It is well-known that pain management in Europe was developed around the end of the Middle Ages. During this time, European physicians were attempting to alleviate pain, usually through the use of opium or, after 1680, laudanum, which is a mixture of opium and sherry, first used by the London-based doctor Thomas Sydenham [1]. Medieval treatments also included the use of particular plants, such as mandrake, henbane, and various nightshades [2]. However, the use of particular plants presented challenges because it was necessary to pick, prepare, and transport them. By contrast, acupuncture does not require any resources and there is evidence that acupuncture has functioned as a form of “field therapy” since prehistoric times [3].

Even during the classical period, there was an understanding that physical stimulation of specific body points might have analgesic effects. For example, the idea that “when two concurrent pains occur in different parts of the body, the stronger pain weakens the other one,” began to be recognized [4]. This phenomenon has been explained more recently by the gate-control theory of pain [5]. Additionally, the influence of acupuncture on the endogenous opiate system has been confirmed by multiple studies, for example Pomeranz and Chiu [6]. Acupuncture has also been shown to have other benefits, such as reducing muscle tension and alleviating mental stress [7].

In the European medical tradition, the physical stimulation of acupuncture points was employed in the form of bloodletting, which dates back to the time of Hippocrates. It is believed that Hippocrates was the first to employ phlebotomy as a means of analgesia. In his work, Nature of Man, Hippocrates provides a detailed description of the body’s veins, including instructions on which vein to cut when a patient is experiencing pain [4]. Furthermore, Hippocrates’ [8] On Internal Affections (paragraph 18) contains a discussion about “a great disease of the veins,” which results from inflammation of the kidneys. He also described the veins as “running from the head along the length of the neck, then continuing along the spine and descending to the lateral malleolus of the foot and the intermediate place of the first toes.” This description closely resembles the depiction of the Bladder primary channel in modern acupuncture. The assumption that ancient European scholars could have understood the term “vein” to include channels through which Qi circulates is a matter for debate. However, it cannot be entirely ruled out. Adams [9], in his insightful article on Hippocrates’ [8] On Internal Affections, noted that “On Internal Affections is less difficult to translate than it is to understand, and perhaps this is the reason it is not often analyzed in detail”.

In Hippocratic medicine, there was an idea of universal vital energy (“spiritus”) that circulates throughout the body via certain channels. Galen distinguished three types of spiritus: spiritus naturalis, produced by the liver and distributed throughout the body by veins; spiritus animalis, which comes from the heart and is distributed via the arteries; and spiritus vitalis, produced in the brain and distributed by nerves. Each organ was believed to have a primary vein for bloodletting. For the liver, it was Vena Basilica, id est epatica, and bloodletting was performed at a location corresponding to point PC3 (Qu Ze, in modern acupuncture) [10].

The Vena Mediana (associated with point LU5, Chi Ze) was the main vein for the heart, which is why some people called it the Cordiaca [11]. The Vena Cephalica was used to treat ailments of the head. The vein “leads from the shoulders to the bend of the arm on the upper side and, progressing further, reaches the hand between the thumb and forefinger.” “Its name derives from the Greek word cephas (meaning “head”), and icos (meaning “guardian”), making it a kind of “guardian” of the head” [11]. The Cephalica was described by a medieval physician as a channel or meridian linking points on the upper limb, specifically at the bend of the elbow (LI11, Qu Chi) and the thumb (LI4, He Gu). From this, we can conclude that ancient European medicine contained concepts that closely parallel those found in Traditional Chinese Medicine.

It is important to address the issue of blood loss during bloodletting in medieval times. The exact volume of blood released during these procedures has always been unclear. On the one hand, bloodletting was never symbolic. According to the instructions of Hippocrates, bloodletting should be performed until the blood changes from dark-colored and thick to light-colored and thin [11]. Ancient and medieval authors wrote that blood loss should be adequate: “flebotomia non est aliud nisi artificialis venarum recta incisio pro sanguinis superflui aut corrupti moderata efusione” [11]. The amount of blood released depended on various factors including the time of year, the patient’s condition, gender, age, physical fitness, and the type of illness [11,12]. Interestingly, Payer z Lokte [13] in his Tractatus Treatise on Karlovy Vary from 1522, recommended a volume of bloodletting of 3-4 drachms (12-16 g) per session, with a maximum of two procedures.

