1. health and fitness
2. disease

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Histol'Y 01 Medicine
In Defence of Ancient Bloodletting
P. BRAIN
SUMMARY
The ancients used bloodletting extensively in infectious
and other diseases. When recent work on iron and bacterial
infection is taken into account, it is possible to argue
that bloodletting, which reduced plasma iron and transferrin saturation, might have been of value in increasing
resistance to infection by bacteria or plasmodia. Galen's
bloodletting methods are summarized, and their probable
effect on plasma iron is considered. The ancient physicians, who had no specific remedies for infection whatsoever, may well have been justified in making responsible use of bloodletting, both for the treatment and for
the prophylax:s of infectious disease.
S. Afr. med. J., 56. 149 (1979).
The ancients used bloodletting extensively as a general
therapeutic measure. a practice that began before Hippocrates and became extinct, except for a few special indications, within living memory. Until a few years ago it
would probably have been impossible to put forward a
rational justification of the ancient practice in the light of
modern pathology. I believe, however. that when recent
work on iron and bacterial infection is taken into account
it is possible to argue that the general use of venesection
in infectious disease, which prevailed in antiquity. may have
been justified in the circumstances then obtaining. I attempt such an argument in this article.
By far the most extensive account of bloodletting in
antiquity is that of Galen. In addition to numerous references in other books, he has left 3 extensive works on venesection,' the first dating from his arrival in Rome for the
first time in AD 162. when he was in his early thirties. and
the third from the closing years of his life, some 30
years later. Since no English translations of any of them
have ever been published. it is not surprising that they are
little known today. They offer, however, much interesting
information on Galen's personality and on medical practice
in Rome in his time, in addition to his views on venesection.
Galen used venesection both as an evacuant and as a
revulsive or derivative remedy, but only its use as an
evacuant is relevant to the present argument. The writers
of the Hippocratic corpus in the 5th and 4th centuries
BC, although Galen would like to think otherwise.
generally used venesection only occasionally and in moderation; Galen, on the other hand, employed it in all the
acute infectious diseases and in others. too. as long as the
Natal Blood Transfusion Service, Durban
P. BRAIN. :\1.A .. :\1.0 .. Medical Director
D.lle received:
I
March 1979.
patient's strength permitted and certain other conditions
prevailed. He did not originate this practice. Celsus say
that in his own time, the beginning of the Christian era.
it was a new doctrine that venesection should be used in
almost all diseases,' and this idea does not appear anywhere in the Hippocratic corpus except once in the
Appendix to the work Regimen in Acute Diseases. This
appendix is a lengthy collection of disjointed notes,
generally regarded as spurious (if, indeed, anything in
the Corpus can be regarded as genuine); hence part of
it may well be late. The relevant pas age reads: 'In the
acute diseases you will phlebotomise if the disease appears
severe, and the patients are in the prime of life and in
possession of strength',' and Galen remarks that it i worthy
of Hippocrates and that he should have included it in the
Aphorisms! He is less complimentary about other parts
of the same Appendix,' which makes it clear that he does
not attribute the whole of it to the father of medicine.
Galen employed venesection in the acute diseases both
when the disease was already severe and when it was expected to be so. 'The magnitude of the disease, therefore,
together with the strength of the powers, are the chief
indications for phlebotomy: the first a showing what one
must do, the second as not forbidding it by what ome of
the younger physicians call a contra-indication. For sometimes the patient's condition demands phlebotomy, while
the weakness of the powers forbid it. When both of these
indications require it, it is clearly catled for.'"
