Descriptions of blood and blood disorders before the advent of laboratory studies

Abstract

Since antiquity, blood has been recognized as the essential component of life. Without knowledge of the circulation, ancient Egyptian religion recognized the heart as the seat of the soul and entry into the afterlife depended upon Osiris weighing the heart on the scales of justice. In the New World, the supreme offering to the Incan gods was the beating heart of a human sacrificial victim. In the Holy Bible, Leviticus 17: 11 contains a universal truth about blood, ‘the life of the flesh is in the blood’, Ancient Egyptians believed that bathing in blood was a tonic for rejuvenation and recuperation and, in contrast to this, ancient Hebrew dietary laws were probably based on the knowledge that animal blood could transmit disease to humans. Some Roman gladiators, by drinking the blood of their fallen adversaries, hoped to acquire additional strength and valour. The Christians forbade their followers to ingest blood, and religious hospitals in mediaeval England excluded haemorrhaging, menstruating and pregnant patients. In the fifteenth century, blood was recommended for fits, melancholia, lunacy, palsy and bad disposition, but it was not used for bleeding or pallor. In Greek mythology, the Gorgons were horrendous creatures who had serpents sprouting from their heads and whose stare turned beholders into stone. Perseus beheaded their leader Medusa and presented the severed head as a trophy to Athena (Minerva), the Goddess of Wisdom. She had learned that the blood from the right side of the Gorgon could revive the dead while blood from the left side would be the scourge of mankind. Athena favoured Asclepius, the God of Medicine, and gave him some of the Gorgon's blood (Fig 1). This gift of blood became ‘the gift of life’ and empowered him to revive the dead. Ancient Greek mythology anticipated the future place of blood transfusion in medical care but foresaw that improper blood would inflict suffering (a possible ancient anticipation of transfusion reactions and acquired immune deficiency syndrome). Following the Renaissance, many physicians, polymaths and enthusiastic experimenters attempted various methods in order to administer blood directly or indirectly from animal and human sources into the circulation in order to treat human disease. Louis K. Diamond (1980) summarized the many unsuccessful empirical attempts at transfusion prior to 1901–2 when Karl Landsteiner identified in his laboratory the four basic human blood groups. Ancient coin depicting gorgon's head. © Classic Numismatic Group Inc. Since antiquity, Rabbis have circumcized all the newborn boys in their congregations; they had a unique opportunity to observe the presence of operative and postoperative bleeding. Dr F. Rosner (1977) reviewed haemophilia in the Talmud and reported that Rabbi Judah (?135–?220) taught in the Babylonian Talmud that if two successive brothers bled to death following circumcision then the third son of the same mother is excused from circumcision. This led to the development of formal laws allowing rabbinical exception from circumcision for new offspring whose brothers had died from post-procedural haemorrhage. Maimonides (Moses ben Maimon 1135–1204), a physician and talmudist from Cordova, Spain, recognized that a mother bearing children with the disorder would transmit the disease to all male offspring, even if conceived by different fathers. Rabbis had identified the carrier state of haemophilia, two millennia before Mendel and the clotting time. The study of nature by ancient Greek physicians included the study of both medicine and philosophy. Aristotle observed that one might begin with philosophy but would end with medicine or begin with medicine and end with philosophy. Pythagoras, Empedocles, Alcmaeon, Hippocrates, Plato, Aristotle and Socrates are just a few of the physician philosophers. Some were more clinical in their interests while others were more concerned with philosophy. Their studies attempted to explain disease as a result of the forces of nature rather than displeasure of the gods. However, a surviving text of each paradoxically recorded their simultaneous belief and worship of Asclepius, the Greek god of medicine (Hart, 2000). Pythagoras was a polymath who established his school at the Dorian colony of Croton in Southern Italy ≈ 529 bc. He believed that illness was the result of an imbalance between body and soul. Diet and music created a favourable disposition but gluttony adversely effected harmony and health. He and his followers adopted strict dietary regimens for the maintenance of health and they specifically forbade the eating of beans. Today, residents of this same area of Southern Italy have the highest incidence of Mediterranean-type G6PD enzyme deficiency. It is probable that this genetic trait was present in ancient times and Pythagoras witnessed attacks of explosive haemolytic anaemia occurring in local residents who had ingested fava beans. Unfortunately, no written clinical descriptions survive. This dietary observation probably influenced followers of the Cult of Demeter (goddess of the harvest) to restrict the eating of beans. Empedocles of Acragas in Sicily (≈ 490–430 bc) was a disciple of Pythagoras. His philosophy was based on all matter being formed from fire, water, air and earth. Each of these basic elements possessed the characteristics of opposites, namely hot and cold, dry and moist. Empedocles is credited with relieving the recurring epidemics in the Sicilian city of Selinus located on the banks of the Selinus and Hypsos rivers. He recommended joining the rivers surrounding the city so that the marshes would be drained and the recurring epidemics (undoubtedly malaria) relieved. This major public health measure was recorded and celebrated on beautifully illustrated coins (Fig 2.). The circulation of these coins around the Mediterranean world would have spread the public health message. Coin from Selinus 460–440 bc depicting river-god Hypsas sacrificing at altar of Asclepius. ©Classic Numismatic Group Inc. The writings ascribed to Hippocrates are in reality the thoughts of not only Hippocrates but also various Hippocratic practitioners from his school on the island of Cos. These were written from the fifth to fourth century bc, and 70 or so of these were compiled into the Hippocratic Corpus at Alexandria around 200 bc. The Treatise of Airs, Waters and Places translated by W. H. S. Jones (1984) stated that people living near marshy water were noted to have large stiff spleens, protuberant abdomens, emaciated facies and shoulders; they were noted for suffering summertime epidemics of dysentery and long quartan fevers. With dry summers the disease ceased more quickly, but