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historical review
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 scientif-
ically 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 instru-
ments, 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
Correspondence: Prof. L. Parapia, Farnhill, Kelcliffe Lane, Guiseley,
Leeds LS20 9DE, UK.
E-mail: parapia@doctors.org.uk
First published online 8 September 2008
doi:10.1111/j.1365-2141.2008.07361.x Journal Compilation ª 2008 Blackwell Publishing Ltd, British Journal of Haematology, 143, 490–495
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 indica-
tions 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 compli-
cations that militated against bloodletting were as follows:
convulsive disorders, severe insomnia, anginal type pain,
obesity, anxiety, fearful and cowardly predisposition, or
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Historical Review

someone not accustomed to giving blood or someone plagued

by diarrhoea and colitis. The frequency, timing, and site of
venesection, the quantity to be removed and other facets of
bloodletting were discussed. During the procedure examina-
tion of the pulse was considered to be the most important. If
one perceived that the pulse was changing either in its
‘largeness or evenness’, then phlebotomy was to be terminated
(Rosner, 1986).
Blood-letting was part of Arab traditional medicine and it
was mentioned by Prophet Mohammed that there are three
methods to cure illness: ‘a drink of honey, a scratch of
Hijamah and cautery’ (Albinali Hajar, 2004). It was practiced
by the Arab physicians of the Middle Ages and soon spread
to the Middle East and eventually to the rest of Europe
during the Renaissance. The Arabs had rules as to how much
blood should be taken and when. Bloodletting was not
recommended with a full moon or when the wind blew from
the south (Strepellone, 1986, p 70–79). They also taught that
blood should be taken from a vein at a distance from the
diseased part, and from the opposite side of the body.
Phlebotomy was used as an analgesic by inducing syncope
for conditions such as childbirth, fractures, dislocations, etc.
There were times when venesection was used as a non-
therapeutic tool. Zenobia, a famous Arab queen, killed an
Arab king, Jothima Al Abrash, with venesection (Albinali
Hajar, 2004).
The art of blood letting also appears to have been practised
in other parts of the world (Lillico, 1940). The Baganda tribe,
Fig 1. Early 14th century pen drawing showing a nude figure of a man
in Uganda, bled patients to relieve headaches. North Austra- indicating parts of the body for bloodletting. Surrounding text in
lians and the Aborigines in Tasmania similarly bled for pain Latin. Courtesy of Wellcome Library, London.
relief. In Fiji bamboo shoots were used for bleeding and in
Sumatra the ‘bad’ blood had to be buried (Lillico, 1940). In
South America, fatigue was attributed to the presence of a September, St Lambert’s day,’ he shall not fall in no dropsie,
foreign element in the blood. A Patagonian, on getting tired on fransy or tisyke’ (Dingwall, 1995).
a journey, would bleed himself to rid himself of evil spirits. Bleeding appears to have been a standard treatment for fever
Bloodletting, therefore, has been a world-wide practice over in the middle of the 18th century, although it was not used so
many centuries. Hindus were bleeders and performed leeching, much in putrid fevers (typhus and typhoid fever). As might be
cupping and castigation (Schneeberg, 2002). expected, it was considered of value in the treatment of
In feudal times, in England, most Abbeys had a ‘flebotom- hypertension, cases of comas, drowsy headaches. Bleeding was
aria’ or ‘bleeding-house’ in which the inmates underwent recommended for inflammation of the lungs according to the
‘minutions’ or bleedings at stated periods of the year. An early amount of pain, the pounding of the pulse and the difficulty in
14th century pen drawing delineates parts of the body for breathing. As much as 210 ounces were bled over a 6-d period.
bloodletting (Fig 1). The brethren of the order of St. Victor John Hunter was commended for using bleeding in his
underwent five bleedings annually – before Advent, before practice, particularly for the treatment of inflammation as well
Lent, after Easter, May Day, and at Pentecost (Jaefferson, as for apoplexy. Bleeding was one of the standard methods of
1862). A manuscript dated 1595 ‘Ane Gude Boke of Medicines’ treating inflammation. He considered that one bleeding
states ‘for letting of blude thair be thrie perrellous dayis in the session was insufficient and recommended up to five. He paid
year’, and gives the following advice ‘The last day of Apryll the considerable attention to the appearance of the blood, if it was
first Monday of August and the last Monday of December. thick, viscous and clotted, bleedings could be performed
These thrie dayis be forbidden for they beb all ye waynes full of without much risk. If the blood clotted poorly and lay flat on
bode of every man. And yrfoir gif a women or man be latten the dish, bleeding was contraindicated. Hunter considered
blude on these dayis they sall dye wtin xv dayis’. There were, bleeding to be sometimes beneficial in smallpox and gonor-
on the other hand, some auspicious days for, bloodletting. If rhoea but in cases of doubt, he commended the use of leeches
the procedure was carried out on 18 April there would be no to the scrotum for swelling of the testicles due to gonorrhoea
fever; on 3 April no headache; and on 17 December or (Turk & Allen, 1983).

