The History of Phlebotomy: How Bloodletting Has Evolved Through the Ages

The blood running through our veins is vital. It transports nutrients from food to different parts of the body. It provides clues to determining what maladies ail us.

However, this vital fluid wasn’t always linked to the human anatomy. Early civilizations mythologized its existence and used it in rituals (http://hermetic.com/casa_del_campo/blood_ritual.pdf). This was changed with the advent of science. Blood was then regarded as an essential component of human anatomy. Eventually, medical pioneers also realized that it could be isolated for study and use. Indeed, it has played an important role in saving millions of lives.

Today, the process of blood collection is called Phlebotomy; derived from the Greek words phlebo (blood vessels) and tomos (cutting).

In this article, we’ll be stepping back in time. We’re going back hundreds of years to trace the origins of this billion dollar industry.

A Greek’s discovery

Ancient civilizations like the Mayans, Aztecs, Egyptians and Mesopotamians used bloodletting it as a cure for a variety of infirmities. But it was the Greeks who would discover its connection with the human body.

To appreciate the rationale behind this process, understanding the disease paradign 2300 years ago is crucial. Hippocrates (~460–370 BC) believed that existence was made up of four basic elements. These are earth, air, fire, and water. In humans, these were manifested via the four basic humors: blood, phlegm, black bile, yellow bile. Illness was brought about by an imbalance in these. Thus, treatment consisted of removing excessive humor. There are various ways to do this. One of which is bloodletting.

The practice was already popular when Galen of Pergamon (129–200 AD) proposed that the arteries were filled with blood, not air. He believed that blood is the vital liquid contained within our veins. Galen propagated his ideas through writing. His total written output is said to exceed two million words. Consequently, his observation steered the practice in a more scientific direction.  Overall, he had a big impact on early medicine. His teachings would persist for many centuries after.

Still, he wasn’t completely on the mark. For one, he thought that blood was static. It stayed motionless and would eventually stagnate in the body.

Bloodletting and religion

Early versions of phlebotomy also had ties with religion. A central text in Judaism called the Talmud included rules for performing bloodlettings. Meanwhile, early Christian writings identified which saint’s days were ideal for the said ritual. Even Islamic texts contained a reference to the practice as a treatment for fever.

The Middle Ages

At this point, the history of phlebotomy takes a strange turn. Bloodletting duties fell into the hands of barbers during the Middle Ages. The revolving poles outside barber shops serve as testaments to this. The swirling red line symbolized blood while the white represented a tourniquet. Finally, the pole stood for the stick the patient squeezed in order to dilate the veins.

In the realm of medicine

During the 1800s, doctors employed leeches to drain a patient’s blood. In 1830, France was said to have imported approximately 40 million of the specie Hirudo medicinalis for this purpose.  At each feeding, a leech ingests about five to ten milliliters of blood. This is equivalent to almost ten times its own weight. Francois-Joseph-Victor Broussais, a medical practitioner at the time, used as many as 50 of these critters all at once. The Parisian claimed that fevers were due to an inflamed organ in the body. His form of therapy  was widely used  in Europe.

Bloodletting as a medical procedure was brought to the Americas by European colonists. Its practice stretched in time — from the Plymouth to the Founding Fathers. In fact, one of the signatories of the US Declaration of Independence advocated this form of treatment. Benjamin Rush recommended it to his patients on a regular basis. Unfortunately, being bled out didn’t

Popular Methods

Our look into phlebotomy history now leads us to scrutinize the bloodletting methods used in the past. These were divided into two main categories:

1. Venesection – cutting the median cubital vein at the elbow using either a thumb lancet (a small sharp-pointed, two-edged instrument) or a fleam (a device with multiple sized blades that folded into a case like a pocketknife.
2. Arteriotomy – a process in which the arteries in the temples are punctured and bled. This localized process involves two steps:

2a. Scarification – the skin is scraped using a cube-shaped brass box

2b. Cupping – a dome-shaped glass is placed over the scraped area and extracting the air by suctioning it off.

Famous deaths from a bleeding

Despite its popularity, more patients inevitably died from bleeding. Some of the most well-known casualties include:

• Charles II –suffered a seizure after losing 16 ounces of blood from his left arm and another eight ounces from cupping.
• George Washington – developed a fever and respiratory distress after riding in snowy weather. He had copious amounts of blood drawn, and also had to endure blistering. He lost a total of 24 ounces of blood before he died.

Doctors at war

Bloodletting aroused deep emotions in both practitioners and detractors. Case in point was the ‘medical feud’ between Dr. William Alison and Dr. Hughes Bennett. The former was a strong believer in bloodletting. The latter was a resolute debunker of this practice. Dr Bennett was partial (and relied on) new methods of pathology and physiology, supported by such instruments as the microscope and the stethoscope.

The doctors’ debate was centered on the observation that the improved conditions of pneumonia patients were parallel to the decrease in bleeding treatments. Dr Alison ascribed this to a change in the type of illness. Dr. Bennett believed it was due to the diminished used of a dangerous therapy.

Clearing the air

It would take another scientific-minded physician to establish ascendancy over this issue. French doctor Pierre Louis wanted to assess the overall efficacy of bloodletting. To achieve this goal, he examined over 70 patients with acute pneumonia taken from hospital records. He compared results in those who were bled in the early phase with the ones who underwent the same treatment during the latter phase. While Dr. Louis didn’t outwardly condemn bloodletting, he still concluded that its effect “was actually much less than has been commonly believed.”

Other experts like Pasteur, Koch and Virchow would later confirm the validity ofusing new scientific methods. Its practice gradually diminished to select conditions.

In an article posted in the British Columbia Medical Journal (http://www.bcmj.org/premise/history-bloodletting), Dr. Gerry Greenstone identified diseases that employed phlebotomy therapy:

Hemochromatosis is a genetic disorder of iron metabolism leading to abnormal iron accumulation in liver, pancreas, heart, pituitary, joints, and skin. It is treated with periodic phlebotomy to maintain ferritin levels at a reasonable level so as to minimize further iron deposition.

Polycythemia vera is a stem cell bone marrow disorder leading to overproduction of red blood cells and variable overproduction of white blood cells and platelets. Its treatment includes phlebotomy to reduce the red blood cell mass and decrease the chance of dangerous clots.

Porphyria cutanea tarda is a group of disorders of heme metabolism with an associated abnormality in iron metabolism. Phlebotomy is also used to decrease iron levels and prevent accumulation in various organs.

Mordern day phlebotomy

Modern day phlebotomy is a medical practice focused on the collection of blood from patients for the purpose of testing, diagnosis, or blood donation. Today, most phlebotomists are certified technicians who work in healthcare settings or blood donation centers. They use a range of techniques to safely and accurately collect samples, often using a syringe or specialized vacutainer tubes. Phlebotomists must also be familiar with the proper use of medical equipment, such as centrifuges, and must follow strict safety protocols to prevent contamination.