A small child is brought into a modern day ER. Her newly transplanted ear is looking like it wants off and the doctors are out of suggestions. It seems the painful and engorged ear will have to come off just a few days after it was put on. But a voice calls from a forgotten cot. A creaky Vietnam veteran urges the doctors to apply leeches to the ear. At the end of their collective rope, the doctors indulge the old man. Low and behold, the child's ear recovers. The moral: sometimes all the degrees in the world are nothing compared to antiquated medical quackery brought back to the west from war-ravaged jungles.

So the story runs, anyway. A few years ago it (or something like it) was very popular in the nation's newspapers and magazines. Today it enjoys a healthy repertory career. It makes for a cute, feel-good story about segmented worms gorging on a small child's flesh. It also marked the leech's triumphant return to the halls of legitimate medicine as one of the best ways to curb the venous congestion that can result from transplanting skin or reattaching fingers.

Of course, like all good quackery, bloodletting (also known as phlebotomy and venesection) was broadly accepted once upon a time. Indeed, leeches and lancets had their millennia in the sun, being prescribed for everything from fever to obesity.

During may of its centuries atop the medical heap, bloodletting was practiced with justifications that dated back to the ancient Greeks, who held that human health was dependent on the balance of the four basic elements; blood, black bile, yellow bile and phlegm. When one of these seemed too prevalent it made all the sense in the world to crack open a vein and reestablish homeostasis.

Surgery, forsaken by most physicians, was taken up by barbers who not only cut hair but let blood, amputated limbs, and pulled teeth. The red and white pole that symbolizes the barbershop is an old-time illiterate advertisement: "Bloodletting spoken here." The red stands in for the blood, the white for the tourniquet used to stop the bleeding, and the pole itself is a symbol for the rod the patient clasped to dilate the veins that were to be cut. (For those who have given blood this may sound all too familiar.) Anyone feeling ill and desiring some internal balance could pop round to the barber and have blood let, usually until he fainted. This means anywhere from 16 - 30 ounces left the body in one sitting. If the patient did not show improvement this could go on for several days.

Slowly, scientific inquiry and empirical study came back into fashion and bloodletting became one of the first medical procedures to undergo the sometimes vigorous, sometimes insane process of modern written review. Pamphlets, books, and treatises dedicated entirely to bloodletting became common place as the practice itself peaked in the 18th and 19th centuries.

Starting around 1800, contrarians made themselves heard, with some physicians condemning phlebotomy as irresponsible. They argued the process drained a patient of his strength just when he needed it the most. Other physicians combated this point of view by narrowly defining when and how bloodletting should be employed. The idea of the four elements was abandoned and a new rationale for letting blood emerged. Certain ailments, it was decreed, were the result of slowed circulation caused by an excess of blood in the body. William Cockburn, who published one of the first books on phlebotomy in 1736, wrote that the veins and arteries of a feverish patient were "stuffed and filled with blood." Letting a few pints at the physician's discretion, not the patient's, would allow the body's remaining blood supply to circulate more freely and bring relief from fevers and inflammation.

Amid the flurry of discourse, safety received new emphasis. The guidelines for how much blood was to be drained became stricter. The area to be bled was commonly dressed and prepared with elaborate concoctions, oftentimes involving cream of tartar. The patient was no longer stood up and bled until he reached syncope (that is, vertigo, fainting, and a slowed heart beat) mercifully leaving him with at least some modicum of strength.

In 1804, Dr. Elias Winfield published a treatise "Relative to the effects of blood-letting in fevers." Winfield condemned the overuse of phlebotomy, claiming (with tongue planted firmly in cheek) that most physicians would use bloodletting to cure hydrophobia. Winfield continued, "A modern physician. . . is considered a mere unqualified novice, destitute of professional acquirements and talents, if he does not use the lancet and it's auxiliary attendants." Winfield said letting blood was "fraught with disaster, and probably in many instances destructive." While the good doctor was hesitant (noting that every "evacuation" after the first two only seemed to harm the patient "proportionate to its frequency") it did not stop him from writing a lengthy dissertation on when and how one should let blood.

