Bleeding and Purging*
‘Bleeding, Vomiting, and Purging, are the chief Operations in Physick, by which Diseases are cured, and Health preserved’.[1]
Dioscorides, De medicinali materia libri sex I. Ruellio … interprete. Singulis cum stirpium, tum animantium historiis, ad naturae aemulationem expressis imaginibus … ; Accesserunt priori editioni V. Cordi … ; annotationes … in Dioscoridis de medica materia libros. E. Cordi … iudicium de herbis & simplicibus medicinae … ; Herbarum nomenclaturae … aut. C. Gesnero … cum indice … copiosissimo (Frankfurt, 1549), p. 116.
In Hippocratic-galenic medical practice, bleeding, vomiting and purging were the most common methods used both to preserve health and to treat disease. The aim was to restore humoral balance and, even after the seventeenth-century discovery of the circulation of the blood, and the rise of iatrochemistry, bleeding (and purging) continued to be used to treat a variety of diseases. According to the medieval Articella, patients might be bled in the Spring and Autumn to help preserve their health, but, should they fall ill, they could be bled at any time.[2] In Ireland, as elsewhere in Europe, bleeding had a long history for Irish medical practitioners, educated in medieval continental universities, returned home and translated Latin medical texts into Irish.[3] Worth did not collect any of these Irish translations – instead he had recourse to more contemporary Latin and English writings by a range of medical practitioners. He would have been very familiar with bleeding and purging for, as Kelly notes, ‘the response to illness practised in Ireland in the eighteenth century remained firmly humoralist’.[4]
In the above image we see the patient being bled from her arm. The medical practitioner (usually a surgeon), might use either a ‘fleam’ which was somewhat like a pen-knife, or a lancet, which was double edged. As Grace notes, bleeding was usually divided into ‘general’ bleeding or ‘local bleeding’: the first involved opening a vein or artery in the arm (as above), foot or neck.[5] It was generally done by venesection and most commonly at the elbow.[6] ‘Local bleeding’ involved the use of leeches (Hirudo medicinalis), and scarification followed by cupping.[7] Greenstone describes the process as follows: ‘scarification … meant scraping the skin with a cube-shaped brass box containing multiple small knives, followed by cupping, which involved placing a dome-shaped glass over the skin and extracting the air by suction or prior heating’.[8]
Diagram of Richard Lower’s lancet in Wilhelm Fabricius Hildanus’ Cista militaris, or, a Military Chest, furnished either for Sea, or Land, with convenient Medicines, and necessary Instruments. Among which is also a Description of Dr Lower’s Lancet, for the more safe bleeding. Written in Latin, By Gulielmus Fabritius Hildanus, Englished for publick benefit, which is appended to Paul Barbette’s Thesaurus chirurgiae: the chirurgical and anatomical works … Composed according to the doctrine of the circulation of the blood, and other new inventions of the moderns. Together with a treatise of the plague, illustrated with observations. Translated out of Low-Dutch into English (London, 1676), p. 4.
Bleeding was meant to be prescribed by physicians and was usually undertaken by surgeons and apothecaries. However, in practice, the physician was sometimes left out of the process as surgeons and apothecaries took matters into their own hands – often at the request of an anxious patient.[9] There were real dangers with this approach and Worth’s authors (predominantly, though not exclusively, physicians), were keen to point them out for blood-letting could be a dangerous pursuit in the hands of an unskilled practitioner. Wilhelm Fabricius Hildanus (1560–1634), one of the most famous early modern surgeons, noted ruefully that:
‘For it [is] often happening, either by want of skill, or common practice of Bleeding, (which makes the Mind fear-ful, and consequently the Hand trembling and uncertain) that an Artery is opened, or a Nerve or Tendon cut or prick’d, whence follows Swellings, Pains, Inflammations, Gangrenes or Convulsions, which put the member in danger of being cut off, or render’d useless’.[10]
Fabricius Hildanus’ tract is included in Worth’s English translation of the surgical and anatomical works of the famous seventeenth-century Dutch surgeon and physician Paul Barbette (1620–65) and in it Fabricius Hildanus focused on what any practitioner interested in surgery should have in their medicine chest. First and foremost came a description of a contemporary innovation, Richard Lower’s famous lancet, which, as Fabricius Hildanus noted approvingly, allowed for ‘the more secure Letting of Blood’.[11] Worth owned a copy of the Tractatus de corde. Item de motu & colore sanguinis et chyli in cum transit (London, 1669) of the English physician and physiologist Richard Lower (1631–91), a famous work on the anatomy of the heart.