Cupping was also a popular therapy in the Middle Ages and was performed at the same points used for bloodletting [11,12] either with or without scarification. Another method for stimulating active points in the body without bloodletting was cauterization; Hippocrates himself used it at special body points for analgesia, and the technique is still used in Ethiopia today [14]. He recommended using beech sticks dipped in boiling oil, or a hot iron. Detailed descriptions of cauterization methods can be found, for instance, in Hippocrates’ [8] book On Internal Affections (paragraph 28), where he mentions cauterization points for treating acute pain in the head, neck, lower back, lower back muscles, and joints of the lower extremities, as well as for constipation and urinary retention. Paired points were selected on each side of the vertebrae: four on the lower back, 15 on the back, and two on the neck, with the indicated locations and the number of points closely resembling extra points in Chinese acupuncture, such as Ex-B-1 (Dingchuan) and Ex-B-2 (Huatuojiaji) (17-point pairs). Hippocrates [8] specifically referenced 21 paired points, including two pairs on the neck, and noted that the points on the neck lie “between the tendons.” which may potentially correspond to the GB 20 (Fengchi) points in modern acupuncture.

The principle behind bloodletting, cupping, and cauterization was to inflict controlled damage to the skin and underlying tissues at special points known as “Vene.” However, these did not always correspond to large veins. For example, there was a point at the tip of the nose (Vena in sumitate nasi, corresponding to Du 25 [Su Liao] in modern acupuncture). Another example is the paired veins at the corners of the eyes, vene, que sunt in angulis oculorum, which correspond to GB 1 (Tong Zi Liao).

It therefore seems clear that medieval European medicine incorporated methods for stimulating acupuncture points, with and without bloodletting. These methods were based on ancient European traditions and included ideas about the existence of specific types of energy (spiritus naturalis, spiritus animalis, and spiritus vitalis) produced by certain organs in the body. These energies were believed to circulate through the body via special channels, much like the flow of Qi in Traditional Chinese Medicine. In the previous article, the author demonstrated the close relationship between bloodletting practices in medieval Europe and acupuncture in Traditional Chinese Medicine [15]. This study aimed to explore how acupuncture-based treatment had been applied in medieval Europe. The author hypothesizes that the physical stimulation of acupuncture points associated with bloodletting was one of the primary methods of pain management at that time.

This study analyzed three European medical manuscripts, two of which date from the early 15th century. The first of these, Practica Medicinalis, was written by Sigismundus Albicus, who served as the Archbishop of Prague and as personal physician to the Czech king [16]. The manuscript was copied between 100 and 150 years later, with an illustration for phlebotomy (bloodletting) pasted onto the inside cover of the manuscript (Fig. 1). This was likely transferred from earlier versions of the text, possibly even from the original Practica Medicinalis. The explanatory text on the illustration is written in the Gothic Bastarda script, which was used between the late 13th and the early 15th centuries.

Figure 1. Albici M. [16] Practica medicinalis, The Archive of the Prague Castle: L9, imago viri.

In Fig. 1, the human body is depicted with 25 bloodletting points (“Vene”). The surrounding text includes the names of these points and instructions for their use. The medical indications (symptoms) listed in the texts are very brief, so to fully understand them, references are made to two other medical works that Sigismundus Albicus cites in Practica Medicinalis. The first of these, De Sanguinis Minucione, was written by de Prachaticz [11] around 1430. Sigismundus Albicus knew de Prachaticz personally and cited his bloodletting timing tables in Practica Medicinalis [16]. The second manuscript, Lilium Medicinae, was written by de Gordonio [12]. This text was chosen because Sigismundus Albicus quoted Bernardus’ work several times in his Practica Medicinalis.

The text surrounding the drawing of the human body in the illustration of Practica Medicinalis (Fig. 1) contains 76 distinct symptoms, which serve as indications for bloodletting. These symptoms could not be classified into syndromes according to modern medical concepts, such as acute versus chronic conditions or infectious versus non-infectious diseases. Instead, they were assembled into four groups: 1) Pain and inflammation symptoms; 2) Symptoms commonly associated with pain and inflammation; 3) General symptoms affecting various organs and functions; and 4) Conditions unrelated to pain or inflammation (Table 1).