This does not apply only when disease is already present.
but also when it is incipient:
'For not only when severe disease is already pre ent is
it the time for phlebotomy, but also whenever it is likely
to occur. The doctrine that Hippocrates enunciated ha
anticipated us by teaching that however much we may
rightly do once diseases are already pre ent, it is nevertheless better for us to forestall them by acting at their beginnings or when they are about to begin. Thu it i possible to carry over the said indication to people in
health. For you will phlebotomise these too when there
is a likelihood that they will be eized with a evere
disease. taking into consideration their age and their
trength. For if someone is apt to fall into a severe di ea e,
even if no sign exists anywhere in the body. we think it
proper to perform phlebotomy. It is enough to con ider
the patient's age. with his strength, 0 that the three thing
comprising the decision are the magnitude of the disease.
whether present or expected; the tage of life in the prime.
and the strength of the power .'7
Prophylactic venesection of the kind mentioned above
should take place at the beginning of spring;" we are told
ature of Man that blood inin the Hippocratic work
crea e in pring. Patient who had u tained injurie
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thought likely to be followed by inflammation were al 0
venesected prophylactically. Even the empiricist physicians,
ay Galen, who based their treatment on experience alone,
used it in this way when some part of the body had been
brui ed.9 Galen believed that in u ing venesection he was
imitating nature. Even irrational brutes, he says, evacuate
themselve by provoking vomiting and giving themselve
enemas, as the ibis doe :'.
'Does nature not evacuate all women every month,' he
a k , 'pouring forth the uperfluity of the blood? . . . Jf
you could learn what great benefit the female sex enjoys
from this evacuation, 1 don't know how you could delay
further and not hasten by every mean to evacuate superfluous blood . . . A woman who is well cleansed is not
eized with gouty or arthritic or pleuritic or peripneumonic
diseases, and neither epilepsy nor apoplexy nor dyspnoea
nor loss of speech ever come on at any time if she is well
cleansed. Was a woman ever seized with phrenitis or lethargy or spasms or tremors or tetany while her periods were
coming? or did you ever know a woman to suffer
from melancholy or madness or haemoptysis or haematemesis, or headache, or suffocation from synanche, or from
any of the major and severe diseases, if her menstrual
secretions were well established? If they are suppressed
again, she is certain to fall into every sort of evil, and when
the evacuations return. they are healing remedies. But
leave the women now and come to the men, and learn
how a many as habitually evacuate the excess by means
of a haemorrhoid, all pass their lives unaffected by
diseases; while those in whom evacuations have been restrained have fallen into the gravest illnesses. Will you not
evacuate even these of blood, not even if they should fall
into a synanche, or into peripneumonia, but through refu ing to retract your erroneous opinions allow so many to
perish? You, perhaps, will do this; 1, on the other hand.
have often cured not only these diseases, but also spasm
and dropsy, by evacuation of blood.'"
Galen regarded a moderate evacuation as 3 cotyles (about
800 ml) of blood." He did not venesect children under
the age of 14 years; in older children, I cotyle might be
removed, followed by a further half cotyle later, if necessary." Even thin people, he said, could have too much
blood; this was what was wrong with an anorexic girl
who had not menstruated for 8 months, so he removed
3 Roman pounds (about I I) over 3 days, which cured
her." Copious venesection, up to 6 pounds (2 I) in one operation, was in Galen's opinion a most effective means of
extinguishing the flame of severe fevers; the amount, however, depended on the patient's strength, and some could
not tolerate the removal of more than a pound and a haiL"
During these heroic evacuations, which continued until the
patient lost consciousne s, his trength, as indicated by the
pulse, had to be carefully watched; Galen knew of three
doctor who had killed patients by evacuating them in thi
way." It wa not always necessary to take the full amount
at one operation; sometime, particularly when there was
an accumulation of crude humour, it might be spread
over everal days. Thi was known a epaphairesis (repeated removal).'~
The Hippocratic belief in beneficial evacuations, whether
by the menses, haemorrhoids, or phlebotomy, which Galen
JOUR
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trongly upported, was no doubt current for many centurie thereafter; by 1946, however, most doctors would
certainly have said that, except in a few special conditions,
there wa no advantage in losing blood. In that year, however, Schade and Caroline'" described a plasma protein.
