The Radical History Of Bloodletting Explained

Misquotes litter the internet, spreading like wildfire through faulty retellings via Twitter, Instagram, Facebook, and other social media channels. One of the most iconic of these sayings is reportedly a part of the Hippocratic Oath, "First, do no harm." But as the National Library of Medicine reports, the original Greek text doesn't include this direct statement. Instead, think of it more like an overarching theme. 

The intellectual wellspring from which the Hippocratic Oath sprang can be attributed to the Greek physician Hippocrates of Kos, per Live Science. He lived from 460 B.C. to 375 B.C. and gained acclaim as one of the first individuals to look at illness in a natural rather than supernatural way. Essentially, he argued that curing ailments required proper upkeep rather than devotion to the gods. He dedicated his life to creating the first intellectual school of medicine, earning a reputation as the "father of medicine." Hippocrates and his students produced 60 medical documents still preserved today and unified by the concept of a "healthy mind in a healthy body" (via the Journal of Medical Ethics and History of Medicine).

But one of Hippocrates' most famous medical theories, the four humors, inadvertently led to incalculable harm for centuries, leaving a veritable blood bath in its wake. It involved the practice of bloodletting, considered an essential tool in reestablishing balance in the four humors through the removal of excess liquids. Keep reading as we explore the radical history of bloodletting and some of its most famous victims.

More than two millennia ago, Hippocrates first steered people away from supernatural explanations regarding natural ailments of the body (via the British Columbia Medical Journal). Instead of sending sick people off to make sacrifices to the gods, he counseled them to participate in holistic health management that involved eating better, regular exercise, and even art therapy, per the Journal of Medical Ethics and History of Medicine. Sound familiar? If so, that's because Western medicine still takes significant cues from him. 

Hippocrates represented a man ahead of this time, except when it came to the disease paradigm to which he subscribed. He perceived disease in terms of four basic elements: air, earth, water, and fire. Hippocrates and his students related these to four humors in human beings: phlegm, black bile, yellow bile, and blood. In other words, illness stemmed from too much of a good thing when it came to an imbalance of humors.

To right such a situation, physicians naturally advocated for the removal of the excess humor. Unfortunately, this removal required some really unpleasant treatment options: purging, catharsis, diuresis, and bloodletting, to name a few. But phlebotomy as the be-all, end-all of cures didn't have a firm foundation until the first-century medical figure Galen of Pergamum (via Heinrich Stern's "Theory and Practice of Bloodletting"). Concluding that blood marked the dominant culprit in 99 percent of diseases, you could say he put venesection on the map. Soon, everybody was doing it.

During the Middle Ages, physicians relied on venesection to treat everything from epilepsy to the plague, per History. Up through the 12th century, sick people visited their neighborhood monk or priest for such procedures. But by 1163, the church banned the practice, declaring it "abhorrent." Soon, barbers stepped in to fill the void, offering shaves and trims along with tooth pulling, bleeding, cupping, and even amputations. These barber-surgeons hung red and white blood-smeared rags outside to advertise their services. If this sounds familiar, it should — scarlet and white barber pole stripes evoke this barbaric imagery today. 

Barber-surgeons retained a central role in bloodletting for centuries, even when physicians recommended the procedure. To avoid getting blood on their hands, physicians often recommended their patients go to barber-surgeons to have the dirty work of bloodletting done, as reported by Brewminate. Some physicians and barber-surgeons even advocated for bloodletting to prevent illness in the first place. Although visiting a barber that dabbled in bleeding on the side sounds sketchy at best, it's important to note that the separation of physicians and barber-surgeons set the stage for one of the most critical distinctions still found in medicine today: doctors versus surgeons.

Before Christopher Columbus saw the New World, the Maya practiced bloodletting, per Jessica Munson et al.'s study in PLOS One. Rituals included piercing lips, tongues, genitals, and whatever else a sharpened stone implement might pass through. The greater the pain and blood loss, the more meaningful the sacrifice. The researchers refer to these displays as "costly ritual behaviors." But Munson et al. hypothesize that bloodletting rituals did more than underscore religious fervor — they also provided cohesion within Maya society. For this reason, bloodletting permeated every stratum of society, from elite priests to average warriors. Maya iconography depicts men from all walks of life piercing parts of their bodies — especially tongues, ears, cheeks, and penises — to release the red stuff. Besides using sharp stone implements to get the gore rolling, Maya codices depict bone awls, stingray spines, and lancets with bowls in use.

Ethnohistorical accounts of eyewitnesses like Diego de Landa also provide valuable details. As quoted in Munson et al., de Landa observed, "Sometimes they scarify certain parts of their bodies, at others they pierced their tongues in a slanting direction from side to side and passed bits of straw through the holes with horrible suffering, others slit the superfluous part of the virile member leaving it as they did their ears." In a world where favor from the gods meant robust health and long life, think of bloodletting as a divinely-inspired prophylactic. 

Medical treatments require money — lots of it, if you live in America, according to Investopedia. For example, one broken leg can cost $35,000 to fix (via Talk to Mira), and prescription drug costs remain through the roof (per Vox). But in the 17th century, monetary advantage and a slew of doctors at your side pretty much ensured a torturous death. Take the astonishing case of King Louis XIII.

He enjoyed the best money could buy when it came to hedging off disease. His royal physicians proved so aggressive that he endured up to 47 phlebotomies in one year alone (via Heinrich Stern's "Theory and Practice of Bloodletting"). But this is nothing compared to one of the king's attendants, who underwent 64 venesections that year. Healthline reports that bloodletting sessions typically lasted until a patient fainted — give or take 20 ounces for most people. But the torture didn't stop there ⁠— post-bloodletting involved "heroic purgings." (Yes, it's as bad as it sounds.)