with rainy summers the fevers were more protracted. The airs associated with the waters were thought to be responsible for the epidemics, but they ignored the mosquitoes inhabiting the air (anyone living in mosquito-infested areas is familiar with the effects of climate on the mosquito population). The fevers were described as intermittent and remittent. The intermittent variety occurred in quotidian, tertian or quartan patterns. The remittent pattern was accompanied by a sensation of intense heat, pain in the hypochondrium and delirium. Patients with cachexia and enlarged spleens were noted to have a dark complexion and suffered from weakness. The treatises do not have any specific treatment recommendations. The lowly mosquito defeated Alexander the Great, the conqueror of the ancient world. A few days before his death he became lost in the swamps around Babylon where he acquired a febrile illness, became delirious and died. The probable cause of death was cerebral malaria. Marcus Terentius Varro (≈100 bc), a Roman scholar, postulated that tiny animals inhabiting the marshes entered the body and caused the disease. There were many marshes and landlocked lakes around Rome. Over the years attempts were made to drain them and make the land habitable and healthy. This public health manoeuvre was commemorated on coins. One of these minted by Emperor Trajan (98–117 ad) commemorated draining a portion of the Pontine Marshes, and Emperor Hadrian (117–38 ad) celebrated early efforts to drain Lake Fucinus by minting a coin depicting a farm labourer standing upon a pump. These two coins minted by successive emperors suggest a coordinated long-term public health project. Hippocrates incorporated the four qualities of universal matter (hot/fire; cold/earth; moist/water; dry/air) with the concept of the balance of opposites in order to explain the physiology and pathology of health and disease. The four essentials of life became the four humours, which were blood (hot/moist), black bile (cold/dry), yellow bile (hot/dry) and phlegm (cold/moist). Illness occurred when an external cause upset the balance of the humours. The body reacted to this alteration and attempted to correct the imbalance by mixing (physically and chemically blending) the constituents in order to recreate a perfect fusion of all the humours without any excesses remaining. The process was called ‘coction’ and its occurrence was accompanied by a crisis whereby the remaining excesses were expelled by means of fever, sweating, urination, defaecation, expectoration and vomiting. Sometimes the usual means of evacuation were not successful and the excesses accumulated locally (abscession), causing an abscess or boil, fluid in the body cavities or general oedema. Black and yellow bile did not equate to modern laboratory determined pigments derived from the liver and the red cell, i.e. those involved with choleric and acholuric jaundice. Fahråeus (1921), a Swedish physician who devised the erythrocyte sedimentation rate, suggested that the four humours were based upon the observation of blood clotting in a transparent container. Following the clotting of the homogeneous red fluid, it separates into a dark red/black clot at the bottom with a thin layer of red cells above it. Above this is a pale green or whitish layer and the contents are surrounded by clear yellow serum. Certainly, clotted blood reveals the humours of blood and yellow bile, but the appearance of black bile and phlegm is not so apparent. The ancient philosophers agreed about blood and its function and their views were upheld for nearly two thousand years. Galen (on Natural Faculties translated 1952) and Celsus (De Medicina translated W. G. Spencer, volume I, reprinted 1960) summarized these beliefs. Haematopoiesis occurred in the veins in which nutrients in proper balance were converted by innate body heat into blood. The lack of body heat resulted in decreased production of blood, and severe chilling of the whole (a possible clinical of heart severe Galen 1952) that be on the different of for blood production rather than on the process of its A complexion the presence of and thin blood and The was thought to in the same that blood flesh and the qualities of were it was not associated with was by the and The had the of and all that it with and In all nutrients to the and portion of were not by innate heat and were to the The of a while the presence of in the body caused the to and humours associated with a was in and the blood was and disease was recognized as a cause of Celsus 1960) made one to a of which was the of water in which the from to had his red hot treatment of the that on The eating of was to and it was recorded that animals by had In were fevers accompanied by pain and a variety of local were recommended for to be in order to the of pain from the to the area was recognized and a of the was described with of dark blood, of and Marcus was one of the Roman of the century bc. 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The depicting is a unique and by the of specific treatment of deficiency. 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In the were of its for modern Dr W. a and his about the he a in at the The was a with severe deficiency as a result of The heart was the were and was She was on and the before the had made any in Dr the and, without this the of the would have to be and no one would be to a Dr that resulted from a in both and These both the of the and the of the red is not black but is dark and spread might and with the in blood might A more and the of is credited with the of the in Dr observation that the before any in the anaemia that only a the green complexion and the to the and to was as the Hippocrates (Fig He acquired this by as they presented at the and by that upon their and clinical He as a of but in treatment by which a or to the animal which are and of © With of the of of He bleeding and with some but for and he recommended that this be of ‘the strength and the the pale and death a and This was the of as a specific for He made this years before and the presence of in the of blood and years before the deficiency of in blood not only did the laboratory that was correct but also on to that could not be or incorporated into was the for laboratory medicine that in his of and of Medicine, stated is present in the of before they are on it that the disease not result from a deficiency of It was not the that the of and the of the of many of with the laboratory was responsible for years of specific for their and was the specific for anaemia in the ancient and modern world. He did this by the laboratory and as the of There are many and century and who to the presented but did not a The is for the of and for the by Dr The Natural of and and the