Unaware of how blood circulates around the body, Greek physicians believed that it could become stagnant and thereby cause ill-health. Hence, they advocated the removal of this stagnant blood, prescribing specific procedures for different illnesses. For example, liver problems were treated by tapping a vein in the right hand, whereas ailments relating to the spleen required tapping a vein in the left hand.
The Greek medical tradition was held in such reverence that bloodletting grew to be a popular method for treating patients throughout Europe in the centuries that followed. Those who could afford it would often receive bloodletting from monks in the early Middle Ages, but then in 1163 Pope Alexander III banned them from practising this gory medical procedure. Thereafter it became common for barbers to take on the responsibility of being the local bleeder. They took their role very seriously, carefully refining their techniques and adopting new technologies. Alongside the simple blade, there was the phleam, a spring-loaded blade that cut to a particular depth. In later years this was followed by the scarificator, which consisted of a dozen or more spring-loaded blades that simultaneously lacerated the skin.
For those barbers who preferred a less technological and more natural approach, there was the option of using medicinal leeches. The business end of these bloodsucking parasitic worms has three separate jaws, each one of them carrying about 100 delicate teeth. They offered an ideal method for bloodletting from a patient’s gums, lips or nose. Moreover, the leech delivers an anaesthetic to reduce pain, an anticoagulant to prevent the blood from clotting, and a vasodilator to expand its victim’s blood vessels and increase flow. To enable major bloodsucking sessions, doctors would perform bdellatomy, which involved slicing into the leech so that blood entered its sucker end and then leaked out of the cut. This prevented the leech from becoming full and encouraged it to continue sucking.
It is often said that today’s red-and-white barbershop pole is emblematic of the barber’s earlier role as surgeon, but it is really associated with his position as bleeder. The red represents the blood, the white is the tourniquet, the ball at the end symbolizes the brass leech basin and the pole itself represents the stick that was squeezed by the patient to increase blood flow.
Meanwhile, bloodletting was also practised and studied by the most senior medical figures in Europe, such as Ambroise Paré, who was the official royal surgeon to four French kings during the sixteenth century. He wrote extensively on the subject, offering lots of useful hints and tips:
If the leeches be handled with the bare hand, they are angered, and become so stomachfull as that they will not bite; wherefore you shall hold them in a white and clean linen cloth, and apply them to the skin being first lightly scarified, or besmeared with the blood of some other creature, for thus they will take hold of the flesh, together with the skin more greedily and fully. To cause them to fall off, you shall put some powder of Aloes, salt or ashes upon their heads. If any desire to know how much blood they have drawn, let him sprinkle them with salt made into powder, as soon as they are come off, for thus they will vomit up what blood soever they have sucked.
When Europeans colonized the New World, they took the practice of bloodletting with them. American physicians saw no reason to question the techniques taught by the great European hospitals and universities, so they also considered bloodletting to be a mainstream medical procedure that could be used in a variety of circumstances. However, when it was administered to the nation’s most important patient in 1799, its use suddenly became a controversial issue. Was bloodletting really a life-saving medical intervention, or was it draining the life out of patients?
The controversy began on the morning of 13 December 1799, the day that George Washington awoke with the symptoms of a cold. When his personal secretary suggested that he take some medicine, Washington replied, ‘You know I never take anything for a cold. I’ll let it go just as it came.’
The sixty-seven-year-old former president did not think that a sniffle and a sore throat were anything to worry about, particularly as he had previously suffered and survived far more severe sicknesses. He had contracted smallpox as a teenager, which was followed by a bout of tuberculosis. Next, when he was a young surveyor, he caught malaria while working in the mosquito-infested swamps of Virginia. Then, in 1755, he miraculously survived the Battle of Monongahela, even though two horses were killed beneath him and four musket balls pierced his uniform. He also suffered from pneumonia, was repeatedly afflicted by further bouts of malaria, and developed ‘a malignant carbuncle’ on his hip that incapacitated him for six weeks. Perversely, having survived bloody battlefields and dangerous diseases, this apparently minor cold contracted on Friday 13th would prove to be the greatest threat to Washington’s life.
His condition deteriorated during Friday night, so much so that he awoke in the early hours gasping for air. When Mr Albin Rawlins, Washington’s estate overseer, concocted a mixture of molasses, vinegar and butter, he found that his patient could hardly swallow it. Rawlins, who was also an accomplished bloodletter, decided that further action was required. Anxious to alleviate his master’s symptoms, he used a surgical knife known as a lancet to create a small incision in the General’s arm and removed one-third of a litre of blood into a porcelain bowl.
By the morning of 14 December there was still no sign of any improvement, so Martha Washington was relieved when three doctors arrived at the house to take care of her husband. Dr James Craik, the General’s personal physician, was accompanied by Dr Gustavus Richard Brown and Dr Elisha Cullen Dick. They correctly diagnosed cynanche trachealis (‘dog strangulation’), which we would today interpret as a swelling and inflammation of the epiglottis. This would have obstructed Washington’s throat and led to his difficulty in breathing.
Dr Craik applied some cantharides (a preparation of dried beetles) to his throat. When this did not have any effect, he opted to bleed the General and removed another half a litre of blood. At 11 a.m. he removed a similar amount again. The average human body contains only 5 litres of blood, so a significant fraction was being bled from Washington at each session. Dr Craik did not seem concerned. He performed venesection again in the afternoon, removing a further whole litre of blood.
Over the next few hours, it appeared that the bloodletting was helping. Washington seemed to recover and for a while he was able to sit upright. This was, however, merely a temporary remission. When his condition deteriorated again later that day, the doctors conducted yet another session of bloodletting. This time the blood appeared viscous and flowed slowly. From a modern perspective this reflects dehydration and a general loss of bodily fluid caused by excessive blood loss.
As the evening passed, the doctors could only watch grimly as their numerous bloodlettings and various poultices failed to deliver any signs of recovery. Dr Craick and Dr Dick would later write: ‘The powers of life seemed now manifestly yielding to the force of the disorder. Blisters were applied to the extremities, together with a cataplasm of bran and vinegar to the throat.’
George Washington Custis, the dying man’s step-grandson, documented the final moments of America’s first President:
As the night advanced it became evident that he was sinking, and he seemed fully aware that ‘his hour was nigh’. He inquired the time, and was answered a few minutes to ten. He spoke no more — the hand of death was upon him, and he was conscious that ‘his hour was come’. With surprising self-possession he prepared to die. Composing his form at length and folding his arms on his bosom, without a sigh, without a groan, the Father of his Country died. No pang or struggle told when the noble spirit took its noiseless flight; while so tranquil appeared the manly features in the repose of death, that some moments had passed ere those around could believe that the patriarch was no more.