HISTORY IN MEDIC INE

Medicinal use of leeches in the texts of ancient Greek, Romanand early Byzantine writersimj_1965 624..627

N. Papavramidou1 and H. Christopoulou-Aletra2

1History of Medicine, Department of Anatomy, School of Medicine, Democritus University of Thrace, Alexandroupolis, and 2History of Medicine,

School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece

Key wordshistory of leech, medicinal leech, antiquity,

leech.

CorrespondenceHelen Christopoulou-Aletra, 73 Nikis Avenue,

54622, Thessaloniki, Greece.

Email: ealetra@hotmail.com; ealetra@

med.auth.gr

Received 24 September 2008; accepted 10

October 2008.

doi:10.1111/j.1445-5994.2009.01965.x

Abstract

Blood-letting was a common therapeutic method in antiquity; many meanswere used to draw blood, including the application of leeches. In this paper,ancient Greek, Roman and Byzantine authors up to the 7th century AD werestudied, a research that provided us with references that may be divided intotwo groups: those related to the medicinal use of leeches, and those related tocases in which leeches were swallowed and had to be removed. In the firstgroup, detailed descriptions of the method of usage and of the diseases requir-ing leeching were found. In the second group, brief reference is made to theproblems caused by swallowing leeches, and to the methods used to expelthem from the human organism. The earliest references to the medicinal useof leeches may be found in the writings of Theocritus (3rd century BC),Nicander (2nd century BC) and Horace (1st century BC, while the phenom-enon of swallowing a leech is first mentioned in one of the Epidaurian ‘iamata’dating to the 4th century BC.

Introduction

Blood-letting was one of the most common therapeuticmethods in Greek, Greco-Roman and Byzantine medi-cine. The methods used for this purpose were cupping,venesection and application of leeches. Each methodwas used in different cases, depending on the desirableamount of blood to be extracted and the part of the bodyaffected. For the present paper, we studied texts from the4th century BC to the 7th century AD.

Leeches appear in the Biblical Proverbs as always beingunsatisfied and craving for more blood.1 Aristotle, in hisDe incessu animalium, refers – strictly from the standpointof natural history – to the way leeches move, andcompares them to worms.2 The ability of leeches tosuck blood is mentioned in the poetry of Theocritus.3

In Horace’s The art of poetry: to the Pisos, a leech isdescribed as an animal that would not abandon the skin,unless satiated with blood; in the same way, a mad poetcan become tenaciously attached to anything or anyone.4

On the other hand, Dioscorides (1st century AD) listsleeches among the poisonous animals in his book Devenenis eorumque praecautione et medicatione.5

Medicinal use of leeches

The first use of leeches for medical purposes appears inthe wall of an Egyptian tomb (1567–1308 BC),6 but itis only to Nicander that the earliest written evidence isattributed.

In the 5th century AD, Caelius Aurelianus mentionsthat Themison of Laodicea was the first to use leeches formedical purposes.7 However, Nicander of Colophonappears in the literature to be the actual first, whenwriting that one should apply leeches after having beenbitten by a poisonous animal, so that they extract thepoisoned blood.8

Pliny the Elder believes that leeches relieve the body ofsuperfluous blood and open the pores of the skin. Hementions, however, that once leeches have been used,they have to be used again at the same period in eachsucceeding year and that they only fall off when they losetheir grip through the weight of the blood; if they do notfall off by virtue of their weight, they should be sprinkledwith salt. Pliny also mentions the mishap where a leechleaves its ‘head’ buried in the flesh; such a case wouldleave an incurable wound that could cause death as a

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result of the poisonous nature of leeches. Leeches,according to Pliny, are appropriate for the treatment ofgout and for killing bugs, when used as an ingredient infumigators.9

Aretaeus of Cappadocia prescribes the use of leeches inthree different circumstances: in the case of ‘acute dis-eases of the liver’, in the case of ‘satyriasis’ and for thetreatment of ‘abdominal diseases’. In the first case, thenecessity for leeching derives from the physiology ofthe liver, because the production of blood is attributed tothat organ, whence it is distributed to the entire body. Ifthe passageways are closed, the liver becomes inflamedand bleeding should be induced.10 In the case of ‘satyri-asis’, which was believed to be an inflammation of thenerves of the pubic area causing genital erection accom-panied by intense sexual desire, blood should be removedwith the aid of leeches.10 Finally, leeches are prescribedfor the treatment of ‘abdominal diseases’, caused by theinability of the stomach to digest food.11

During the same period, Demosthenes Philalethes,physician and member of the school founded by Hero-philus,12 refers to the use of leeches for the treatment of‘paralysis of the eye’.13