Despite a lifetime of extreme bloodletting, Louis XIII developed tuberculosis of the intestines. On April 13, 1643, doctors informed him the condition would kill him, but not before they tortured him some more. A steady routine of bleedings and enemas likely made Louis XIII beg for the end, which happened one month later on May 14, per Britannica. Following his death, a detailed autopsy revealed intestinal perforations, ulcerations, and peritonitis, per N.V. Addison's "Abdominal Tuberculosis: A Disease Revived."

Ludwig van Beethoven dodged the bullet when it came to death by physician (at least for a while), but other famous people didn't prove as lucky. Consider King Charles II of Scotland. New Scientist reports that after suffering a seizure, royal physicians pounced on the monarch, treating him with immediate venesection. They removed 16 ounces from an incision in the king's left arm, which sounds relatively gentle compared to Louis XIII (via the British Columbia Journal of Medicine). But that was just the beginning.

Next came the removal of another 8 ounces through cupping. After the bloodletting, the real fun began — physicians kept Charles II busy with constant enemas, purgatives, vomit-inducing emetics, and mustard plasters. Mustard plasters alone cause skin inflammation, painful blistering, and even severe burns, but Charles II's doctors weren't done. Science History Institute tells us they scalded him with hot irons and cups, covering him from head to toe in excruciating blisters. Thanks, but no thanks.

Once he'd endured this brutal treatment, which even required drinking "boiled spirits from a human skull," the bleeding started again, per the New Scientist. This time, they tapped directly into his jugular until he fell into a coma. Thankfully (at least from his point of view), he never woke up again, dying on February 6, 1685. Burned and blistered, dangerously deficient in blood, and forced into countless enemas, the medicine of Charles II's day made the certainty of death inviting.

Countless theories swirl around Wolfgang Amadeus Mozart's ultimate cause of death, according to the Orlando Sentinel. Physicians have spent the last couple hundred years trying to decipher this medical mystery, putting forth everything from poisoning to kidney disease, strep infection, tuberculosis, or even assassination by Freemasons.

The mystery of the genius' abrupt end starts with his death certificate. Unable to verify his ailment definitively, attending doctors named his cause of death as a "heated military fever," a catch-all term for the inexplicable (per Orlando Sentinel). That said, Simon Jong-Koo Lee points out in his article "Infective Endocarditis and Phlebotomies May Have Killed Mozart" in Korean Circulation Journal that this terminology might also refer to fevers accompanied by a skin rash. The New York Times has put forth streptococcal infection as another possibility, and Lee also mentions that such an infection could cause "acute and severe heart failure."

But we do know Mozart's recovery chances stopped the moment he called in his physician, which resulted in — you guessed it! — heavy bloodletting. Correspondence between Mozart's sister-in-law, Sophie Heibel, and Georg Nikolaus Nissen, author of the first comprehensive biography of the composer, reveal Mozart died within two hours of his last doctor's visit. Heibel observed (per Korean Circulation Journal), "On the night Mozart died, Dr. Closset arrived and bled him then ordered cold compresses be placed on his burning head, which was such a shock to him that he never recovered consciousness before he expired."

Another death modern researchers puzzle over is that of the famed composer Frédéric Chopin, as reported by Victoria Wapf's "The Disease of Chopin: A Comprehensive Study of a Lifelong Suffering." Although most people assume he died from tuberculosis, a handful of researchers have put forth other diseases like cystic fibrosis. What we do know for sure is that his life remained plagued by serious illness, leaving him weak and coughing up blood.

Interestingly, the Polish composer refused to undergo general bloodletting. Wapf argues that he had at least two compelling reasons for skepticism about venesections. First, he watched his sister, Emilia Chopin, die after days of massive bleedings to treat anorexia. In a letter to a friend dated 1827, he wrote (per "The Disease of Chopin"), "The bloodletting, which was done once, twice, innumerable leeches, vesicle-producing plasters, mustard plasters, and herbs, adventures over adventures". Emilia Chopin died within a month, and her brother never forgot the lesson she taught him about bad medicine.

Second, one of his doctors, Pierre Charles Alexandre Louise, proved outspoken against bloodletting, citing statistical data to demonstrate the procedure did far more harm than good. Yet, Chopin did give into some aspects of 19th-century treatment protocols, including dry cupping and "blister plasters." Considering the severity and duration of his illness, it's remarkable he avoided more meddling on the part of physicians.

Although bloodletting proves rare today, some vital applications for this therapy exist, per the Journal of Lancaster General Hospital. For example, doctors treat hemochromatosis and porphyria cutanea tarda with venesection. Left untreated, these conditions lead to organ damage due to too much iron in the body. But regular removal of blood does the trick. It also reduces the thickness of the blood, averting clotting complications.

But perhaps the most utilized and promising area of bloodletting involves leeching. Those "beautiful ... velvety" leeches (via JSTOR Daily) we discussed earlier are used with great success to promote blood flow after microsurgery and reimplantation. Leeching works because these parasites make substances like fibrinase, vasodilators, anticoagulants, and hyaluronidase and release them into the patient's system. These naturally occurring chemicals ensure an interruption-free meal while providing patients with the healing benefits of unrestricted blood flow. Hirudo medicinalis has also proven to be an excellent collaborator in the healing process post-plastic surgery, via I.S. Whitaker et al.'s "Hirudo Medicinalis and the Plastic Surgeon."

Wet and dry cupping has also enjoyed a revival in the United States due to influences from traditional Chinese medicine. Unlike leeching, however, data on the effectiveness of cupping prove scant, which has led many physicians to label it a waste of time and money. Fortunately, more egregious forms of bloodletting — like hacking into jugular veins or draining half a person's bodily fluids — have disappeared along with the indiscriminate use of emetics, enemas, and blister-producing plasters.