SECT. XL.—ON VENESECTION.
Although the mode of performing venesection be known to everybody, yet, in order that no part of surgery may be omitted, and for the sake of its technical distinctions, it must not be overlooked by us. The first object then in venesection is the evacuation of a fulness of blood. It has been shown that fulness of blood is of a twofold nature: first, with regard to the strength, although the veins do not appear full, in which case those affected soon become weak and enervated, nature not being able to support, as it were, the load; and second, with regard to the containing vessels, as is seen in the parenchymatous parts, in which case, although the strength seems able to support the fulness without stress, the vessels sometimes burst, and a spitting of blood or some other discharge takes place. Plethora then as regards the strength may be ascertained from the heaviness upon the body; and plethora of the veins from their distension and from their appearing full. In both cases evacuation is indicated; and, therefore, if necessity require, you must bleed on the first attack of the disease, waiting only for the digestion of the food in the stomach, or the complete sanguification thereof in the liver. But if on any account venesection has not been had recourse to in the beginning, and has been postponed until after the seventh day, there will be no impropriety of bleeding even then when necessity requires it, and the strength does not contra-indicate. But when about to let blood it is necessary to ascertain that there be not a great obstruction of fæces in the intestines, and, if there be, the bowels ought first to be evacuated by an emollient clyster, lest the veins of the intestines suck in the putrid matter of the excrements. Those requiring the abstraction of blood from the presence of a disease we may bleed at any season, avoiding only the acme of particular paroxysms in fevers. But if it be a continual fever, the morning is by all means the fittest season for the operation. Those who require the evacuation of blood, not from the presence of any disease, but as a preventive, will find the spring the fittest season of the year. With regard to age, bleeding must not be practised before the fourteenth, nor after the seventieth year, unless some urgent necessity compel us. And upon the whole we must avoid bleeding those persons whose strength is reduced. In recent inflammations we must make the evacuation from the opposite parts, but in chronic from the adjoining. We abstract blood from many parts of the body, but more especially from the inner part of the elbow. But it is to be recollected that in general the artery lies below the inner vein called the alar; that below the middle one (median) there is a nerve; whereas the upper one, called also the humeral, is free from all risk. In diseases of the head we open the humeral, but in those below the neck, the alar. The median is applicable in both cases. Wherefore we must tie a narrow band around some muscular part of the arm, and having by friction of the hands upon one another produced the necessary fulness of the vein, we divide it transversely, but only along its breadth; for larger incisions than this are difficult to heal, whilst those which are very narrow occasion inflammations by obstructing the passage of the thicker fluids. When we expect to have to abstract blood again on the second, third, and sometimes the fourth day, we must divide the vein more obliquely, in order that by bending the arm the incision may be kept open and not heal speedily. Such is the opinion of Antyllus. The quantity of the evacuation must be determined by the strength of the patient and the magnitude of the disease. When, therefore, there is a humeral plethora, and the matter is in a state of inflammation, we are to make our evacuations to deliquium animi, provided the strength be firm, and the patient does not swoon from an overflow of the humour upon the stomach. Wherefore many at the commencement fall into deliquium animi before a sufficient evacuation has taken place, and, therefore, the deliquium must be judged of from the measure of the evacuation. If there is a necessity for much evacuation, and the strength is weak, we must husband the evacuation, and making the first abstraction in small quantity, bleed again, or even a third time, if required. We have recourse to general evacuation not only