Archigenes (1st century AD) also refers to leeches,information acquired through the physician Posidonius,(1st century AD) and Aetius of Amida (6th century AD).According to Archigenes, leeches should be used for thetreatment of ‘mania’, by applying them in a circle aroundthe entire head, especially on the bregma.13

A century later, Galen describes the medicinal use ofleeches in his treatise De hirundinibus, cucurbitula, incisioneet scarificatione. He first refers to their preparation beforeuse: leeches just found should be kept in a vase for a dayand fed with a little blood, in order to decrease their‘poison’. Then, the site of the body where leeches are tobe placed should be cleaned with niter and scratchedwith the nails, to increase blood circulation. The leechesshould first be placed in tepid water and cleaned of theslime covering them with a sponge. Next, tepid oil was tobe poured on the body member. After leeches begansucking, it was difficult to extract them, unless the doctorput some ‘salt or ash’ on their ‘mouth’. After theirremoval, cupping was to be used to extract the poison leftat the site from which the leeches drew blood. If blooddribbled from the wound left by the leeches, cumin orflour should be sprinkled on the site.14

The general indication for the use of leeches, describedin the pseudo-Galenic treatise Definitiones medicae, is anexcess of blood, especially when the physician believesthat it is the cause of a disease.15 Leeches are helpful incases of satyriasis or priapism,13 or nasal congestion. Inthe latter case, leeches were to be applied to the tip of thenose to extract the blood gathered there.13

In the same period (2nd century AD), another physi-cian, Menemachus from Aphrodisias, wrote numerousworks no longer extant. We have his views on the useof leeches via Oribasius (4th century AD). According toMenemachus, leeches are applied on ailing parts or onplaces adjacent to them. The site of application of leechesshould be free of fat, ‘because the fat stops their appetite’.In order to extract the leeches from the affected bodilypart, Menemachus proposes the use of hot oil, andrenounces Galen’s use of salt. If the leeches are slow indrawing blood, the physician should superficially scarifi-cate the skin, because ‘when leeches taste blood, theysearch for it even more’. The quantity of blood suckedmay be evaluated either by squeezing the leeches andemptying the blood or by gathering the blood they‘vomit’ after detachment from the body.16

The Emperor Flavius Claudius Julianus, also known asJulian the Apostate, whose physician was Oribasius,12

refers to leeches and their ability to suck unhealthyblood from the body and leave the healthy blooduntouched.17

At the same time, Antyllus, another surgeon, refers tothe medicinal use of leeches in his treatise On the means ofdepletion. Again, none of his works has been preservedand we know of his opinions through the writings ofOribasius, Paulus of Aegina and Aetius of Amida. Antyl-lus suggests the use of leeches 1 day after they have beenfound. After being stored and fed with some blood, theyare left for a period of time to move about, so as todiminish their venom. Before leeches are applied to theskin, the affected part should be rubbed with unrefinedsoda and coated with the blood of animal or damp clay, orscratched by the physician’s nails. ‘Thanks to these prepa-rations, the leeches suck blood more promptly.’16 In orderfor the leeches to keep sucking blood, the physicianshould cut their tails with scissors. To extract them fromthe skin, salt, ash or unrefined soda should be applied ontheir mouth. Their venom should then be removed fromthe affected part with a specific instrument, or by fumi-gation. If blood leaks from the wound left by the leeches’bite, it should be sprinkled with ash from frankincense,cumin or flour, and then be covered with linen soaked inoil. In case extremities are involved, a bandage is used,and if the bleeding has stopped on the second day, thenthe area is washed. According to Antyllus, leeches do notdraw blood from the inner structures, only from super-ficial ones. Leeches are applied to those patients that areafraid of scarification or on those body parts wherecupping cannot be applied, due to their small size or theircurvature. The leeches are removed from the body whenthey have sucked half the blood initially scheduled forremoval. The physician should then allow blood to runfrom the wound for a while.16

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Caelius Aurelianus, another famous physician, sug-gests the use of leeches in cases of headache or mania,with their application on the head, and in cases of inflam-mation of the throat, with their application to the neck.18

Two centuries later, in the 6th century AD, Aetius ofAmida notes that leeches should be used in two cases: inthat of ‘catharsis’13 or in the case of an eye disease called‘onychia’. ‘Catharsis’ is the restoration of the distortedbalance of bodily fluids, specifically blood. ‘Onychia’ isdescribed as a disease where pus accumulates from a deepulcer between the folds of the eye and forms a circlearound the iris. In this case, leeches should be applied tothe temples.13

Alexander of Tralles, at the same period, prescribes theapplication of leeches to the head for the treatment of‘melancholy’.19 Such application makes sense, bearing inmind that in ancient times, ‘melancholy’ was thought tobe caused by an excess of black bile resulting in diseasedcondition of either the brain or the entire bloodstream.20

In the latter case, extracting the diseased blood with theaid of leeches could solve the problem.