tran ferrin, which has the property of binding iron. The
iron in the plasma (as distinct from that in the haemoglobin) normally exists bound to transferrin rather than free,
since there is more transferrin than is necessary to bind
the amount of iron that enters the plasma. In normal ubject the transferrin is 30 - 40"{, aturated, and at this level
the binding i extremely firm. As the transferrin saturation increases, however, the binding becomes looser, so
that the transferrin is more easily deprived of some of its
iron, for instance by invading bacteria. Bacteria require
iron, and many species cannot grow in normal human
plasma unless iron is added, the reason being that they
cannot detach iron from the transferrin at its normal level
of saturation; if, however, enough iron is added to saturate
it fully, any excess will exist free in the plasma and bacterial growth will be greatly encouraged. Some bacteria
have developed iron-binding compounds of their own (mycobactin in the case of Mycobacterium Illberculosis) which
are efficient enough to compete with transferrin for iron.
The higher the transferrin saturation, the easier it is for
bacteria to grow; it is not surprising, therefore. that a
natural mechanism exist by which, at the onset of bacterial infection, plasma iron, and hence also transferrin
aturation, falls sharply."
A normal adult has about 4 g of iron, of which about
half is in the haemoglobin and the rest in the iron stores.
principally in the liver. (Plasma iron makes up an insignificant proportion of the total.) When the body is depleted of iron by the removal of red cells, iron is mobilized from the stores, and red cell production is not much
affected until these are almost exhausted. Only then does
the haemoglobin fall to abnormally low levels.'" Plasma
iron, similarly, does not fall to unusually low levels,
de pite losses of blood, while any stores remain; never·
theless it and the transferrin saturation are somewhat
lower in people who are losing blood, such as women
during the reproductive period, than in those who
are not. It has recently become possible to estimate the total
iron stores by the simple method of determining the serum
ferritin level; I Jig ferritin per litre is an indication of about
8 mg storage iron, although this may not apply in all ab·
normal conditions. Z1 It is thus possible to determine easily
whether the subject is in iron balance, i.e. whether losses
in the stools, through the skin and by bleeding are being
made up by absorption of iron from food, so that the
tore remain constant. If more is lost than is absorbed.
the subject is in negative balance and stores decline; if
more is absorbed than is lost, the balance is positive and
stores increase, as they do in many Black men in South
Africa because of the large amounts of iron in their
traditional diet.
Since, then, in plasma at least, it is more difficult for
bacteria to grow if iron and transferrin saturation are at
low levels, it might be argued that this would apply to all
the body fluids and, hence, that in conditions where bacterial infections were prevalent, it might be to the subject'
:2
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advantage to be iron-deficient. The beneficial eva uations
of the Hippocratic authors. in fact, might have been beneficial after all. Is there any evidence that this might be so?
It might be thought that the physicians of the 19th
century were still under the influence of the Hippocratic
writers if they believed this. but the testimony of Trousseau, a most acute clinician, is nevertheless of interest.
He wrote: 'When a very young physician, I was called to
see the wife of an architect, suffering from neuralgia, a
pale woman, presenting every appearance of chlorosis; I
prescribed large doses of preparations of iron ... fn less
than a fortnight there was a complete change: the young
woman acquired a ravenous appetite and an unwonted
vivacity; but her gratitude and my delight did not last
long . . . A short cough supervened, and in less than a
month from the commencement of the treatment, there
appeared signs of phthisis which nothing could impede.'
He wrote of another patient, 'a girl of fifteen, who after
a mild attack of dothinenteria fell into a state of anaemia
and prostration, which I considered chlorosis. I administered ferruginous remedies, which rapidly restored her to
florid health; and although there was nothing in the family
history to lead me to fear the coming calamity, she was
simultaneously seized with haemoptysis and menorrhagia,
and died two months afterwards with symptoms of phthisis_
which had advanced with giant strides. I do not blame the
iron for having caused this calamity; but [ do blame myself
for having cured the anaemia, a condition, perhaps, favourable to the maintenance of the tuberculous affection in a
latent state.''''
