A sanguine personality, for example, was presupposed to depend on the quality of the element of air (wet and hot). 6 The perfect temperament resulted when none of these humours dominated. According to this theory, the four elements in nature, air, fire, earth and water with their specific qualities determine one of four temperaments (sanguinic, choleric, melancholic and flegmatic) which in turn depend on the equilibrium between the humours. At that time bloodletting evolved from ceremonial use and witchcraft to a logical and therapeutic act, based on knowledge, skill and idea, based on the theory of the four bodily fluids or humours, blood, yellow bile, black bile and mucus. At first bloodletting was supposed to literally facilitate the release of evil spirits from the body but later on the Hippocratic-Galen doctrine which lasted until the 16th century provided a physiological reason in a logical and clearly defined framework. The Egyptians practised bloodletting 1000 years BC and then this tradition spread to the Greeks and Romans, who embedded its usage in their concept of health and disease. In the setting of orthopaedic surgery, 1% of elderly patients undergoing hip or knee surgery seem to experience circulatory overload and then phlebotomy and supplemental oxygen are the key therapies. Finally, phlebotomy is mentioned in connection with lung injury and circulatory overload as a complication of blood transfusion resulting in pulmonary oedema.
3 In the management of acute pulmonary oedema phlebotomy may still be of some use in reducing pulmonary capillary wedge pressure, especially when rapid action is required.
2 There is consensus now that phlebotomy should only be used for the acute resolution of hyperviscosity symptoms. Until recently regular bleeding was also the treatment of choice in cyanotic congenital heart disease with symptomatic erythrocytosis, but because repeated phlebotomy causes iron deficiency with microcytic erythrocytes, which increases the whole blood viscosity and therefore can potentially accentuate rather than decrease the risk of a cerebrovascular accident, this policy became less advisable. Nowadays, phlebotomy is indicated in specific circumstances and conditions, such as hereditary haemochromatosis, polycythemia vera, essential thrombocythemia and porphyria cutanea tarda, to reduce the amount of red blood cells. This paper is an attempt to define such a path.
To find such a path that involves step by step progress, with pay-offs at each step, and with experience gained at each step to refine and improve the use of phlebotomy, may provide insight into the development of modern medicine. The long history attached to this peculiar practice, which dated to 1000 years BC, however, makes time travelling worthwhile as its usage has survived in modern times like an evolutionary path in the growth of idea. 1 Phlebotomy as a therapy has nowadays been driven back to the outskirts of critical care medicine and no longer seems to be worth mentioning. Nevertheless in those days too, our predecessors relied on some sort of guideline, balanced and well thought out, as may follow from a textbook dating from the 1760s. As excess bleeding and the risk of upper gastrointestinal bleeding with antithrombotic regimens constitute a primary concern in modern day cardiology, how distinct is the connotation with bloodletting as a well-known and widespread therapy in the past when doctors, at first sight in season and out of season, confronted their poor patients with the advantages of tapping blood.
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