Bleeding: The History
The history of bloodletting has been marked by controversy. The extensive literature on bloodletting contains numerous polemical treatises that both extol and condemn the practice. Bloodletting was no sooner criticized as ineffective and dangerous than it was rescued from complete abandonment by a new group of zealous supporters.
From the time of Hippocrates (5th century B.C.)—and probably before, although no written record is available—bloodletting had its vocal advocates and heated opponents. In the 5th century B.C. Aegimious of Eris (470 B.C.), author of the first treatise on the pulse, opposed venesection, while Diogenes of Appolonia (430 B.C.), who described the vena cava with its main branches, was a proponent of the practice. Hippocrates, to whom no specific text on bloodletting is attributed, both approved and recommended venesection.[3]
The anatomist and physician Erasistratus (300-260 B.C.), was one of the earliest physicians to leave a record of why he opposed venesection, the letting of blood from a vein. Erasistratus, who practiced at the court of the King of Syria and later at Alexandria, a celebrated center of ancient medicine, recognized that the difficulty in estimating the amount of blood to be withdrawn and the possibility of mistakenly cutting an artery, tendon, or nerve might cause permanent damage or even death. Since Erasistratus believed that only the veins carried blood while the arteries contained air, he also feared the possibility of transferring air from the arteries into the veins as a result of venesection. Erasistratus was led to question how excessive venesection differed from committing murder.[4]
Through the writings of Aulus Cornelius Celsus (25 B.C.-?), the Roman encyclopedist, and Galen (ca. A.D. 130-200) venesection was restored as a form of orthodox medical treatment and remained so for the next fifteen hundred years. By the time of Celsus, bloodletting had become a common treatment. Celsus remarked in his well-known account of early medicine: “To let blood by incising a vein is no novelty; what is novel is that there should be scarcely any malady in which blood may not be let.”[5] Yet criticism of bloodletting continued, for when Galen went to Rome in A.D. 164 he found the followers of Erasistratus opposing venesection. Galen opened up discussion with these physicians in two books, Against Erasistratus and Against the Erasistrateans Dwelling in Rome. These argumentative dialectical treatises, together with his Therapeutics of Venesection, in which he presented his theory and practice of venesection, established Galen’s views on bloodletting, which were not effectively challenged until the seventeenth century.[6]
The fundamental theory upon which explanations of health and disease were based, which had its inception in ancient Greek thought and lasted up to the eighteenth century, was the humoral theory. Based on the scientific thought of the Pre-Socratics, the Pythagoreans, and the Sicilians, this theory posited that when the humors, consisting of blood, phlegm, yellow bile, and black bile, were in balance within the body, good health ensued. Conversely, when one or more of these humors was overabundant or in less than adequate supply, disease resulted. The humors were paired off with specific qualities representing each season of the year and the four elements according to the well-accepted doctrine of Empedocles, in which all things were composed of earth, air, fire, and water. Thus, yellow bile, fire, and summer were contrasted to phlegm, water, and winter, while blood, air, and spring were contrasted to black bile, earth, and autumn. When arranged diagrammatically, the system incorporating the humors, elements, seasons, and qualities appears as shown in Figure [1]. The earliest formulation of humoralism was to be found in the physiological and pathological theory of the Hippocratic treatise, On the Nature of Man.[7]
Plethora, an overabundance of body humors, including blood, which characterized fevers and inflammations, was properly treated by encouraging evacuation. This could be done through drugs that purged or brought on vomiting, by starvation, or by letting blood. During starvation the veins became empty of food and then readily absorbed blood that escaped into the arteries. As this occurred, inflammation decreased. Galen suggested that instead of starvation, which required some time and evacuated the system with much discomfort to the patient, venesection should be substituted to remove the blood directly.[8]
Peter Niebyl, who has traced the rationale for bloodletting from the time of Hippocrates to the seventeenth century, concluded that bloodletting was practiced more to remove excess good blood rather than to eliminate inherently bad blood or foreign matter. Generally, venesection was regarded as an equivalent to a reduction of food, since according to ancient physiological theory, food was converted to blood.[9]
Figure 1.—Chart of elements, seasons, and humors.
Galen defined the criteria for bloodletting in terms of extent, intensity, and severity of the disease, whether the disease was “incipient,” “present,” or “prospective,” and on the maturity and strength of the patient.[10] Only a skilled physician would thus know when it was proper to bleed a patient. Venesection could be extremely dangerous if not correctly administered, but in the hands of a good physician, venesection was regarded by Galen as a more accurate treatment than drugs. While one could measure with great accuracy the dosages of such drugs as emetics, diuretics, and purgatives, Galen argued that their action on the body was directed by chance and could not easily be observed by the physician.[11] However, the effects of bloodletting were readily observed. One could note the change in the color of the blood removed, the complexion of the patient, and the point at which the patient was about to become unconscious, and know precisely when to stop the bleeding.