Trousseau wrote that very few doctors shared his views,
but that his conviction of their truth increased daily. In
fact. von Niemeyer. the eminent] 9th century authority on
tuberculosis, expressed the contrary view. which is the
orthodox one today. to the effect that the better the
nutrition the better the prognosis. There has recently_
however. appeared some evidence that suggests that Trousseau may have been right. When food shelters were provided for starving nomads in the Ogaden desert, bacterial
and plasmodial infections, previously latent, were lighted
up as soon as they were given a good diet." The same
phenomenon had been observed by others in the treatment of kwashiorkor: there was a grave danger of overwhelming bacterial infection when a good diet was given
to these children.'" apparently because the transferrin. in
common with other plasma proteins. is reduced in consequence of malnutrition. and thus a small amount of
iron will aturate it fully and permit free growth of
bacteria. The same phenomenon has been observed in
domestic cattle. which are free from outward signs of
infection while they are short of food, but become clinically
ill when the rains arrive and food becomes plentifuL'" The
authors of the Ogaden studies have suggested, in fact,
that some such mechanism is an ecological necessity, preventing, by an increased resistance to infection, the total
annihilation of the specie in times of famine, and at the
ame time the unbridled increase of numbers in time of
plenty. through an increased susceptibility to infectious
disease."
There i a significant remark in the Hippocratic work
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151
all/re of Mall, to the effect that in epidemic the body
hould be kept as thin and weak as possible.'" The observation that the state of the highly trained athlete i a
dangerous one also appear more than once in the Corpus.'"
A study specifically implicating iron in the mechanism has
recently been published by the Murrays.'" Somali nomad
who were not malnourished were studied. The diet of
these people i low in iron, and many of them are irondeficient. while otherwise not badly nourished. Of 94
nomads entering the camp, 64 were not iron-deficient according to the criteria adopted,31 and 26 were iron-deficient.
ineteen of the non-deficient subjects, but none of
the deficient ones. howed evidence of infection (malaria
parasites in blood smears. tubercle bacilli in sputum, fever
of unknown origin. pneumonia, hepatiti , eye infection.
brucellosis, etc.). The authors then collected all the available
iron-deficient subjects who showed no evidence of infection, and divided them into 2 groups. The first group of
71 subjects was treated with 900 mg of ferrou sulphate
by mouth daily for 30 days; the control group, numbering
66, received tablets containing no iron. Haemoglobin.
plasma iron. and transferrin saturation increased notably
in the first group. The interesting finding, however, was
that this group had far more epi~odes of infection during
the period of treatment than the group receiving the inactvie tablets. Only ] of the placebo group, compared
with 13 in the group receiving iron, had clinical evidence
of malaria, while malaria parasites appeared in the blood
of 21 of the treated group. but only in that of 2 of the
controls. Tuberculosis was reactivated in 3 of the treated
group_ but in none of the placebo group. In all, there were
46 episodes of clinical infections of various kinds in the
treated group. as against 3 in those receiving the placebo.
The authors suggest that iron deficiency probably play
a part in suppressing certain infections, suggesting that in
Somali nomads it may be part of an ecological corn promi e. Their diet i deficient in iron: 'The iron deficiency.
debilitating in some but rarely fatal. prevent the more
serious consequence of potentially fatal infections with
malaria. tuberculosis. and brucellosis to which the nomad
are constantly exposed . . . It may be unwise to attempt
to correct iron deficiency in the face of quiescent infection. especially in isolated societies where the natural
ecological balance is often a first line of iefence against
severe infections.'
[t is at lea t arguable. therefore. that in certain circumstances iron deficiency might be desirable. TO one would
suggest that it should be encouraged in civilized countrie
today. since we have better method of dealing with infection than the ancients possessed; but the physician of
antiquity was not in this fortunate position. He had no
specific remedie at all. If he could reduce plasma iron
and transferrin saturation by bloodletting. or by omitting
to treat beneficial natural evacuations. he could perhaps
increa e his patients' resistance to infectiou di ease. H. in
Galen's time, the woman who was well cleansed by her
menses was. in fact. somewhat iron-deficient. she might
well have been in the same po ition a the Murray'
Somali nomads: the minor degree of debility from the
anaemia was a small price to pay for very considerable
immunity from the clinical manife tation of infection.
