HUMANITIES | MEDICINE AND SOCIETY

Sweating blood: history and review

n Cite as: CMAJ 2017 October 23;189:E1315-7. doi: 10.1503/cmaj.170756
See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.161298

T
he case report in credible, though scant, obser-
this issue of CMAJ 1 vations of sweating blood
raises two intriguing persist — as clinical phenom-
questions. First, do humans ena of unspecified cause, if
really sweat blood? Second, not as disease.
what is the medical history Regarding the second
of this phenomenon? question about the clinical
Hematohidrosis has made history of bloody sweat,
brief but increasingly fewer medical writers often trace it
appearances in dermatology to the story of Christ’s suffer-
texts. In 1895, Moritz Kaposi ing as told in the Bible by the
defined it as “the occasional physician evangelist (Luke
spontaneous oozing of arte- 22:44). But hematohidrosis
https://commons.wikimedia.org/wiki/File%3ATaisten-Tabernakelbildstock_04.jpg

rial blood from the sweat appeared in the scientific lit-

glands,” and he cited observa- erature long before.4 As early
tions by distinguished prede- as the third century B.C., two
cessors, including Ferdinand treatises by Aristotle con-
Ritter von Hebra.2 Referring to tained passages about sweat
a 1930 article, two editions of that either looked like, or
Rook’s Textbook of Dermatol- really was, blood.
ogy (1968 and 1992) stated
that it was “rare”; however, by Instances, indeed, are not
unknown of persons who in con-
2007, the statement had van- sequence of a cachectic state
ished. In 2012 and earlier, have secreted sweat that resem-
Bolognia and colleagues, in bled blood (Parts of Animals
their Textbook of Dermatol- [3.5:668]).
ogy, declared that “hemati-
drosis,” as a disorder of sweat If the blood get exceedingly liq-
glands, “has not been con- uid, animals fall sick; for the
firmed scientifically,” al- blood then turns into something
like ichor, or a liquid so thin that
though they did not deny its Tabernakelbildstock in Taisten. Christus am Ölberg [Wayside Shrine at Taisten, Italy: at times has been known to
existence. On the other hand, Christ on the Mount of Olives]. exude through the pores like
standard hematology text- sweat (History of Animals [3:19]).
books have long ignored hematohidrosis. based on their careful review of 76 selected
When I asked some of my senior hematology cases published from the 17th century to The opinion may have derived from the
colleagues at University of Toronto, Toronto, 1980.3 Historians quake at the irresistible wisdom that some animals known to the
and Queen’s University, Kingston, Ontario, if practice of retrospective diagnosis, often ancients, such as the hippopotamus and
they had seen a case, none had, although calling it futile or condescending, because certain horses, secrete red sweat long con-
two had witnessed bloody tears. epistemic and social conditions change, strued as blood. The physiologic possibility
In answer to the first question, then, diseases mutate and older descriptions of bloody sweat also appeared in the work
ambivalence is evident. Nevertheless, a lack parameters that are fundamental now: of Aristotle’s successor, Theophrastus (On
steady stream of reports prompted the we must treat the experience of predeces- Sweat, 11–12).5
physician couple Joe E. Holoubek and Alice sors with respect and use our own views Many medical writers insist that the
B. Holoubek, both devout Catholics, now with humility. The Holoubeks navigated second-century Greek physician, Galen,
deceased, to publish a 1996 classification these challenges well, reminding us that described bloody sweat. But this assertion

© 2017 Joule Inc. or its licensors CMAJ | OCTOBER 23, 2017 | VOLUME 189 | ISSUE 42 E1315
 stems from the oft-repeated reference to tures, possibly from sweat, or blood, or however, including George Gilles de la
the pseudo-Galenic Latin text, De utilitate both. Notwithstanding its dubious origins, Tourette, invoked psychogenic factors and
HUMANITIES

