Iain Whitaker

Cronfa at Swansea University

British Journal of Oral and Maxillofacial Surgery (2004) 42, 133—137Historical Article: Hirudo medicinalis: ancientorigins of, and trends in the use of medicinalleeches throughout historyI.S. Whitakera,*, J. Raob, D. Izadi c, P.E. Butlerda Department of Anatomy, University of Cambridge, Cambridge, UKb Department of Oral and Maxillofacial Surgery, South Manchester University Hospitals NHS Trust,Manchester, UKc Addenbrooke’s Hospital School of Clinical Medicine, University of Cambridge, Cambridge, UKd Royal Free Hospital, London, UKAccepted 30 October 2003KEYWORDSHirudo medicinalis;Medicinal leech;HistorySummary Blood letting and the therapeutic use of Hirudo medicinalis date back toancient Egypt and the beginning of civilisation. Their popularity has varied over theyears, reaching such a peak in Europe between 1825 and 1850 that supplies wereexhausted. Towards the end of the century they fell out of favour and, during thisperiod, the leech, once used by the physicians of emperors and inﬂuential academicsurgeons, became associated with lay therapists and quackery. Leeches have enjoyeda renaissance in reconstructive microsurgery during the last 15 years, having beenused by maxillofacial [Br. J. Oral Maxillofac. Surg. 41 (2003) 44] and other recon-structive surgeons to aid salvage of compromised microvascular free tissue transfers[Laryngoscope 108 (1998) 1129; Br. J. Plast. Surg. 34 (1984) 358], replanted digits[Int. J. Microsurg. 3 (1981) 265], ears [Ann. Plast. Surg. 43 (1999) 427], lips [Plast.Reconstr. Surg. 102 (1998) 358; J. Reconstr. Microsurg. 9 (1993) 327] and nasal tips[Br. J. Oral Maxillofac. Surg. 36 (1998) 462]. Peer-reviewed evidence suggests thatthe survival of compromised, venous-congested tissues is improved by early applica-tion of a leech [J. Reconstr. Microsurg. 12 (1996) 165; Arch. Otolaryngol. Head NeckSurg. 114 (1988) 1395; Br. J. Plast. Surg. 45 (1992) 235]. Leeches have also recentlybeen used to treat a wide range of conditions, including periorbital haematomas [Br.J. Ophthalmol. 75 (1991) 755], severe macroglossia [Otolaryngol. Head Neck Surg.125 (2001) 649; J. Laryngol. Otol. 109 (1995) 442] and purpura fulminans [Ann. Plast.Surg. 35 (1995) 300]. The ﬁrst medicinal leech farm, Biopharm, was set up in Swanseain 1981 by Dr Roy Sawyer, and now supplies leeches to hospitals all over the world. Inthis paper, we summarise the history of treatment with Hirudo medicinalis from itsorigin to the present day, and take a brief look at the possible future of the annelid.© 2003 The British Association of Oral and Maxillofacial Surgeons. Published by ElsevierLtd. All rights reserved.*Corresponding author. Present address: 8 Avonlea Road, Sale, Cheshire M33 4HZ, UK. Tel.: +44-161-962-7563.E-mail address: iain whitaker@yahoo.com (I.S. Whitaker).0266-4356/$ — see front matter © 2003 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.doi:10.1016/S0266-4356(03)00242-0134 I.S. Whitaker et al.History of leech therapyHirudo medicinalis has stimulated human imag-ination for centuries. Its intimate contact withhumans have provoked a somewhat symbioticrelationship in which the leech feeds off humansand humans use the leech for medicine, storiesand imagery in popular culture12,13 (Fig. 1).It is impossible to note accurately the time whenman learned of the existence of leeches. How-ever, we do know that both the annelid and thedoctor have been closely linked since the darkages. ‘Leech’ is derived from the Anglo-Saxonword ‘laece’ which, when literally translated,means physician. It is also important to note that‘leech’ is etymologically distinct from the Latinword ‘Hirudo’. The name Hirudo medicinalis wasassigned by Linnaeus in 1758.14 Linnaeus (also Carlvon Linné, 1707—1778) was a Swedish botanist,physician and zoologist whose work laid the founda-tions of modern biological systematics and nomen-clature.The ﬁrst recorded use of medicinal leechesdates back to ancient Egypt and the beginning ofcivilisation. Leeches can be seen in wall paintingsfound in sepulchre of the 18th dynasty pharaohs(1567—1308 b.c.). The ﬁrst written record of theirmedicinal use has been attributed to Nicader ofColophain (200—130 b.c.) in his medical poemAlexipharmaca.15 In the 1st century a.d. there wasmore extensive written reference to their usage.About this time, Chinese writings described medic-inal leeching, as did references in Sanskrit, PersianFigure 1 