*Unclear text. But the de Prachaticz [11] manuscript lists both chest and jaw pain; †Apostema is usually translated to abscess, but the term has a lot of meanings, for example it also means swelling, tumor, tuber or pustule; ‡Bilious syndrome (fellis effusioni = excess of the yellow bile) had at least two means: liver dysfunction and “bilious” temperament. It is not completely clear what did it mean in medieval medicine. The problem needs a future investigation; §There is no exact definition for this indication. It is most likely a condition, where a woman after childbirth which has a menstrual retention..

&md=tbl&idx=1' data-target="#file-modal"">Table 1

Inflammation and non - inflammation symptoms from the illustration of Practica Medicinalis (total number of symptoms = 76).

Groups of symptoms	Number of symptoms/per cent	Single symptoms (frequency of mentions of each symptom)
I. Pain and inflammation symptoms	42/55%	Emigraneo/migraine (1) Dolori capitis/headache (5) Dolor/pain: aurium (1), dencium (1), mamillarum or maxillarum*(1), pectoris (2), gutturis (1), oculorum (2), stomachi (2), costarum (1), pulmonis (1), dyaframatis/diaphragma (1), epatis (1), spatulis (1), splenis (1), vesice (1), coxarum (2), ancharum (1), femorum (1), lumbos (lumborum) dolorem (1), dolori laterisque (1) Stratice/sciatica (1) Apostemati/apostema†: oculorum (1), gutturis (1), testic<ulorum> (2), renum (1), vesice (1) Squinantem (squinancia, synanche) gule (1)/throat abscesses Obtaliginem (obthalmia, ophthalmia) oculorum (1)/apostema of eye Pustulis/pustules: faciei (2), oculorum (1), crurium (1)
II. Symptoms which as a rule are accompanied with pain and inflammation	11/15%	Reumati capitis (1)/“cold in the head” Inflacioni uvule (1)/swollen uvula Fellis effusionis (effusioni) (1)/bilious syndrome‡ Contra ytericum (ictericia) (1)/jaundice Quartanam/quartana (1)/fever, that comes every fourth day Difficultati anhelitus (1)/probably asthma Difficili inspiracioni (1)/breathing difficulties Emerroidorum/ hemorrhoids (1) Inflacioni (1) et tempestati corporis (1)/edema, body swelling. Feeling of the thoracic and/or abdominal fullness, nausea Passio<ni>, artelorum (= articuli) passioni (1)/joint diseases
III. Common symptoms for different organs and function	14/18%	Ad visum et egritudinem oculorum (1)/vision disorder Aliisque passionibus (passionibus oculorum) (1)/eye diseases Capiti (1) et spatulis (1)/for the head and the upper back region (spatulis = between scapulas) Sanguini de naribus (1)/nosebleed Stupori mentis (1)/stupor Contra tremorem (1)/tremor Tinienciam/tinnitus (1)/, tinnitus Novellam surditatem aurium (1)/inchoative deafness Orthomie (= orthopnoea) (1)/orthopnea Rubedini oculorum (1) red eyes Epati (1)/liver diseases Vicio renum (1)/kidney diseases Recepcionem (recepcioni) menstruorum (1)/menstrual retention
IV. Conditions which do not accompany with pain and inflammation	9/12%	Visui valet, ad visum (2)/vision improvement Contra fluxus oculorum (1)/watering eyes Ad memoriam (1)/memory improvement Scabei (scabies) capitis (1)/head scabies (impetigo) Pruritui narium (1)/itchy nose Epati et eius replecione (replecioni) valet (1)/improvement of the liver function Postpartum n<on> purgate (1) nec conceptui apte (1)/for non purgata women, after childbirth§ sterility

*Unclear text. But the de Prachaticz [11] manuscript lists both chest and jaw pain; †Apostema is usually translated to abscess, but the term has a lot of meanings, for example it also means swelling, tumor, tuber or pustule; ‡Bilious syndrome (fellis effusioni = excess of the yellow bile) had at least two means: liver dysfunction and “bilious” temperament. It is not completely clear what did it mean in medieval medicine. The problem needs a future investigation; §There is no exact definition for this indication. It is most likely a condition, where a woman after childbirth which has a menstrual retention..

