To Bleed or not to Bleed?

Bloodletting has been used as a therapeutic measure for more than 3000 years

Bloodletting reached its peak in the early 19th century, but with the advance in medical research and knowledge, the study of the physiology of the human body and the understanding of the role of bacteria in infections, the practice underwent a steady decline and acquired a bad reputation among medical personnel.

The History of Bloodletting

Up until the mid 19th century, bloodletting in its different forms was believed to have a therapeutic role against a wide range of diseases. Many methods were in use and these methods, as well as the theories behind them, changed over time.

Bloodletting instruments have been found that date as far back as the Stone Age. It is known that many ancient civilizations used bloodletting as a form of therapy, including the Ancient Egyptians, Aztecs, Babylonians, Greeks, Romans as well as the Hindus.

Tools used in this practice varied widely and included thorns, sharply pointed sticks, bones, flint or shell, shark teeth, lancets and the dreadful scarifier, which was an instrument that produced numerous incisions at the same time. In South America and New Guinea, miniature bow and arrow devices have also been found.

Leeches are thought to have been used for bloodletting since the second century BC. During the 19th century, they were the mainstay of medical practice in European countries. Their use was so extensive that in 1833 the number of leeches imported by France alone was more than 42 million. They were superior to other tools of bloodletting as they could remove blood painlessly and the amount of blood removed could be more or less controlled. They were used to treat headaches, to reduce inflammation, as well as to remove blood from hard to reach areas such as hemorrhoids, the tonsils, and the cervix. The use of leeches declined with the decline of the practice of bloodletting; however, in the past 30 years their application has returned once again to bio-medicine.

Theories Behind the Practice

Bloodletting was needed to re-establish the proper balance of the four humors

The theories behind the practice of bloodletting have changed over time as the theories behind the causes of disease evolved. In primeval times, disease was thought to be caused by evil spirits, demons and other supernatural causes. Religious ceremonies were performed in which sorcerers or witch doctors would use bloodletting as a means to flush out these evil spirits and force them to leave the body.

The first documentation of the practice of bloodletting was found in the Corpus Hippocraticum. The concept of the four humors was developed by Hippocrates, who believed that all diseases were caused by an imbalance of the four humors namely blood, phlegm, yellow bile, and black bile. In order to restore health, bloodletting was needed to re-establish the proper balance of the four humors.

During the 14th and 15th centuries, astrology played a vital role in the medical practice. Patients would be positioned on a phlebotomy table designed to show the relation of each body part to the signs of the zodiac. Surgical procedures and bloodletting were only performed when the planets were in a certain position. Therefore, bloodletting would only be performed at certain times for certain body parts.

The Decline of the Practice

Research performed in the 1830s by Pierre C. A. Louis on hundreds of patients in Paris hospitals was the first sustained critique of the therapeutic value of bloodletting. Between the mid and late 19th century, scientific advances and laboratory studies led to the understanding of physiology and pathology at the cellular and biochemical levels, the identification of the components and functions of blood, as well as the physiology of the cardiovascular system and knowledge regarding bacteria.

Furthermore, the study of blood pressure and volume as well as the understanding of the importance of blood in the delivery of oxygen to tissues made the custom of intentional removal of large amounts of blood appear to be counterproductive to healing. Such knowledge led to the steady decline of the practice. However, bloodletting did not disappear completely and was still being used in the early 20th century for certain conditions such as cerebral hemorrhage, arterial aneurysms, during high fevers in patients with acute renal insufficiency and also to treat gas poisoning before and throughout World War I.

The Return of Bloodletting into Modern Medicine

Although bloodletting had begun to receive a bad reputation in the 19th century, the practice did not disappear entirely from the medical practice. In the 1920s, it was used as an emergency procedure for patients requiring a rapid reduction of venous pressure to help relieve stress on the heart and lungs such as for relief of congestion following acute heart failure. It was also - and is still - used for patients suffering from polycythemia (American Society of Hematology), which is a disease characterized by having an excess of red blood cells and of blood volume. These individuals were found to benefit from routine bloodletting.

In 1950, it was also found to benefit those with hemochromatosis. Patients with this disease suffer from the deposition of excessive iron in their various body organs. Bloodletting allows the body to use the excess iron for the production of new red blood cells instead of those lost in the procedure.

It was recently discovered that bloodletting also helped patients with hepatitis C to better respond to interferon since it reduces their serum iron content. Given that the virus needs iron to replicate, high iron levels may therefore correlate with high viral replication. Furthermore, most patients with hepatitis C have an abundance of iron stored in their liver and it has been found that high levels of hepatic iron may reduce patient response to interferon therapy (U.S. Pharmacist Continuing Education, May 2002).

Bloodletting using leeches has also recently re-emerged on the medical scene after they were found to have exceptional benefits to certain procedures following plastic and reconstructive surgery (American Journal of Orthopedics).

In the 1980s, leeches were rediscovered by plastic surgeons for their local anticoagulant and bloodletting properties, which were found to be extremely useful following certain procedures such as the re-implantation of fingers, skin grafts and breast reconstructions. It was found that by placing the leech on the region, the rapid blood sucking and anticoagulant properties of the leech could relieve any congestion at the surgery site and allow the blood to flow more efficiently (Microsurgeon.org).

Bloodletting in Islam

Cupping is a popular form of phlebotomy in the Middle East

According to Sheikh `Abdul-Majeed Subh, a prominent Azharite scholar, "Bloodletting or cupping is a practice approved of by the Prophet (peace and blessings be upon him) who used to pay an amount of money for this therapeutic measure" (Islamonline.net).

However, although bloodletting is recommended in Islam, it should be practiced in accordance with the scientific data and knowledge currently available, and not in the disorderly and unscientific manner in which it is being used in many Islamic countries today by unprofessional individuals for everything from aches and pains to weight loss. A proper understanding of the procedure and its benefits is also required by those who perform the technique to avoid any side effects.

It should also be noted that despite the fact that certain medical procedures such as bloodletting were previously considered to be outdated, by no means should they be deemed obsolete nor should their possible re-emergence as respectable therapeutic intervention be disregarded.

Sources:

• U.S. Pharmacist Continuing Education (May, 2002) - Update on Hepatitis C Virus - Lesson
• Lawrence, Susan C. (1999): Two Millennia of Bloodletting: Part II. Debating Therapeutic Value: Decline and Survival in Modern Medicine.
• Weinkove, Robert (1998): The fall and rise of the medicinal leech, Student BMJ August
• Seigworth, Gilbert R. (1980): Bloodletting over the Centuries. New York State Journal of Medicine, 2022-2028.
• Fatwa bank (2004): Cupping as a Therapeutic Measure (Islamonline.net)
• Spivak, Jerry L. (2002): Polycythemia vera: myths, mechanisms, and managementVol. 100, No. 13, pp. 4272-4290. American Society of Hematology
• Daane S, Zamora S, Rockwell WB. Clinical use of leeches in reconstructive surgery. Am J Orthop. 1997 Aug; 26(8):528-32.
• Hirudensis Medicinalis-Medicinal Leeches. Microsurgeon.org.

Aisha El-Awady M.D is an editor at the Health and Science section of IslamOnline.net. She is currently working as Lecturer of Parasitology at the Faculty of Medicine, Cairo University. She may be contacted at sciencetech@islamonline.net