when the body is in a plethoric state (as Galen says), but on account of the magnitude of the affection, when the general system is in a moderate state with regard to the humours, as we do also in hemorrhage from the nose or elsewhere, when although the discharge do not proceed from plethora, we bleed from the opposite parts in order to produce revulsion; and so also in violent inflammations, as in colics and affections of the kidneys from calculi, ophthalmies, and other such acute and urgent attacks; for the heat and pain of the inflamed parts occasion a defluxion upon it, although the general system be free from superfluities. In such cases we must bleed more sparingly, proportioning the evacuation particularly to the age and constitution of the patient, and also taking into account the season, country, and habits of the person affected. When there is a strong inflammation near the vein which is opened, as in pleurisy and hepatitis, it will be most proper to wait the change of the blood in colour and consistence. Blood in inflammation is different from the natural, since being excessively heated, if it was formerly crude, it becomes ruddier and brighter; or if it was such before, it turns black from being over-heated. Yet we must not in every case wait for the change, but sometimes give over before this takes place; for two reasons, either from the weakness of the patient’s powers, which you may ascertain to have sunk by feeling the pulse (for you will find it either unequal as to strength and magnitude, or indistinct, the stream of the blood failing also indicates that the strength is sunk), or from the malignity of the inflammation; for sometimes it will not remit, but the constriction continues strong. But if none of these circumstances contra-indicate, and if the patient be in the vigour of age, we may wait until a change takes place, especially if the atmosphere be mild. But if the flow of blood stop before a sufficient evacuation has taken place (this happens from fear, deliquium animi, and coagulum, or too tight an application of the bandage), we must attend to each of these causes, rousing from deliquium with strong-scented things, slackening the bandage when too tight, and a coagulum may be dissolved by pouring in oil, or by rubbing it with the fingers. The rest of the apparatus for phlebotomy is known to everybody. But these things apply to venesection at the bend of the arm. When we would abstract blood from the forehead as for headache, having first used fomentations, we apply a bandage round the neck, placing a finger over the windpipe to prevent suffocation, and when the frontal vein is properly filled we divide it with the point of a lancet or scalpel. In the same manner we may open the external jugulars for chronic ophthalmy, producing a discharge of blood with the concave part of the scalpel. The vessels also below the tongue we open transversely for angina, but without the application of any bandage. Some also open in like manner the veins which appear in the great canthi, as for chronic affections of the head or eyes, in which cases they also sometimes rupture the vessels within the nostrils either by rubbing them with the extremity of a specillum, or by tickling them with rough substances. They also open those behind the ears for the affections about the head; and those about the top of the thighs, as in affections of the kidneys; and those in the extremities they also open, after by the application of the ligatures to the parts above, by friction in the case of the hands, and walking in that of the feet, the vessels having become distended with blood; in affections of the spleen opening the vessel in particular between the small and middle finger of the left hand, and in affections of the liver those of the right hand; for the evacuation of the extremities, being from a distance, occasions a more powerful revulsion. In ischiatic diseases, and those of the uterus, they open the vein in the foot above the inner toe.
Commentary. We have to regret that our limits prevent us from doing more ample justice to the sound and enlarged views of the ancient physicians on this subject, and we must be content with making a few desultory observations and giving a few extracts.
We have had occasion frequently to remark that Hippocrates practised venesection freely in various diseases. He has left no treatise, however, expressly on the subject.
