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]