The first group comprises pain in various forms (e.g., migraines, sciatica, apostema and its varieties [e.g., throat and eye abscesses], and skin pustules). In this study, it was assumed that the signs of inflammation (calor, dolor, rubor, tumor, and functio laesa), which were described in antiquity, would have been well-known to medieval physicians, who considered inflammation to be a syndrome, with pain an integral component. Therefore, conditions such as apostema and pustules, which were undoubtedly understood as inflammatory processes, were associated with pain.

The second group, symptoms commonly associated with pain and inflammation, includes head colds, swollen uvula, bilious syndrome, jaundice, fever recurring every fourth day, breathing difficulties, asthma, hemorrhoids, edema, body swelling, feelings of thoracic and/or abdominal fullness, nausea, and joint diseases. This group also includes symptoms that have at least one sign of inflammation. For example, inflacioni uvule (swollen uvula) is often accompanied by pain. Joint diseases are also included in this group because they almost always present with pain as a key symptom.

The third group comprises common symptoms affecting different organs and functions, which may or may not be accompanied by pain. This group includes indications for bloodletting that are described by general terms such as vision disorder and eye diseases, conditions of the head and the area between the scapulae (referred to as “for the head and the upper back region”), nosebleeds, stupor, tremors, tinnitus, inchoative deafness, orthopnea, red eyes, liver and kidney disease, and menstrual retention. The symptom of red eyes (rubedini oculorum) was placed in the third group rather than the second because red eyes are not always associated with inflammation; they can also be caused by other conditions, such as hemorrhages.

The fourth group consists of symptoms that do not involve pain or inflammation, such as vision and memory deterioration, watering eyes, head scabies (impetigo), itchy nose, deterioration of liver function, sterility, and women after childbirth. The last symptom in this group is somewhat ambiguous as the term for “non purgata” women is not well understood. It is most likely a condition in which a woman post-childbirth experiences menstrual retention.

In summary, dividing the 76 symptoms into four groups allowed for the identification of symptoms related to pain and inflammation (Group 1) and those that almost inevitably accompany pain and inflammation (Group 2). In Group 3, pain is not a mandatory symptom, and in Group 4 it is excluded entirely.

1. Group I

Pain and inflammation symptoms account for approximately 55% of all symptoms (42 out of 76), as shown in Table 1. Pain (dolor) is the most commonly reported symptom, with local pain described as follows: pain in the head, ears, eyes, teeth and gums, maxillae, throat, thorax and lungs, scapulae, ribs (including pleuritic pain), mammillae, stomach, liver, spleen, kidneys and bladder, testicles, lumbago, and hips, joints, and thighs. The various pain syndromes were often polysemous. For example, the term dolor ancharum included not only hip pain but also lumbago and sciatica. Bloodletting from the Vena sub cavilla/exterior is suggested as treatment, a point that is located near the modern acupuncture point BL 62 (Shen Mai). Another treatment option was to use Vena, que est inter minimam pedicam et sequentem, which, in the illustration, corresponds to GB 43 (Xia Xi) or Ex-LF 10 (Ba Feng). This point was used to treat rib pain, femoral pain, low back pain, menstrual retention, and apostema of the testis. The point Vena supra magnam pedicam et sequentem (marked near point LR3 [Tai Chong] in the illustration) was used to treat lower leg pain and irregular menstruation. All three authors also linked gout or rheumatism to musculoskeletal disorders.

According to all three manuscripts, headaches were the most common pain syndrome after problems with the locomotor system, as they were mentioned six times in the illustration (7.9%). Medieval physicians recognized migraine as a distinct type of headache. Sigismundus Albicus described migraine as: “emigranea, id est de dolore in media parte capitis” (pain in the medial part of the head). To treat a migraine, bloodletting at the Vena in fronta was used, which corresponds to Ex-HN 3 (Yin Tang). It was also used for eye swelling (apostema). de Prachaticz [11] also recommended using the point Vene in tymporibus (= tempora) on both sides of the head (probably ST 8 [Tou Wei]). Other points on the head and hands that could also be used to treat headaches included Vene retro aures (an unclear point), Cephalica (LI11, [Qu Chi]), Mediana (LU5 [Chi Ze]), and, according to de Prachaticz [11], Inter pollicem et indicem (LI4 [He Gu]). Cephalica has also been used for throat and eye pain. Sigismundus Albicus recommended Mediana for stomachache and rib pain (possibly pneumonia with pleurisy).