Celsus says, that to let blood was no new discovery in his day; but that blood might be let with advantage in almost every disease was a discovery. He states it also as a recent discovery that children, old men, and pregnant women might be safely bled, the operation having been anciently proscribed in all these cases. Yet, notwithstanding the authority of Celsus, the prejudice against bleeding young and old persons seems to have generally prevailed, for it will be perceived, that our author, copying from Galen, forbids persons to be bled before fourteen and after seventy, except in urgent cases. However, Averrhoes mentions that his countryman Avenzoar had bled a child only three years old with great success; and relates further that he had known certain persons who had been bled at the age of eighty. Celsus properly directs us to judge of a patient’s ability to endure venesection from his strength, and not from his tender or advanced age. He also acutely remarks that there is a difference between a strong body and a fat, and between a lean and a weak; for that a lean body contains most blood, and a fat most flesh. (See also Arist. H. A. iii, 19.) Those, therefore, who are lean bear depletion best, and the corpulent suffer most from it. The strength of the body, therefore, is to be estimated from the veins rather than from the general appearance. When the nature of the disease indicates evacuation, and the strength appears ill fitted to bear it, he advises us first to give warning of the danger, and then to abstract blood; for, he adds, “satius est remedium anceps experiri quam nullum.” In general he forbids venesection when the stomach is loaded with impurities; and upon this rule of practice all the ancient authorities, we believe, agree with him. Thus, to give an example from the Arabians, Averrhoes says, our famous physician, Abumeron Avenzoar, states that venesection ought not to be had recourse to until the body is purged, for the veins being emptied of blood attract the crude superfluities. (Collig. vii, 1.) This rule of practice is now too little attended to. In general Celsus holds that the second or third day of a disease is the fittest time for abstracting blood. He forbids bleeding upon the very onset of a fever, which he says is enough to kill a man outright. Upon the whole he approves of letting blood as near as possible to the affected part. He admits, however, that venesection may sometimes act by producing revulsion. The operation, he remarks, although easy to a skilful person may prove dangerous when performed by an unskilful one, as a nerve or artery may be wounded. In securing the arm after the operation he directs us to bind on the wound a compress soaked in cold water. (ii, 10.)
Galen wrote three treatises on venesection, to which operation he was very partial. They are: De venesectione adversus Erasistratum; de venesectione adversus Erasistrateos in Româ; and de curatione per venæ sectionem. These works are deserving of great attention as containing many judicious observations and rules of practice, but which are delivered at so great length that we can scarcely venture even upon an abstract of them. His principles of treatment, however, are nearly the same as those of our author. He appears to have abstracted blood in great quantities. Thus he mentions having seen six lib. taken away in the course of a fever, and six heminæ at once in a case of hæmoptysis. Now the hemina being somewhat more than a half a pint, the quantity abstracted must have exceeded three pints. He strenuously inculcates that venesection proves useful by occasioning revulsion, and as a proof of this he instances the beneficial effects produced by opening a vein of the arm in cases of epistaxis. He practised bloodletting occasionally in cases of dropsy, as we have mentioned under that head. Bleeding from the arm he thinks prejudicial in cases of amenorrhœa, as it causes a determination of blood to the upper parts of the body, and, therefore, he directs us rather to bleed at the ankle. He agrees with Celsus that lean persons bear depletion better than such as are fat; and that venesection is not to be performed when there are undigested matters in the stomach. He states that persons in extreme heat or cold do not bear bleeding. He mentions that in bleeding from the basilic vein there is danger of wounding the artery, that a nerve lies under the median; but that the cephalic may be opened without danger.
Oribasius gives an interesting dissertation on venesection, principally condensed from the works of Herodotus, Antyllus, and Galen. (Med. Collect. vii.) Antyllus directs us when going to bleed at the elbow to apply a ligature two fingers broad round the arm, so as to produce a swelling of the veins; and remarks that they are mistaken who affirm that the same effect may be produced by applying the ligature below, for that the veins will not then swell, even when the arm is fomented. When going to bleed at the ankle he directs us to apply the ligature above the knee; to put the limb into hot water, and make the person walk about. When the blood does not flow readily, he advises us to slacken the bandage if too tight; or if the opening in the vein be covered with the skin, to turn the arm into all positions until the opening of the vein and of the skin correspond; and if it be too small, to enlarge it. When fear retards the flow of the blood it will be of advantage, he says, not to allow the patient to hear the sound of it. When it stops from deliquium animi he advises us to lay the patient in a reclining posture on a couch; to promote vomiting, and to rouse by tight ligatures to the extremities, and by aromatics. When a clot of blood obstructs the vein he directs us to squeeze it out, or to dissolve it with oil or vinegar. When coldness of the body, occasioned whether by the temperature of the air, or the nature of the disease, prevents the flow of blood, he recommends fomentations and frictions. When a piece of fat or flesh blocks up the opening of the vein, he says there is no remedy for it but to cut it out or push it aside. When the object is to produce a sudden depletion he directs us to make a large incision in the vein, but a small one when it is intended to procure revulsion.