A contemporary of Winfield's, Jean Charles van Rotterdam published a treatise on bloodletting in fevers that further cautioned physicians and patients in the overuse of the process. While acknowledging that a quickened pulse (a common way for doctors to determine if the patient had an excess of blood) may indicate the need for an incision, one must take care to factor in sex, age, and temperament.

With this growing concern that bloodletting may be a broadsword where only a scalpel was needed (perhaps that's a poorly chosen metaphor) the use of leeches became more widespread. The United States alone imported 30 million European leeches per year during the 1830s. Even today the flat, little worms are the best way to let blood thanks to their saliva's phlebotomous cocktail of anesthetics, vasodilators, anti-coagulants, and dispersal agents. Like all good cottage industries, bloodletting was big business and leeches were pushed to the brink of extinction before farms were established to meet the need.

The popularity of this method culminated with a treatise dedicated solely to leeches published in the early 1800s. The article, titled "A Concise Treatise on Leeches. . . That most Singular and Valuable Reptile," was penned by Dr. George Horne. After assuring his readers that his project was in much demand, Horne launched into discourses on the different species of leech, their physiology and how to apply the "reptile," among many other subjects.

The key to using leeches, Horne wrote, is that after they fall off the patient should "keep bathing the orifice, in order to encourage bleeding as long as possible, and not the least danger can ensue from the continuation thereof." (This bit, at least, jives with modern leech use.) Horne urges those who keep leeches in their homes to "put a little moss among them, for they are much enamoured with it." Anthropomorphism aside, it is important to keep the worms about the house, for Horne recommends their use for everything from fevers to black eyes to headaches to venereal disease (among men anyway). For the last, the prescribed treatment is to "apply six or eight leeches to the bag; when the leeches come off, let the orifices bleed till they stop themselves." Leeches take about a half of an hour to gorge themselves. How a man is supposed to pass thirty minutes with eight leeches on his scrotum, Horne does not say.

Headaches call for leeches on the temples. Black eyes can be cleared up with leeches just under the eye. Bronchial congestion can be eased with a few leeches on the "pit of the stomach." In all these cases Horne argues that the "useful creatures collect and absorb the obstructed fluids" helping to promote circulation and "carry off the complaint."

The use of leeches only declined after this. Perhaps Horne's over enthusiasm hastened their decrease in popularity. Now leeches have a new medicinal use and the body of leech literature is again on the rise, although the new batch lacks the bold vision and charming lunacy of the first. 2000 and 2001 saw a flurry of leech praise in publications like the Journal of Audiovisual Media in Medicine and The American Surgeon, but the discussion now centers on the tightly proscribed use of leeches post-microsurgery. The blood to be let is discussed in milliliters, not ounces, and no one suggests applying leeches "to the bag," let alone the temples.

Still, since 1900 most doctors have gone well beyond Cockburn's guarded skepticism, and declared general phlebotomy quackery, though in many third world countries medicinal phlebotomy is still practiced. As recently as 1997, CNN reported on a string of deaths in India related to excessive bloodletting.

Indeed, despite the obvious appeal of the story of the little girl and her veteran lifesaver leading to a leech renaissance in American medicine, phlebotomy has not been a carefully controlled practice for most of its long history. There are plenty of horror stories to counter the happy ending of The Transplanted Ear and Too Much Blood. I would be remiss if I didn't close with at least one such cautionary tale and give modern medicine a fair shake, even if its literature uses phrases like "outflow obstruction in pedicle flaps."

In December of 1799 a wealthy Virginia plantation owner fell ill. He had contracted a throat infection and was having difficulty breathing. His team of doctors bled him. One young upstart recommended a controversial new practice he had seen in Scotland: the tracheotomy. The young doctor pleaded that the patient needed his strength and further bleeding would only drain his energy. The elder doctors dismissed this argument and resumed bloodletting. In 24 hours, nine pints were let from the man's body. On December 14, a very weakened George Washington succumbed to an infection that today would be diagnosed as strep throat.

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