Internal Medicine Journal 39 (2009) 624627

H I S TO RY I N M E D I C I N E

Medicinal use of leeches in the texts of ancient Greek, Roman

and early Byzantine writers
imj_1965

624..627

N. Papavramidou1 and H. Christopoulou-Aletra2

1
History 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 words
history of leech, medicinal leech, antiquity,
leech.
Correspondence
Helen 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 means
were used to draw blood, including the application of leeches. In this paper,
ancient Greek, Roman and Byzantine authors up to the 7th century AD were
studied, a research that provided us with references that may be divided into
two groups: those related to the medicinal use of leeches, and those related to
cases in which leeches were swallowed and had to be removed. In the first
group, detailed descriptions of the method of usage and of the diseases requiring leeching were found. In the second group, brief reference is made to the
problems caused by swallowing leeches, and to the methods used to expel
them from the human organism. The earliest references to the medicinal use
of leeches may be found in the writings of Theocritus (3rd century BC),
Nicander (2nd century BC) and Horace (1st century BC, while the phenomenon of swallowing a leech is first mentioned in one of the Epidaurian iamata
dating to the 4th century BC.

Introduction

Medicinal use of leeches

Blood-letting was one of the most common therapeutic

methods in Greek, Greco-Roman and Byzantine medicine. The methods used for this purpose were cupping,
venesection and application of leeches. Each method
was used in different cases, depending on the desirable
amount of blood to be extracted and the part of the body
affected. For the present paper, we studied texts from the
4th century BC to the 7th century AD.
Leeches appear in the Biblical Proverbs as always being
unsatisfied and craving for more blood.1 Aristotle, in his
De incessu animalium, refers strictly from the standpoint
of natural history to the way leeches move, and
compares them to worms.2 The ability of leeches to
suck blood is mentioned in the poetry of Theocritus.3
In Horaces The art of poetry: to the Pisos, a leech is
described as an animal that would not abandon the skin,
unless satiated with blood; in the same way, a mad poet
can become tenaciously attached to anything or anyone.4
On the other hand, Dioscorides (1st century AD) lists
leeches among the poisonous animals in his book De
venenis eorumque praecautione et medicatione.5

The first use of leeches for medical purposes appears in

the wall of an Egyptian tomb (15671308 BC),6 but it
is only to Nicander that the earliest written evidence is
attributed.
In the 5th century AD, Caelius Aurelianus mentions
that Themison of Laodicea was the first to use leeches for
medical purposes.7 However, Nicander of Colophon
appears in the literature to be the actual first, when
writing that one should apply leeches after having been
bitten by a poisonous animal, so that they extract the
poisoned blood.8
Pliny the Elder believes that leeches relieve the body of
superfluous blood and open the pores of the skin. He
mentions, however, that once leeches have been used,
they have to be used again at the same period in each
succeeding year and that they only fall off when they lose
their grip through the weight of the blood; if they do not
fall off by virtue of their weight, they should be sprinkled
with salt. Pliny also mentions the mishap where a leech
leaves its head buried in the flesh; such a case would
leave an incurable wound that could cause death as a

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Leeches in antiquity

result of the poisonous nature of leeches. Leeches,

according to Pliny, are appropriate for the treatment of
gout and for killing bugs, when used as an ingredient in
fumigators.9
Aretaeus of Cappadocia prescribes the use of leeches in
three different circumstances: in the case of acute diseases of the liver, in the case of satyriasis and for the
treatment of abdominal diseases. In the first case, the
necessity for leeching derives from the physiology of
the liver, because the production of blood is attributed to
that organ, whence it is distributed to the entire body. If
the passageways are closed, the liver becomes inflamed
and bleeding should be induced.10 In the case of satyriasis, which was believed to be an inflammation of the
nerves of the pubic area causing genital erection accompanied by intense sexual desire, blood should be removed
with the aid of leeches.10 Finally, leeches are prescribed
for the treatment of abdominal diseases, caused by the
inability of the stomach to digest food.11
During the same period, Demosthenes Philalethes,
physician and member of the school founded by Herophilus,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 the
treatment of mania, by applying them in a circle around
the entire head, especially on the bregma.13
A century later, Galen describes the medicinal use of
leeches in his treatise De hirundinibus, cucurbitula, incisione
et scarificatione. He first refers to their preparation before
use: leeches just found should be kept in a vase for a day
and fed with a little blood, in order to decrease their
poison. Then, the site of the body where leeches are to
be placed should be cleaned with niter and scratched
with the nails, to increase blood circulation. The leeches
should first be placed in tepid water and cleaned of the
slime covering them with a sponge. Next, tepid oil was to
be poured on the body member. After leeches began
sucking, it was difficult to extract them, unless the doctor
put some salt or ash on their mouth. After their
removal, cupping was to be used to extract the poison left
at the site from which the leeches drew blood. If blood
dribbled from the wound left by the leeches, cumin or
flour should be sprinkled on the site.14
The general indication for the use of leeches, described
in the pseudo-Galenic treatise Definitiones medicae, is an
excess of blood, especially when the physician believes
that it is the cause of a disease.15 Leeches are helpful in
cases of satyriasis or priapism,13 or nasal congestion. In
the latter case, leeches were to be applied to the tip of the
nose to extract the blood gathered there.13
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Journal compilation 2009 Royal Australasian College of Physicians