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for which, once they had appeared, there wa no specific
treatment whatever. And the problems of ancient medicine were, for practical purposes, all problems of infection. Malaria, remarks Jones," was undoubtedly the greatest medical problem of antiquity; together with bacterial
diseases of the chest it provided the ancient physician
with most of his work. The only question is how rich in
iron the diet in antiquity was, and what the effects of
bleeding, whether natural or therapeutic, were. These
effects will be considered first.
Fortunately, although bleeding as a therapeutic measure has been almost entirely abandoned, there is abundant information available from blood donors. A single
donation of whole blood, say 400 ml, removes about 200
mg of iron in the form of haemoglobin; Galen would
have regarded it as a small evacuation. Many donors, however, give blood repeatedly at intervals which may be as
short as 2 months, and may thus lose more than 2 I of blood
a year. It has been estimated that a daily loss of 6 - 8 ml,
as a result, for example, of bleeding piles or hookworm
infestation, may put a patient into negative iron balance
even on a normal diet, since even with the increased absorption that prevails in iron deficiency, not enough can
be absorbed from the diet to make up for it.'" This
amount is about the same as that given by a donor who
donates once every 2 months. Laurell'" has published some
figures on the effects of giving blood on serum iron and
transferrin saturation. Seventeen donors, most of whom had
given one previous donation several months before, were
tested before and 1 week after donating 400 ml of blo~d.
The mean serum iron was 117 ,,ug/dl, and the mean transferrin saturation 37%, before the donations; a week
later the figures were 79 .,ug/ dl and 23 ob respectively. This
would be a temporary effect, but might none the less be
significant when a patient was bled at the onset of infection,
as was Galen's practice. A group of 17 donors who had
given repeated donations, totalling between 1,5 and 3 I
per donor in the preceding year, had a mean plasma iron
level of 95 ,ug/ dJ, and mean transferrin saturation of 27%.
These studies were conducted in Sweden immediately
after World War n, and suggest that. at least in the dietary
conditions then prevailing, the loss of even 400 ml of blood
had some effect on plasma iron and transferrin saturation.
while the loss of 2 I or thereabouts in the course of 1 year
reduced both these levels considerably. Laure1J'" also stu·
died 11 patients with haematological signs of iron deficiency. as a result of chronic bleeding from the gut or
uterus. The mean haemoglobin level was nearly
g/d\.
JOUR
28 July 1979
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the mean plasma iron level was 33 .ug/dl and the mean
transferrin saturation was 8 %. These patients would no
doubt correspond to some of those in antiquity who were
enjoying beneficial evacuations from haemorrhoids or
menorrhagia, which the doctors refrained from treating;
this is clear from two observations of Galen's. He says that
bleeding from haemorrhoids was sometimes so severe as
to kill the patient, or to leave him grossly hydropic or
cachectic;" such haemorrhoids would, of course, be treated.
In the management of patients who had not reached this
stage, however, doctors sometimes planned totally unnecessary treatment in an attempt to satisfy them, while
leaving their evacuations unchecked.'"
Further information can be obtained from a study of
blood donors in South Africa. If Galen's methods were
applied to this modern population, what might their effects
be? His moderate evacuation of 3 cotyles removes about
400 mg of iron as haemoglobin, and a single such evacu·
ation should thus precipitate a subject with a plasma ferritin of less than SO ,ug/I into iron deficiency anaemia. In
Table I the serum ferritin levels for new donors (before
any donations have been given) in Durban are shown. The
population groups differ in dietary habits. The means for
Whites are almost identical with those found in Washington State, USA." In Table I it is made clear that the
majority of the women, and an appreciable proportion of
the men, would be rendered anaemic, or brought to the
verge of anaemia, by just one of Galen's moderate evacuations, and that few (except some of the siderotic Zulu
men) could withstand his more heroic ministrations with
haemoglobin levels intact.
