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.

The Analogy Between the Tradition Chinese Acupuncture and Phlebotomy in Medieval Bohemia.

The common opinion is that in Europe acupuncture was introduced in China at the end of the XVII century. However there are some publications, which describe the similar treatment method in the Stone Age Europe. From ancient to late middle century theoretical and practical aspects of medieval medicine in Europe were very similar to the Tradition Chinese medicine. So it is possible that historical phlebotomy in Europe (bloodletting) played the same role as the acupuncture in the Chinese therapy and they had one scientific source. In this article we are comparing the modern acupuncture with some Bohemian medical tractates (Practica medicinalis by Sigismundus Albicus from 1408-1424, De sanguinis minucione by Cristannus de Prachaticz from 1430). We can see the close relationship between localizations and indications of medieval phlebotomy and modern acupuncture points. 40% of the bloodletting points have close localization with the modern acupuncture points and 57% of their indications are common or very similar. The similarity of two methods may be explained in two ways. First is a common scientific source and intensive interaction and crosscultural transmission of knowledge during medical development in China and Europe up to the beginning of the XV century. This possibility indicates also some linguistic coincidences. On the other hand, both methods could have been developed separately based on common clinical empire and objective neuro-physiological patterns of human body.

The 'bloody Moloch': Osler and van Helmont on bloodletting.

In a passage on the treatment of pneumonia, Osler quoted van Helmont's remark that 'a bloody Moloch presides in the chairs of medicine'. This paper explores Helmont's use of 'Moloch' as a term of abuse against the bloodletting of traditional Galenist physicians and his vigorous opposition to the use of bleeding in treating diseases. The possible reasons for Helmont's opposition to the practice of bloodletting are discussed, leading to the conclusion that it arose from his theories of the origin of diseases, reinforced by some observations of its malign effects on a patient who had been bled excessively. The question of whether Helmont knew of Harvey's discovery of the circulation of the blood is explored and the conclusion reached that, if he did, he ignored it completely. Helmont believed that 'pure' and 'impure' blood coexisted in disease and could be affected selectively by bloodletting which, in effect, concentrated the 'impure' at the expense of the 'pure' blood to the great detriment of the patient.

Battle of the Bulge: Aortic Aneurysm Management From Early Modernity to the Present.

For centuries, physicians have recognized aortic aneurysms as an acute threat to life. Therapeutic approaches to the disease began in the 18th century when leading physicians, such as René Laennec and Antonio Valsalva, applied research on circulation and blood coagulation to devise whole-body fasting and bleeding regimens to prevent rupture. After John Hunter's success in ligating arteries to treat peripheral aneurysms, surgeons attempted analogous operations on the aorta, but even the renowned Sir Astley Cooper and William Halsted met with disastrous results. Other clinicians tried various methods of creating intraluminal clots, including the application of such new technologies as electricity and plastic. Vessel repair techniques, pioneered by Alexis Carrel and others in the 20th century, eventually provided a reliably effective treatment. In the past few decades, minimally invasive methods that approach aneurysms endovascularly through small groin incisions have been adopted. A successful 2005 congressional campaign to fund screening for aortic aneurysms brought the disease to national attention and symbolizes current confidence in curing it. Drawing on various published and unpublished sources, this paper elucidates the development of specific treatments for aortic aneurysms over time and more broadly addresses how medicine and surgery apply the knowledge and technology available in particular eras to treat a specific, identifiable, and lethal disease. Examining the evolution of these therapeutic efforts unveils broader trends in the history of medicine. This allows aortic aneurysms to serve as a case study for exploring shifting philosophies in medical history.

van Helmont's proposal for a randomised comparison of treating fevers with or without bloodletting and purging.

Around the year 1643, Joan Baptista van Helmont, a Flemish chemist, alchemist and physician who had devised what he claimed to be a new form of medicine, proposed a 'challenge' to traditional Galenic physicians to compare treatment of fever by traditional methods and by a regime which did not involve bloodletting and purging. Two groups of patients were to be treated and 'casting of lots' was to be used - in some way not specified in detail - to decide who received which treatment. This 'challenge' has been regarded as the first proposal for the use of randomisation in a clinical trial. This paper explains the background to the challenge and discusses what can be deduced from Helmont's text about the details of how he proposed that the 'trial' was to be carried out. It concludes that internal evidence in Helmont's writings makes it certain that no such 'trial' was ever conducted. It seems that the 'challenge' was probably a rhetorical device to support Helmont's vehement criticism of traditional Galenic medicine and its practitioners, and, in particular, toemphasise his absolute opposition to the use of bloodletting as a medicaltreatment. An appendix includes a short summary of Helmont's theories of the origins of disease and transcriptions of the passages of Helmont's Latin text translated in the article.

[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.

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.

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.

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.