Paulus Aegineta, a celebrated physician of the 7thcentury AD, suggests the use of leeches in many cases. Heprescribes leeching in the case of ‘cephalea’, a permanentpain of the head aggravated by noises, cries, bright light,wine-drinking and intense smells. When ‘cephalea’becomes chronic, the use of leeches is indicated.18 Paulusalso suggests leeches for two eye diseases: ‘amaurosis’and ‘ophthalmy’. ‘Amaurosis’ was defined as ‘a completeimpediment of the sight without any apparent affectionabout the eye, without any sensible cause’. For its treat-ment, the application of leeches to the temples was nec-essary.18 ‘Ophthalmy’ was an inflammation of one ormore membranes of the eye, especially the conjunctiva.21

So, if the cause of this disease is a congestion of thehumours accumulated in the head, leeches should beapplied to the forehead, near the affected eye.18 Anotherdisease requiring leeching to which Paulus Aeginetarefers is ‘synanche’, which appears to be an inflammationof the throat. In this case, leeches should be applied to thechin and neck of the patient.18 Finally, leeching is pre-scribed for headaches accompanied by fever, and in thecase of mania, in which cases they are applied especiallyto the head.18

Discussion

The Greek word ‘bd�lla’ derives from the verb ‘bd�llw’,‘to suck’,22 so one of the abilities of leeches is indicated bythe animal’s name itself. In his Natural History, Pliny theElder refers to leeches by their Latin name ‘sanguisuga’(sanguis = blood, ‘suctus’ = to suck).9 Here as well, theability of leeches is clearly denoted. A new name was

attributed to leeches by Carl von Linné (1707–1778):‘Hirudo medicinalis’; here, the term used referred directlyto the medicinal use of leeches.6 Their current Englishname derives from the old English word ‘leace’, meaningdoctor.23 The successive renaming of leeches through thecenturies proves not only their long-standing and impor-tant role in medicine but also their effectiveness. Theirmedicinal use lasted for centuries, reaching its peakduring the 19th century, when great numbers wereimported from various countries to cover medical needs;in France, for example, 30 million leeches per year wereimported.23

Galen introduces the use of leeches, which had beenaltogether ignored by the Hippocratic physicians. Heagrees with Dioscorides, Pliny and Antyllus about the‘poisonous’ nature of leeches, for which Darembergattempts to give an explanation, reckoning that the appli-cation of leeches to a diseased person made it easy totransmit the infected blood to a relatively healthier per-son.16 Thus, the presence of ‘poison’ gave a satisfactoryinterpretation. The point Daremberg makes, however, isnot proved, as direct re-use of the same leech is notmentioned by the authors and was probably impossible,given that leeches are fed from once every 6 months toonce a year.24 Today, things may be explained in fullscientific way: a bacterium, the Aeromonas hydrophila,thrives in the leech’s gut and has been shown to beresponsible for causing infection after its use.25 Galen waswise enough to advise cupping with scarification toextract the ‘poison’ and Antyllus also advised allowingblood to run from the wound after the application ofleeches.

Until the beginning of the second decade of the 20thcentury, physicians supported the use of leeches.23 Today,they are used experimentally for venous congestion, forthe anticoagulant substance of their saliva, and the anti-histaminic vasodilator property that promotes slowbleeding from the area to which a leech is applied. It isalso considered that leeches can be used for several kindsof thromboses in lieu of heparin.23 Thus, contemporaryresearch on the properties found in leeches has explainedthe haemorrhage after the suction of blood, because wenow know the anticoagulant properties of the leeches’saliva.

Leeches were used in all times for their decongestantproperties and are indeed still used for this purpose. Theypromote better local haemostasis, they prevent necrosisor apoptosis of an implanted structure, they induce anti-coagulant treatment (with the secretion of hirudin) andthey secrete anaesthetic, an ‘antihistamine-like vasodila-tion, hyaluronidase that promotes the spread of salivainto the bitten wound’.24 They are also used in recon-structive surgery for the restoration of microvascular

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congestion.25 It appears that the positive effects of thisancient remedy may now be explained through scientificmethods, promising potentially even more uses of thisadmirable creature in medicine.

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