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Ancient Greek painting on a vase, showing a physician (iatros) bleeding a patient
Bloodletting (or bloodletting) is the withdrawal of blood from a patient to prevent or cure disease. The restriction of blood, whether by the physician or the leeches, was based on an old system of medicine in which blood and other body fluids were considered "humors" that needed to remain in proper balance to maintain health. It is claimed to have been the most common medical practice performed by surgeons from antiquity until the late 19th century, a period of nearly 2,000 years. In Europe, the practice continued to be relatively common until the late 18th century. The practice has been abandoned by modern medicine for all but a few very specific conditions. It is conceivable that historically, in the absence of other treatments for high blood pressure, bloodletting has sometimes had a beneficial effect in temporarily lowering blood pressure by reducing blood volume. However, since hypertension is very often asymptomatic and therefore unchallenged without modern methods, this effect was unintentional. In the overwhelming majority of cases, the historical use of bloodletting has been harmful to patients.
Today, the term phlebotomy refers to the drawing of blood for laboratory analysis or blood transfusion. Therapeutic phlebotomy refers to the withdrawal of a unit of blood in specific cases such as hemochromatosis, polycythemia vera, porphyria cutanea tarda, etc., to reduce the number of red blood cells. The traditional medical practice of bloodletting is considered pseudoscience today.

In the ancient world
A diagram showing the parts of the body that need blood for various diseases, c. 1310-1320

Points for Bleeding, Hans von Gersdorff (Surgeon), Field Book of Wound Medicines, 1517
Passages in the Ebers Papyrus may indicate that the release of blood by scarification was an accepted practice in Ancient Egypt. Egyptian burials have been reported to contain implements for draining blood. According to some accounts, the Egyptians based their idea on their observations of the Hippopotamus, mistaking its red sweat for blood and believing that it was scratching itself to escape suffering.
In Greece, bloodletting was used in the 5th century BC during the lifetime of Hippocrates, who mentions the practice, but it was generally based 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. Herophilus advocated the elimination of blood. Archagathus, one of the first Greek physicians to practice in Rome, also believed in the value of relief.
A patient's "bleeding" to health was modeled on the process of menstruation. Hippocrates believed that menstruation functioned to "cleanse women of evil humours". During the Roman Empire, the Greek physician Galen, who subscribed to the teachings of Hippocrates, advocated physician-initiated blood washing.

The popularity of bloodletting in the classical Mediterranean world was strengthened by Galen's ideas, 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 blood care system. The first was that blood was created and then consumed; it did not circulate and thus could "stagnate" in the extremities. The second was that humoral balance underpinned disease or health, the four humors being blood, phlegm, black bile, and yellow bile, referring to the four classical Greek elements of air, water, earth, and fire. Galen believed that the blood was the dominant humor and the one most in need of control. To balance the humors, a doctor would remove the "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 the amount of blood to be removed according to the age, constitution, season, weather and place of the patient. Do-it-yourself bleeding instructions have been developed following these systems. Symptoms of the plethora were thought 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 affected body. He connected different blood vessels with different organs according to their supposed drainage. For example, the vein in the right hand would be left for liver problems and the vein in the left hand for spleen problems. The more severe the disease, the more blood will be left. Fevers required copious amounts of bloodletting.
Middle ages

The Talmud recommended a specific day of the week and days of the month for bloodletting. During the medieval period, bleeding charts were common, showing specific bleeding sites on the body in alignment with the planets and zodiacs. Islamic medical authors also advised the care of blood, especially for fever. It was practised according to the seasons and certain phases of the moon in the lunar calendar. The practice was probably passed on by the Greeks with the translation of ancient texts into Arabic and it is distinct for the care of blood by cupping mentioned in Muhammadan traditions. When Muslim theories became known in the Latin-speaking countries of Europe, the care of blood became more widespread. Along with the cautery, it was central to Arab surgery, the key texts Kitab Al-Qanun and especially Al-Tasrif li-man "ajaza", an al-ta'lif both recommend it. It was also known in Ayurvedic medicine, described in the Susruta Samhita. Use through the 19th century.

Ioannis Sculteti, Armamentarium Chirurgie, 1693 - Transfusion diagram of sheep blood

Phlebotomy set of a barber surgeon, early 19th century, Märkisches Museum, Berlin
Even after the humoral system fell into disuse, the practice was continued by surgeons and barbers. Although bloodletting was often recommended by physicians, it was performed by barbarians. This led to the distinction between physicians and surgeons. The red and white striped barber pole, still used today, is derived from this practice: red symbolizes blood while white symbolizes bandages. Bleeding was used to "treat" a wide range of diseases, becoming a standard treatment for almost every condition, and was practiced prophylactically as well as therapeutically.