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Historical Review
Fig 2. Operators letting blood from the arm of a woman in a room
crowded with pharmacy jars. Oil painting by Egbert van Heemskerck.
Late 17th Century. Courtesy of Wellcome Library, London.
Napoleon, who himself had been venesected and survived,
said of doctors ‘Medicine is the science of murderers’ and he
could have been very right! Thousands may have been bled to
death, including some notable names. In July 1492, Pope
Innocent VIII received blood donations from three youths who
all died in the process and so did the Pope! (Pelczar, 1996).
Charles II (1630–1685) of England suffered a stroke in 1685, he
was bled 24 ounces of blood, his speech improved but he died
soon after. The physicians in attendance apparently fled
(Schneeberg, 2002). Queen Anne (1665–1714), niece of
Charles II, had two fits and became unconscious. She was
bled amongst other things but died 2 d later (Gordon, 1998).
In the late 17th century, Egbert Van Heemskerck depicted the
nature of venesection in his painting (Fig 2). Lord Byron
(1728–1824) died of encephalitis as shown at his post-mortem
but before he died he had been bled several times. He is quoted
as saying ‘Come as you are, I see a damned set of butchers.
Take away as much blood as you will; but have done with it’
(Gordon, 1998). Mozart (1791) is likely to have suffered from
end stage renal failure following an infection which was
prevalent in Vienna, and died of shock from severe blood-
lettings and purgation (Karhausen, 1998). On December 13,
George Washington (1799) was taken ill with a ‘cold’ and ‘mild
hoarseness’. A total of 2365 ml of blood was taken over 12 h.
James Craik, an Edinburgh trained physician, offered no
explanation for this. Washington’s blood eventually became
viscous and flowed slowly, reflecting dehydration and hypo-
volaemia. On reflection it appears that he suffered from acute
epiglottitis, probably bacterial in origin and Quinsy may also
have been present. The New York Historical Society have an
18th century picture (Fig 3) showing his final days under the
492 Journal Compilation ª 2008 Blackwell Publishing Ltd, British Journal of Haematology, 143, 490–495
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Fig 3. George Washington in his last illness, attended by Doctors
Craik and Brown; Olds Collection, #96, c.1800 unidentified engraver;
negative #46066. Collection of The New-York Historical Society.
care of the physicians. James Craik never again spoke of the
events of December 14th but went on to name one of his sons
George Washington (Morens, 1999). In 1820 King George IV
(1762–1830) was bled 150 ounces and survived another
10 years!
Blood-letting appeared to be one of the main methods of
treatment during the cholera epidemic of 1831. This was so
extensively carried out that the Medico-Chirurgical Review
(1832) warned of the over zealous treatment and abuse of
patients. The question was raised as to the best time to bleed,
but this question remained unanswered due to lack of
evidence! (Dobson, 1832). The number who died of dehydra-
tion compounded by blood-letting will never be known.
During the American Civil War (1861–1865), military doctors,
unable to cope with widespread disease and infection, bled
Union soldiers and civilians alike (See Fig 4) (Schneeberg,
2002). Sir William Osler (1850–1919) recommended blood-
letting for pneumonia in all editions of his textbook, including
the final 1942 revised edition (Schneeberg, 2002).
Early instruments included anything sharp, such as horned
stones, quills, thorns or animal teeth (Pelczar, 1996). The
thumb lancet was introduced in the fifteenth century. It was a
double-edged instrument, often with ornate handles made out
of turtle shells (Figs 4–8). As early as 1654, Francesco Folli
designed a cannula made of gold, silver and a crow quill to go
into the receiver’s vein with a flexible connecting tube made of
sheep gut; and a small bone or ivory funnel with strings, to be
ª 2008 The Author