Galen discussed in great detail the selection of veins to open and the number of times blood might be withdrawn.[12] In choosing the vein to open, its location in respect to the disease was important. Galen recommended that bleeding be done from a blood vessel on the same side of the body as the disease. For example, he explained that blood from the right elbow be removed to stop a nosebleed from the right nostril.[13] Celsus had argued for withdrawing blood near the site of the disease for “bloodletting draws blood out of the nearest place first, and thereupon blood from more distant parts follows so long as the letting out of blood is continued.”[14]
Controversy over the location of the veins to be opened erupted in the sixteenth century. Many publications appeared arguing the positive and negative aspects of bleeding from a vein on the same side (derivative—from the Latin derivatio from the verb derivare, “to draw away,” “to divert”) or the opposite side (revulsion—from the Latin revulsio, “drawing in a contrary direction”) of the disordered part of the body. This debate mirrored a broader struggle over whether to practice medicine on principles growing out of medieval medical views or out of classical Greek doctrines that had recently been revived and brought into prominence. The medieval practice was based on the Moslem medical writers who emphasized revulsion (bleeding from a site located as far from the ailment as possible).[15] This position was attacked in 1514 by Pierre Brissot (1478-1522), a Paris physician, who stressed the importance of bleeding near the locus of the disease (derivative bleeding). He was declared a medical heretic by the Paris Faculty of Medicine and derivative bleeding was forbidden by an act of the French parliament. In 1518, Brissot was exiled to Spain and Portugal. In 1539, the celebrated anatomist, Andreas Vesalius, continued the controversy with his famous Venesection Letter, which came to the support of Brissot.[16]
Only with the gradual awareness of the implications of the circulation of the blood (discovered in 1628) did discussion of the distinction between derivative and revulsive bloodletting become passé.[17] Long after the circulation of the blood was established, surgical treatises such as those of Lorenz Heister (1719) recommended removing blood from specific parts of the body—such as particular veins in the arm, hand, foot, forehead, temples, inner corners of the eye, neck, and under the tongue. In the nineteenth century this practice was still challenged in the literature as a meaningless procedure.[18] (Figure [2].)
How Much Blood to Take
According to Galen, safety dictated that the first bloodletting be kept to a minimum, if possible. Second, third, or further bleedings could be taken if the condition and the patient’s progress seemed to indicate they would be of value. The amount of blood to be taken at one time varied widely.[19]
Galen appears to have been the first to note the amount of blood that could be withdrawn: the greatest quantity he mentions is one pound and a half and the smallest is seven ounces. Avicenna (980-1037) believed that ordinarily there were 25 pounds of blood in a man and that a man could bleed at the nose 20 pounds and not die.[20]
The standard advice to bloodletters, especially in the eighteenth and nineteenth centuries, was “bleed to syncope.” “Generally speaking,” wrote the English physician and medical researcher, Marshall Hall, in 1836, “as long as bloodletting is required, it can be borne; and as long as it can be borne, it is required.”[21] The American physician, Robley Dunglison, defined “syncope” in his 1848 medical dictionary as a “complete and, commonly, sudden loss of sensation and motion, with considerable diminution, or entire suspension of the pulsations of the heart and the respiratory movements.”[22] Today little distinction is made between shock and collapse, or syncope, except to recognize that if collapse or syncope persists, shock will result.
We know today that blood volume is about one-fifteenth to one-seventeenth the body weight of an adult. Thus an adult weighing 150 pounds has 9 or 10 pounds of blood in his body. Blood volume may increase at great heights, under tropical conditions, and in the rare disease polycythemia (excess red blood cells). After a pint of blood is withdrawn from a healthy individual, the organism replaces it to some degree within an hour or so. However, it takes weeks for the hemoglobin (the oxygen-bearing substance in the red blood cells) to be brought up to normal.
If blood loss is great (more than 10 percent of the total blood volume) there occurs a sudden, systemic fall in blood pressure. This is a well-known protective mechanism to aid blood clotting. If the volume of blood lost does not exceed 30 to 40 percent, systolic, disastolic, and pulse pressures rise again after approximately 30 minutes as a result of various compensatory mechanisms.[23]
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Figure 2.—Venesection manikin, 16th century. Numbers indicate locations where in certain diseases venesection should be undertaken. (From Stoeffler, 1518, as illustrated in Heinrich Stern, Theory and Practice of Bloodletting, New York, 1915. Photo courtesy of NLM.)
If larger volumes than this are removed, the organism is usually unable to survive unless the loss is promptly replaced. Repeated smaller bleedings may produce a state of chronic anemia when the total amount of blood and hemoglobin removed is in excess of the natural recuperative powers.
When to Bleed
Selecting a time for bleeding usually depended on the nature of the disease and the patient’s ability to withstand the process. Galen’s scheme, in contrast to the Hippocratic doctrine, recommended no specific days.[24] Hippocrates worked out an elaborate schedule, based on the onset and type of disease, to which the physician was instructed to adhere regardless of the patient’s condition.