Johnson, James Rawlins. ‘A treatise on themedicinal leech’ (London, 1816) (History & Special Col-lections UCLA Louise M. Darling Biomedical Library).and Arabic literature. The Romans were also famil-iar with leeches during this period, and it was theywho named them ‘Hirudo’.Plinius, described and noted that leeches suckedblood, and documented their useful effects whentreating ‘rheumatic pains, gout or fevers of anykind’. He compared them with sanguisuga–—fromsanguis (blood) and sugo (I suck).The Syrian, Themisson of Laodicae, a pupil ofAsclepiades16 advanced the use of leeches for bloodletting at the beginning of the Christian era. He pos-tulated that evil spirits caused illness and removalof these evil spirits required withdrawal of blood.Galen (130—201 a.d.), physician to Marcus Aure-lius, further advanced the practice of blood lettingthrough the development of his humoral conceptof disease. This concept built on one ﬁrst outlinedby Hippocrates (460—370 b.c.), who believed in therule of harmony and the theory that all body sys-temswere in balance and that disease resulted fromimbalance.Galen taught the importance of maintaining bal-ance between the four bodily ﬂuids, or humours:blood, phlegm, yellow bile and black bile. Each ﬂuidwas associated with a speciﬁc personality charac-teristic. The belief was that removal of the patientsblood would correct the humoral imbalance and re-store good health. Alexander de Tralles (525—605a.d.) even treated hearing loss with leeches, in ad-dition to more novel treatments, such as the juicesof roaches. Avicenna (980—1037 a.d.), believed thatleeches drew blood from deeper sources than wetcupping. His ‘Canon of Medicine’ included severalpages of instruction about leeches.17In the Middle Ages, barber surgeons, armed with astaff for the patient to grasp (so the veins on the armwould stand out sharply), a basin to hold leechesand catch blood, and a copious supply of linen ban-dages, continued the practice of blood letting.The blood stained linen bandages wrappedaround the barber’s pole in the wind was respon-sible for the modern day red and white stripedpole outside some hairdressers salons. The earliestbarber’s poles were surmounted by a leech basin,which in time has transformed into a ball on top ofthe poles.Leeches were kept in special vessels that wereﬁlled with water and had perforated tops to letthem breathe. Early leech jars were glass (Fig. 2),and later ceramic, and were often beautifully dec-orated and highly prized collectors’ items. Forhouse calls, physicians would often carry smallglass or pewter containers containing a dozen orso leeches.18 Leeches were better tolerated thanother methods of blood letting (e.g. the ﬂeam andthe scariﬁer19) (Fig. 3) as the pain of the bite wasHirudo medicinalis: ancient origins of, and trends in the use of medicinal leeches 135Figure 2 Bossche, Willem van den. Historia Medica(Bruxellae, 1639).far less painful than the wound inﬂicted by theother two methods. The ﬂeam consisted of a bladecocked by a spring mechanism, and was also knownas a spring lancet. The scariﬁer was used to makeseveral cuts in the skin at one time, and a bleed-ing cup was placed over the abrasions. In general,leeches were considered to be of greater beneﬁtwhen blood had to be removed from a part of thebody where a lancet or cup could not be used,such as ‘haemorrhoidal tumours, prolapsed rec-tum and inﬂamed vulva . . . watching that they didnot creep out of reach within any of the internalcavities, as serious results might ensue’.27In France, under the inﬂuence of Broussais(1772—1832), head doctor of the Val de Graˆce Hos-pital in Paris and surgeon in Napoleon’s GrandeArmée, the use of leeches spread rapidly.Figure 3 ‘Bloodletting man’. The Calendar of Re-giomontanus (1475).Figure 4 François-Joseph-Victor Broussais (1772—1838).Broussais has been referred to as ‘the most san-guinary physician in history’20 (Fig. 4). He proposedthat all diseases resulted from an excess build upof blood and alleviation of this condition requiredheavy leeching and starvation. French physicianswould commonly prescribe leeches to be appliedto newly hospitalised patients even before seeingthem.21 Leeches became the therapeutic agentpar excellence, and even inspired fashion. Fe-males wore imitation leech decorations; ‘fastidiousladies . . . used to deck their dresses with embroi-dered leeches’22 and their cosmetic uses includedenhancement of their pale complexions.During