respirationi. This treatise, which bears the the veil was said to have hung in the old St. insisted that hematohidrosis was a prod-
same name as an authentic but different Peter’s Basilica and been used in religious uct of hysteria.9 Later, doubt about that
text, was paraphrased and popularized by processions from at least the 13th century. disease category itself probably led some
the physician Richard Mead in his 1749 After the 1527 sack of Rome, according to to assume it was factitious.
medical disquisition on the bloody sweat of the scholars I. Wilson and E. Kuryluk, some Religious writers eventually cited the
Christ: “Contingere interdum, poros ex multo thought it had been destroyed; others medical authors, as science lent credibility
aut fervido spiritu adeo dilatari, ut etiam claimed it was taken elsewhere or lost, to gospel. For example, two theologians
exeat sanguis per eos, fiatque sudor sanguin- while yet others maintain it is still in St. cited Richard Mead: Adam Clarke in his 1831
eus. [It sometimes happens that the pores Peter’s. A brisk industry of making and sell- edition and commentary of the New Testa-
are so vastly dilated by a copious and fervid ing copies arose, but by 1617 Pope Paul V ment, and C. George Griffin’s 1846 commen-
spirit, that even blood issues thro’ them, had restricted their manufacture to desig- tary on the Sufferings of Christ. The accumu-
and constitutes a bloody sweat].” nated authorities. In 1629, Pope Urban VIII lation of religious and medical texts all
The passage does not describe a case; ordered the destruction of all copies and citing each other influenced an erudite sur-
rather, it repeats Aristotle’s view, emphasiz- excommunication for anyone daring to geon, J.H. Pooley of Toledo, Ohio, to com-
ing the etiological role of a “fervid spirit.” It own one. The strict regulations surely pose an essay on bloody sweat for Popular
appears that the authentic Galen did not enhanced the cachet of these objects. The Science magazine in January 1885.10 Draw-
witness such a case, although his volumi- parallel outpouring of medical and scien- ing upon physician Mead, theologian Clarke
nous opus contains a great deal about tific interest in bloody sweat may have and a number of other unreferenced
blood and perspiration in relation to respi- been stimulated by attempts to verify the sources, Pooley claimed that it had been
ration. But blood as a humour, and sweat as claims of authenticity. It resembles the described by Aristotle, Theophrastus and
its derivative, were of considerable impor- recent forensic investigations applied to Galen, whom he piously cited in Latin. Then
tance in religion and literature throughout the Shroud of Turin and various contenders he briefly summarized more than 40 mod-
the middle ages.6 Chaucer described a for cloths that had once wrapped the same ern cases. Because this article is readily
horse ridden so hard that it “did sweat till body, such as the Sudarium of Orviedo. available online, pseudo-Galen, masquer-
men his coat might wring/His two flanks Notwithstanding their religious over- ading as Galen, is enjoying a renaissance in
were all blood” (“Tale of Sir Thopas”). Skep- tones, scattered throughout these early recent examinations of the subject.
tics of equine hematohidrosis might won- modern medical works appear the first A century later, the Holoubeks selected
der about the role of abrasions. eyewitness accounts of hematohidrosis, in many of Pooley’s cases for their extensive
In the late medieval and early modern what we would recognize as “case review. They identified several categories
periods, several physician authors referred reports.” For example, in 1627, Georg Spör- of conditions associated with hematohi-
to bloody sweat, but few presented origi- lin, a physician from Basel, reported on a drosis: systemic disease (e.g., scurvy and
nal cases. Most described its possibility 12-year-old boy with a high fever who lupus), vicarious menstruation, physical
and plausibility, appealing to the physio- sweated blood through his shirt.7 In 1628, exertion, psychological stress (repeated or
logic authority of Aristotle and (pseudo-) the papal physician, Paolo Zacchia, unique), religious stigmatics and idiopa-
Galen and referring to the passion of described a young Belgian condemned to thy. With the scant, second-hand descrip-
Christ. They include the 12-century Bene- death who, in his anguish, sweated blood tions, suspicion of underlying bleeding dis-
dictine, William of Saint-Thierry, and the (Quaestiones medico-legales [Lib III, Tit II, Q orders or malingering remained. Only a
authors of several medical dissertations in II]). Several other writers observed the handful of the Holoubeks’ cases came
Latin concerning “sudor cruentus” (bleed- same phenomenon in prisoners facing exe- from the 20th century. Consequently, few
ing sweat) and “sudor sanguineus” (bloody cution. Samuel Ledelius described a case had been investigated to rule out coagu-
sweat). In most of these works, the pur- associated with scurvy.8 lopathy or skin pathology.
pose was to apply scientific knowledge to “Sudor cruentus” and “sudor sanguin-
assess the plausibility and the naturalness eus” appear in 18th- and 19th-century A recent review
of the story of the passion (Appendix 1, medical dictionaries. According to the To assess the frequency of case reporting of
available at www.cmaj.ca/lookup/suppl/ Oxford English Dictionary, the various the condition in modern times, a keyword
doi:10.1503/cmaj.170756/-/DC1). Greek-derived spellings of h[a]emat[oh] search on “h[a]ematohidrosis” (also “hema-
The scientific preoccupation with idrosis appeared more recently, in 1854. tidrosis” or “hemathidrosis”) resulted in a
bloody sweat in this period might be Another lesser-used term, “ephidrosis cru- list of 42 articles: 10 from the Index Cata-
related to a heated controversy surround- enta,” also emerged in the mid-19th cen- logue of the Library of the Surgeon General,
ing one of the sacred relics of the church. tury. Because most observations had been published from 1880 to 1935; and 32 from
Since the Middle Ages, the Veil of Veronica made in women, some 19th-century MEDLINE, published from 1952 to 2016, in
or Sudarium was reputed to be the cloth authors, citing Gerard van Swieten and reputable journals (mostly dermatological),
used to wipe Christ’s face on his way to cru- Philippe Pinel, favoured vicarious or sup- including the International Journal of Der-
cifixion; it retained an imprint of his fea- pressed menstruation as the cause; others, matology and Blood. Until now, none have