According to Drs. Freind and Milward, Alexander Trallian is the first authority who recommends bleeding by opening the jugulars. As far as we know this statement is correct.
Aëtius’s account of this subject is similar to our author’s, but less copious. (iii, 10.)
Actuarius in like manner has many judicious remarks on venesection, which our limits prevent us from giving to the reader. He forbids venesection when any natural secretion is increased, and this is in general a very proper rule, although, as Galen and Avicenna remark, profuse sweatings are sometimes remedied by bleeding. Bloodletting, he says, is contra-indicated by crudities in the stomach, and a loose state of the bowels. (Meth. Med. iii, 1.)
Little additional information is to be gleaned from the Arabians. We have mentioned, however, that Averrhoes and Avenzoar approved of venesection at a later and earlier period of life than the Greeks permitted it.
Avicenna with his customary accuracy collects everything of importance which had previously been written on the subject, but makes hardly any addition to the ancient stock of information. We can scarcely venture upon an abstract of his important chapter on phlebotomy. We may just mention that as a general rule he approves of bleeding after any accident. He disapproves of bleeding both at the onset and the crisis of a disease. In constitutions requiring bloodletting he holds that spring is the best season for it. Even in cases in which there is a deficiency of blood, but there is congestion in some particular part, he permits blood to be abstracted, in order to produce revulsion, the patient’s strength being recruited afterwards by a nourishing diet. When the colour of the blood is dark, and it is thick in consistence, a larger amount is to be abstracted than when it is thin and of a light colour. He makes the important remark, that bleeding sometimes kindles up a fever. He forbids the bath immediately before the operation, and food or exercise immediately afterwards. When a piece of fat obstructs the flow of blood, he directs that it should be gently pushed aside, but not cut out. (i, 4, 20.)
No author, ancient or modern, has described the modes of performing venesection in all parts of the body more accurately than Albucasis. Bleeding from the jugular vein he describes in much the same way that it is now practised by veterinary surgeons, namely, by placing a sort of scalpel, bent at the point, which he calls fossorium, upon the vein, and striking the instrument with a hammer, or some such body. He gives drawings of variously-shaped lancets for opening the veins of the arm. (Chirurg. ii, 97.)
The reader is also referred to Haly Abbas for a copious account of the operation, and the circumstances under which it may be performed. It is contra-indicated, he says, when the bowels are loaded with vitiated fæces. He allows it to be performed even after seventy years of age, provided the patient be of a vigorous constitution. (Pract. ix, 2.)
Rhases, with admirable judgment, condenses all the information supplied by preceding authorities, and mixes it up with his own personal observations. He forbids us to give food immediately after bleeding, as the empty veins will absorb the chyle before it is properly digested, which will prove a pabulum of disease. For the same reason, he, like the others, forbids bleeding when the stomach is loaded with crudities, lest they should be absorbed, and carried over the system. In retention of the menses he directs us to open the saphena, or to apply a cupping instrument to the ankle. When the disease is an acute attack of inflammation, he recommends us to abstract blood fully from an opposite part, so as to procure revulsion; but when it is a chronic affection, he advises to take it from the part affected. (Contin. xxviii.) He enjoins, as a prudent precaution in bleeding a person who is intoxicated, to apply two bandages about the arm, and to have proper attendants to restrain the bleeding, which is often difficult to stop in such cases. (Ad Mansor. vii, 21.)
The veterinary surgeons practised bleeding freely in the treatment of the diseases of cattle. Vegetius, the great authority on this subject, mentions that many persons bled their cattle every year, in the spring. He adds, however, that the ancient and more prudent authorities disapproved of indiscriminate depletion. (Mulom. i, 22.)