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Early Practices

A Brief History of Bloodletting

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The cupping devices were most often dome-shaped glasses. ... Bailey13 defines a cupping glass as "a sort of glass vial applied to the fleshy part of the body to draw out corrupt blood and windy matter." This same dictionary uses cucurbitula as a synonym for cupping glass. The word is derived from Latin curcurbita meaning a gourd, or made in the shape of a gourd. It is interesting to note that small gourds were actually used as cupping devices for drawing blood. There were several ways to create suction in the cupping glass. One was to heat the air in the glass before application to the skin; as the air cooled, a suction developed. Another way was to attach a brass syringe to the glass cup to produce suction. However, the heated cupping glasses remained the favorite method. Some cups were made from the hollowed, distal portion of an animal's horn called cupping horns. A hole, which was used for mouth suction, was made in the pointed end. Once suction was established, the hole was plugged with wax. Such devices were described by Paré.2

Wet cupping involved scarification of the skin so that blood and fluid could be extracted. Most of the scarificators were cube-shaped, brass boxes containing multiple small knives operated by a spring mechanism. ... The scarificators, some of which were cylindric in shape, contained from 1 to 20 blades; however, most had 12 small knives. An early nineteenth-century bloodletting set contained cupping glasses, scarificator, and spirit heater. ...

The following method for wet cupping was described by Druitt in 1860.17 The equipment included a scarificator, cupping glasses, torch, spirits of wine, lighted candle, hot water, and sponge. The skin was sponged with warm water to increase the vascularity. A towel was used to dry the skin, after which a small torch, soaked in spirits of wine, was set on fire. The burning torch was introduced into the cupping glass for one second, and the cupping glass was then applied to the intact skin. As soon as the skin became red and swollen, the cup was removed by insinuating the fingernail under its edge. The spring-loaded scarificator was then placed on the prepared skin, and, with the release of the spring, 12 small lancets perforated the skin. The cupping glass was reheated and reapplied. After 3 to 5 ounces of blood had been extracted, the cup was removed and the wound was dressed with lint and plaster. Several precautions were given. To avoid burning the patient's skin, the edges of the cupping glass were not to be heated. If the scarificator blades were set too deeply, the fat protruded through the skin incision and prevented the flow of blood. The direction of the incision was to correspond to the course of the muscular fibers.

Local bleeding by use of leeches

The word leech comes from an Old English word "laece" meaning physician. In 1668 the veterinarian was known as a horse-leech. The spelling later became leech and was used to name a worm used in bloodletting. The leech belongs to the class "Hirudinea" and phylum "Annelida." The technical name for the medicinal leech is "Hirudo medicinalis." Leeches release an anticoagulant known as hiruden, and are found in many parts of the world including North America, Sweden, and Portugal. The Swedish leeches were said to draw four times the blood an American leech could extract. The leeches were stored in special porcelain jars with perforated lids, which contained spring water and were kept in a cool place. ...

An instrument known as an artificial leech was used for the over-sensitive patient who objected to live leeches; the device consisted of a pointed lancet inside a glass syringe cylinder or "sucker."

The following paragraph is a translation of the Old English from the 1634 text of Ambroise Paré.2
In those parts of the body whereto cupping-glasses and horns cannot be applied, to those leeches may for the most part be put, as to the fundament to open the coat of the haemorrhoid veins, to the mouth of the womb, the gums, lips, nose, fingers. After the leech being filled with blood shall fall off, if the disease require a large evacuation of blood, and the part affected may endure it, cupping-glasses, or horns, or other leeches shall be substituted. If the leeches be handled with the bare hand, they are angered, and become so stomachfull as that they will not bite; wherefore you shall hold them in a white and clean linen cloth, and apply them to the skin being first lightly scarified, or besmeared with the blood of some other creature, for thus they will take hold of the flesh, together with the skin more greedily and fully. To cause them to fall off, you shall put some powder of Aloes, salt or ashes upon their heads. If any desire to know how much blood they have drawn, let him sprinkle them with salt made into powder, as soon as they are come off, for thus they will vomit up what blood soever they have sucked. If you desire they should suck more blood than they are able to contain, cut off their tails as they suck, for thus they will make no end of sucking, for that it runs out as they suck it. The leeches by sucking draw the blood not only from the affected part whereto they are applied, but also from the adjacent and distant parts. Also sometimes the part bleeds a good while after the leeches be fallen away, which happens not by scarification after the application of cupping-glasses or horns. If you cannot stop the bleeding after the falling away of the leeches, then press the half of a bean upon the wound, until it stick of itself, for thus it will stay; also a burnt rag may be fitly applyed with a little bolster and fit ligature.
The application of leeches was described by William Bennett in 1886.9The leech was removed from water and dried in a soft towel for 30 minutes before use. The skin of the affected area was sponged with warm water to increase the flow of blood to that part. Milk, or milk and sugar, was applied to the skin to encourage the leech to attach. The small end of the leech was held between the thumb and index finger, and the leech was placed against the desired area of skin. If several leeches were needed, they were placed in a teacup or wine glass which was then inverted over the skin. For application of a leech inside a body cavity such as the vagina, a leech-glass was used. Into this test-tube shaped cylinder of glass, a leech was placed and directed to the desired location. A rolled tube of paper served the same purpose. When leeching in the immediate vicinity of an orifice, the use of a plug of cotton wool was advised to prevent the leech from escaping through the opening. Thomas18 cautioned that this should be done when placing leeches on the cervix for the treatment of amenorrhea. A quotation from his text is as follows:
Three or four large leeches, or a sufficient number of small ones, to take from three to five ounces of blood, may be applied in the following manner: A cylindrical speculum, of sufficient size to contain the entire vaginal portion of the cervix, being passed and the part thoroughly cleansed, a small pledget of cotton, to which a thread has been attached for removal, should be placed within the os, so as to prevent the entrance of the leeches to the cavity above. A few slight punctures, sufficient to cause a flow of blood, should then be made in the cervix, and all leeches to be employed thrown in, and the speculum filled at its extremity by a dossil of cotton pushed toward the bleeding surface. The speculum should be watched until they cease sucking, for if left for a very short time, even with the mouth of the instrument filled with cotton, they will escape. After their removal all clots of blood should be removed by a sponge or a rod wrapped with cotton, the speculum withdrawn, a large sponge squeezed out of warm water placed over the vulva, and the patient directed to remain perfectly quiet.
Leeches usually fell off when they became engorged with blood. If not, salt, snuff, or vinegar was applied to discourage their hold. The bleeding was arrested by pressure, a drop of perchloride of iron, a suture, or cautery with a red hot needle.