Natural events outside the body served as indicators for selecting the time, site, and frequency of bloodletting during the Middle Ages when astrological influences dominated diagnostic and therapeutic thought. This is illustrated by the fact that the earliest printed document relating to medicine was the “Calendar for Bloodletting” issued in Mainz in 1457. This type of calendar, also used for purgation, was known as an Aderlasskalender, and was printed in other German cities such as Augsburg, Nuremberg, Strassburg, and Leipzig. During the fifteenth century these calendars and Pestblatter, or plague warnings, were the most popular medical literature. Sir William Osler and Karl Sudhoff studied hundreds of these calendars.[25] They consisted of a single sheet with some astronomical figures and a diagram of a man (Aderlassmann) depicting the influence of the stars and the signs of the zodiac on each part of the body, as well as the parts of the anatomy suitable for bleeding. These charts illustrated the veins and arteries that should be incised to let blood for specific ailments and usually included brief instructions in the margin. The annotated bloodletting figure was one of the earliest subjects of woodcuts. One early and well known Aderlassmann was prepared by Johann Regiomontanus (Johannes Müller) in 1473. It contained a dozen proper bleeding points, each suited for use under a sign of the zodiac. Other Aderlassmanner illustrated specific veins to be bled. The woodcut produced by the sixteenth-century mathematician, Johannes Stoeffer, illustrated 53 points where the lancet might be inserted.[26]
“Medicina astrologica” exerted a great influence on bloodletting. Determining the best time to bleed reached a high degree of perfection in the late fourteenth and fifteenth centuries with the use of volvella or calculating devices adopted from astronomy and navigation. These were carried on a belt worn around the waist for easy consultation. Used in conjunction with a table and a vein-man drawing, the volvella contained movable circular calculators for determining the accuracy, time, amount, and site to bleed for an illness. The dangers of bloodletting elicited both civic and national concern and control. Statutes were enacted that required every physician to consult these tables before opening a vein to minimize the chance of bleeding improperly and unnecessarily. Consultation of the volvella and vein-man was more important than an examination of the patient.[27] (Figure [3].)
For several centuries, almanacs were consulted to determine the propitious time for bleeding. The “woodcut anatomy” became a characteristic illustration of the colonial American almanac. John Foster introduced the “Man of Signs,” as it was called, into the American almanac tradition in his almanac for 1678, printed in Boston. Other examples of early American almanacs featuring illustrations of bleeding include Daniel Leed’s almanac for 1693, printed in Philadelphia, and John Clapp’s almanac for 1697, printed in New York.
As in many of the medieval illustrations, the woodcut anatomy in the American almanac consisted of a naked man surrounded by the twelve signs of the zodiac, each associated with a particular part of the body (the head and face with Aries, the neck with Taurus, the arms with Gemini, etc.). The directions that often accompanied the figure instructed the user to find the day of the month in the almanac chart, note the sign or place of the moon associated with that day, and then look for the sign in the woodcut anatomy to discover what part of the body is governed by that sign. Bloodletting was usually not specifically mentioned, but it is likely that some colonials still used the “Man of Signs” or “Moon’s Man” to determine where to open a vein on a given day.[28]
Figure 3.—Lunar dial, Germany, 1604. Concentric scales mark hours of the day, days, months, and special astrological numbers. In conjunction with other dials, it enables the user to determine the phases of the moon. (NMHT 30121; SI photo P-63426.)
The eighteenth-century family Bible might contain a list of the favorable and unfavorable days in each month for bleeding, as in the case of the Bible of the Degge family of Virginia.[29]
Barber-Surgeons
Even though it was recognized that bleeding was a delicate operation that could be fatal if not done properly, it was, from the medieval period on, often left in the hands of the barber-surgeons, charlatans, and women healers. In the early Middle Ages the barber-surgeons flourished as their services grew in demand. Barber-surgeons had additional opportunities to practice medicine after priests were instructed to abandon the practice of medicine and concentrate on their religious duties. Clerics were cautioned repeatedly by Pope Innocent II through the Council at Rheims in 1131, the Lateran Council in 1139, and five subsequent councils, not to devote time to duties related to the body if they must neglect matters related to the soul.[30]
By 1210, the barber-surgeons in England had gathered together and formed a Guild of Barber-Surgeons whose members were divided into Surgeons of the Long Robe and Lay-Barbers or Surgeons of the Short Robe. The latter were gradually forbidden by law to do any surgery except bloodletting, wound surgery, cupping, leeching, shaving, extraction of teeth, and giving enemas.[31] The major operations were in the hands of specialists, often hereditary in certain families, who, if they were members of the Guild, would have been Surgeons of the Long Robe.
Figure 4.—Bleeding bowl with gradations to measure the amount of blood. Made by John Foster of London after 1740. (Held by the Division of Cultural History, Greenwood Collection, Smithsonian Institution; SI photo 61166-C.)