In Fabricius Hildanus’ view, Lower’s lancet had much to recommend it, for it transformed the act of bleeding a patient into a relatively safe operation. He described how it managed to do this: ‘For the Lancet is so contrived, that it is not cutting on each side, unless it be near the point, but is purposely blunt, and made round on the lower side, which is to be applied next to the skin, that it may more easily slide over it …’[12] In addition, he also provided much needed instructions as to how it should be used:
‘The way of using it is only this, that the Member being tied, and the Vein swelling, the Lancet must be applied as neer to it as possible, but so that the Lancet may be depress’d as much as may be; then the Point of it being directed upwards, it must be gentle, and by an oblique transverse Incision be put into the Vein: which if so directed, neither can the Vein avoid the point of the Lancet, or the parts underneath be any way offended. Which way of Blood-letting, as it is most easie, so it will never prove unhappy to any one, though but meanly skilful’.[13]
Fabricius Hildanus, writing ‘for the benefit of young Beginners’ (in surgery) emphasised the dangers of un-skilled practitioners indulging in a popular treatment ‘because a good Chirurgeon could not timely be called in by Physicians, who most commonly forbear the Practice of it’.[14]
One might have expected Fabricius Hildanus to focus solely on surgical instruments, but instead he began with what was necessary for purging his patients:
‘The first contains purging Simples, which must be put up in Leather-bags, except Manna and Cassia extracted, which may more conveniently be kept in Galli-pots. Those Bags again are to be put into other larger, and write upon in great Characters, Purging Simples’.[15]
To these he added ‘Purging Electuaries, which are to be kept in Gally-pots, writ upon, Purging Compounds’ but these were only the tip of the iceberg, which included, among other things ‘Syrups, and distill’d Waters’; ‘Pills’; ‘Cordial Powders and Electuaries’; ‘Roots, Herbs, Flowers, and Seeds’; ‘Unguents, and Fats’; ‘Plaisters, Gums, the Sewet of Bears, Cows, Goats; not to mention ‘Metals, and subterraneous Medicaments, as Vitriol, Allum, Letharge, Bole, &c’.[16] ‘Arsnick, Orpiment, crude Mercury, sublimate, praecipitate, caustic Minium Troches, Spirit of Vitriol, Aqua fortis and the like corrosive Medicines’ were also included but kept separate due to danger of cross contamination.[17]
Fabricius Hildanus provided his readers with a list of ‘Purging Simples’, which included ‘Agarick’; ‘Aloes’; ‘Rhubard’; ‘Cassia’; ‘Crocus Metallorum’; ‘Colocinthis’; ‘Diagridium’; ‘Senna’; ‘Hermodacts’; ‘Manna’; ‘Mechoacans’; ‘Myrobalans’; ‘Juice of Damask Roses’; Trochisci Albandal’; and ‘Turbith’.[18] To these he added the following ‘Purging Compounds’: ‘Benedicta Laxativa’; ‘Confectio Hamech’; ‘Diacarthamum’; ‘Diacatholicon’; ‘Diaphænicon’; ‘Diaturbith cum rhabarbaro’; ‘Electuarium de succo Rosarum’; ‘Electuarium Lenitivum’; ‘Pulvis Sennæ præp: Brassavoli’; ‘Syrup of Roses solutive’.[19] While such ‘purging’ remedies formed the initial sections of his medicine chest Fabricius Hildanus did not stop there and included a surprisingly large array of medicinal substances: ‘Pills’, ‘Powders strengthening the Heart, and noble parts’, ‘Aromaticks, or Spices’; ‘Distill’d Waters’; ‘Syrups’; ‘Roots’; ‘Herbs’; ‘Flowers’; ‘Seeds’; ‘Fruits’; ‘Oyl’; ‘Unguents’; ‘Fats’; ‘Plaisters’; ‘Gums’; ‘Minerals’ and ‘Meals’.[20]
Thomas Brugis, Vade mecum: or, A companion for a chirurgion. Fitted for sea, or land; peace, or war. Shewing the use of his instruments, and virtues of medicines simple and compound most in use, and how to make them up after the best method. With the manner of making reports to a magistrate, or corroner’s inquest. A treatise of bleeding at the nose. With directions for bleeding, purging, vomiting, &c. (London, 1681), frontispiece and title page.