After pain (dolor), the next most common symptom was apostema. This is usually translated as “abscess,” but the term also refers to swelling, tumors, tubers, or pustules. Fig. 1 shows five types of apostema: eyes, throat, kidneys, bladder, and testicles. The term apostema could also refer to any form of inflammation. For example, apostema costarum included lung-related issues, with pleurisy described as an apostema of the ribs. de Prachaticz [11] suggested bloodletting from Basilica (PC3 [Qu Ze]) for pleurisy: et sic valet in pleuresi, quod est apostema costarum. Squinantia refers to a throat abscess, while ophthalmia is an apostema of the eye: obtalimam, quo est apostema oculorum. de Gordonio [12] detailed that ophthalmia is “apostema calidum coniunctivae” (a “hot apostema” of the eye).

All three authors suggested treating ophthalmia with bloodletting at the Vena supra magnam pedicam et sequentem (LR 3 [Tai Chong]), which was also used to treat conjunctivitis. The term squinantem referred to a dangerous throat abscess, or squinanciam seu apostemata gutturis [11].

Two skin symptoms, pustulis and scabie, are also described. A pustule is a “pustulae sunt quaedam parua apostemata” – a type of small apostema. The term scabie is synonymous with impetigo: et impetigine aut scabie [11]. Bloodletting from paired Vene faucibus (vene palati) was used to treat both pustules and impetigo. There is no direct equivalent for this point in modern acupuncture.

2. Group II

This group contains symptoms commonly associated with pain and inflammation, accounting for 11 symptoms in total (15%).

One key concept in medieval medicine was Reumata capitis, meaning “cold in the head,” and often interpreted as rhinitis, coughing, and snoring. According to de Gordonio [12], Reumata capitis could lead to ear diseases such as tinnitus and inchoative deafness, as well as eye and nose problems (e.g., polyps), throat abscesses, swollen uvula, pleuritis, and diseases of the spleen and stomach. Reumata capitis was also considered a possible cause of headaches. Bloodletting from the sub lingwa was recommended for the treatment of Reumata capitis. This point is located on the vein of the inferior side of the tongue, where points Ex-HN12 (Jin Jin) and Ex-HN 13 (Yu Ye) are located. Other uses for this point included treating tooth and gum pain, throat abscesses, swollen uvula (inflationi uvulae), and, according to de Prachaticz [11], diseases of the oral cavity.

For liver, gallbladder, and spleen diseases, bloodletting from Vena Basilica, id est epatica (corresponding to PC3 [Qu Ze]) was suggested. This point was used for liver pain, pain between the scapulas, and nosebleeds (dolori epatis, spatulis, sanguini de naribus). de Gordonio [12] confirmed that an apostema hepatis can manifest as a nosebleed, placing it in this second group. The Vena Basilica was also used for upper back pain, stomachache, and pain in the side of the body.

Bloodletting from the Vena Salvatella (synonyms: Inter anularem et sequntem, Scilicet, Salvacella) has also been recommended for liver and spleen diseases. The right hand was designated for liver diseases, while the left was used for spleen disease. “When the blood is bad in quantity or quality, Salvatella is being opened on the right hand because the liver is on the right side…On the contrary in the case of spleen diseases it is being opened on the left hand” [11]. The Salvatella phlebotomy point was connected with visual assessment of quantity and qualitative characteristics of the blood pattern. Blood, according to ancient and medieval authors, originated in the liver. The Vena Salvatella (“Inter anularem et sequentem”, corresponding to TE 3 [Zhong Zhu]) was also used to treat jaundice (contra ictericum). Medieval authors correctly associated jaundice not only with liver disease but also with disorders in other organs. de Gordonio [12] wrote that ictericia could appear in three colors: citrina, viridis, nigra (yellow, green, and black), and it appears in diseases of the abdomen, liver, spleen, and gall bladder. According to de Gordonio [12], the yellow form was typically associated with bilious syndrome (fellis effusioni or excess yellow bile), which he described as manifesting through such signs as yellow skin, thirst, poor appetite, and vomiting, weak pulse, dark urine, and oliguria (all clinical signs of hepatitis).

Both Albicus [16] and de Gordonio [12] recommended the Vena Inter pollicem et indicem (LI4 [He Gu]) for treating this condition.

