Northwest Deanery, UK
Vue du Cimetiere de Melegnano – le lendemain du Combat. [View of the Cemetery at Melegnano – the aftermath of combat.]
“Carne fa carne e vino fa sango” [Meat makes flesh and wine makes blood] – Italian proverb
Laura was covered in blood when the paramedics arrived at her house. Her husband, in a state of shock, had gathered every available towel in the vicinity, but it seemed too little and too late. Blood had been spewing out of Laura’s mouth for the last fifteen minutes, onto her clothes, the sofa, the carpet and curtains. Even the dog was not spared. The stench of dried, semi-digested blood filled the room, masking the usual smell of cigarette smoke.
Like many other patients, Laura had become addicted to alcohol at a young age. She now depended on large amounts of wine throughout the day just to function. Without it, she would become agitated, confused, and tremulous. Years of alcohol use had scarred her liver, causing the blood vessels in her esophagus to dilate in response to chronically raised pressure. These esophageal varices had suddenly burst, much like a ruptured dam.
The ancient Greek and Roman physicians such as Galen and Hippocrates believed that wine helped produce blood and promote good health. This idea was not confined to Western thought. Traditional Chinese Medicine texts describe how wine replenishes the 气 (qi) in the body, which enables the flow of blood.1
“Wine (vinum) is so called because a drink of it speedily replenishes the veins (vena) with blood.” – The Etymologies, Isidore, Bishop of Seville (c.560-636 CE)
“Wine and honey are wonderfully suited to man if, in health and disease, you administer them appropriately and in accordance with individual constitutions.” – Affections, Hippocrates
Yet the ancients also knew that alcohol damaged the liver and caused bleeding. Hippocrates acknowledged the vasodilatory effects of alcohol during bleeding2 while Galen wisely prohibited wine in liver cirrhosis.3
“There is not topic more difficult to handle, or more full of detail, seeing that it is hard to say whether wine does good to people rather than harming them.” – Pliny the Elder
Laura came rapidly through the emergency department to intensive care, where even the gastroenterologist struggled to control the bleeding by means of endoscopy. Multiple lines inserted reflected the numerous complex interventions attempted to save her life. A Sengstaken-Blakemore tube helped plug the torrent from Laura’s esophagus and help to prevent further massive bleeding.
Ancient speculation of the relationship between wine and blood was tenuous at best, but the understanding of circulating blood and life was much more easily grasped. The Bible emphasizes the inseparability of blood and life:
“. . . because the life of every creature is its blood. ‘You must not eat the blood of any creature, because the life of every creature is its blood . . .’” – Leviticus 17:14
Indeed so intimate was this relationship in Christian texts that the shedding of blood repeatedly represented the sacrifice of a life, from the use of animal blood to spare the Israelite boys during the Passover in Exodus 12, to the blood of Christ as an atonement for sin and eternal death in the New Testament. During the Last Supper, Jesus famously used wine to represent his blood, asking his disciples to drink it as an acceptance of his sacrifice of life for them, a purposeful but incredibly symbolical deviation from the ancient Levitical command. Holy Communion today continues to be a solemn affirmation of the intimacy between a life sacrificed through the shedding of blood and the acceptance of eternal life through the taking of wine.
A central venous catheter (CVC) was inserted. Liters of blood were dripped and pumped into Laura to replace the blood she had lost.
James Blundell was credited with the first published human-to-human blood transfusion in 1818, but the concept of blood transfer to another as a means of restoring life probably existed in pre-history. In Homer’s Odyssey Book 11 (eighth century BCE), Odysseus uses blood to reanimate dead spirits. Common to many ancient cultures are the depictions of creatures that depend on the ingestion of blood to preserve their own life. These vampiric creatures include the Lilitu of Mesopotamia, the 僵尸 (jiāng shī) in China, or demons in Persia.4 The rationale behind blood transfusions seemed logical from the loss of life witnessed through exsanguination. However, it took almost two millennia before physicians became able to transfuse blood to preserve life. In 1665 Richard Lower transfused a dog with the blood of another dog, paving the way to the eventual transfusion capabilities we have today.5
For Laura, stopping the bleeding was not enough, nor was replacing her blood. Her kidneys had been damaged by the blood loss, so we inserted a large bore line that allowed us to connect Laura to a renal replacement machine and carry out dialysis to maintain the biochemical balance in her blood.