E1316 CMAJ | OCTOBER 23, 2017 | VOLUME 189 | ISSUE 42

appeared in Canadian journals, although bloody sweat from normal-appearing skin viewed with similar skepticism. Ironically,
Canadians George Adami and John McCrae on multiple occasions through time, rang- for an increasingly secular world, the long-

HUMANITIES
(physician poet who wrote “In Flanders ing from one month to four years. The most standing association of hematohidrosis
Fields”), both of McGill University, men- common sites were forehead, scalp, face, with religious mystery may make its exis-
tioned it briefly as a form of cutaneous hem- eyes and ears, but bloody sweat could also tence harder to accept. It seems that
orrhage in their pathology textbook. Most of appear on the trunk and limbs, sometimes humans do sweat blood, albeit far less often
the articles were isolated case reports. The heralded by pain or tingling. Several had literally than metaphorically.
few that were not case reports are histori- associated hypertension or headache. All
cal, retrospective diagnoses linking hema- were tested to confirm the presence of Jacalyn Duffin MD PhD
tohidrosis to Christ’s bloody sweat, the stig- blood (as opposed to chemical discolor- Hannah Chair of the History of Medicine,
mata of St. Francis or Louise Lateau (1875), ation) and to rule out bleeding disorders; Queen’s University, Kingston, Ont.
or the death by accidental poisoning of only two displayed a coagulopathy (platelet
Charles IX of France, a story purveyed by factor 3 disorder in one patient and vitamin References
Voltaire and immortalized by Alexandre deficiency in another). Thirteen underwent   1. Maglie R, Caproni M. A case of blood sweating:
Dumas in his novel, La Reine Margot (1845). skin biopsy, which was normal or showed hematohidrosis syndrome. CMAJ 2017;189:​
E1314.
In discussion, several authors linked nonspecific changes with blood cells in
2. Kaposi M. Pathology and treatment of diseases of the
bloody sweat to hysteria or psychic causes, sweat ducts. At least 15 (54%) had suffered skin: for practitioners and students. Johnston JC,
raising the question of its association with severe psychological stress, either with translator. London (UK): Bailliere. Tindall and Cox;
1895:118, 409.
psychogenic purpura (Gardner-Diamond mental illness, such as depression or anxi-
 3. Holoubek JE, Holoubek AB. Blood, sweat and fear. A
syndrome).11 Some continue to suggest ety, or in the posttraumatic setting, having classification of hematidrosis. J Med 1996;27:115-33.
that it is factitious, or a product of malin- witnessed violence at home, school or  4. Stolberg M. Sweat: learned concepts and popular
perceptions, 1500–1800. In: Horstmanshoff M, King
gering, especially in articles from the early beyond (the abduction of a sibling; the
H, Zittel C, editors. Blood, sweat and tears: The
20th century. beheading of a neighbour). Most patients changing concepts of physiology from antiquity into
The 42 medical articles from 1880 to were observed in one or more episodes by early modern Europe. Leiden-Boston: Brill;
2012:503-22 (esp. 509).
2017 appeared at an average rate of one multiple medical observers whose suspi-
5. Debru A. La sueur des corps: le De sudore de Théo-
every three years. Of this total, however, cions that the symptom might be factitious phraste face à la tradition médicale. In: Forten-
five appeared in 2013, four in 2014, three in were allayed. Vasculitis was hypothesized baugh WW, Wöhrle G, editors. On the opuscula of
Theophrastus. Stuttgart (Germany): Franz Steiner
2015, four in 2016 and two in 2017 (so far). as an underlying cause in two cases, but
Verlag; 2002:163-74 (esp. 168n23).