An intriguing indication is the use of the Vena Inter auricularem et anularem (corresponding to acupuncture point TE 2 [Ye Men]), pro dolore splenis et quartanam. The term quartana refers to a fever that recurs every four days, a pattern typical of plasmodium malaria, which is a milder form of the disease. This form of malaria is often associated with an enlarged, painful spleen and severe abdominal pain. de Gordonio [12] noted that black skin color (ictericia nigra) is characteristic of splenic diseases. However, modern medicine now recognizes that untreated malaria can cause thrombocytopenia and hematomas. Vena Inter auricularem et anularem was only mentioned by Sigismundus Albicus; de Prachaticz [11] did not write about it. This is probably because Sigismundus Albicus is known to have lived for a long time in northern Italy, where malaria was prevalent, while de Prachaticz [11] spent his life in Bohemia [17].

The Vena circularis (also known as Asselario or Funis brachii) was used to treat trachea and lung problems, chest, lung, and diaphragmatic pain, breathlessness, and wheezing, likely indicative of “anhelitus” or asthma. Bloodletting was performed at the location corresponding to the modern acupuncture point LU4 (Xia Bai). The Vene prepucii was indicated for a sensation of thoracic or abdominal fullness, and nausea. This vein does not have a direct counterpart in modern acupuncture. The paired De venis laterum, whose exact location remains unclear, was to treat hemorrhoids and other conditions. de Prachaticz [11] mentioned that De venis laterum was also useful for liver diseases (treated on the right hand) and spleen diseases (treated on the left hand).

3. Group III

This group includes general symptoms affecting various organs and functions. It contains 14 individual symptoms, accounting for 18% of the total, and they will be discussed using several examples.

The first example concerns paired veins on the head: Due sunt vene in angulis (GB 1 [Tong Zi Liao]), which are used for diseases of the eye and to improve vision. This point is still utilized for the same purpose in modern acupuncture.

A vein used to treat stupor and headaches and to improve memory (stupori mentis et dolori capitis et ad memoriam haec valet), is not visible in the illustration as it is located behind the ears. Stupor, headache, and memory impairment are often associated with concussion. However, since medieval physicians also employed this point to treat stupor that was unrelated to concussion, we have categorized this particular symptom of stupor in this group.

The Vena in concavitatibus aurium does not have a direct counterpart in modern acupuncture. Bloodletting from this vein was performed to address symptoms such as tremors, tinnitus, and inchoative deafness. These issues are generally linked to neurological or otolaryngological conditions, as well as degenerative changes in the cervical spine. Pain is often present, particularly in spinal cases.

The well-known acupuncture point LI4 (He Gu) was used during medieval times for treating orthopnea, red eyes, and various other eye conditions. Bloodletting from the area corresponding to the LR2 (Xing Jian) (or LR3 [Tai Chong]) point was used for menstrual irregularities. This point was also used to treat eye inflammation (obtaliginem [obthalmia] ophthalmia oculorum, pustulis oculorum), as well as lower leg pustules.

4. Group IV

The final group includes conditions unrelated to pain or inflammation, comprising only nine symptoms – 12% of the total. To improve vision, the previously mentioned paired vein Due sunt vene in angulis (GB 1 [Tong Zi Liao]) was used. Additionally, bloodletting from the temporal vein Due sunt vene in tymporibus (= tempora) was also employed to treat vision disorders. The location of the bloodletting point from this vein is close to the acupuncture point ST 8 (Tou Wei).

Out of the 25 points we examined, only one did not correspond to symptoms related to pain or inflammation: the azygos vein, in sumitate nasi, located similarly to acupuncture point GV 25 (Su Liao), which was used to treat lacrimation (contra fluxus oculorum). The Vena sub mento was used during medieval times for treating an itchy nose, and there is no similar modern acupuncture point. The vein was also used to treat chest pain, jaw pain, and pustules on the face. In de Prachaticz’s [11] manuscript, there are indications for this point that match those depicted in Sigismundus Albicus’s illustration, including pain in the jaw (dolori maxillarum) and chest pain (dolori mamillarum).

The Vena Inter anularem et medium (its location in Fig. 1 is similar to acupuncture point Ex-AH 9 [Ba Xie]) was indicated for liver diseases and the improvement of liver function.

The Vena Saphena mulieri interio was bloodlet in the area corresponding to point KI 6 (Zhao Hai). Sigismundus Albicus recommended bloodletting from this vein for women after childbirth and for those having trouble conceiving. de Prachaticz [11] added further indications, including menstrual retention, hemorrhoids, spleen disorders, and male genitalia diseases.

