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Back to the Future: Appraisal of 200 Years of Therapeutic Phlebotomy

Mention of therapeutic phlebotomy probably brings to mind the 1970’s American comedy sketch Theodoric of York, Medieval Barber, as well as leeches, evil humors, and the death of George Washington, our first President.  Washington’s physicians hastened his demise with phlebotomy therapy for probable acute bacterial epiglottitis by removing approximately 35% of his blood volume in twelve hours.  A dubious legacy, perhaps. 

The Medical Case of George Washington

Washington’s case was an early example of the V.I.P. syndrome, in which consideration of a patient’s celebrity leads to therapeutic misadventure.  In his case, emergency tracheotomy was suggested and might have been life-saving for someone with a compromised upper airway, as appeared to be the case with Washington.  However, this suggestion was vetoed by his senior attending physician James Craik:

“Undoubtedly, the specter of failure with a grisly, painful (in the absence of anesthesia), and untried surgical experiment on the former president weighed heavily in Craik's decision to veto this radical suggestion.”  

It should also be remembered that "former president" does not begin to describe Washington's stature.  He was the most famous man in the world, for 20 years the pre-eminent person in American national life, and was held in almost religious esteem by his countrymen.

Thus, the unfortunate outcome for Washington is not necessarily an indictment of therapeutic phlebotomy.  Twentieth century medical care could neither prevent an adverse outcome in the assassination of Huey Long, governor of Louisiana, and 21st century medical practices proved fatal for Michael Jackson, the king of pop.  In another example involving a president, V.I.P. syndrome is a more plausible explanation for the botched autopsy of John F. Kennedy than conspiracy to suppress the truth.

Clearly, the most important variable in determining health outcomes in V.I.P. syndrome is not the therapeutic modality but the judgment of the clinician.  

Sir William Osler, MD:  Astute Clinician or a Genius of His Generation?

As I have written previously in these pages, I am impressed by the quality of the observations made by previous generations of physicians regarding bloodletting.  In this commentary, I examine the teachings of Sir William Osler, MD, regarding therapeutic phlebotomy in the early 20th century.  I will also briefly examine 19th-century British medical opinions regarding therapeutic phlebotomy.

Osler is widely regarded as being the most influential physician of his day, largely due to his classic textbook, The Principles and Practice of Medicine.  He performed nearly 1,000 autopsies, and no doubt it was this experience which informed his statement that “longevity is a vascular question.” 

This statement was made at least 90 years before cardiovascular disease became the number one killer on the planet and is evidence of his remarkable insight and powers of observation.  What Dr. Osler appreciated, like few do today, was the importance of arteriosclerosis, hardening of the arteries, as distinguished from atherosclerosis, the focal obstruction of arteries caused by plaque.  Indeed, atherosclerotic cardiovascular disease was so rare in his time that the terms “atherosclerosis” and “claudication” were not included in the index of his 1921 edition textbook. 

Nevertheless, it is probably Osler’s clinical work for which he is best known.  After all, his most famous aphorism was: “Listen to your patients. They will tell you what is wrong with them.” 

Osler attended the smallpox ward at Johns Hopkins Hospital in Baltimore, Maryland.  Because pneumonia was a well-documented cause of death in smallpox, it is likely that Osler was experienced in treating pneumonia.  This quote is from his chapter entitled, “The Pneumonias and Pneumococcic Infections” in the 1921 edition of his text.  Writing about therapeutic phlebotomy:

The reproach … that ‘a bloody Moloch presides in the chairs of medicine’ can not be brought against this generation of physicians… We employ it much more than we did a few years ago, but more often late in the disease than early.   To bleed at the very onset in robust, healthy individuals in whom the disease sets in with great intensity and high fever is good practice.  Late in the course marked dilatation of the right heart is the common indication.

Moloch was an ancient god who demanded excessive bloody tribute.  Here, Osler is saying that he was aware that previous generations of physicians bled to excess, but his own generation of physicians had learned from their predecessors’ failures and therefore practiced more prudently.  At the very least, he attests that he himself has come to utilize therapeutic phlebotomy more often!

What Would be the Expected Effect of Therapeutic Phlebotomy in a Robust Healthy Individual With an Intense Presentation of Pneumonia?