Worth’s London edition of Thomas Brugis’ Vade mecum: or, A companion for a chirurgion was printed in 1681 but the text had been composed three decades earlier, in 1651, and therefore did not include a discussion of Richard Lower’s famous lancet, which Lower subsequently elaborated on in his section on venesection in his Dissertatio de origine catarrh et de venae sectione (London, 1672).[21] Brugis (b. in or before 1620, d. in or after 1651), did, however, advise his young surgeons to always carry a lancet, and gave them instructions on how to use it.[22] He clearly considered bleeding a patient to be the work of a surgeon, but he advised his readers that should ‘any come to thee to be let Blood, do it not without good advice of a Physician’.[23] It is interesting advice as it simultaneously reminds us of the agency of patients at this time – here taking the initiative in their own medical care – but also the some-times uneasy position of early modern surgeons, caught between the demands of their patients and professional rivalries with other practitioners. Brugis’ advice to play it safe: ‘when thou goest according to his [the physician’s] directions, whatsoever happens, thou shalt go blameless’ was an acknowledgment that bleeding, as a treatment, might easily go wrong.
Brugis outlined five different cases where phlebotomy might be attempted:
-
-
-
- To evacuate in a Plethora, and Inflammation.
- To draw from the part affected, as months supprest.
- To revel, derive, of which before, all this per se: For
- It cools, but by accident.
- To preserve, by hindring fluxions, and inflammations, Spring and Fall, for divers other griefs…’[24]
-
-
He advised his readers to pay attention to the location of bleeding and reminded them of Galen’s maxim to keep the age of the patient in mind, and to avoid bleeding children or people over the age of 70. Equally important factors were not only the sex of the patient but also the timing of the treatment.[25]
Like Fabricius Hildanus, Brugis also gave advice on purging and vomiting. While he quoted Galen, stating that ‘Purgation is an evacuation of humors, that offend in quality’, he was well aware of the circulation of the blood and his knowledge informed his instructions on purging:
‘Now, according to the three Regions of the body, you are to order your Purges; the first Region, since the invention of the circulation of the blood, is the intestines and stomach; the 2d takes in all kind of vessels, including the meseraics and capillaris; the 3d includes what is without the vessels; yet the method still remains inviolable: that to the first you must use lenient, to the 2d cathartics, to the third strongest and sudorifics. Purging is either by vomit or dejection, gently, meanly, or vehemently, and taken at mouth, or anus, as clysters’.[26]
Timing the purge was crucial: Brugis advised his readers not to purge at the beginning of a disease and certain categories were not to be purged at all (those with ‘cold, dry bodies’ and pregnant women).[27] Moderation was key for too strong a purge might well injure the patient.
Henry Cope, Medicina vindicata: or, reflections on Bleeding, Vomiting and Purging, in the beginnings of Fevers, Smallpox and Pleurisies, and other Acute Diseases (Dublin, 1727), title page. © The Board of Trinity College, Dublin.
Worth might not have collected Gaelic manuscripts on the subject of bleeding, vomiting and purging, but he did possess one locally produced text, written by one of his colleagues at the King and Queen’s College of Physicians in Ireland (i.e. Royal College of Physicians of Ireland): the Medicina vindicata (Dublin, 1727) of Henry Cope (1686–1743), who, like Worth, was a former President of the College.[28] This fascinating treatise not only sheds invaluable light on the rivalries between physicians and apothecaries in Dublin in the 1720s: it also reflects early eighteenth-century attitudes to bleeding, vomiting and purging patients.