Pain management in medieval Europe often began with the stimulation of acupuncture points on the body, employing methods such as bloodletting, cauterization, and cupping. Of the 76 distinct symptoms that we found in the illustration in Sigismundus Albicus’s Practica Medicinalis, more than half (55%) were aimed at treating pain and inflammation. An additional 11 symptoms (15%) targeted conditions associated with pain and inflammation (Fig. 2). Interestingly, only one bloodletting point out of 25 was not intended for these purposes. This suggests that bloodletting was used in “strong” patients as the first method of treatment by medieval medical practitioners. According to the texts analyzed in this study, the main indication for bloodletting was plethora: “qui habent venas amplas, et cum hoc sunt fortis virtutis” where a patient has full veins and a robust “life force” [11]. Plethora typically included common symptoms of inflammation such as pain, heat, redness, swelling, and loss of function. A typical example of a “strong patient” with an acute inflammatory process might be someone suffering from pneumonia.

Figure 2. Ratio of symptom types from the illustration of Practica Medicinalis.

Recent studies have considered the effect of bloodletting in conditions such as pneumonia and other inflammatory processes [18]. For instance, the positive effects of bloodletting at LU11 (Shaoshang) and LI1 (Shangyang) acupuncture points on prognosis and mortality have been discussed [19]. Medieval scholars recommended bloodletting at acupuncture points LU5 and PC3 for pneumonia. However, at that time, bloodletting was considered a serious procedure with numerous contraindications. These included high fever, bleeding disorders, constipation, patients who were very elderly or very young, menstruating women, girls who were prone to fainting, exhaustion, and dehydration, among others [11,12]. However, de Prachaticz [11] noted one exception: bloodletting could be performed in cases of dangerous throat abscesses (squinanciam seu apostemata gutturis). In other cases, when bloodletting was contraindicated, alternative treatments were carried out.

Medieval European physicians also focused on treating disorders of the locomotor system, often using the same acupuncture points employed by modern practitioners. For example, Traditional Korean medicine treats lumbosacral radiculopathy using points LI4, TE5, LI11, LR3, GB41, and ST36 for the first round of treatment, and EX-B-2 (lumbar region), BL40, BL57, and BL60 in the second round [20]. Similarly, other medieval scholars recommended bloodletting at points like BL62, GB43, or Ex-LF 10 and LR3 for similar problems. Cauterization points, as described in Hippocrates’ [8] book On Internal Affections, were used for lower back pain, similar to Ex-B-1 and Ex-B-2.

In the works of medieval authors, there are examples of acupuncture points being used simultaneously or interchangeably. For example, the bloodletting points Cephalica and Custos capitis are believed to be connected in one meridian in the same way as points LI11 and LI4 are connected into the Large Intestine Channel System in modern acupuncture. This suggests that medieval physicians, as well as their Greek counterparts, appeared to understand the concept of channels connecting acupuncture points and facilitating the circulation of vital energy.

Functional magnetic resonance imaging (fMRI) studies have demonstrated that acupuncture affects the motor cortex of the brain. Early pioneering studies, such as the research by Yoshida et al. [21] at the Meiji College of Oriental Medicine in Kyoto, provide evidence of the powerful effect of acupuncture on both the nervous system and the musculoskeletal systems. Notably, one study found that bloodletting acupuncture on venules between BL60 and BL61 rapidly alleviated a four-month episode of lower back pain [22].

Therefore, the widely held belief that pain management in medieval times was ineffective before the advent of modern pharmacotherapy must be re-evaluated. Clinical evidence now suggests that acupuncture’s effect on pain is comparable to that of non-steroidal anti-inflammatory drugs (NSAIDs) [23,24]. In summary, this article suggests that acupuncture-based therapies were a practical and effective method for treating pain and inflammation in the Middle Ages, with outcomes that could be comparable to contemporary medical approaches.

The authors wish to thank Dr. Hana Florianová (Centre for Classical Studies at the Institute of Philosophy of the Czech Academy of Sciences) for help with the transcription of Latin texts and for her advice concerning medieval Latin.

Grant number SGS21/141/OHK4/2T/17 - Czech Technical University in Prague.

All authors contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript.

No one declared.

The authors declare no conflict of interest.