To distinguish his profession from that of a surgeon, the barber-surgeon placed a striped pole or a signboard outside his door, from which was suspended a basin for receiving the blood (Figure [4]). Cervantes used this type of bowl as the “Helmet of Mambrino” in Don Quixote.[32] Special bowls to catch the blood from a vein were beginning to come into fashion in the fourteenth century. They were shaped from clay or thin brass and later were made of pewter or handsomely decorated pottery. Some pewter bowls were graduated from 2 to 20 ounces by a series of lines incised around the inside to indicate the number of ounces of fluid when filled to that level. Ceramic bleeding bowls, which often doubled as shaving bowls, usually had a semicircular indentation on one side to facilitate slipping the bowl under the chin. Bowls to be used only for bleeding usually had a handle on one side. Italian families had a tradition of passing special glass bleeding vessels from generation to generation. The great variety in style, color, and size of bleeding and shaving bowls is demonstrated by the beautiful collection of over 500 pieces of Dr. A. Lawrence Abel of London and by the collection of the Wellcome Historical Museum, which has been cataloged in John Crellin’s Medical Ceramics.[33] These collections illustrate the stylistic differences between countries and periods.
The barber-surgeons’ pole represented the stick gripped by the patient’s hand to promote bleeding from his arm. The white stripe on the pole corresponded to the tourniquet applied above the vein to be opened in the arm or leg. Red or blue stripes appeared on early barber poles, but later poles contained both colors.[34]
The dangers posed by untutored and unskilled bleeders were noted periodically. In antiquity Galen complained about non-professional bleeders, and in the Middle Ages, Lanfranc (1315), an outstanding surgeon, lamented the tendency of surgeons of his time to abandon bloodletting to barbers and women.[35] Barber-surgeons continued to let blood through the seventeenth century. In the eighteenth and nineteenth centuries, the better educated surgeon, and sometimes even the physician, took charge of bleeding.
Bloodletting and the Scientific Revolution
The discovery of the blood’s circulation did not result in immediate changes in the methods or forms of bloodletting. William Harvey, who published his discovery of circulation in 1628, recognized the value of investigating the implications of his theory. Harvey could not explain the causes and uses of the circulation but he believed that it did not rule out the practice of bloodletting. He claimed that
daily experience satisfies us that bloodletting has a most salutary effect in many diseases, and is indeed the foremost among all the general remedial means: vitiated states and plethora of blood, are causes of a whole host of disease; and the timely evacuation of a certain quantity of the fluid frequently delivers patients from very dangerous diseases, and even from imminent death.[36]
The English scientist Henry Stubbe brought to the surface what would appear to be an obvious dilemma: How could one bleed to produce local effect if the blood circulated? Stubbe commented in 1671:
I do say, that no experienced Physician ever denied the operation of bloodletting though since the tenet of the Circulation of the Blood the manner how such an effect doth succeed admits of some dispute, and is obscure. We the silly followers of Galen and the Ancients do think it an imbecility of judgement, for any to desert an experienced practice, because he doth not comprehend in what manner it is effected.[37]
In the early nineteenth century the physiologist François Magendie (1783-1855), who argued against bloodletting, showed that the physiological effects of opening different veins was exactly the same, and therefore the choice of which vein to bleed did not affect the procedure.[38]
The first serious modern challenges to bloodletting were made in the sixteenth and seventeenth centuries under the leadership of the German alchemist Paracelsus and his Belgian follower, Van Helmont. The medical chemists or iatrochemists espoused explanations for and treatments of diseases based on chemical theories and practices. They believed that the state of the blood could best be regulated by administering the proper chemicals and drugs rather than by simply removing a portion of the blood. Iatrochemistry provided a substitution in the form of medicinals to quell the flow of blood for therapeutic purposes.[39]
The revival of Hippocratic medicine in the late seventeenth and eighteenth centuries also led to questioning the efficacy of bloodletting. The Hippocratic treatises, while they occasionally mentioned bloodletting, generally stressed nature’s power of cure. This school of medicine advocated a return to clinical observation and a reduction of activist intervention. Treatments such as bloodletting, it was felt by the neo-Hippocratists, might merely serve to weaken the patient’s strength and hinder the healing processes of nature.[40]
A rival group of medical theorists also flourished in this period. The iatrophysicists, who concentrated on mechanical explanations of physiological events, remained adherents of bloodletting. Their support of the practice ensured its use at a time when the first substantial criticism of it arose.
