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Early Practices

A Brief History of Bloodletting

(continued)

Scientific community reacts to phlebotomy

In 1885 bloodletting in London had fallen into disfavor.3 At this time it was thought that disease represented a depressant effect to be overcome. Since bloodletting aggravated depression, its usefulness was limited to the treatment of local inflammations. "The year 1830 and subsequent years were marked by the epidemic visitations of cholera and of influenza. These diseases were characterized by extreme depression. If antiphlogistic measures were adopted, they proved failures, and taught the physician that bloodletting was not the universal panacea it was supposed to be."3 Bloodletting reached its high point in the United States by the end of the eighteenth and very early nineteenth centuries. Benjamin Rush, M.D., used it extensively during the yellow-fever epidemic in Philadelphia in 1793. In 1799 Dr. Rush treated George Washington for acute laryngitis by use of heavy bleeding; Washington died some 24 hours later.

The foregoing concepts of bloodletting came under increasing attack after 1850. The credit for undermining the antiphlogistic doctrine of treatment of inflammation in general, and of pneumonia in particular, belongs to Josef Skoda, M.D., and Josef Dietl, M.D., in Vienna; and to Pierre Charles Louis, M.D., Grissolle, M.D., August Chomel, M.D., and Gabriel Andral, M.D., in Paris.6 By the mid-nineteenth century Hughes Bennet, M.D., professor of medicine at the University of Edinburgh, is quoted by Watson and Condie5 as saying, "The principles on which bloodletting and antiphlogistic remedies have hitherto been practiced are opposed to sound pathology." The tide against bloodletting had begun. Oliver Wendell Holmes, M.D. (1809 to 1894), said, "The lancet was the magician's wand of the dark ages of medicine." Once the concept of microorganisms as the causative factor in disease was understood, the quest for cure of disease was redirected. The swelling, redness, and fever became secondary factors to be resolved.

A tradition of several thousand years dies hard. Austin Flint, M.D.,7 in 1881 gave the following advice:
A great change has taken place with respect to bloodletting in the treatment of acute inflammations. This measure was formerly thought to be highly important, and was rarely omitted. It is now considered by many as seldom, if ever, called for. The infrequent use of the lancet now, contrasted with its frequent use forty years ago, constitutes one of the most striking of the changes in the practice of medicine which have occurred during this period. It can hardly be doubted that this measure was formerly adopted too indiscriminately, and often employed too largely, but the natural tendency being to pass from one extreme to another, the utility of blood letting in certain cases, at the present time, is perhaps not sufficiently appreciated.
As late as 1920, Osler and McCrae8 gave the following information regarding bloodletting in pneumonia:
We employed it much more than we did a few years ago, but more often late in the disease than early. To bleed at the very onset in robust, healthy individuals in whom disease sets in with great intensity and high fever is good practice. Late in the course marked dilatation of the right heart is the common indication. The quantity of blood removed must be decided by the effect; small amounts are often sufficient.
Methods of bloodletting

The following quotation comes from the DICTIONARY OF PRACTICAL SURGERY of 18869:
Bloodletting is said to be general when blood is taken from a vein or artery so that the amount in the vascular system is materially diminished as shown by diminution on the tension of the blood vessels: it is termed local when, by means of leeches, cupping, or scarification, blood is taken in smaller quantities, with a view of relieving limited congestion and vascular tension. It may be safely said that in these two methods the surgeon possesses the means of treating, in a powerful and beneficial manner, those acute inflammations and engorgements of certain important organs and serous membranes associated with hard pulse, great pain, and distress occurring from injury in persons of healthy constitutions.
Bloodletting can therefore be listed under the following headings:

    I. General bloodletting
     A. Venesection
     B. Arteriotomy

    II. Local bloodletting
     A. Scarification with wet cupping
     B. Leeches

General bloodletting by venesection

Bloodletting by venesection was the method most commonly used; instruments used included lancets and fleams. A thumb lancet is a small, sharp-pointed, two-edged surgical instrument which was the principal instrument used for phlebotomy in human beings. ... The lancets, several of which might be contained in a special case, had either tortoise shell, ivory, or pearl folding guards. The cases were often made of silver or tortoise shell, and resembled a pocket cigarette lighter in size and shape ... which the physician usually carried in his waistcoat pocket.