In the same period (2nd century AD), another physician, Menemachus from Aphrodisias, wrote numerous
works no longer extant. We have his views on the use
of leeches via Oribasius (4th century AD). According to
Menemachus, leeches are applied on ailing parts or on
places adjacent to them. The site of application of leeches
should be free of fat, because the fat stops their appetite.
In order to extract the leeches from the affected bodily
part, Menemachus proposes the use of hot oil, and
renounces Galens use of salt. If the leeches are slow in
drawing blood, the physician should superficially scarificate the skin, because when leeches taste blood, they
search for it even more. The quantity of blood sucked
may be evaluated either by squeezing the leeches and
emptying the blood or by gathering the blood they
vomit after detachment from the body.16
The Emperor Flavius Claudius Julianus, also known as
Julian the Apostate, whose physician was Oribasius,12
refers to leeches and their ability to suck unhealthy
blood from the body and leave the healthy blood
untouched.17
At the same time, Antyllus, another surgeon, refers to
the medicinal use of leeches in his treatise On the means of
depletion. Again, none of his works has been preserved
and we know of his opinions through the writings of
Oribasius, Paulus of Aegina and Aetius of Amida. Antyllus suggests the use of leeches 1 day after they have been
found. After being stored and fed with some blood, they
are left for a period of time to move about, so as to
diminish their venom. Before leeches are applied to the
skin, the affected part should be rubbed with unrefined
soda and coated with the blood of animal or damp clay, or
scratched by the physicians nails. Thanks to these preparations, the leeches suck blood more promptly.16 In order
for the leeches to keep sucking blood, the physician
should cut their tails with scissors. To extract them from
the skin, salt, ash or unrefined soda should be applied on
their mouth. Their venom should then be removed from
the affected part with a specific instrument, or by fumigation. 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 in
oil. In case extremities are involved, a bandage is used,
and if the bleeding has stopped on the second day, then
the area is washed. According to Antyllus, leeches do not
draw blood from the inner structures, only from superficial ones. Leeches are applied to those patients that are
afraid of scarification or on those body parts where
cupping cannot be applied, due to their small size or their
curvature. The leeches are removed from the body when
they have sucked half the blood initially scheduled for
removal. The physician should then allow blood to run
from the wound for a while.16

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Papavramidou & Christopoulou-Aletra

Caelius Aurelianus, another famous physician, suggests the use of leeches in cases of headache or mania,
with their application on the head, and in cases of inflammation of the throat, with their application to the neck.18
Two centuries later, in the 6th century AD, Aetius of
Amida notes that leeches should be used in two cases: in
that of catharsis13 or in the case of an eye disease called
onychia. Catharsis is the restoration of the distorted
balance of bodily fluids, specifically blood. Onychia is
described as a disease where pus accumulates from a deep
ulcer between the folds of the eye and forms a circle
around the iris. In this case, leeches should be applied to
the temples.13
Alexander of Tralles, at the same period, prescribes the
application of leeches to the head for the treatment of
melancholy.19 Such application makes sense, bearing in
mind that in ancient times, melancholy was thought to
be caused by an excess of black bile resulting in diseased
condition of either the brain or the entire bloodstream.20
In the latter case, extracting the diseased blood with the
aid of leeches could solve the problem.
Paulus Aegineta, a celebrated physician of the 7th
century AD, suggests the use of leeches in many cases. He
prescribes leeching in the case of cephalea, a permanent
pain 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 Paulus
also suggests leeches for two eye diseases: amaurosis
and ophthalmy. Amaurosis was defined as a complete
impediment of the sight without any apparent affection
about the eye, without any sensible cause. For its treatment, the application of leeches to the temples was necessary.18 Ophthalmy was an inflammation of one or
more membranes of the eye, especially the conjunctiva.21
So, if the cause of this disease is a congestion of the
humours accumulated in the head, leeches should be
applied to the forehead, near the affected eye.18 Another
disease requiring leeching to which Paulus Aegineta
refers is synanche, which appears to be an inflammation
of the throat. In this case, leeches should be applied to the
chin and neck of the patient.18 Finally, leeching is prescribed for headaches accompanied by fever, and in the
case of mania, in which cases they are applied especially
to the head.18

