= Solution
\b[By 1867 the central change was from confidence in <bloodletting> as a general remedy to a disputed, increasingly restricted practice tested against clinical outcomes.] <Bloodletting> includes opening a <vein>, local <wet cupping>, and the application of <medicinal leeches>. The history must explain both the theories that supported it and why clinical comparisons weakened that support.
\b[Ancient explanations and qualifications.] In the <Hippocratic Corpus>, <disease> could be explained through disturbances of bodily fluids. The four-fluid account underlying <humorism> named <blood>, <humoral phlegm>, yellow <bile> and <black bile>; restoring their proper mixture offered a rationale for evacuation. This was a historical explanatory system, not a modern description of <blood> composition. Nor was ancient practice uniformly indiscriminate. <Aulus Cornelius Celsus> describes <bloodletting> as a powerful intervention whose suitability depends on bodily strength and whether the condition represents excess rather than exhaustion. <Galen> likewise distinguishes whether evacuation is needed, whether it should be by <venesection>, and whether the patient can tolerate it; he discusses the site, quantity and repetition. Thus the ancient debate already included selection and restraint. <On the Nature of Man in the Hippocratic Corpus>[Selection 1, The Elements of Life, paragraphs 1–2: four distinct fluids; translated primary excerpt]{ref} <On Medicine by Aulus Cornelius Celsus>[II.10.1–8, strength, depletion and the risks of bloodletting]{ref} <On Treatment by Bloodletting by Galen>[§1, successive questions governing evacuation, tolerance, site and amount]{ref}
\b[Medieval continuity and the instruments.] The <Canon of Medicine by Ibn Sina> preserves a carefully qualified doctrine of <venesection>, including cases where removing good <blood> would leave harmful fluids behind. Its reasoning belongs to <humorism>; its distinctions should not be mistaken for verified modern indications. In late medieval Europe, <bloodletting> was also organized by calendars: a surviving Augsburg calendar for 1472 specifies supposedly favourable times according to the patient and the <Moon>. This documents an additional astrological framework, not evidence of therapeutic efficacy. <Canon of Medicine by Ibn Sina>[Book I, translation §§1019–1022, contraindications, timing and choice of vessels]{ref} <Bloodletting calendar for Augsburg (1472)>[Princeton copy and catalogue description: days selected by lunar phases, patient age, affected part and temperament]{ref}
The material distinction between general and local removal mattered. <Venesection> opened a <vein> with a sharp instrument. <Wet cupping> combined superficial cuts in the <skin> with suction under a cup; <Celsus> describes bronze cups in which burning material reduced the enclosed air's <pressure>, and horn cups from which air was sucked through a small opening. <Dry cupping> did not include the cuts and therefore did not itself remove <blood>. <Medicinal leeches> provided another means of local removal. These instruments made depletion visibly demonstrable, but the visible removal of <blood> did not establish that a <disease> had been removed. <On Medicine by Aulus Cornelius Celsus>[II.11.1–6, bronze and horn cups, scarified versus intact skin, and local versus general depletion]{ref}
\b[New <physiology> did not immediately settle <treatment>.] <William Harvey>'s 1628 account of <blood circulation> undermined the older picture of <blood> simply being supplied and consumed in the parts. His observations of <venous valves> and experiments with arm ligatures showed directional movement: filling below a ligature and the behaviour of compressed <veins> helped demonstrate return towards the <heart>. Nevertheless, a circulating <blood> supply could still be invoked to explain relief through depletion or redistribution. Establishing <blood circulation> and establishing the benefit of <bloodletting> were different questions. <On the Motion of the Heart and Blood in Animals by William Harvey>[chapters 8–9, quantitative argument for circulation; chapter 13, ligatures and venous valves]{ref}
In the early nineteenth century, <François-Joseph-Victor Broussais>'s emphasis on local irritation and <inflammation> encouraged extensive use of <medicinal leeches>. This illustrates why changing theory could increase <bloodletting>: a local inflammatory explanation supplied a fresh reason to remove <blood> near the supposed seat of <disease>. The accompanying claims of efficacy still needed comparison with what happened under other <treatments>. <Re-imagining Bleeders by Robert G. W. Kirk and Neil Pemberton>[section discussing Broussais, local irritation, leeching, and the claim that leeches offered a relatively gentle intervention]{ref}
\b[Comparative evidence weakened general claims.] In 1835 <Pierre Charles Alexandre Louis> asked whether comparable patients with <pneumonia> did better when first subjected to <bloodletting> during days 1–4 than when first bled later. He explicitly considered age and other differences. This <numerical method in medicine> shifted attention from selected recoveries to outcomes in defined groups. His work restricted confidence in a large, general benefit; it should not be presented as a <randomized controlled trial> proving that every use was ineffective. In modern terms, these were <observational studies>: <confounding by indication> could make the earlier-treated group differ in severity, and surviving long enough to enter the later-treated group could introduce <selection bias>. Counting cases was an advance, but did not automatically remove these problems. <Research on the Effects of Bloodletting by Pierre Charles Alexandre Louis>[1835, pp. 70–76; primary passages reproduced by the James Lind Library on timing, age and comparisons between groups]{ref}
\b[The dispute still alive in 1867.] <William Pulteney Alison> defended earlier experience of benefit, while <John Hughes Bennett> opposed routine depletion and developed a restorative approach. One defence of the altered practice was the <change-of-type theory of disease>: formerly vigorous or “sthenic” inflammatory illness was said to have become weak or “asthenic”, so that measures once borne well were now inappropriate. The rival explanation was that understanding of <pathology> and the evidence about <treatment> had improved. <Alison>'s 1856 argument and the contemporary 1858 review show that this was an active disagreement, not a completed unanimous rejection. <Reflections on the Results of Experience as to the Symptoms of Internal Inflammations by William Pulteney Alison>[1856, pp. 769–788, opening response to Bennett and defence of previous clinical experience]{ref} <The Bloodletting Controversy (1858 review)>[opening pp. 1–3, contrasting altered disease type with altered pathological understanding]{ref}
<Bennett>'s 1864 discussion made the theoretical contrast explicit: an account centred on altered <blood> and vessels favoured depletion, whereas his account of tissue irritation and <inflammatory exudation> led him towards the opposite practice. That historical account of <inflammation> should itself be evaluated historically, rather than adopted as current <pathology>. The durable methodological lesson is that recovery after <treatment> is insufficient evidence of recovery because of it: <acute disease> may resolve naturally, as even the Latin extract acknowledges. Changes in theory, recognition of the patient's limited reserve, and comparative <clinical observation> together explain the retreat from routine <bloodletting>. <Treatment of Inflammation by John Hughes Bennett>[1864, p. 142, opening comparison of vascular and extravascular accounts of inflammation and their therapeutic consequences]{ref}
\b[Present-day distinction.] Contemporary <venesection> has specific indications: in <haemochromatosis>, removal of <red blood cells> helps reduce excess <iron>; in <polycythaemia vera>, it can reduce an excessive <red blood cell> burden. Those uses concern defined abnormalities, rather than correction of historical <humorism> or a general remedy for <fever> and <inflammation>. They are a modern explanatory coda, not knowledge attributed to the 1867 candidate. <Haemochromatosis treatment by the NHS>[Venesection: removal of iron-containing red blood cells and use of iron to replace them]{ref} <Erythrocytosis by the NHS>[Treatment, Venesection: use in polycythaemia vera and selected other circumstances]{ref}
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