this period in Russia, Mudrov and Di-adkovsky were equally enthusiastic about usingleeches. They reported that phlebotomy withleeches achieved excellent results in various con-ditions, including inﬂammation of the cerebrum,liver and kidney disease, rheumatism, tubercu-losis, epilepsy, hysterics and sexually transmit-ted diseases. Contraindications to the treatmentwere not mentioned, and it seemed that theytreated patients irrespective of age and state ofhealth.The use of leeches became so popular during thisperiod that the species became endangered in Eu-rope. Patients were prescribed up to 80 leeches asession. Russia consumed about 30 million leechesannually. In 1833 alone, French doctors importedalmost 42 million leeches, and the annual consump-tion approached 100 million. The ever increasingdemand made prices soar, and the French govern-ment granted awards to companies who could im-prove production by developing new stocks frommarshes, streams and ponds. Leech harvesting be-came a popular way of earning money, and people136 I.S. Whitaker et al.waded into ponds and then removed and sold theleeches that had become attached to their feet andlegs.In Germany, they shipped an estimated 30 millionleeches annually to the United States, and Germanauthorities too became concerned about the abilityof the country to meet domestic needs. Europeanleeches were preferred to their American counter-part, Hirudo decora, as the American leech did notmake as deep or as large an incision and drew lessblood. Americans were having difﬁculty in obtain-ing Europeanmedicinal leeches, and in 1835, a $500award was offered to anyone who could breed Eu-ropean leeches in the United States.23By the end of the 19th century, the leech had lostits popularity. This is well illustrated by the recordsof a certain English hospital, which stated that in1832 almost 100,000 leeches were used, whereas50 years later the number had fallen to less than2000 leeches.24 Their therapeutic use did not ﬁtinto the emerging modern concepts of medicine.There was now an increased emphasis on exper-imental methods and stringent restraints on em-pirical methods. With the development of modernphysiology, pathology andmicrobiology, leeches fellout of favour, not only with physicians, but alsowith patients. During this period only occasionalreferences can be found with regard to removal ofblood.Haycraft25 brought leeches back into mainstreamthinking with his discovery in 1884 that a pure anti-coagulating preparation was contained in the salivaof leeches which he named ‘Hirudine’ from theLatin ‘Hirudo’. In hindsight it seems that Haycraftsimply conﬁrmed an earlier observation made by aRussian, Professor Diakonov. In his article Changesof human blood in the leech in 1809, he wrotethat ‘lack of blood coagulation and dissolution ofred blood corpuscles in the leech’s intestinal ducttestiﬁes that some dissolving agent exists there’.In 1955, Markwardt26 isolated and accurately char-acterised Hirudin from leeches’ pharyngeal glands.It was not until 1986 that this potent anticoag-ulant was ﬁrst produced in quantity by geneticengineering.27Medicinal leeches have recently been re-discovered and are used by maxillofacial andother microsurgeons to aid salvage of compro-mised venous engorged tissue, including freeand pedicled ﬂaps, and amputated digits, earsand nasal tips.2—8 Peer-reviewed evidence hassuggested that the survival of a compromised,venous-congested ﬂap is improved by early appli-cation of a leech.9—11In 1981, an American biologist, Roy Sawyer, aban-doned his academic career to found Biopharm Ltd,a company in Swansea, Wales, devoted to breed-ing and farming leeches and developing new drugsfor clinical use. Biopharm estimates that it sup-plies about 25,000 leeches to the United Kingdomand Ireland each year and 60,000 to the UnitedStates.Researchers led by head and neck surgeon Gre-gory Hartig at the University ofWisconsin at Madisonin the United States, are developing a mechanicalleech,28 which they think has distinct advantagesover its ﬂesh-and-blood counterpart.They postulate that the device can deliver anddisperse the anticoagulant heparin better to com-promised tissue, and the device’s porous tip, im-planted just beneath the skin, rotates to inhibit co-agulation further. The development team think thatthe biggest advantage of the mechanical leech is apsychological one, as patients seem to prefer beingattached to a machine than a