Fig 4. American Civil war lancets 1861–1865 (From the author’s col-
lection).
Fig 5. Late 18th century scalpel (From the author’s collection).
Fig 6. Fleam with Brass shield, 18th and 19th Century (From the
author’s collection).
tied over the phlebotomy incision in the donor’s arm
(Strepellone, 1986, p 80–100). During the late 17th century,
Sir Christopher Wren injected drugs with a quill. Subse-
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Historical Review
Fig 7. Late 19th century scalpel (From the author’s collection).
Fig 8. Thumb lancets, 19th and early 20th century. (From the author’s
collection) (Identification and dating of the lancets obtained Wilbur,
2003).
quently, silver and copper cannulaes were constructed. In
1719, Lorenz Heister developed the spring lancet (the schnep-
per or fleam). This eliminated the need for manual pressure
when lancing (Pelczar, 1996). The fleam, scalpels and lancets
from seventeenth to early twentieth centuries are shown in
Figs 4–8. Luer, a Frenchman, designed the fitting for the needle
and syringe. Currently, vascular devices are usually made of
synthetic material and directed towards clinical intent and
infection control.
As early as 3rd century BC there was opposition to the
volume to be withdrawn and the potential of an adverse event
such as severing a tendon, artery or nerve (Pelczar, 1996).
Vetenarians were amongst the first in the 18th century to
question the value of phlebotomy. As early as 1793, J. Thomp-
son, a British vet, recognized at least that bloodletting should
be controlled, and that the volume of blood should be
measured to avoid excessive blood loss (Hosgood, 1991).
Proponents of bloodletting during the 18th century included
Rene Laennec (1781–1826) a famous French physician, who
invented the stethoscope. In the mid 1800s Paerre Louise
(1787–1872), a French statistician, demonstrated statistically
493
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Historical Review