The iron content of ancient diets is crucial to the argument. If the diet of most of Galen's patients contained
the same amount of iron as modern Western diets, his
bloodlettings would have approximately the effects mentioned. If, on the other hand, there was as much iron in it
as there is in the diet of the average middle-aged Black
man, the effects would be far less_ Jacques Andn?' has
published a fully documented study of Roman diet, from
which some indications of iron content can be obtained.
There is nothing to suggest that the staple diet of cereals.
vegetables and oil was particularly rich in iron; this would
have been obtained chiefly from meat and from wine.
There is, again, no evidence that the consumption of
animal flesh exceeded that of today; in the early centuries
the Roman diet was in fact largely vegetarian, although
more meat was eaten later. Unless we can discover some
article of diet which contained large amounts of iron and
TABLE I. SERUM FERRITIN LEVELS IN DURBAN BLOOD DONORS
Population group
White
Black (Zulu)
Indian
Sex
Male
Female
Male
Female
Male
Number of
subjects with
serum ferritin
level
Number of
donors
examined
Mean serum
ferritin level
(,ug/I)
SD
96
100
99
100
100
93
36
223
32
65
27
275
41
43
64
<SO,ug/1
26
81
17
85
42
2
Julie 1979
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was taken in very large quantitie
like the traditional
sorghum beer of the modern Black man, who may take
in 150 mg iron a day in beer alone - it is unlikely that
the average patient in Galen's time was in positive iron
balance. Such an article of diet might have existed,
however, in the wine of antiquity. ome red wine today
contain twice a much iron as traditional African beeL"
although they are admittedly usually drunk in smaller
quantities; nevertheless, some French red wine drinker
become siderotic. as do Black. It is possible, therefore,
that the red wines of antiquity contained ubstantial
amounts of iron: on the other hand, they were invariably
drunk diluted with water. There is some evidence that
the wine of poorer quality derived from later pressings
of the grapes might have contained more iron; this is
particularly so of the worst wine. made by macerating
the exhausted skins in water and returning them to the
press. From these the elder Cato prepared 'un horrible
vin d'hiver' for his laves. diluting 260 parts of this
pressing with 1 500 parts of a mixture of fresh and sea
water, vinegar and heated wine. The ration for a slave
engaged in the hardest labour was at most a litre a
day." which, allowing 100 mg iron per litre in the original
pressing. could scarcely, in view of the dilution, have provided more than 10 or 12 mg of iron, most of which in any
case would not be absorbed. Slaves with lighter duties got
only a quarter of this amount.
How much the free man drank depended. of course, on
the price. Under Diocletian, a century after Galen, half a
litre of the best wine sold at the price of a kilogram of
pork, while the same amount of vin ordinaire could be got
for a quarter of that amount. The ratio i almost the same
in South Africa today. Andre's conclusion is that the price
of wine was not excessive at any tage of Roman history,
but on the other hand was never so low that the poor
could use it habitually. Athenaeus, who flourished at about
the time of Galen's death, made the surprising observation
that at that time neither women nor lave in Rome drank
wine, and that the free man began doing so only at the age
of 30." Although women were certainly forbidden wine in
Rome up to 200 BC. Galen mentions it use to bring on
the menses," and we have already seen that the elder Cato
gave wine (if this mixture can be so described) to his laves.
It therefore seems unl ikely that Athenaeus was reporting
correctly the situation in the time of Galen. although it
might well be that most women. through a combination
of tradition and domestic circumstances (fewer parties!)
still drank substantially less wine than men did. thus unwittingly rendering their beneficial evacuation even more
beneficial because of an iron-deficient diet.
It seems likely. therefore, that there was no more iron
in the diet of the average Roman in Galen's time than
there is in ordinary Western diets today, and that many
women, if not men. were therefore in negative iron balance. That this was so in Galen's time. if my thesi is correct. would appear from Galen's observation that women
who had copious menstrual evacuations were protected
from many diseases. as were men who had bleeding
haemorrhoids.
