Bloodletting may hold a promising secret

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ironjustice@aol.com - 06 Mar 2005 19:06 GMT

http://www.boston.com/news/globe/health_science/articles/2004/10/05/bloodletting
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Bloodletting
A long-discredited cure may hold a promising secret
By Carolyn Y. Johnson, Globe Correspondent | October 5, 2004

For 2,500 years, doctors unleashed a single, gory cure-all on nearly
every ailment known to mankind -- a good bleeding. Confronted with a
fever, rattly cough, intermittent seizures, heart disease, or even
mental illness, doctors bled their patients, sometimes until they
passed out.

The common practice of bloodletting weakened and probably killed some
patients -- including George Washington, who was bled of 2 to 3 quarts
of blood after getting sick and died shortly thereafter. Undaunted,
barber-surgeons and doctors continued bloodletting to the cusp of the
20th century, when it was finally consigned to the trash bin of
discredited medicine.

Now, however, a discovery published last month in the journal Science
suggests that bloodletting actually might have helped some patients --
and offers a tantalizing reason why. Microbiologists at the University
of Chicago found that when infectious Staphylococcus aureus bacteria
were deprived of the iron in red blood cells, they did not spread and
cause disease in the body.

''In the earliest 20th century, some of the most respected physicians
advocated using bloodletting and had honed it down to use at the
beginning of a sudden onset with a harsh fever, which is very much the
hallmark of a bacterial infection," said Dr. Tracey Rouault, an expert
on iron metabolism who looked at the Chicago study and saw a connection
to the painful ancient practice. ''Right at that point, you may be
doing some good."

No one today is advocating a return to the lancet. But if Rouault is
right, bloodletting may be joining the list of cures from the past,
including maggots and leeches, proving to be of interest to modern
doctors.

''If something rather invasive has a hold on therapy for 2,500 years,"
Rouault said, ''there must be some incident when somebody benefited
from it."

The scientists behind the bacterial study didn't set out to find a
justification for bloodletting. They were trying to solve a mystery
about bacteria: The cells need iron to grow and thrive, but doctors
have never known which sources of iron in the body were the first
choice. So a research team at the University of Chicago put bacteria on
a low-iron diet and then set them loose in a dish, with the two most
common forms of iron found in the body.

Researchers found the bacteria overwhelmingly preferred heme iron,
which is stored within red blood cells, especially at the beginning of
the infection. ''They blow open the red blood cells, which leads to the
release of heme," said Eric Skaar, a microbiologist at Chicago who
coauthored the study.

He and his colleagues found that when the bacteria were altered so they
could no longer capture the iron stored in the red blood cells, they
were unable to cause disease in mice.

Rouault said that when she first saw the study results, she was
excited. The head of the section on human iron metabolism at the
National Institutes of Health, she had been musing on the rationale for
bloodletting, ''because it's just so curious." The new study suggested
an answer: Maybe it caused iron starvation in bacteria. She wrote a
commentary drawing the connection, which appeared in the same issue of
Science.

Other science historians, however, caution that Rouault's idea does not
mean bloodletting was an effective therapy. The only cases in which it
would have worked were bacterial infections -- a fraction of the total
number of diseases treated with the technique over the centuries, at a
time when doctors had no way to tell a bacterial infection from a
tension headache.

Hippocrates, ''the father of medicine," first advocated bloodletting in
ancient Greece as a method of bringing an unbalanced, diseased person
back to equilibrium. Those ideas evolved into a theory about the body's
four humors, which had to be kept in balance -- too much blood and a
person would be overexcited; too much phlegm, sluggish; and so on. From
there, bloodletting never got much more scientific. It was used
indiscriminately on viral infections, psychosis, and even heart failure
-- although, as Rouault noted, it was sometimes singled out for use at
the beginning of a harsh fever, which often indicates a bacterial
infection.

Medical historians say that it is impossible to divine the real reason
bleeding seemed to ''work," and that to use a modern explanation would
be a gross oversimplification. The perceived power of physicians
wielding such an invasive procedure likely had a potent placebo effect,
said Dr. David Jones, who teaches in the science, technology, and
society program at the Massachusetts Institute of Technology.

A scientific rationale for bloodletting would put the practice in the
growing company of outdated therapies that have shown some medical
value -- and in some cases are enjoying a full-bore revival, though not
always for their original purposes.

Maggots, which evoke images reeking of death and decay, may seem
definitively unmedical, but can actually save limbs. The tiny white fly
larvae were used to clean wounds in wartime hospitals in the 1930s
until replaced by modern surgical techniques and antibiotics -- but are
now gradually returning at wound clinics across the country, despite
the ''yuck" factor. The US Food and Drug Administration approved
maggots as a medical device to clean out wounds this January. The
larvae are applied to an open wound, secured there with mesh, and left
to eat the dead tissue and kill bacteria -- which they can do with a
precision beyond that of a skilled surgeon, according to some studies.

Leeches were once an important method of bloodletting, but now serve a
completely different purpose. Bred in sterile conditions by special
leech farms, they are applied to surgically reattached fingers or ears,
where they help to stimulate circulation. The most important component
of a leech bite is the saliva, which prevents blood clotting, and
synthetic forms of leech spittle are being used as anticoagulant drugs.
Marie Bonazinga, president of Leeches U.S.A., said that her company
sells in excess of 10,000 farm-raised leeches each year to major trauma
centers across the country.

What may seem strangest about some of the old cures -- the fact that
doctors had little understanding of how they truly affected the body --
is true of much modern medicine as well. ''There are a lot of things we
think of as therapy, but have no scientific rationale," said Dr. Robert
Aronowitz, who teaches history and sociology of medicine at the
University of Pennsylvania.

Even with a scientific rationale, no researcher is going to start
bleeding patients to see whether it actually works. But the
iron-starvation research may yet yield a new therapy.

Skaar's work suggests that doctors could one day kill bacteria by
disrupting their ability to gather iron from red blood cells -- in
essence, starving them by locking the food away rather than by throwing
it out, as bloodletters may have unwittingly been doing for centuries.

As for bloodletting, the question of whether it really worked will
probably never be resolved, and no one anticipates a randomized
clinical trial to set the record straight.

''Bloodletting," Jones said, ''would probably hurt the patient before
it hurt the bacteria."

Carolyn Y. Johnson can be reached at cjohnson@globe.com.

© Copyright 2004 The New York Times Company

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