Instrumentation and Techniques
Sharp thorns, roots, fish teeth, and sharpened stones were among the early implements used to let blood.[41] Venesection, one of the most frequently mentioned procedures in ancient medicine, and related procedures such as lancing abcesses, puncturing cavities containing fluids, and dissecting tissues, were all accomplished in the classical period and later with an instrument called the phlebotome. Phlebos is Greek for “vein,” while “tome” derives from temnein, meaning “to cut.” In Latin, “phlebotome” becomes “flebotome,” and in an Anglo-Saxon manuscript dating from A.D. 1000, the word “fleam” appears. The phlebotome, a type of lancet, was not described in any of the ancient literature, but its uses make it apparent that it was a sharp-pointed, double-edged, and straight-bladed cutting implement or scalpel similar to the type later used for splitting larger veins.[42]
Several early Roman examples of phlebotomes have been collected in European museums. One, now in the Cologne Museum, was made of steel with a square handle and blade of myrtle leaf shape. Another specimen, made of bronze, was uncovered in the house of the physician of Strada del Consulare of Pompeii. This specimen, now in the Naples Museum, is 8 cm long and 9 mm at the broadest part of the blade, and its handle bears a raised ring ornamentation.[43] A number of copies of Roman instruments have been made and some have passed into museum collections. Some of the copies were commissioned by Sir Henry Wellcome for the Wellcome Historical Medical Museum collection and the Howard Dittrick Historical Medical Museum in Cleveland. They emulate the size, color, and aged condition of the originals and make it very difficult for the inexpert to distinguish an original from its replica. It is, however, impossible to fully duplicate the patina of ancient bronze.[44] Seventeenth-century and later bloodletting instruments usually have not been copied.[45]
From the earliest examples of the fleam, such as the specimen found at Pompeii, this instrument has been associated with the veterinarian. Since early practitioners, particularly the Roman physician, performed the duties of the surgeon as well as those of the veterinarian, it is possible that they used the same instrument to open blood vessels in humans and animals.[46]
In the seventeenth and eighteenth centuries a type of fleam (German fliete, French flamette), which had a pointed edge at right angles to the handle, was in use in Germany, Holland, and Vienna, Austria.[47] Since the specimens found in museums vary in size, it is likely that this type of fleam was used on both animals and humans.
In about the fifteenth century the thumb lancet, also called a gladiolus, sagitella, lanceola, lancetta, or olivaris, was introduced.[48] It soon became the preferred instrument for opening a vein in any part of the body. The double-edged iron or steel blade was placed between two larger covers, usually made of horn or shell, and all three pieces were united at the base with a riveted screw. The blade could be placed at various angles of inclination when in use. The shape of the blade, whether broad or narrow, determined the ease with which the skin and vein could be penetrated. A long slender blade was essential to pierce a vein located below many layers of fatty tissue.[49] These tiny and delicate thumb lancets were often carried in small flat cases of silver, tortoise shell, shagreen, or leather with hinged tops and separate compartments for each lancet. (Figure [5].)
A surgeon was advised to carry lancets of various sizes and shapes in order to be prepared to open veins of differing sizes and in different locations. Even Hippocrates had cautioned bloodletters not to use the different size lancets indiscriminately, “for there are certain parts of the body which have a swift current of blood which it is not easy to stop.”[50] For vessels that bled easily, it was essential to make narrow openings; otherwise it would be difficult, if not impossible, to stop the flow of the blood. For other vessels, lancets that made larger openings were required or the blood would not flow satisfactorily.
The blood as it spurted from the vein would be collected in a container and measured. When enough blood was removed, the bleeding would be stopped by a bandage or compress applied to the incision.
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Figure 5.—18th-19th century lancets and lancet cases. The cases are made of mother-of-pearl, silver, shagreen, and tortoise shell. (NMHT 308730.10. SI photo 76-9116.)
Teaching a medical student how to bleed has had a long tradition. Before approaching a patient, the student practiced opening a vein quickly and accurately on plants, especially the fruits and stems.[51] The mark of a good venesector was his ability not to let even a drop of blood be seen after the bleeding basin was removed.[52]
It required some degree of skill to strike a vein properly. The most common vein tapped was in the elbow, although veins in the foot were also popular. The arm was first rubbed and the patient given a stick to grasp. Then a tourniquet would be applied above the elbow (or, if the blood was to be taken from the foot, above the ankle), in order to enlarge the veins and promote a continuous flow of blood. Holding the handle between the thumb and the first finger, the operator then jabbed the lancet into the vein. Sometimes, especially if the vein was not close to the surface of the skin, the instrument was given an extra impetus by striking it with a small mallet or the fingers to insure puncturing the vein.[53] The incisions were made diagonally or parallel to the veins in order to minimize the danger of cutting the vein in two.[54]
For superficial veins, the vein was sometimes transfixed, that is, the blade would be inserted underneath the vessel so that the vessel could not move or slip out of reach. The transfixing procedure ensured that the vein would remain semi-divided so that blood would continuously pass out of it, and that injury to other structures would be avoided. Deep-lying veins of the scalp, for example, could not be transfixed. They were divided by cutting through everything overlying them since there were no important structures to injure.[55]
The consequences of puncturing certain veins incorrectly were discussed by many early writers including Galen, Celsus, Antyllus, and Paul of Aegina.[56] Injury to a nearby nerve, muscle, or artery resulted in convulsions, excessive bleeding, or paralysis.