Diagram of scarifier showing depth adjustment
A number of different methods have been used. The most common was phlebotomy or venipuncture (often called "vein breathing"), in which blood was drawn from one or more larger external veins, such as those in the forearm or neck. In arteriotomy, an artery was punctured, although generally only in the temples. In scarification (not to be confused with scarification, a method of body modification), "superficial" vessels were attacked, often using a syringe, spring-loaded lancet, or glass cup containing heated air, producing a vacuum inside . (see cup of fire). There was also a specific tool for releasing blood called a scarifier, mainly used in 19th century medicine. It has a spring-loaded mechanism with gears that pull the blades through slots in the front and back of the cap in a circular motion. The case is cast from copper and the mechanism and blades from steel. A knife bar slipped its teeth, turning the blades in a different direction than the other bars. The last photo and diagram shows the rear and side depth adjustment bar.

Bloodletting in 1860, one of only three known photographs of the procedure.
Photo of a Bloodletting in 1922
Leeches could be used. Withdrawing so much blood as to induce syncope (fainting) was considered beneficial, and many sessions would only end when the patient began to tingle.
William Harvey rejected the basis of the practice in 1628, and the introduction of scientific medicine, la méthode numérique, allowed Pierre Charles Alexandre Louis to demonstrate that phlebotomy was completely ineffective in the treatment of pneumonia and various fevers in the 1830s. However, in 1838 , a lecturer at the Royal College of Physicians would further state that "bleeding is a remedy which, when judiciously employed, is hardly possible to overestimate," and Louis was dangerous by the sanitarian Broussais , who could recommend fifty leeches at once. Some doctors resisted Louis's work because they "were not prepared to give up therapies validated by both tradition and their own experience because of someone else's numbers."
Blood purification has been used to treat almost every disease. A British medical text recommended the removal of blood for acne, asthma, cancer, cholera, coma, convulsions, diabetes, epilepsy, gangrene, gout, herpes, indigestion, insanity, jaundice, leprosy, ophthalmia, plague, pneumonia, scurvy, smallpox, accident stroke, tetanus, tuberculosis and for a hundred other diseases. Bloodletting has even been used to treat most forms of bleeding, such as nosebleeds, excessive menstruation, or hemorrhoidal bleeding. Before surgery or at the onset of labor, blood was removed to prevent inflammation. Before amputation, it was customary to remove an amount of blood equal to the amount believed to be circulating in the limb to be removed.

There were also theories that bleeding would heal the "heart" and "heartbreak". A French physician, Jacques Ferrand wrote a book in 1623 on the use of bloodletting to heal a broken heart. He recommended bloodletting to the point of heart failure (literally).
Leeks became especially popular at the beginning of the 19th century. In the 1830s, the French imported about forty million leeches a year for medicinal purposes, and in the next decade, England imported six million leeches a year from France alone. During the first decades of the century, hundreds of millions of leeches were used by doctors all over Europe.
A typical course of medical treatment began on the morning of July 13, 1824. A French sergeant was stabbed through the chest while engaged in single combat; within minutes, he passed out from blood loss. Arrived at the local hospital was immediately blood twenty ounces (570 ml) "to prevent inflammation". During the night, there was another 24 ounces (680 ml) of blood. The next morning, the chief surgeon bled the patient another 10 ounces (285 ml); over the next 14 hours, he was bled five more times. Thus, the medical attendants intentionally removed more than half of the patient's normal blood supply—in addition to the initial blood loss that caused the fainting. The bleeding continued for the next few days. By July 29, the wound had become inflamed. The doctor applied 32 leeches to the most sensitive part of the wound. Over the next three days, there was more bleeding and a total of 40 leeches. The sergeant recovered and was discharged on October 3. His physician wrote that "by the great quantity of blood lost, amounting to 170 ounces [nearly eleven pints] (4.8 liters), besides that extracted by the application of the leeches [perhaps two more pints] (1.1 liters ), the patient's life was preserved". By 19th-century standards, thirteen pints of blood taken over the course of a month was a large amount, but not an exception. The medical literature of the period contains many similar accounts - some successful , others do not. [27]
Bloodletting was also popular in the young United States, where Benjamin Rush (a signer of the Declaration of Independence) saw the condition 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 profusely after developing a throat infection from exposure to the elements. In a ten-hour period, a total of 124–126 ounces (3.75 liters) of blood was withdrawn before his death from a throat infection in 1799.
Sticksuri de sânge pentru utilizare la animalele care sângerează