Comment

Phlebotomy still goes on. Blood removal is a recognized treatment of polycythemia and hemochromatosis. Exchange transfusions are used in hemolytic disease of the newborn. The phlebotomist makes his daily rounds in hospitals and physicians' offices around the world. Now bloodletting is used primarily for diagnosis rather than for treatment, and the lancet and fleam have been replaced by the syringe and needle. Blood loss for diagnostic testing in modern hospitals can be considerable. With some philosophic reflection, one might wonder whether or not the loss of blood could have any therapeutic benefit. Does the acute withdrawal of blood stimulate the defense mechanisms of the body? The body is known to respond more promptly to acute blood loss than to chronic loss of small amounts. It seems hard to believe that the many educated observers over the centuries were completely wrong in their assessment of clinical improvement following bloodletting. Whether bloodletting represents treatment or mistreatment continues to depend on the evolution of our ideas as to the basic causes of disease. Perhaps some day a rational explanation for the popularity of bloodletting will be found. A closing quotation from the year 1935 by Randolph6 seems appropriate. "With alternating periods of excess and moderation it is about the only remedy that has held its own throughout our history."

Summary

An occasional glance into our medical past can provide a refreshing interlude in our present-day practice of medicine. Medicine has many important roots in our cultural past. One of our medical roots is entwined in the history of bloodletting, the changing therapeutic uses of which follow the evolution of man's concept of disease. The tools of bloodletting include the lancet, fleam, scarificator, cupping-glass, and leech. These instruments have joined the ranks of interesting nostalgia and deserve to be remembered as part of colorful medical heritage.

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References

1. Thornwald, J.: SCIENCE AND SECRETS OF EARLY MEDICINE, New York, Harcourt, Brace and World, Inc., 1963, p. 152.
2. Johnson, T.: THE WORKES OF THAT FAMOUS CHIRURGION AMBROSE PARÉY (PARÉ), London, printed by T. Cotes and R. Young, 1634, p. 692.
3. Quain, R.: A DICTIONARY OF MEDICINE, London, Longmans, Green, and Company, 1885, p. 111.
4. Buchan, W.: "Domestic Medicine," London, printed for W. Strahan, T. Cahill in THE STRAND, and J. Balfour and W. Creech, at Edinburgh, 1784, p. 623.
5. Watson, T., and Condie, D.: WATSON'S PRACTICE OF PHYSIC, Philadelphia, Pennsylvania, Blanchard and Lea, 1858, p. 167.
6. Randolph, B.: "The blood letting controversy in the nineteenth century," ANN M. HIST. 7: 177 (1935).
7. Flint, A.: PRACTICE OF MEDICINE, Philadelphia, Pennsylvania, Henry C. Lea's Son and Company, 1881, p. 133.
8. Osler, W., and McCrae, T.: THE PRINCIPLES AND PRACTICE OF MEDICINE, New York and London, D. Appleton and Company, 1920, p. 102.
9. Heath, C.: DICTIONARY OF PRACTICAL SURGERY, London, Smith, Elder, and Company, 1886, p.162.
10. SURGICAL INSTRUMENTS, New York, George Tiemann and Company, 1889, p. 115.
11. Bell, B.: A SYSTEM OF SURGERY, Edinburgh, printed for Charles Elliot, 1790, p. 42.
12. Bennion, E.: ANTIQUE MEDICAL INSTRUMENTS, London, Philip Wilson Publishers Ltd., 1979, p.49.
13. Bailey, N.: ENGLISH DICTIONARY, London, printed for R. Warf, A. Ward, J. and P. Knapton, and T. Longman, 1742.
14. Abel, A.: "Bloodletting. Barber-surgeons' shaving and bleeding bowls," J.A.M.A. 214: 900 (1970).
15. White, J.: THE VETERINARY ART, London, printed for Longman, Hurst, Rees, Orme, Brown, and Green, 1825, p. 296.
16. Clark, J.: A TREATISE ON THE PREVENTION OF DISEASES INCIDENTAL TO HORSES, Edinburgh, printed by the author, 1790, p. 202.
17. Druitt, R.: MODERN SURGERY, Philadelphia, Pennsylvania, Blanchard and Lea, 1860, p. 602.
18. Thomas, T.: DISEASES OF WOMEN, Philadelphia, Pennsylvania, Henry C. Lea's Son and Company, 1880, p. 333.



"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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