Bloodletting was at its most fashionable in the eighteenth and early nineteenth centuries. In this period it was considered an art to hold the lancet properly and to support the arm of the patient with delicacy and grace.[57] Many patients had by repeated bloodlettings become inured to its potential danger and unpleasantness. In the mid-eighteenth century one British physician declared: “People are so familiarized to bleeding that they cannot easily conceive any hurt or danger to ensue, and therefore readily submit, when constitutional fear is out of the question, to the opening of a vein, however unskillfully advised.”[58] In England in the early nineteenth century people came to the hospital to be bled in the spring and fall as part of the ritual for maintaining good health. At some periods there were so many people undergoing prophylactic bloodletting that they could be seen lying on the floor of the hospital while recovering from the faintness induced by venesection.[59]
The lancet was perhaps the most common medical instrument. The Lancet was the name of one of the oldest and most socially aware English medical journals, founded by Thomas Wakeley in 1823.[60]
In America, Benjamin Rush (1746-1813) promoted vomits, purges, salivation, and especially bleeding. Rush, a signer of the Declaration of Independence, is notorious in medical history for his resorting to massive bleedings during the epidemics of yellow fever at the end of the eighteenth century. Rush told a crowd of people in 1793: “I treat my patients successfully by bloodletting, and copious purging with calomel and jalop and I advise you, my good friends, to use the same remedies.” “What?” called a voice from the crowd, “Bleed and purge everyone?” “Yes,” said the doctor, “bleed and purge all Kensington.”[61]
The alternatives to bleeding in this period included administering mercury (calomel) to promote salivation and tartar emetic to induce vomiting. These substitutes could be as hazardous as bleeding and offered little choice to the patient who had to bear the unpleasant effects. Thus, the late eighteenth and early nineteenth century has been referred to by historians as the era of heroic medicine because of the large amounts of strong medications given and excessive bloodletting.[62]
One of the most notable victims of heroic medicine during this period was George Washington (1732-1799), who was bled four times in two days after having contracted a severe inflammation of the throat. Washington’s physician, Dr. Craik, admitted that the removal of too much blood might have been the cause of his death. Additional bleeding was prevented only by Washington’s request to be allowed to die without further medical intervention, since he believed that his illness was incurable.[63]
Bloodletting was especially resorted to in times of crisis. One woman, Hannah Green, had been anesthetized in 1848 by chloroform before undergoing a minor operation on her toe. The physician bled her in a futile attempt to revive her, but she died, becoming the first known victim of inhalation anesthesia.[64]
Spring Lancets
The great vogue in phlebotomy inspired the invention of ingenious instruments. From Vienna came the automatic or spring lancet, originally called a Schnepper or Schnepperlein, which permitted the operator to inject the blade into a vein without exerting manual pressure.[65] It was widely adopted if the variety of models now extant is a proper indication. In the spring lancet, the blade was fixed into a small metal case with a screw and arranged to respond to a spring that could be released by a button or lever on the outside of the case. The blade was positioned at right angles to the spring and case, thus adopting the basic shape of the fleam. The case of the spring lancet was usually made of copper, silver, brass, or an alloy. It was often decorated with engraved furbelows or embossed with political or other symbols depending on the preference of the owner and the fashion of the period. The mechanism of this handsome implement has been described by a modern collector (Figures [6, 7]):
The curved projection (1) is the continuation of a heavy coiled spring. When pushed up it catches on a ratchet. A razor sharp blade (2), responding to the pressure of a light spring placed under it, follows the handle as it goes up. A lever (3) acting on a fulcrum (4) when pressed down, releases handle which in turn strikes the lancet down with lightning speed.[66]
The spring lancet was initially described by Lorenz Heister in 1719.[67] Another early description appeared in 1798 in the first American edition of the Encyclopedia or Dictionary of Arts and Sciences, in which the spring lancet was called a “phleam.”[68]
The spring lancet for use on humans was a rather tiny instrument. Its casing was about 4 cm long and 1.5 to 2 cm wide. The blade added another centimeter in length. Larger size instruments, often with a metal guard over the blade, were made for use on animals. Eighteenth- and early nineteenth-century spring lancets are found in a wide variety of shapes. Mid- and late nineteenth-century spring lancets are more uniform in shape, most having the familiar knob-shaped end. In most lancets the blade was released by a lever, but in the late nineteenth century, the blade of a more expensive model was released by a button.
Figure 6.(left)—Spring lancet, 19th century. (NMHT 321636.01; SI photo 73-4236.)
Figure 7.(right)—Interior of spring lancet. (NMHT 308730.10; SI photo 76-13535.)
In general, German, American, and Dutch surgeons preferred the spring lancet to the simple thumb lancet. In contrast, the French tended to prefer the thumb lancet. Ristelhueber, a surgeon in Strasbourg, maintained in 1819 that the simple lancet was preferable to the spring lancet both in terms of simplicity of design and application. While allowing German surgeons some credit for attempting to improve the spring lancet, Ristelhueber remained firm in his view that the spring lancet was too complicated and performed no better than the thumb lancet. The only advantage of the spring lancet was that it could be used by those who were ignorant of anatomy and the art of venesection. Untutored bleeders could employ a spring lancet on those veins that stood out prominently and be fairly confident that they could remove blood without harming other blood vessels. The bagnio men (bath attendants), who routinely bled the bathers in public baths, preferred the spring lancet.[69] It was more difficult to sever a vein with a spring lancet and thereby cause serious hemorrhaging. However, since the spring lancet was harder to clean because of its small size and its enclosed parts, it was more likely to induce infection (phlebitis).