Blood sticks for use in bleeding animals
One reason for the continued popularity of bloodletting (and purging) was that, while anatomical knowledge, surgical and diagnostic skills increased enormously in Europe from the 17th century onwards,
the key to curing the disease remained elusive, and the underlying belief was that any treatment was better than none at all. The psychological benefit of blood loss to the patient (a placebo effect) may sometimes have outweighed the physiological problems it caused. Bloodletting slowly fell out of favor during the 19th century after French physician Dr. Pierre Louis conducted an experiment in which he studied the effect of bloodletting on patients with pneumonia. A number of other ineffective or harmful treatments were available as placebos - mesmerism, various processes involving the new technology of electricity, many potions, tonics and elixirs. However, bloodletting persisted during the 19th century in part because it was readily available to people of all socioeconomic statuses.
Possible validity
In the absence of other treatments, blood cleansing is actually beneficial in some circumstances, including hemochromatosis, fluid overload in heart failure, and possibly simply to lower blood pressure. In other cases, such as those involving agitation, lowering blood pressure may appear beneficial due to sedative effects. In 1844, Joseph Pancoast listed the advantages of blood thickening in "A Treatise on Operative Surgery." Not all of these reasons are outrageous these days:
The opening of the superficial vessels for the purpose of blood extraction is one of the most common operations of the practitioner. The main results we achieve are 1. Diminishing the mass of blood, by which the overburdened or larger capillary vessels of an affected part may be relieved; 2. Changing the strength and frequency of heart action; 3. A change in the composition of the blood, which makes it less stimulating; the proportion of serum increases after bleeding, in consequence of its reproduction with greater facility than the other elements of the blood; 4. The production of syncope, in order to effect a sudden general relaxation of the system; and, 5. The derivation or drawing, as it is claimed, of the force of circulation from some internal organs, to the open outlet of the superficial vessel. These indications can be met by opening a vein or an artery.
Controversy and use in the 20th century

Blood restriction gradually declined in popularity throughout the 19th century, becoming quite uncommon in most places, before its validity was thoroughly debated. In the Edinburgh medical community, bloodletting was abandoned in practice before it was challenged in theory, a contradiction highlighted by the physiologist John Hughes Bennett. Authorities such as Austin Flint I, Hiram Corson, and William Osler became prominent proponents of bloodletting in the 1880s and beyond, challenging Bennett's premise that bloodletting fell out of use because it did not work. These advocates framed blood care as an orthodox medical practice that should be used despite its general unpopularity. Some physicians considered bleeding to be useful for a more limited range of purposes, such as "wiping out" infected or weakened blood or its ability to "stop bleeding"—as evidenced in a call for a "due process for bloodletting as a remedy" in 1871.
Some researchers have used statistical methods to evaluate the effectiveness of treatment to deter bleeding. But at the same time, publications by Philip Pye-Smith and others defended blood care on scientific grounds.
Blood restriction persisted into the 20th century and was recommended in the 1923 edition of the textbook Principles and Practice of Medicine. The manual was originally written by Sir William Osler and continued to be published in new editions under new authors after Osler's death in 1919.
Today it is well established that blood relief is not effective for most diseases. Indeed, it is especially harmful because it can weaken the patient and facilitate infections. Blood purification is used today in the treatment of several diseases, including hemochromatosis and polycythemia; however, these rare diseases were unknown and undiagnosable before the advent of scientific medicine. It is practiced by specially trained practitioners in hospitals, using modern techniques. In most cases, phlebotomy now refers to the removal of small amounts of blood for diagnostic purposes. However, in the case of hemochromatosis, which is now recognized as the most common hereditary disorder in European populations, bloodletting (venesis) has become the main treatment option. In the US, according to an academic article published in the Journal of Infusion Nursing with data published in 2010, the primary use of phlebotomy was to draw blood that would one day be re-infused into a person.

In alternative medicine
Although it has been shown to be harmful as a general health measure, it is still commonly indicated for a wide variety of conditions in Ayurvedic, Unani, and traditional Chinese systems of alternative medicine. Unani is based on a form of humor, so in this system, bloodletting is used to correct the supposed humor imbalance.
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