In other words, almost half the total out- never proven by biopsy. More often, the 6. Bynum CW. Wonderful blood: Theology and Practice
put from more than a century came in the examples pointed to psychosomatic origins in Late Medieval Northern Germany and Beyond. Phil-
adelphia: University of Pennsylvania Press; 2007.
last five years. Is the incidence of this con- in mental anguish, the “fervid spirit” of
7. Spörlin G. Letter [1627], in Wilhelm Fabricius Hil-
dition increasing? Is it being more fre- pseudo-Galen via Mead. Some authors danus. In: Opera quæ extant omni. Frankfurt (Ger-
quently recognized, as other causes or hypothesized varying sympathetic activity many): Johannis Beyeri; 1646;601.
8. Ledelius S. in Manget JJ. Bibliotheca medico-prac-
diagnoses are identified and eliminated? on microvasculature.
tica sive rerum medicinarum thesaurus etc. Vol. 4.
Does the “need to publish” goad authors As for treatment, β-blockers were Geneva: Chouet and Ritter; 1697;592.
to describe cases that they might other- effective in six patients. Anxiolytics and 9. de la Tourette GG. Traité clinique et thérapeutique
de l’hystérie d’après l’enseignement de la
wise have ignored? It seems unlikely that antidepressants were also used in some,
Salpêtrière. In: Part 1: Hystérie normale ou interpar-
anyone who witnessed such a case would with variable results. An atropine skin- oxystique. Paris (France): Plon; 1891;438-58 (esp.
not want to write about it: as Thomas K. wipe produced symptomatic relief for 446-7).
10. Pooley JH. Bloody sweat. Popular Science Monthly
Chambers wrote in 1861, “I suppose since another; one patient who also had sei-
1885;26:357-65.
the invention of printing, very few exam- zures improved after starting oxcarbaze- 11. Ratnoff OD. Psychogenic purpura (autoerythrocyte
ples of so strange a thing can have escaped pine. Several cases resolved spontane- sensitization): an unsolved dilemma. Am J Med
1989;87:16N-21N.
being put into type.”12 ously. All authors emphasized the
12. Chambers TK. Clinical Lecture on a case of “bloody
To revisit and update the Holoubek clas- tremendous fear associated with hemato- sweat.” Given at St. Mary’s Hospital, Feb. 9th, 1861.
sification, the 28 new cases in the peer- hidrosis and the importance of reassur- Lancet 1861;77:207-9. (esp. 208).
reviewed literature between 2004 and 2017 ance. No one appears to have died of it.
were analyzed. They came from nations on The report from Italy in CMAJ1 is typical: a This article was solicited and has been peer
every continent, except North America. young woman with debilitating psychic reviewed.
Twenty-four were female, four male. Most distress. Additional resources are available in Appendix 3
were young, with an average age of 14.1 In sum, clinical reports of true hematohi- (available at www.cmaj.ca/lookup/suppl/
doi:10.1503/cmaj.170756/-/DC1).
years for females (range 7 mo to 34 yr) and drosis persist at a steady and possibly rising
26.5 years for the four males (9, 10, 15 and rate. This collection of well-documented Acknowledgements: The author thanks Profes-
72 yr) (Appendix 2, available at www.cmaj. observations commands respect and sors Paul Potter, Beate Gundert and Vivian Nut-
ton for their Galenic wisdom; Dr. Belle Song for
ca/lookup/suppl/doi:10.1503/cmaj.170756/-/ acceptance. But why — with all this evi- translation from Chinese; and Hissan Butt, Wal-
DC1). Many were photographed. dence — do we still harbour doubts about ton Schalick III, R.D. Wolfe and the anonymous
All experienced transient but recurring its existence? Other rare conditions are not readers for their comments.

CMAJ | OCTOBER 23, 2017 | VOLUME 189 | ISSUE 42 E1317