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.)