Although there i now ome theoretical ground for believing that iron deficiency might have thi protective effect
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and some evidence that it is 0 in pra tice, it mu t be made
clear that the problem i not imple. Cau ation in medicine
i always complex. the result of many factors which
have different, and ometime oppo ite, effe t . There is
evidence that cell-mediated immunity i defective in iron·
deficient ubjects," uggesting that such ubject might be
more rather than le . u ceptible to viru disease; and
furthermore, there is no doubt that iron deficiency anaemia.
by \ eakening the patient. might decrea e re i tan e to
di ease. Galen was clearly aware of this, since he took into
account the patient'
trength when onsidering veneection, and stopped the evacuation at once if it eemed
to be failing. Hi use of epaphaire i is interesting; by
taking blood in repeated smaller amounts rather than in
one large one he could reduce plasma iron and transferrin
aturation without dangerously diminishing the blood
volume and imperilling life. My the is i that. in the conditions prevailing in Galen's time. the good effect of
moderate iron deficiency. in increasing resistance to certain
infections, outweighed the bad effects of debilitating the
patient. If, by removing blood. the physician of the time
was able to prevent, or to keep latent, infections that, once
established, he was powerle
to cure. he wa right in
using phlebotomy. This wa clearly the experience of most
practitioners, since Galen tells u tliat the empiricist school.
who abjured all theory and based their treatment purely
on experience, all made use of it. Tt wa not. however.
universally practised by competent phy icians: the great
exception was Erasistratus'" That uch a man could acquire
a distinguished reputation without ever employing vene·
section show that its benefits were not so entirely obviou
that no one could ignore them and make a uccess of
practice. Erasistratus. however. like his master Chry ippu .
wa an exception. Almost every other celebrated physician
of antiquity. and for many centuries thereafter. made ome
use of the remedy: is it conceivable that they were all
completely wrong?
REFERENCES
C. G .. ed. (1964): Clalld,i Gale"i Opera Omnia, 20 vol,.
Hildesheim: G. Olms. (Reprint of the 19th century edition.) Abbreviated
to K. The 3 works are in K XI. pp. 147 - 316.
Celsus: De Medici"a, H. 10.. I.
littre, E., ed. (1962): Qellvres completes d'Hippocrate, 10 vol'.
Amsterdam: A. Hakken. (Reprint of the 19th century edition)
Abbreviated to L. The passage is in L 2. 39 .
K XV, 763.
e.g. K XV, 891. 893.
K Xl, 289 - 90.
K XI, 277 - 8.
K XI, 27I.
K X, 27.
K X, 16. The ibis. according to one old auth.,r. . purges itsell
I. Kiihn,
2.
3.
4.
5.
6.
7.
9.
10.
at tbe fundament with its crooked beak.'
I I.
12.
13.
14.
IS.
16.
17.
1 .
19.
20.
11.
22.
23.
K Xl, 165 - 6.
K XI. 174.
K XI, 290 - 91.
K XVI lb.
I. As she was of a prominent family. Galen sub·
sequently received many such patients. whom he cured in the ~ame
way. This is perhaps the first account of anorexia nervosa in the
literature. and Galen's cure was presumably psychologica1.
K XI. 294.
K Xl, 2 - 9.
K Xl, 2 6.
Schade, A. L. and Caroline. L. (I 46):
ience, 104. 340.
For reviews of the topic ee Weinbers. E. D. (1974): Science, 184,
952: Kochan. I. (1973): Curr. Top. Microbiol. Immunol.. 60. I'
Bullen. J. J.• Rogers. H. J. and Grifliths. E. (197 ): Ibid .• 80. I.
Bothwell. T. H. and Finch. C. A. (1962): Iron Metabo/lsm. p. 2 I
London: Churchill Livingstone.
Jacobs. A. (1977): Semin. Haemat.. 14. 89.
Trousseau, A. () 6 - 72): l.eClures 0" Clinical AIel/idOl!. vol
V,
D.
9. London:
ew Sydenham Society.
Von Niemeyer. F. (I 70): Clinical Lec/urn 011 Plllmollary Con·
sumption. London:
lew
ydenham
iety
A
154
MEDICAL
24. t\1urray.