While the French and British surgeons remained critical of the spring lancet, it became popular in the United States. John Syng Dorsey, a noted Philadelphia surgeon, wrote in 1813:
The German fleam or spring lancet I prefer greatly to the common English lancet for phlebotomy; it is now in some parts of the United States almost exclusively used. In a country situated like the United States, where every surgeon, except those residing in our largest cities, is compelled to be his own cutler, at least so far as to keep his instruments in order, the spring-lancet has a decided preference over the lancet; the blade of this can with great ease be sharpened by any man of common dexterity, and if not very keen it does no mischief, whereas a dull lancet is a most dangerous instrument; and no one can calculate with certainty the depth to which it will enter. To sharpen a lancet, is regarded by the cutler as one of his nicest and most difficult jobs; it is one to which few surgeons are competent.
The safety of using the fleam is demonstrated by daily experience; there is no country in which venesection is more frequently performed than in the United States, and perhaps none where fewer accidents from the operation have occurred, of those few, I beg leave to state, that all the aneurisms produced by bleeding, which I have seen, have been in cases where the lancet was used. Among the advantages of the spring-lancet economy is not the least. A country practitioner who is constantly employing English lancets, and who is particular in using none but the best, must necessarily consume half the emoluement derived from the operation, in the purchase of his instruments. One spring-lancet, with an occasional new blade, will serve him all his life.[70]
This popularity is also reflected in various medical dictionaries of the eighteenth and nineteenth centuries that described the instrument and in the wide variety of spring lancets in the Smithsonian collection.
One American user of the spring lancet, J. E. Snodgrass of Baltimore, was inspired to compose a poem about the instrument, which appeared in the Baltimore Phoenix and Budget in 1841. He wrote:
To My Spring-Lancet
There was little change in the mechanism of the spring lancet during the nineteenth century, despite the efforts of inventors to improve it. Approximately five American patents on variations of the spring lancet were granted in the nineteenth century. One patent model survives in the Smithsonian collection. Joseph Gordon of Catonsville, Maryland, in 1857 received patent No. 16479 for a spring lancet constructed so that three different positions of the ratchet could be set by the sliding shield. The position of the ratchet regulated the force with which the blade entered the vein. This also had the advantage of allowing the blade to enter the vein at the same angle irrespective of the depth to which it penetrated.[71]
The Decline of Bleeding
Throughout the seventeenth, eighteenth, and nineteenth centuries, most physicians of note, regardless of their explanations of disease, including Hermann Boerhaave, Gerard Van Swieten, Georg Ernst Stahl (phlogiston), John Brown and Friedrich Hoffmann (mechanistic theories), Johann Peter Frank, Albrecht von Haller, Percival Pott, John Pringle, William Cullen, and Francois Broussais, recommended bloodletting and adjusted their theories to provide an explanation for its value. At the end of the eighteenth century and in the early nineteenth century, the practice of bloodletting reached a high point with the theories of F.-J.-V. Broussais (1772-1838) and others. After 1830, however, the practice gradually declined until, by the end of the century, it had all but disappeared.
This decline occurred even though many medical theories were brought to the defense of bleeding. A French medical observer commented in 1851 that “l’histoire de la saignée considerée dans son ensemble, constituerait presque à elle seule l’histoire de toutes les doctrines médicales” (the history of bloodletting, considered in its totality, would constitute almost by itself the history of all medical doctrines).[72] There was no crisis of medical opinion, and no one event to account for this decline. The French physician, Pierre Louis’s statistical investigation (numerical method) into the effect of bloodletting in the treatment of pneumonia has often been cited as a cause for the downfall of venesection,[73] but the results of Louis’s research showed only that bloodletting was not as useful as was previously thought. Louis’s work, however, was typical of a new and critical attitude in the nineteenth century towards all traditional remedies. A number of investigators in France, Austria, England, and America did clinical studies comparing the recovery rates of those who were bled and those who were not.[74] Other physicians attempted to measure, by new instruments and techniques, the physiological affects of loss of blood. Once pathological anatomy had associated disease entities with specific lesions, physicians sought to discover exactly how remedies such as bloodletting would affect these lesions. In the case of pneumonia, for example, those who defined the disease as “an exudation into the vessels and tissues of the lungs” could not see how bloodletting could remove the coagulation. John Hughes Bennett, an Edinburgh physician, wrote in 1855: “It is doubtful whether a large bleeding from the arm can operate upon the stagnant blood in the pulmonary capillaries—that it can directly affect the coagulated exudation is impossible.”[75] Bennett felt that bloodletting merely reduced the strength of the patient and thus impeded recovery.
