SOMETHING ON THE DISUSE OF PHLEBOTOMY.
BY RUFUS W. GRISWOLD, M. D.
When I began looking into medical books preparatory to practice, fifty years ago, the standard authors given us to read were not backward in recommending blood-letting in the acute diseases; and a little later, when an attendant at lectures at the College of Physicians and Surgeons at New York, the professors were not lacking with the like advice. But there has come a change, and so much of a change that, in this section of country at least, the lancet has mostly gone out of use. That the frequent use to which it was put seventy-five or a hundred years ago was not at all times wise is likely; but the extent to which it has been given up is also not wise. Rather more to notice some of the reasons why it has so largely been abandoned than to argue for a reintroduction of that ready and efficient instrument is the purpose of this paper.
A prominent point in the consideration of this comparative abandonment of the lancet is presented in the question: Has there been such a change in the type of the acute inflammatory diseases from three or four generations ago as to render the abstraction of blood less necessary and less useful? There are plenty of sound, hard-headed old doctors who will give a negative reply to this query; and occasionally we may notice some of them putting themselves in print to that effect. A Baltimore practitioner not so very long ago said: “The necessity for the use of the lancet is as great at the present time as it ever was in the past; the type of the disease has undergone no such changes as to render the abstraction of blood unnecessary or improper in the successful management of all cases attended with a full, tense, and quick pulse.” Others speak the like; but the majority of opinion is not pronounced in that direction, but rather adverse. Conversations during a forty-four years’ practice with men who began their professional calling sixty years ago, when the lancet was in often call, is to the import that there has been such a change in diseases as renders the frequent resort to blood-letting less important than formerly; that there is less of the sthenic type in even inflammatory fevers, a more general disposition to take on what we call typhoid forms, and thus depletion, either by the evacuation of blood or the exhibition of reducing drugs, is not so beneficial in even the acute inflammatory diseases as formerly. This is the view that has been entertained by a large part of those who began practice half a century or more ago, and this view has been sustained by a large amount of written authority; but it does not go to the extent of justifying that degree of abandonment of bleeding that has prevailed for the last forty years. The general opinion of to-day is, that while positions like that taken in the quotation given are too positive, on the other hand our practice is quite too lax; for while we still believe in blood-letting to some extent, we but seldom make use of it. Now as to the why.
Perhaps the first reason why the lancet is less used than formerly is found in the fact, or rather in the belief, of the change indicated. It is largely accepted as true by the older men in the profession that patients do not bear blood-letting as well as three generations ago. Accepting this as correct, it rationally follows that we should bleed less. But this is only one of the factors in the account, and not the largest one. The opinion that the physicians of the early part of this century used the lancet too often is beyond doubt correct. The doctrine of the purely symptomatic nature of fever put prominently forward by Brousais, and earnestly championed by active and pushing minds a century ago, and which was generally received in Europe and in this country, gave such an unfortunate impetus to the use of the lancet as finally led to its abuse. Patients were bled for almost every thing; not only for the fevers of acknowledged inflammatory type, such as acute pleurisy and the like, were bled for, but also cases of typhus, typhoid, etc., upon the ground that the fever in the case was only a symptom of the inflammatory action and was to be subdued or lessened by antiphlogistic remedies, chief of which was the abstraction of blood. The theory of the essentiality of fever became lost sight of, and the doctor treated for an inflammation rather than for a fever.
Without giving up the theory in which they had been educated, some physicians began to see that in some epidemics of disease a larger percentage of cases were lost among those where venesection had been used than among those similarly sick who were not bled. The deduction from this was that it would be better to bleed less. But a change was not to be made without a struggle. Reference to the medical literature of the first half of the century shows that there was a deal of warm discussion between the blood-letters and the anti-blood-letters. Out of the observations and discussions made there was cultivated a prejudice, professional to a moderate extent but popular to a large one, against bleeding per se, and without reference to the character of the disease under treatment or to the differing conditions that might exist, which helped to carry the usage from its former abuse at times to the opposite extreme of general abandonment. It is a universal law in nature that the farther the pendulum swings in one direction, the farther will it swing in the opposite on its return. The pendulum of venesection had swung too far forward for the best in the treatment of disease, and the return carried it quite beyond the best in the backward reaction.
Beyond the reasons noted for the present comparative non-use of the lancet, there has been added a pressure of an erroneous and illegitimate nature that has aided to put bleeding under a general ban more unfortunate for the sick than was the former rather indiscriminate use. Somewhat contemporaneously with the warm discussion upon bleeding carried on in the profession, and perhaps partly out of that discussion, there started up in various parts of the country an illegitimate class of practitioners, mostly illiterate and destitute of preliminary culture, interchangeably known as Botanics, Thompsonians, Eclectics, etc., whose chief stock in trade for public acceptance was denunciation, without regard to the conditions that might be met in a case, of leeching, bleeding, blistering, scarification, and other agents for cures. This denunciation found ready public credit. Not only from the mouths of the class named, but in various other ways, the prejudice they sought to create was widely diffused. Outside of the libraries of the profession you seldom see a medical book; anywhere else they have been rarities. But in many sections of the country for the last sixty years a canvass of the families would show an abundance of books, published for family reading, emanating from irregular practitioners, all of them saturated with lying abuse of the methods of treatment of the regular physicians. These books were loaned from one family to another, much as the weekly papers or the cheap novel; and they were read and believed in. The result was that many who read were indoctrinated with the belief that bleeding, no matter what the disease or the conditions, was not only not necessary, but pernicious, and often the cause of death; and there was little printed contradiction offered to disabuse the public mind of this false accusation.
