19th Century medicine: what’s with the blood-letting?

Anyone who reads pre-Twentieth Century literature or watches period films has come across an episode in which a character is ill and they are bled by their doctor.  I have been asked many times if doctors really did this, why they did it, and what it was supposed to do.  Indeed, bleeding, either by opening a vein or using leeches to suck out the blood, was a major treatment for a number of disorders before the second half of the 19th Century, when a massive wave of medical scientific discoveries completely changed the practice of medicine and the practice of bleeding gradually died out.  I posted a similar article on The Book Rat in June, 2011.

Medical science in England before the modern era was based on concepts first delineated by ancient Greek physicians, such as Hippocrates and Galen. These principles were distilled into the holistic medicine (treatment of the entire body or constitution) practiced in the Georgian and Regency Eras. Human health was a situation where the patient’s constitution was balanced between “weakness” and “plethora.” In modern use, the word plethora means “a large amount, or many,” but in medical terminology it meant an excess of  heat, blood, body fluids, etc.  Plethora was diagnosed in conditions where the patient became more red, warm or swollen,  and might include fevers, localized infections such as cellulitis (where affected areas of skin become red and swollen), inflammatory arthritis (such as gout), and pregnancy (where the skin is typically more pink and warm than usual because of the increased blood volume during pregnancy).  Weakness, on the other hand, was any condition that would make the patient paler, thinner or weaker: blood loss, fainting, chills, or wasting diseases.  Because physicians in the 18th and 19th Centuries did not do any surgical procedures (you could not be a gentleman if you worked with your hands), the actual blood-letting was done by surgeons.

The treatment of plethora included changes in diet to avoid anything which was thought to be “heating”, and generally meant anything red, rich or fatty, or stimulating. Foods to be avoided included red meat, eggs, spices, and “stimulants” such as wine, coffee, and tea. “Cooling” foods were encouraged, such as fruits and vegetables, and simply prepared white meats, such as chicken and fish, and bland foods such as gruel (a sort of runny cereal made by boiling oats or other grain in milk or water). In addition, physicians would take blood from patients to directly remove the “excess” blood that was engorging their bodies and causing them to be red and hot.  This treatment would be likely to help patients with gout, where there is an excess of uric acid in the blood (see my post on Gout).  This results in red, hot joints, most commonly in the big toe and the knee.

Fever was a common medical problem because of the lack of antibiotics and vaccinations (except for smallpox vaccination, which was widespread by the Regency Era).  With this theory of health and disease states, bleeding a patient who was hot and feverish to decrease the fever made perfect sense to pre-modern practitioners.  Ironically, blood-letting was often used after gunshot wounds to prevent a fever from the almost inevitable wound infection which resulted from having the ball and bits of clothing fibers implanted in the body.  One wonders how many gunshot accidents resulted in death because the surgeon finished off the patient after the bleeding from the wound stopped.

Pregnancy was considered to be a plethoric condition and women in this “interesting condition” were often given “cooling” diets to promote health. Because these would include plenty of fruits and vegetables, it would often improve constipation, which is common in pregnancy, and this  was taken as encouragement that the diet was working as it should.  Fortunately for the health of the patients and their infants, most women did not follow these diets as strictly as their physicians would have liked. Women who had a history of miscarriage or infertility would be more likely to rigorously follow the suggestions of their physician, and to change physicians if their condition did not improve to find one whose care they liked better.

Patients who were pale and weak, such those who were having chills in the early stages of a cold or who had wasting diseases such as tuberculosis, were encouraged to have a “heating” diet and could eat as much red meat and drink as much wine, especially red wine, as they wished to warm an overly cool and weakened constitution.  They would also be treated with heating treatments, such as mustard foot baths or mustard plasters to the chest. In this case, of course, blood-letting was not used.

So, infections such as malaria, bacterial wound infections, or influenza (all of which are characterized by fever) would be treated as plethora, while infections such as tuberculosis, which causes chronic cough and gradual wasting, would be treated as weakness.  People who were weakened by blood loss might be treated with blood-letting and fed with gruel rather than with red meat, which would help restore their iron stores needed to replace their blood loss.  Today, blood-letting is used to treat hemochromatosis (an inherited problem which causes the storage of too much iron, damaging the liver), polycythemia vera (excess red blood cell production, which can increase the risk of stroke), and porphyria.

Blood-letting shown in medieval illuminated manuscript

An interesting historical side note to this treatment was the condition of the Prince Regent and his father, King George III. The king is well known for the periods of insanity from which he suffered, which eventually became permanent and required that the Prince of Wales become Regent.  A number of medical historians believe that King George III suffered from a form of porphyria, an inherited disease in which the patient lacks one of the enzymes required to break down hemoglobin into smaller molecules which can then be excreted by the kidneys. The major symptoms of hereditary porphyrias are abdominal pain and psychiatric symptoms.  The treatment for porphyria, still used today, is to remove blood from patients on a regular basis until they are slightly anemic and thereby decrease the number of porphyrins in their blood.  This treatment is done at blood center and is just like donating blood, except that the blood removed is discarded. The Prince Regent had a long history of various types of illness, including frequent abdominal pain, and he was a great believer in blood-letting, having it done whenever he felt unwell. His symptoms might have been from his unrestrained eating and drinking, but if they were an indication of porphyria, his enthusiasm for having his blood let might have prevented him from developing the severe mental symptoms from which his father suffered.