Instruments known as spring lancets,10 spring fleams,11 or schnappers were introduced in Germany about 1680. ... Bennion12 labeled them single-bladed scarificators; they are spring loaded, and are constructed with a brass or white metal handle, and vary from 5 to 8 cm. in length. Pressure on a release lever allows the lancet to spring forward and penetrate the skin and vein. Small spring lancets were used for human beings; large ones were used for domestic animals such as the horse. The small, manually controlled thumb lancet was preferred by the physician; the spring lancet was used more by the laity. The spring lancet was more difficult to control, and the incision in the vein was often either too small or too large. Transfixation of the vein, injury to the tendon or nerve, and accidental arteriotomy were serious complications of the spring lancet.

According to Bailey,13 a fleam is a farrier's tool for letting blood in horses; a farrier is a smith who shoes and doctors horses. The term fleam has been applied to several bloodletting tools including the spring lancet, but should be used principally to indicate a bloodletting instrument with several shafts that fold into a case much like a pocketknife. Each shaft has a different size cutting blade, constructed at right angles to the shaft ...; sometimes the brass handles are decorated with animal horn.

In using the thumb lancet for venesection, the practitioner followed a prescribed set of instructions. The arm of the patient was bound above the elbow with a broad tape tight enough to compress the vein, but not tight enough to diminish the arterial pulse. The blade of the lancet was grasped between the thumb and forefinger, and the hand was steadied by the other three fingers. The lancet was then introduced into the vein in an oblique direction until blood rose up at the point. The front edge of the lancet was then pulled up in as straight a line as possible to make the skin wound the same size as that in the vein. The thumb of the left hand which was compressing the vein distally was removed, and the blood was allowed to flow into a bowl for measurement. Care was taken to avoid transfixation of the vein, accidental arteriotomy, or injury to the nerve or tendon. The spurting blood was caught in various types of vessels. Barber's shaving bowls were sometimes used. ... Soon after 1500 A.D., the design of the bowl was changed to include a semicircular notch in the rim.14 The notch allowed the bowl to be pressed against the skin of the neck or antecubital fossa. When sufficient blood had been withdrawn, the tourniquet was removed and the wound was dressed with dry lint (shredded linen) and a roller bandage.

Venesection was used to treat horses as well as man. In 1825 White15 stated, "In almost all the internal diseases of horses bleeding is the essential remedy; and the earlier and more freely it is employed the more effectual will it generally be found." "Bleed 'em White," as he became known, indicated his liberal views on bloodletting. The horse was bled most often from the jugular vein of the neck; a small lancet was used for small veins, but a fleam was preferred for the large veins. The preference for the fleam was its rapid introduction before the horse could pull free. Except in expert hands, the lancet was slightly slower and caused considerable skin pain before the incision could be made in the vein; by this time the horse would be out of control. The blade of the fleam was held against the long axis of the jugular vein, and the fleam handle was struck with the bottom of the fist to drive it through the skin and vein wall. As in human beings, rapid bleeding to a state of faintness was thought to be the proper technique. An instrument known as a blood-stick, a small club of hardwood usually weighted at one end with lead, was sometimes substituted for the rapid stroke of the hand.16

General bloodletting by arteriotomy

Arteriotomy was said to be indicated when there was a relative emptiness of the veins and an overfullness of the larger arteries. In comparison to venesection, the operation was infrequently performed.

Arteriotomy was most often performed on the superficial temporal artery or one of its branches. The vessel was partially cut through by a single transverse incision; when adequate blood was removed, the artery was completely severed so that the ends might contract and thus arrest the hemorrhage. A compress of dry lint was applied to the wound along with a tight roller bandage.

Local bleeding by scarification and wet cupping

Cupping may be wet or dry. Dry cupping is the application of a suction cup over an area of intact skin. The idea was to draw underlying blood and fluid away from the area of inflammation to the surface of the skin. This method relieved the congestion from the inflamed area, but did not remove fluid from the body. An early explanation by Paré2 is as follows: "For (as Celsus saith) a cupping glass where it is fastened on, if the skin be first scarified, draws forth blood, but if it be whole, then it draws spirit."


"Bloodletting Over the Centuries" by Gilbert R. Seigworth, M.D. From the NEW YORK STATE JOURNAL OF MEDICINE (December, 1980): 2022-2028. Reprinted by permission of the Medical Society of the State of New York.



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