Co-ordinating with this means of false instruction has been and is the public press. As respectable practitioners do not stoop to the quackery of advertising, the pecuniary interest of the press, so far as means and methods for the cure of diseases is concerned, is identical with the pecuniary interests of advertising quacks. The public press sells itself to the broad diffusion of the ways and means of medical quackery in all its forms. The subsidies of impostors and patent medicine men fill up one carotid artery for the support of the press; and the influence of that press, however weak the intellect that bestrides its tripod, is more potent than a hundred of the ablest men in the profession, for the sufficient reason that the voice of the men in the profession seldom strikes the public ear through the same broad and forceful channel.
The result of the false teaching of the class of books alluded to and of the medical advertising, and of the bleating of the tramping lecturers was that a large part of many communities came to believe that blood-letting was a crime against health, and a hindrance to recovery from disease, no matter what might be the conditions. The average intelligence of even well-educated communities goes no further than to accept the plausible teaching that is every day thrust upon its tympanum; it does not stop to criticise the motives nor to analyze the arguments of the advertiser, nor is it cultured in this direction to the capacity of justly weighing them according to their true significance. The average intelligence of even well-educated communities is not up to that grasp of the science of medicine necessary to determine between false and fallacious teaching and that which is rational and correct; it does not differentiate between clap-trap and honesty; it does not separate humbug from truth, and as an ocean of humbug passes the public gullet easier than an ounce of truth, it is not strange that the condition obtaining about bleeding is not so much that the physician has discarded it as improper, or has lost sight of its value in many cases, as that the community will not tolerate him in the abstraction of blood. Public prejudice overrides professional opinion, unless the opinion runs current with the prejudice. To bleed your patient and then have him die is to be damned; if he dies without being bled, no matter whatever else you may do or leave undone, the chances of being cursed are largely lessened. Besides this, very little or nothing is gained against the prejudice by recovery after bleeding, since the popular opinion will be that the patient would have gotten well quicker and better without it—an opinion that can seldom be disproved. Exactly in the same way in any case where venesection has been practiced and the patient does not get well, the opponents of the operation will assert that the bleeding caused the death, and that, in the absence of it, the patient would have got well; which also is difficult to disprove. The average mind proceeds from supposed causes to effects with most unreasonable logic.
As a matter of fact, the whole art of the practice of medicine is involved many times in many uncertainties as to the effects that are to follow the administration of drugs or the institution of any procedure, however simple, that it may puzzle the most sagacious to determine the exact weight of any factor introduced, whether it be for good or for ill. It should not therefore surprise us that to minds quite unacquainted with the therapeutical effects of blood-letting in disease, a death that follows a bleeding, however remote in point of time, should be credited to the operation rather than to the disease for which the operation was performed. An uncertain percentage of cases of many acute inflammations will recover, whether bled or not; an uncertain percentage of them will die, whether bled or not, and no matter how treated; and, while it will sometimes happen that of two cases of the same disease the one that is bled will get well and the one that is not bled will succumb, it will the next week happen that of two other cases of the same trouble the one that is bled will slip off and the one not bled will hold on finely. And it is a notorious fact that in some communities, if a patient is bled and then dies, nine out of every ten persons in the neighborhood will say, and part of them will believe, that the bleeding was an accessory if not the chief cause of the untoward event; and it is usually quite impossible for the doctor to show that the nine are not right in their view of the matter.
Under these circumstances it can hardly surprise us that the use of the lancet has gone out of fashion. It is not so much that we have less faith in its beneficence, rationally employed, as that our patients are opposed to it. Whether in spite of the opposition we should employ it oftener than we do is a question that every one must settle for himself. It might be possible for a bold and determined man to work up that road to confidence with his patients in it, but the path is so beset with difficulties that a hundred will fall by the way where one succeeds. A single death after phlebotomy will do more to impede the success of a young man in the profession than a dozen deaths without it; it is wise therefore to be cautious in the use of so potent a remedy, and to sin less in commission than in omission of opening a vein. It may be said that whether he succeeds or fails it is the duty of the physician to do in all cases what he thinks will be the best for his patient. This position may have its merits but it is a better thing to teach than to act upon. There is no law of right that demands of the practitioner that he shall assume the responsibility of the stupidity and ignorance of all his patients, and, worse still, of all the irrational prejudice they have allowed themselves to imbibe, and which no amount of logical facts will dispossess them of.
The writer, in the nearly fifty years of his practice as student and graduate, has had an average share, perhaps, of his patients die; but he has never had one die of any sort of fever after he had been bled as an aid in subduing that fever. On the other side, he has had patients die of the acute inflammatory diseases when they have not been bled; and, to-night, recalling those cases, he is of the opinion that some of them, if they had been well tapped in the arm at the outset of the sickness, they would have been saved.
Rocky Hill, Conn., December, 1897.