Renal replacement machines allow us to mimic a key role of the human kidney—removing toxins from the body. The understanding of filtration developed as a result of microscopic descriptions of kidneys by Malpighi in the 1660s. However, without the means of filtration, physicians then widely practiced bloodletting to remove accumulated toxins. Bloodletting was believed to restore humoral balance in the blood within Hippocratic (~460–370 BC) and Galenic (129–200 AD) humoral theories.6 Earlier still was the use of leeches, as depicted on Egyptian frescoes from around 3000 BCE.6 Bloodletting was thought to treat all sorts of febrile illnesses and inflammatory conditions, delirium and psychological disturbances, even intoxication and cancer.7
“It is appropriate to take patients . . . as far as loss of consciousness.” – Galen, On treatment by venesection.8
Fortunately, several studies refuted the efficacy of bloodletting in the early 1800s.9 Along with the demonstration of dialysis in a laboratory by Graham in 1854, which paved the way for the eventual development of human dialysis,5 the practice of bloodletting dwindled (it is now only used for very specific conditions). It was in 1943 that Willem Kolff successfully reversed the effects of acute kidney injury using hemodialysis.5
Unfortunately for Laura, despite the transfusion of liters of blood, attempts to stop the bleeding, and filtering of the blood, she continued to deteriorate. Slowly she descended into multi-organ failure and died.
The aftermath of resuscitation attempts is not dissimilar to that of a battlefield, blood covering the floor and medical disposables strewn all over like used bullet shells. A patient like Laura, penetrated by multiple medical devices and lines, induces a sense of fear and despair, even for seasoned doctors. The loss of life, even though singular, affects the entire multi-professional team, from the consultant to the cleaner. It begs us to improve practice, from treatment to prevention, from open to minimally invasive, from questionable to evidence-based.
The shedding of blood moves people, just like it did Henri Dunant at the battle of Solferino. Having witnessed the carnage and bloodshed, he was stirred into action. He spent his money and energy campaigning for humanitarian action, eventually cumulating in the Geneva Convention and the formation of the International Committee of the Red Cross. Such humanitarian organizations would go on to save countless lives, playing key roles in improving global health and human progress.
From attempts to produce more blood to ways of maintaining its excesses, from the need to cleanse it from toxins to the symbolism of sanctity of life, blood has been a central theme in health and medicine. Both the sorrow it can bring, and the life it can restore demonstrate that blood will always be a catalyst for action. There is indeed power in blood.10
“This is my blood . . . which is shed for you and for many . . .” – Book of Common Prayer (1662)
- Porter R. The greatest benefit to mankind : a medical history of humanity from antiquity to the present. London: HarperCollins; 1997.
- Hippocrates. Epidemics 6.
- Galen. Commentary on Hippocrates’ Regimen in Acute Diseases 3.
- Marigny J. Vampires: the world of the undead. London: Thames & Hudson; 1994.
- AREP. History of haemodialysis. Fresenius Medical Care. https://www.advancedrenaleducation.com/content/history-hemodialysis. Published 2015. Accessed Dec 2019.
- Whitaker IS, Rao J, Izadi D, Butler PE. Historical Article: Hirudo medicinalis: ancient origins of, and trends in the use of medicinal leeches throughout history. Br J Oral Maxillofac Surg. 2004;42(2):133-137.
- Price R. A treatise on the utility of sangui-suction, or, : Leech bleeding, in the treatment of a great variety of diseases : including the opinions of eminent practitioners, ancient and modern : with instructions for the process of leeching, and an appendix, delineating the characteristic distinction of true leeches : with directions for their management and preservation. London: Simpkin & Marshall; 1822.
- Brain P. Galen on bloodletting. New York: Cambridge University Press; 1986.
- Greenstone G. The history of bloodletting. BC Medical Journal. 2010;52:12-14.
- Lewis EJ. Power in the blood. In. Baptist Hymnal 19911899.
Vue du Cimetiere de Melegnano – le lendemain du Combat. [View of the Cemetery at Melegnano – the aftermath of combat.] ca. June 7th-8th, 1859 Unidentified French Photograher. From the archive of William Johnson. Public Domain due to age: https://vintagephotosjohnson.com/tag/battle-of-solferino/
MARK ZY TAN, MBBS, BSc, MRCS, MRCA, is an Intensive Care Medicine and Anaesthetics Specialty trainee in the Northwest of England. His interest in medical humanities was ignited at Imperial College London during his medical studies. He has long been involved in performing arts, both in Singapore where he grew up, and in UK where he has undertaken his medical training.