Cope was not alone in believing that Nature gave clues as to what particular operation, be it bleeding, vomiting or purging, was called for. As he opined, ‘if Nature expels a diseased Humour by Vomiting, we are to help Nature by promoting that Discharge, provided we apprehend no Inconveniency from it; if that Humour falls upon the lower Bowels, &c, we are to use Purgatives; if the Humour attempts to make its Passage by the Skin, we are to assist it by Sweats, Perspiration, &c but if the Humour issues at an improper Vent, we are to turn the Current, and carry it off at one more convenient’.[29]
While bleeding, vomiting, and purging were undoubtedly popular treatments, practised not only by physicians but also by non-licensed practitioners, there were dangers associated with each practice. Cope, writing a polemical tract in 1727, aimed primarily at apothecaries’ claims to practice bleeding, vomiting and purging, was understandably keen to emphasise the risks involved when treatments such as these were practised by anybody other than learned physicians, arguing that only learned physicians had the requisite knowledge to be able to diagnose a patient correctly and, from that diagnosis, plot a suitable treatment for them.[30] As Cope warned, not every disease warranted bleeding and too much bleeding might well lead to adverse outcomes.[31] Only skilled practitioners would be aware that ‘one size did not fit all’ diseases and that a complex range of factors needed to be taken into consideration before attempting such a treatment: including, among other things, the nature of the diseases, the constitution of the patient, and the time of year.[32] Knowledge was all important: knowing when to bleed and purge and when to avoid it. Otherwise, as Cope reminded his readers ‘in all Likelihood we kill the Patient’.[33]
The dominance of bleeding in these accounts reflects the fact that bleeding was especially popular as a treatment for specific diseases such as smallpox but also for the most frequent symptom of diseases, fever – a topic of absorbing interest to every early modern physician. Worth’s copy of William Cockburn’s Sea Diseases or, A Treatise Of their Nature, Causes, and Cure … (London, 1706) included ‘An essay on Bleeding, And the Quantities of Blood to be Let in Fevers, in any of their periods’. In it Cockburn extolled the practice of the Italian physician Lorenzo Bellini (1643–1704) whose De urinis et pulsibus, de missione sanguinis, de febribus, de morbis capitis, et pectoris. Opus Laurentii Bellini, dicatum Francisco Redi. Cum praefatione Johannis Bohnii (Frankfurt and Leipzig, 1698), may also be found in Worth’s collection. Cockburn’s focus on bleeding was rooted in his belief that it was the safest therapeutic method for dealing with fevers:
‘Bleeding claims a chief Consideration among other evacuations, that are necessary for the Cure of Fevers: For they being necessary this is the most compleat, and the most simple evacuation, h.e. it is the evacuation by which we have the quantity we demand with the greatest certainty, without inducing parts of unaccountable operations to be mixed with the Blood’.[34]
Unlike ‘the doubtful Administration of Purgatives or even of Lenient Purges’, bleeding, in Cockburn’s view, was more controllable.[35]
It should also be remembered that bleeding and purging were not only treatments themselves but might also be used in preparation of another treatment (such as inoculation). Sir Richard Blackmore (1654–1729), draws attention to this in his dissertation on the subject of inoculation (likewise collected by Worth), when he says ‘And is not the Case the same, if a Physician should carry his willing Friend, or Relation, to catch the Infection from one that has a mild distinct Sort, may he not prepare him by purging, bleeding or vomiting, or how he thinks fit?’[36]
Text: Dr Elizabethanne Boran, Librarian of the Edward Worth Library, Dublin.
Sources
Blackmore, Sir Richard, A treatise upon the small-pox, in two parts. Containing, I. An account of the nature and several kinds of that disease, with the proper methods of cure. II. A dissertation upon the modern practice of inoculation. By Sir Richard Blackmore, Knt. (London, 1723).
Brugis, Thomas, Vade mecum: or, A companion for a chirurgion. Fitted for sea, or land; peace, or war. Shewing the use of his instruments, and virtues of medicines simple and compound most in use, and how to make them up after the best method. With the manner of making reports to a magistrate, or corroner’s inquest. A treatise of bleeding at the nose. With directions for bleeding, purging, vomiting, &c (London, 1681).
Cockburn, William, Sea Diseases or, A Treatise Of their Nature, Causes, and Cure … (London, 1706).
Cope, Henry, Medicina Vindicata: or, Reflections on Bleeding, Vomiting and Purging, in the Beginning of Fevers, Small Pox, Pleurisies, and other Acute Diseases (Dublin, 1727).
Fabricius Hildanus, Wilhelm, Cista militaris, or, a Military Chest, furnished either for Sea, or Land, with convenient Medicines, and necessary Instruments. Among which is also a Description of Dr Lower’s Lancet, for the more safe bleeding. Written in Latin, By Gulielmus Fabritius Hildanus, Englished for publick benefit, which is appended to Paul Barbette’s Thesaurus chirurgiae: the chirurgical and anatomical works … Composed according to the doctrine of the circulation of the blood, and other new inventions of the moderns. Together with a treatise of the plague, illustrated with observations. Translated out of Low-Dutch into English (London, 1676).
Felts, John H., ‘Richard Lower: Anatomist and Physiologist’, Annals of Internal Medicine, 132, no. 5 (2000), 420–23.
Grace, Pierce A., ‘Therapeutic bloodletting in Ireland from the medieval period to modern times’, Proceedings of the Royal Irish Academy: Archaeology, Culture, History, Literature, 121C (2012), 227–48.
Greenstone, Gerry, ‘The history of bloodletting’, British Columbia Medical Journal, 52, no. 1 (2010), 12–4.
