History of bloodletting by phlebotomy

Liakat Ali Parapia
Bradford NHS Teaching Hospitals NHS Trust, Bradford University, Bradford, UK

Summary
Bloodletting by phlebotomy has been an obsession with
medical practitioners for thousands of years, causing countless
suffering to patients, initially for unproven indications and
more recently for diagnoses. The approach to medical
evidence-based phlebotomy has been a triumph for scientifically
inclined practitioners. Progress, primarily achieved since
the nineteenth century, has been in spite of considerable
opposition from the medical establishment. The evaluation of
phlebotomy as a useful tool continues and no doubt further
myths will be dispelled. The history of bloodletting remains
one of the greatest stories of medical progress, not because of
new discoveries but mainly by persistent unbiased audit.
Keywords: bloodletting, phlebotomy, history, medical instruments,
venesection.

Professor Liakat Ali Parapia
‘‘Of bleeding many profits grow and great,
The spirits and sences are renew’d thereby,
Thogh these mend slowly by the strenghth of meate,
But these with wine restor’d are by-and-by;
By bleeding to the marrow commethe heate,
It maketh cleane your braine, releeves your eie,
It mends your appetite, restorathe sleepe,
Correcting humors that do waking keep:
All inward parts and sences also clearing,
It mends the voice, touch, smell, and taste, and hearing’’.
Extract from a poem, ‘The Salerne School’, A book about
doctors, Jaefferson (1862).

The practice of phlebotomy (Greek phlebos = vein and
temnein = to cut) has taken place for over five millennium.
The Egyptians may have been the first to perform bleeding by
scarification and there are two passages in the Ebers Papyrus
that have been taken as evidence that scarification was an
accepted procedure (Schneeberg, 2002). The art of phlebotomy
was flourishing at the time of Hippocrates (500 BC). Like the
evacuant medicines used at the time, the knife served to expel
illness through the elimination of impure fluids. The operation
also assumed knowledge of veins and arteries. Bleeding could
be done at many points of the body, chiefly the elbows and
knees. The recommendation for venesection was for fit
patients only (Jounna, 1999).

In 400 BC, Herodotus recorded that cupping should be used
to diminish headache, restore appetite, and improve digestion,
remove the tendency to faint, increase secretions, promote
menstrual flow, hasten the crisis of disease, remove to a greater
disposition to sleep and, if applied behind the ears, to produce
a natural and refreshing repose. Bleeding was used locally to
lessen local inflammation and for checking haemorrhage.
Venesection was regularly used in the treatment of fevers and
apoplexy. Celsus, in 100 BC, was a strong advocate of
bloodletting by scarification and cupping to relieve local
conditions, but preferred resection for active disease. Gallen
(130–200AD) was also an advocate of bleeding and cupping,
which was extremely popular in the latter years of the Roman
Empire (Turk & Allen, 1983).

Treatment of plethora (probably polycythaemia) played a
major role in the pathology of antiquity as well as in the
Babylonian Talmud (Rosner, 1986). There were other indications
mentioned for phlebotomy. If a fever presented for 1 d
only, water was given and no food. If the fever presented for
2 d it was an indication for venesection. At the height of the
fever, however, bloodletting was considered dangerous, in
accordance with the teaching of Celsus. The Talmud also
considered phlebotomy for pain in the eyes to be dangerous. In
Judaism, a physician is considered to be a scholar while a
bloodletter is an artisan. The Sages taught that a learned man
should not live in a town that has no bloodletter! The
bloodletter also acted as a circumciser and had no other
occupation. Not all Jewish writers sanctioned bloodletting; as
the bible prohibited cutting into skin (Leviticus 19:28).

Maimonides considered venesection necessary but hazardous
and stated the patient had to recite to god for healing and after
treatment to say ‘Blessed art thou, Healer of the living’. In his
Laws of Moral Dispositions, and more extensively in his
Medical Aphorisms, he discussed the subject of bloodletting.
He asserted that one should not phlebotomise a youth younger
than 14 nor anyone over the age of 70 years (Rosner, 1986).

Maimonides further stated that the conditions and complications
that militated against bloodletting were as follows:
convulsive disorders, severe insomnia, anginal type pain,
obesity, anxiety, fearful and cowardly predisposition, or

Correspondence: Prof. L. Parapia, Farnhill, Kelcliffe Lane, Guiseley,
Leeds LS20 9DE, UK.
E-mail: parapia@doctors.org.uk

historical review
First published online 8 September 2008 ª 2008 The Author
doi:10.1111/j.1365-2141.2008.07361.x Journal Compilation ª 2008 Blackwell Publishing Ltd, British Journal of Haematology, 143, 490–495