that bloodletting was in fact harmful to healing. He proposed iron also appears to protect donors from ischaemic cardio-
that all therapies be open to scientific evaluation. vascular events (Meyers et al, 2002).
In 1835 Paerre Louise presented statistical evidence that The unconventional practice of blood letting still continues
questioned the efficacy of bloodletting in diseases (Hosgood, in countries such as Morocco, Algeria and Oman (Figs 9 and
1991). In the 1840s and 1850s disagreements about the proper 10). A description of this was given in an article by Lillico
relationship between laboratory science, medical theory, (1940) entitled ‘Primitive Blood-Letting’. ‘Hijamah’ or ‘suck-
empirical observation and therapeutic practice culminated in ing’, as the practice is known, was used before the diving
a series of bitter disputes, the most significant of which erupted season in the belief that the procedure would prevent disease
in Edinburgh in 1855 between Dr William P. Allison (1790 – during the 3 months at sea and was thought to help dizziness
1859) and Dr John Hughes Bennett (1812–1875). Bennett’s (Albinali Hajar, 2004). As recently as April 2008, three
treatise on ‘The restorative Treatment of Pneumonia’ noted Kashmiri hospitals were reported to be using leeches, primarily
that improved mortality figures from pneumonia appeared to to bleed patients as treatment for heart problems, arthritis,
be directly related to the decline in bloodletting (Warner, 1995. gout, chronic headaches and sinusitis (Hussain, 2008). The
He used mortality statistics to argue his case. By showing that leeches are for single use to avoid transmission of disease!
the method of profuse bleeding was followed by death in one The story of bloodletting illustrates how, over 2000 years,
case out of three, while of 129 cases treated by him on the dogma was supplanted by scientific medicine. Venesection is
‘restorative’ principle, only four had died. He did more than now largely used for treatment of polycythaemia, haemochro-
anyone else to banish excessive bleeding as a routine method of matosis, Porphyria Cutanea Tarda, and for purposes of blood
treatment (Comrie, 1932). Bennett was a newcomer, an donation or salvage. It is questionable whether there are
Englishman, who carried out a surgical apprenticeship before benefits of venesection in cyanotic heart disease. Venesection
entering Edinburgh hospitals in 1833. In 1841 he returned to
Edinburgh and was elected professor of the Institute of
Medicine there in 1848 (King, 1961; Kerridge & Lowe, 1995).
Louis Pasteur (1822–1895) and Robert Koch (1843–1910)
proved conclusively that inflammation resulted from infection
and thus was not susceptible to bloodletting. They offered a
scientifically legitimate way of thinking about the cause and
treatment of the patient’s illness (Kerridge & Lowe, 1995).
The 1893 edition of the Dictionary of Medicine edited by Sir
Richard Quain, Queen Victoria’s physician, listed indications
for venesection as engorgement of the heart, pneumonia,
apoplexy, eclampsia, venous engorgement, uraemia, plethora,
peritonitis, pleurisy, asthma, emphysema, disorders of men-
struation, after operations and fever (Quain,1893). Hutchin-
son, as late as 1935, stated in his book entitled ‘An Index of
Treatment’ that bloodletting is indicated in ‘over distension of Fig 9. Modern day blood-letting, ‘Hijama’, in Morocco using silver
collecting vessel (see Fig 10) (From the author’s collection).
the right side of the heart’, ‘asphyxia’, ‘apoplexy, in status
epilepticus, acute suffocative oedema of the lungs, heat-stroke,
acute uraemic convulsions, erythaemia, and in cases of
hypertension with plethora’ (Hutchinson, 1936). The first
edition of ‘The Principles and Practice of Medicine’ published
in 1952 states that venesection is indicated whenever pulmo-
nary congestion or venous engorgement is extreme and other
measures are ineffective (Davidson, 1952).
Valquez (1892) was the first to draw attention to the
importance of neurological symptoms in polycythaemia. Osler
(1903) reported neurological problems in eight out of nine
cases of polycythaemia. The two main determinants of blood
viscosity are flow and haematocrit. Haematocrits of 30%, 35%
and 40% have been suggested as optimal for maximal oxygen
delivery (Thomas, 1985) and a case has been made for
venesection with fluid replacement to be used as a treatment
for cerebral ischaemic episodes (Thomas, 1985). Regular blood
donors have shown statistically better psychological well-being Fig 10. Solid silver vessels (1912) used for blood-letting in Morocco
than a control group (Hinrichs et al, 2008). The lowered body that are still used to the present day (From the author’s collection).

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494 Journal Compilation ª 2008 Blackwell Publishing Ltd, British Journal of Haematology, 143, 490–495

for diagnostic purposes has increased beyond reasonable
practice in some hospitals, sometimes by as much as 10% a
year (Grantham & Weinstein, 1993). Attempts have been made
by various means to reduce this wholesome blood letting with
some success (Bailey et al, 2005). Some benefits of venesection
may still become more apparent with greater scientific
attention to the subject. As new therapies and blood substitutes
are developed, the need for venesections may disappear totally.
For now, we should remember Bernard Shaw’s saying ‘The
Doctors reputation stands, like an African king’s palace, on a
foundation of dead bodies’.
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