live creature.The ancient art of applying leeches still has a roleto play in contemporary reconstructive surgery, butwill the mechanical leech force its living counter-part into retirement? Only time will tell.References1. Rao J, Whitaker IS. Use of Hirudo medicinalis by maxillo-facial surgery units in the UK: current views and practice.Br J Oral Maxillofac Surg 2003;41:44—5.2. Utley DS, Koch RJ, Goode RL. The failing ﬂap in facialplastic and reconstructive surgery: role of the medicinalleech. Laryngoscope 1998;108:1129—35.3. Batchelor AGG, Davison P, Sully L. The salvage of congestedskin ﬂaps by the application of leeches. Br J Plast Surg1984;34:358—60.4. Foucher G, Henderson HR, Maneau M, Merie M, Braun FM.Distal digital replantation: one of the best indicators formicrosurgery. Int J Microsurg 1981;3:265—70.5. Cho BH, Ahn HB. Microsurgical replantation of a partial ear,with leech therapy. Ann Plast Surg 1999;43:427—9.6. Walton RL, Beahm EK, Brown RE, Upton J, ReinkeK, Fudem G, et al. Microsurgical replantation of thelip: a multi-institutional experience. Plast Reconstr Surg1998;102:358—68.7. Hirase Y, Kojima T, Hayashi J, Nakano M. Successful upperlabial replantation after 17 hours of ischemia: case report.J Reconstr Microsurg 1993;9:327—9.8. Mortenson BW, Dawson KH, Murakami C. Medicinal leechesused to salvage a traumatic nasal ﬂap. Br J Oral MaxillofacSurg 1998;36:462—4.9. De Chalain TM. Exploring the use of the medicinalleech: a clinical risk-beneﬁt analysis. J Reconstr Microsurg1996;12:165—72.10. Hayden RE, Phillips JG, McLear PW, Leeches. Objectivemonitoring of altered perfusion in congested ﬂaps . ArchOtolaryngol Head Neck Surg 1988;114:1395—9.11. Lee C, Mehran RJ, Lessard ML, Kerrigan CL. Leeches: con-trolled trial in venous compromised rat epigastric ﬂaps. BrJ Plast Surg 1992;45:235—8.Hirudo medicinalis: ancient origins of, and trends in the use of medicinal leeches 13712. Grzimek HCB. Grzinek’s animal life encyclopaedia, vol. 1.New York: Van Nostrand Reinhold; 1974.13. Sawyer RT. Leech biology and behaviour, vols. 1—2. Oxford:Clarendon Press; 1986.14. Mory RN, Mindell D, Bloom DA. The leech and the physician:biology, etymology, and medical practice with Hirudineamedicinalis. World J Surg 2000;24:878—83.15. Wells MD, Manktelow RT, Boyd JB, Bowen V. The med-ical leech: an old treatment revisited. Microsurgery1993;14:183—6.16. Price RA. Treatise on the utility of sangui-suction or leechbleeding. London: Simpkin and Marshall; 1822. p. 3—4.17. Grunner OCA. Treatise on the Canon of Medicine of Avicennaincorporating a translation of the ﬁrst book. London: Luzacand Co; 1930. p. 513—4.18. Kravetz RE. Leech jar. Am J Gastroenterol 2001;96:894.19. Adams SL. The medicinal leech: historical perspectives.Semin Thromb Hemost 1989;15:261—4.20. Rolleston JD. François-Joseph-Victor Broussais 1772 to 1832:his life and doctrines. Proc R Soc Med 1959;22:405.21. Upshaw J, O’Leary JP. The medicinal leech: past andpresent. Am Surg 2000;66:313—4.22. Thearle MJ. Leeches in medicine. Aust NZ J Surg1998;68:292—5.23. Shurtleff B, Channing W, Walker W. Premium for breedingleeches. Boston Med Surg 1835;12:322.24. Hare CJ. Good remedies–—out of fashion. London: Churchill;1883. p. 30—47.25. Haycraft JB. On the action of secretion obtained from themedicinal leech on coagulation of the blood. Proc R SocLond 1884;36:478.26. Markwardt F. Untersuchungen über Hirudin. Naturwis-senschaften 1955;52:537.27. Fields WS. The history of leeching and hirudin. Haemostasis1991;21(Suppl 1):3—10.28. Conforti ML, Connor NP, Heisey DM, Vanderby R, Kunz D,Hartig GK. Development of a mechanical device to replacemedicinal leech (Hirudo medicinalis) for treatment of ve-nous congestion. Rehabil Res Dev 2002;39:497—504.Further reading29. Menage MJ, Wright G. Use of leeches in a case of severeperiorbital haematoma. Br J Ophthalmol 1991;75:755—6.30. Byrne PJ, Bernstein PE. The use of medicinal leeches totreat macroglossia secondary to blunt trauma. OtolaryngolHead Neck Surg 2001;125:649—50.31. Smeets IM, Engelberts I. The use of leeches in a caseof post-operative life-threatening macroglossia. J LaryngolOtol 1995;109:442—4.32. de Chalain T, Cohen SR, Burstein FD. Successful use ofleeches in the treatment of purpura fulminans. Ann PlastSurg 1995;35:300—6.

Historical Article: Hirudo medicinalis: ancient origins of, and trends in the use of medicinal leeches throughout history

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