Discussion
The Greek word bdlla derives from the verb bdllw,
to suck,22 so one of the abilities of leeches is indicated by
the animals name itself. In his Natural History, Pliny the
Elder refers to leeches by their Latin name sanguisuga
(sanguis = blood, suctus = to suck).9 Here as well, the
ability of leeches is clearly denoted. A new name was

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attributed to leeches by Carl von Linn (17071778):

Hirudo medicinalis; here, the term used referred directly
to the medicinal use of leeches.6 Their current English
name derives from the old English word leace, meaning
doctor.23 The successive renaming of leeches through the
centuries proves not only their long-standing and important role in medicine but also their effectiveness. Their
medicinal use lasted for centuries, reaching its peak
during the 19th century, when great numbers were
imported from various countries to cover medical needs;
in France, for example, 30 million leeches per year were
imported.23
Galen introduces the use of leeches, which had been
altogether ignored by the Hippocratic physicians. He
agrees with Dioscorides, Pliny and Antyllus about the
poisonous nature of leeches, for which Daremberg
attempts to give an explanation, reckoning that the application of leeches to a diseased person made it easy to
transmit the infected blood to a relatively healthier person.16 Thus, the presence of poison gave a satisfactory
interpretation. The point Daremberg makes, however, is
not proved, as direct re-use of the same leech is not
mentioned by the authors and was probably impossible,
given that leeches are fed from once every 6 months to
once a year.24 Today, things may be explained in full
scientific way: a bacterium, the Aeromonas hydrophila,
thrives in the leechs gut and has been shown to be
responsible for causing infection after its use.25 Galen was
wise enough to advise cupping with scarification to
extract the poison and Antyllus also advised allowing
blood to run from the wound after the application of
leeches.
Until the beginning of the second decade of the 20th
century, physicians supported the use of leeches.23 Today,
they are used experimentally for venous congestion, for
the anticoagulant substance of their saliva, and the antihistaminic vasodilator property that promotes slow
bleeding from the area to which a leech is applied. It is
also considered that leeches can be used for several kinds
of thromboses in lieu of heparin.23 Thus, contemporary
research on the properties found in leeches has explained
the haemorrhage after the suction of blood, because we
now know the anticoagulant properties of the leeches
saliva.
Leeches were used in all times for their decongestant
properties and are indeed still used for this purpose. They
promote better local haemostasis, they prevent necrosis
or apoptosis of an implanted structure, they induce anticoagulant treatment (with the secretion of hirudin) and
they secrete anaesthetic, an antihistamine-like vasodilation, hyaluronidase that promotes the spread of saliva
into the bitten wound.24 They are also used in reconstructive surgery for the restoration of microvascular
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Leeches in antiquity

congestion.25 It appears that the positive effects of this

ancient remedy may now be explained through scientific
methods, promising potentially even more uses of this
admirable creature in medicine.

References
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2 Aristotle. De Incessu Animalium (Farquharson ASL, trans.).
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3 Theocritus. The sorceress. In: Hunter R, trans. Theocritus.
Idylls. London: Oxford University Press; 2002; 8.
4 Horace. The art of poetry: to the Pisos. In: Smart C,
trans. Horace. The Works of Horace. New York: Harper &
Brothers; 1863; v. 476.
5 Dioscorides. De venenis eorumque praecautione et
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Anazarbei Per dhlhthrwn, ioblwn kai euporstwn
Spuria. Lipsia: Car. Cnoblochii; 1830; 14.
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11 Aretaeus. De Curatione Diuturnorum Morborum. Athens:
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12 Smith W. Dictionary of Greek and Roman Antiquities, Vol. 1.

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23 Upshaw J, OLeary JP. The medical leech: past and
present. Amer Surgeon 2000; 66: 31314.
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from an anticoagulant peptide in the saliva of medicinal
leech to a recombinant drug and beyond. Thromb Haemost
2007; 87: 11619.
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remedy. Am J Nurs 1988; 88: 165658.

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