George Washington: an end to the controversy?

The controversy surrounding the death of George Washington was immediate, intense, and continues today. After a horse ride in sleet and snow, Washington developed fulminant acute epiglottitis that rapidly claimed his life within 24 hours. In treatment, he endured phlebotomy of over 2500 mL as well as various other painful therapies that were the standard practice of the day. Over the years, numerous criticisms have been lodged against the care his three physicians rendered. Although the marked bloodletting has been most heavily scrutinized, others have argued that Washington could have survived had a tracheostomy been performed. Delayed presentation, prolonged Class IV hemorrhagic shock, acute respiratory failure, and probable septic shock in a 67 year old with preexisting medical comorbidities has a high mortality rate today and would have been irreversible in 1799. George Washington's inevitable death was assured by his own initial actions compounded by the treatments initiated by his physicians.

[Bloodletting; a popular form of treatment that disappeared]

Bloodletting, based on the humoural pathology of Hippocrates and Galen, was done in various ways for thousands of years: phlebotomy, cupping and the use of leeches. There were broad indications for applying this form of treatment. In the 19th century, P.C.A. Louis demonstrated that bloodletting was not an optimal form of treatment for pneumonia. His study was designed in accordance with the first principles of epidemiology. Epidemiology, together with the rise of Virchow's cellular pathology, contributed to the disappearance of bloodletting. The use of leeches still has a place in the medicine of the 21st century in the form of enzymes from the saliva of the leech.

[Notes on blood letting in Denmark]

Blood letting has been documented in Denmark since the thirteenth century. In the following span of time the operation has always been part of both the established medicine and the informal, alternative health sector. The paper demonstrates, based on Danish sources, how the same procedure has been given widely different interpretations depending on the prevailing medical theories.

Young patients in a young nation: scarlet fever in early nineteenth century rural New England

Children in the United States have benefited considerably from advancements in medical and nursing science over the course of the past 200 years. The twentieth century saw dramatic declines in the incidence of childhood diseases; the prevalence of measles, haemophilus influenzae type B, diphtheria, rubella and tetanus are at all time lows (CDC, 2006). Indeed, many pediatric nurses have never seen any of these diseases, something that would certainly have startled their predecessors just a few generations ago. Before the mid- twentieth century, caring for children with communicable diseases represented the cornerstone of pediatric nursing practice. Now that the incidence has decreased among American children, it is easy to forget about these diseases that once decimated whole communities. This article tries to peel back the mists of history by studying children's health in one rural New England town during the days of the early republic in the 1830s.