Kelly, James, ‘‘Bleeding, vomiting and purging’: The Medical Response to Ill-health in Eighteenth-century Ireland’, in Cox, Catherine and Maria Luddy (eds), Cultures of care in Irish medical history, 1750–1970 (Basingstoke, 2010), pp 13–36.
Simpson, Marcus B. jun., ‘Lower, Richard (1631–1691), physician and physiologist’, Oxford Dictionary of National Biography (ODNB).
Ward, Jenny, ‘Brugis, Thomas (b. in or before 1620, d. in or after 1651), surgeon’, Oxford Dictionary of National Biography (ODNB).
*None of these medicines and operations should be attempted!
[1] Cope, Henry, Medicina Vindicata: or, Reflections on Bleeding, Vomiting and Purging, in the Beginning of Fevers, Small Pox, Pleurisies, and other Acute Diseases (Dublin, 1727), p. 7.
[2] Grace, Pierce A., ‘Therapeutic bloodletting in Ireland from the medieval period to modern times’, Proceedings of the Royal Irish Academy: Archaeology, Culture, History, Literature, 121C (2012), 229.
[3] Ibid., 232.
[4] Kelly, James, ‘‘Bleeding, vomiting and purging’: The Medical Response to Ill-health in Eighteenth-century Ireland’, in Cox, Catherine and Maria Luddy (eds), Cultures of care in Irish medical history, 1750–1970 (Basingstoke, 2010), p. 24.
[5] Grace, ‘Therapeutic bloodletting in Ireland from the medieval period to modern times’, 240.
[6] Greenstone, Gerry, ‘The history of bloodletting’, British Columbia Medical Journal, 52, no. 1 (2010), 12.
[7] Ibid. and see Grace, ‘Therapeutic bloodletting in Ireland from the medieval period to modern times’, 241.
[8] Greenstone, ‘The history of bloodletting’, 12–3.
[9] Kelly, ‘‘Bleeding, vomiting and purging’, p. 27 makes the point that patients’ belief in the efficacy of both bleeding and purging ensured their popularity as treatments.
[10] Fabricius Hildanus, Wilhelm, Cista militaris, or, a Military Chest, furnished either for Sea, or Land, with convenient Medicines, and necessary Instruments. Among which is also a Description of Dr Lower’s Lancet, for the more safe bleeding. Written in Latin, By Gulielmus Fabritius Hildanus, Englished for publick benefit, which is appended to Paul Barbette’s Thesaurus chirurgiae: the chirurgical and anatomical works … Composed according to the doctrine of the circulation of the blood, and other new inventions of the moderns. Together with a treatise of the plague, illustrated with observations. Translated out of Low-Dutch into English (London, 1676), p. 3.
[11] Ibid., p. 1.
[12] Ibid., p. 4.
[13] Ibid., p. 5.
[14] Ibid., pp 5–6.
[15] Ibid., p. 9.
[16] Ibid., pp 9–11.
[17] Ibid., pp 11–2.
[18] Ibid., p. 13.
[19] Ibid., p. 13.
[20] Ibid., pp 13–21.
[21] Felts, John H., ‘Richard Lower: Anatomist and Physiologist’, Annals of Internal Medicine, 132, no. 5 (2000), 422.
[22] Brugis Thomas, Vade mecum: or, A companion for a chirurgion. Fitted for sea, or land; peace, or war. Shewing the use of his instruments, and virtues of medicines simple and compound most in use, and how to make them up after the best method. With the manner of making reports to a magistrate, or corroner’s inquest. A treatise of bleeding at the nose. With directions for bleeding, purging, vomiting, &c. (London, 1681), p. 206.
[23] Ibid., p. 207.
[24] Ibid., pp 303-4.
[25] Ibid., p. 304.
[26] Ibid., p. 307.
[27] Ibid., p. 308.
[28] This work is no longer in the Worth Library.
[29] Cope, Henry, Medicina Vindicata: or, Reflections on Bleeding, Vomiting and Purging, in the Beginning of Fevers, Small Pox, Pleurisies, and other Acute Diseases (Dublin, 1727), p. 25.
[30] Ibid., p. 14.
[31] Ibid.
[32] Ibid.
[33] Ibid., p. 19.
[34] Cockburn, William, Sea Diseases or, A Treatise Of their Nature, Causes, and Cure … (London, 1706), p. 252.
[35] Ibid., p. 253.
[36] Blackmore, Sir Richard, A treatise upon the small-pox, in two parts. Containing, I. An account of the nature and several kinds of that disease, with the proper methods of cure. II. A dissertation upon the modern practice of inoculation. By Sir Richard Blackmore, Knt. (London, 1723), p. 111.