J .. i\1urray. 1\1. B..
1urrJ.Y. A. B. et al. (1976) :
L1.ncet, I. 12 3.
t\.1cFarlane. H .. Reddy. S.. Adcock. K. J. et 0/. (1970) : Brit. med. J ..
4. 26 .
ciety of Medicine (1937) : Proc. roy.
26. Royal
oc. I\led .. 30. 1039
and 1O~9.
27. Murray. M. J. and Murray. A. B. (1977) : Lancet. I. 123.
2 . L 6. 56.
29. e.g. L 9, 110.
30. Murray, M. J .. M Lirray. A. B.. Murray. M. B. et al. (197 ): Bnt.
med. J .. 2, 1113.
31. Haemoglobin less than 11 g/dl. serllnl iron less than 25 !'g/dl.
transferrin saturation less than 15%. with hypochromia and micro·
cYlosis in the meaT.
32. Jones, W. H. S. (trans.) (1923): HipPOCTlllf!..'i. vol. I. pp. Ivi· Ivii.
2-
33.
34.
3 -.
36.
37.
38.
39.
40.
41.
42.
43.
44.
28 July 1979
JOUR TAL
London and Cambridge. 1ass: Loeu ClaSSiC.l) Libr~r)'.
BOlhwell and Finch. p. 315.
LaureIl, C-B. 09:+7): Acta physiol. sc::md.. 1-1. <;juppl. ~6. S2.
K Xl, 307.
K XI. 170.
Worwood. M. (1977): Semin. Haemat.. 1·1. 21.
Andre, J. (1961): L'A{imemQtioll et la CUOllle f; Rome. Parl~
Klincksieck.
Jacobs. pp. 9 ·9.
Andr';. pp. 164· 5.
Andr';. pp. 170· I.
K XL 205.
Joynson. D. H. M .. Jacobs. A .. Walker. D. M. et al. (1972):
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Galc:l's first work on venesection is a polemic against Ensistralll"_
Curiosa Paediatrica
n
THEODORE lAMES
SUMMARY
A small series of a dermal curiosity occurring in children
is described. It appears not to have been presented
heretofore in medical writings and certainly not in our
South African medical literature. The constancy of its
presentation suggests strongly a genetic localization for
its origin (if not a fanciful one!) and the name foveae
scapularum cutaneae bilaterales congenitae in true dermatological fashion is wholly descriptive, ponderous
though it be for such light 'residua pennarum'!
S. A/,.. med. l., 56. 154 (1979).
During recent years I have collected a small series of
6 children, ranging in age from I to 6 years, with a curious
dermal anomaly. The presenting complaints of the children
were entirely unrelated. One of the 6 children was brought
to me by a colleague to whom I had demonstrated the
feature with its striking constancy. owhere in the nume·
rous departments of our medical literature have I seen
a mention of the curiosity, which deserves recording if
only for its surely genetic origination.
Fig. 1 shows scapular dimples which occur over the
acromions of the spines of the scapulas. In 5 instances
the symmetry and sameness of the dimples were remarkable; in the 6th child the right dimple was less in
Pinelands, CP
TflEODORE J:\\IE·.
Date received:
24 Octoher
~I.Ll.
197
(,I
LB.
Fig. 1. Scapular dimples.
depth than its twin on the left, but distinct, nonetheless.
That the dimples are congenital I have no doubt. although the youngest exhibitor was only a little less than
I year old. The oldest in the series had turned 5 years.
All were Coloured children, and therefore of mixed blood.
but there is no contributory evidence that the anomaly
is necessarily genetically connected with pigmentation of
the skin and no famili()l relationship among the children
could be determined.
I cannot even venture to guess at the dermato-ana·
tomical significance of the genetic nature implicit in its
constancy other than a whimsical 'residua pennarum·.
but a suitable name for it would be foveae scapularum
cutaneae bilaterales congenitae. satisfactory for a dermal
curiosity of unknown origin.