Such a patient would probably have a marked acute phase response and increased low shear blood viscosity due to elevated fibrinogen levels.  No doubt therapeutic phlebotomy would decrease blood viscosity and improve pulmonary vascular congestion and ventilation-perfusion mismatch.  The observant physician would probably be able to observe a therapeutic response. 

Before the advent of antibiotics, this was the best treatment a physician could offer.  In fact, the 1943 edition of the classic laboratory medicine textbook Clinical Diagnosis by Laboratory Methods states that blood viscosity is increased in “polycythemia, diabetes mellitus, icterus, and usually pneumonia.”  Unfortunately, the association of increased blood viscosity with pneumonia is not emphasized in more recent literature.

Applying therapeutic phlebotomy in the case of cor pulmonale is a no-brainer for any physician focused on providing the best care at the lowest cost.  Therapeutic phlebotomy in such cases reduces blood viscosity, decreases total peripheral resistance, and improves right heart failure. 

The Industrial Revolution: Dawn of the Diseases of Overabundance

British physicians in the 19th century began to note the medical consequences of the increased standard of living that came with the industrial revolution.  Physicians of that era identified patients with “plethora” as those most likely to benefit from therapeutic phlebotomy, and associated this well-recognized medical condition with persons of wealth. 

Briefly, plethora was characterized by “increase of bulk,” “indulgence in diet,” and “little exercise.”  This description suggests obesity or even the metabolic syndrome, conditions commonly associated with an increased standard of living.  Today, we know that obesity and metabolic syndrome are associated with increased blood viscosity, and the hypertension and hyperglycemia associated with the latter can be successfully treated with therapeutic phlebotomy. 

Conclusions on Phlebotomy

I suggest that the salutary response noted by the many physicians who practiced therapeutic phlebotomy was real and due to improved blood viscosity and blood flow.  Moreover, with the increased prevalence of many of the conditions associated with increased blood viscosity—such as obesity, hypertension, hypercholesterolemia, and advancing age—therapeutic phlebotomy will again become a widely-utilized, effective, and economical therapeutic modality.

“The philosophies of one age have become the absurdities of the next, and the foolishness of yesterday has become the wisdom of tomorrow.”  This is my favorite quote of Osler’s.  I don’t know the context in which it was made, but I feel like he could have been referring to therapeutic phlebotomy. 


For Further Reading:   

1.  Health and Medical History of George Washington.  http://www.doctorzebra.com/prez/g01.htm 

2.  “The VIP Syndrome:” A clinical study in hospital psychiatry. Weintraub W.  Journal of Nervous and Mental Diseases 1964;138(2):  181-193. 
http://journals.lww.com/jonmd/Citation/1964/02000/_The_Vip_Syndrome__A_Clinical_Study_in_Hospital.12

3.  Huey P. Long’s Last Operation:  When Medicine and Politics Don’t Mix.  Trotter MC.  The Ochsner Journal 2012;12:  9-16. 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3307515/

4.  When the Patient is a V.I.P.  Klitzman, R.  N.Y. Times 8/27/09.  http://well.blogs.nytimes.com/2009/08/27/when-the-patient-is-a-vip/?_r=0 

5.  Osler’s autopsies:  their nature and utilization.  Med Hist 1973; 17(1):  37-48. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1081415/pdf/medhist00124-0042.pdf

6.  Change of type as an explanation for the decline of therapeutic bloodletting.  Carter KC. Studies in History and Philosophy of Biological and Biomedical Sciences.  2010; 41:1-11

7.  Effects of phlebotomy-induced reduction of body iron stores on metabolic syndrome: Results from a randomized clinical trial. KS Houschyar, R Ludtke, GJ Dobos, U Kalus, M Brocker-Preuss, T Rampp, B Brinkhaus, and A Michalsen. BMC Medicine 2012;10:54 doi: 10.1186/1741-7015-10-54.

8.  Cardiovascular benefits of phlebotomy:  relationship to changes in hemorheological variables.  Perfusion 2013 Sep 25 [Epub ahead of print].

9.  The Principles and Practice of Medicine, Osler and McCrae, 9th Ed., p. 102, 1921.

10.  Clinical Diagnosis by Laboratory Methods, 10th edition, Todd, JC, and Sanford, AH, WB Saunders Company, 1943, p. 328. 
 

Last Updated: 2014-12-30

 

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