Bloodletting was attacked not only by medical investigators, but much more vehemently by members of such medical sects as the homeopaths and botanics who sought to replace the harsh remedies of the regular physicians by their own milder systems of therapeutics.[76]
As a result of all this criticism the indications for bleeding were gradually narrowed, until at the present time bloodletting is used in only a few very specific important instances.
In England and America, in the last quarter of the nineteenth century, a last serious attempt was made to revive bloodletting before it died out altogether. A number of Americans defended the limited use of bleeding, especially in the form of venesection. The noted American physician, Henry I. Bowditch, tried in 1872 to arouse support for venesection among his Massachusetts Medical Society colleagues. He noted that venesection declined more than any other medical opinion in the esteem of the physician and the public during the previous half century. At the beginning of his career, he had ignored the request of his patients who wanted annual bloodlettings to “breathe a vein” to maintain good health. He eventually found that to give up the practice entirely was as wrong as to overdo it when severe symptoms of a violent, acute cardiac disease presented themselves. Lung congestion and dropsy were other common disorders that seemed to him to be relieved, at least temporarily, by venesection.[77]
In 1875 the Englishman W. Mitchell Clarke, after reviewing the long history of bloodletting and commenting on the abrupt cessation of the practice in his own time, wrote:
Experience must, indeed, as Hippocrates says in his first aphorism, be fallacious if we decide that a means of treatment, sanctioned by the use of between two and three thousand years, and upheld by the authority of the ablest men of past times, is finally and forever given up. This seems to me to be the most interesting and important question in connection with this subject. Is the relinquishment of bleeding final? or shall we see by and by, or will our successors see, a resumption of the practice? This, I take it, is a very difficult question to answer; and he would be a very bold man who, after looking carefully through the history of the past, would venture to assert that bleeding will not be profitably employed any more.[78]
An intern, Henri A. Lafleur of the newly founded Johns Hopkins Hospital, reported on five patients on whom venesection was performed between 1889 and 1891. Lafleur defended his interest in the subject by calling attention to other recent reports of successes with bleeding, such as that of Dr. Pye-Smith of London. He concluded that at least temporary relief from symptoms due to circulatory disorders, especially those involving the pulmonary system, was achieved through venesection.
Pneumonia and pleurisy were the primary diseases for which venesection was an approved remedy.[79] It had long been believed by bloodletters that these complaints were especially amenable to an early and repeated application of the lancet.[80] Austin Flint had explained in 1867 that bloodletting “is perhaps more applicable to the treatment of inflammation affecting the pulmonary organs than to the treatment of other inflammatory affections, in consequence of the relations of the former [pulmonary organs] to the circulation.”[81] Thus, while bloodletting for other diseases declined throughout the nineteenth century, it continued to be advocated for treating apoplexy, pneumonia, and pulmonary edema.[82]
The merit of phlebotomy for those afflicted with congestive heart failure was emphasized again in 1912 by H. A. Christian. This condition led to engorgement of the lungs and liver and increased pressure in the venous side of the circulation. Articles advocating bloodletting continued into the 1920s and 1930s.[83]
Bloodletting is currently being tested as a treatment for those suffering from angina or heart attacks. Blood is removed on a scheduled basis to maintain the hematocrit (the percentage of red blood cells in the blood) at a specified level. Keeping the hematocrit low has provided relief to those being tested.[84] Other benefits of removing blood, including the lowering of blood pressure, can be obtained by the use of antihypertensive drugs. Thus the valid indications for bleeding are being supplanted by the use of modern drugs that accomplish the same end.
By the twentieth century the lancet was replaced in some quarters by safer devices for removing blood and injecting fluids into the bloodstream. Heinrich Stern improved Strauss’s special hyperdermic needle. In 1905 Stern designed a venepuncture or aspirating needle that was 7 cm long with a silver cannula of 4 cm. Attached to the handle was a thumb-rest and a tube for removing or adding fluids and a perforator within the cannula. He recommended that the forearm be strapped above the elbow and that the instrument be thrust into the most prominent vein. This streamlined vein puncturing implement reduced the possibility of injecting air and bacteria into the blood.[85] It was, and continues to be, used to withdraw blood for study in the laboratory, to aid in diagnosis of disease, and to collect blood for transfusing into those who need additional blood during an operation or to replace blood lost in an accident or disease. The blood is collected in a glass or plastic graduated container and stored under refrigeration. The study of blood donors has, incidentally, given insights into the physiology of bloodletting since the volume customarily removed from a donor is about the same in volume as that taken by a bleeder (one pint or 500 cc).[86]
The annual physical examination today includes taking a small amount of blood from the finger or a vein in the elbow. This blood is then analyzed for the presence of biochemical components of such diseases as diabetes, anemia, arteriosclerosis, etc. A tiny sterile instrument called a blood lancet may be used by the technician who draws the blood, who is still called by the historical name, phlebotomist.