Part 2

The standard advice to bloodletters, especially in the eighteenth and nineteenth centuries, was "bleed to syncope." "Generally speaking," wrote the English physician and medical researcher, Marshall Hall, in 1836, "as long as bloodletting is required, it can be borne; and as long as it can be borne, it is required."[21] The American physician, Robley Dunglison, defined "syncope" in his 1848 medical dictionary as a "complete and, commonly, sudden loss of sensation and motion, with considerable diminution, or entire suspension of the pulsations of the heart and the respiratory movements."[22] Today little distinction is made between shock and collapse, or syncope, except to recognize that if collapse or syncope persists, shock will result.

We know today that blood volume is about one-fifteenth to one-seventeenth the body weight of an adult. Thus an adult weighing 150 pounds has 9 or 10 pounds of blood in his body. Blood volume may increase at great heights, under tropical conditions, and in the rare disease polycythemia (excess red blood cells). After a pint of blood is withdrawn from a healthy individual, the organism replaces it to some degree within an hour or so. However, it takes weeks for the hemoglobin (the oxygen-bearing substance in the red blood cells) to be brought up to normal.

If blood loss is great (more than 10 percent of the total blood volume) there occurs a sudden, systemic fall in blood pressure. This is a well-known protective mechanism to aid blood clotting. If the volume of blood lost does not exceed 30 to 40 percent, systolic, disastolic, and pulse pressures rise again after approximately 30 minutes as a result of various compensatory mechanisms.[23]

[Illustration: FIGURE 2.--Venesection manikin, 16th century. Numbers indicate locations where in certain diseases venesection should be undertaken. (From Stoeffler, 1518, as illustrated in Heinrich Stern, _Theory and Practice of Bloodletting_, New York, 1915. Photo courtesy of NLM.)]

If larger volumes than this are removed, the organism is usually unable to survive unless the loss is promptly replaced. Repeated smaller bleedings may produce a state of chronic anemia when the total amount of blood and hemoglobin removed is in excess of the natural recuperative powers.

_When to Bleed_

Selecting a time for bleeding usually depended on the nature of the disease and the patient's ability to withstand the process. Galen's scheme, in contrast to the Hippocratic doctrine, recommended no specific days.[24] Hippocrates worked out an elaborate schedule, based on the onset and type of disease, to which the physician was instructed to adhere regardless of the patient's condition.

Natural events outside the body served as indicators for selecting the time, site, and frequency of bloodletting during the Middle Ages when astrological influences dominated diagnostic and therapeutic thought. This is illustrated by the fact that the earliest printed document relating to medicine was the "Calendar for Bloodletting" issued in Mainz in 1457. This type of calendar, also used for purgation, was known as an _Aderlasskalender_, and was printed in other German cities such as Augsburg, Nuremberg, Strassburg, and Leipzig. During the fifteenth century these calendars and _Pestblatter_, or plague warnings, were the most popular medical literature. Sir William Osler and Karl Sudhoff studied hundreds of these calendars.[25] They consisted of a single sheet with some astronomical figures and a diagram of a man (_Aderlassmann_) depicting the influence of the stars and the signs of the zodiac on each part of the body, as well as the parts of the anatomy suitable for bleeding. These charts illustrated the veins and arteries that should be incised to let blood for specific ailments and usually included brief instructions in the margin. The annotated bloodletting figure was one of the earliest subjects of woodcuts. One early and well known _Aderlassmann_ was prepared by Johann Regiomontanus (Johannes Mueller) in 1473. It contained a dozen proper bleeding points, each suited for use under a sign of the zodiac. Other _Aderlassmanner_ illustrated specific veins to be bled. The woodcut produced by the sixteenth-century mathematician, Johannes Stoeffer, illustrated 53 points where the lancet might be inserted.[26]

"Medicina astrologica" exerted a great influence on bloodletting. Determining the best time to bleed reached a high degree of perfection in the late fourteenth and fifteenth centuries with the use of volvella or calculating devices adopted from astronomy and navigation. These were carried on a belt worn around the waist for easy consultation. Used in conjunction with a table and a vein-man drawing, the volvella contained movable circular calculators for determining the accuracy, time, amount, and site to bleed for an illness. The dangers of bloodletting elicited both civic and national concern and control. Statutes were enacted that required every physician to consult these tables before opening a vein to minimize the chance of bleeding improperly and unnecessarily. Consultation of the volvella and vein-man was more important than an examination of the patient.[27] (Figure 3.)

For several centuries, almanacs were consulted to determine the propitious time for bleeding. The "woodcut anatomy" became a characteristic illustration of the colonial American almanac. John Foster introduced the "Man of Signs," as it was called, into the American almanac tradition in his almanac for 1678, printed in Boston. Other examples of early American almanacs featuring illustrations of bleeding include Daniel Leed's almanac for 1693, printed in Philadelphia, and John Clapp's almanac for 1697, printed in New York.

As in many of the medieval illustrations, the woodcut anatomy in the American almanac consisted of a naked man surrounded by the twelve signs of the zodiac, each associated with a particular part of the body (the head and face with Aries, the neck with Taurus, the arms with Gemini, etc.). The directions that often accompanied the figure instructed the user to find the day of the month in the almanac chart, note the sign or place of the moon associated with that day, and then look for the sign in the woodcut anatomy to discover what part of the body is governed by that sign. Bloodletting was usually not specifically mentioned, but it is likely that some colonials still used the "Man of Signs" or "Moon's Man" to determine where to open a vein on a given day.[28]

[Illustration: FIGURE 3.--Lunar dial, Germany, 1604. Concentric scales mark hours of the day, days, months, and special astrological numbers. In conjunction with other dials, it enables the user to determine the phases of the moon. (NMHT 30121; SI photo P-63426.)]

The eighteenth-century family Bible might contain a list of the favorable and unfavorable days in each month for bleeding, as in the case of the Bible of the Degge family of Virginia.[29]

_Barber-Surgeons_

Even though it was recognized that bleeding was a delicate operation that could be fatal if not done properly, it was, from the medieval period on, often left in the hands of the barber-surgeons, charlatans, and women healers. In the early Middle Ages the barber-surgeons flourished as their services grew in demand. Barber-surgeons had additional opportunities to practice medicine after priests were instructed to abandon the practice of medicine and concentrate on their religious duties. Clerics were cautioned repeatedly by Pope Innocent II through the Council at Rheims in 1131, the Lateran Council in 1139, and five subsequent councils, not to devote time to duties related to the body if they must neglect matters related to the soul.[30]

By 1210, the barber-surgeons in England had gathered together and formed a Guild of Barber-Surgeons whose members were divided into Surgeons of the Long Robe and Lay-Barbers or Surgeons of the Short Robe. The latter were gradually forbidden by law to do any surgery except bloodletting, wound surgery, cupping, leeching, shaving, extraction of teeth, and giving enemas.[31] The major operations were in the hands of specialists, often hereditary in certain families, who, if they were members of the Guild, would have been Surgeons of the Long Robe.

[Illustration: FIGURE 4.--Bleeding bowl with gradations to measure the amount of blood. Made by John Foster of London after 1740. (Held by the Division of Cultural History, Greenwood Collection, Smithsonian Institution; SI photo 61166-C.)]

To distinguish his profession from that of a surgeon, the barber-surgeon placed a striped pole or a signboard outside his door, from which was suspended a basin for receiving the blood (Figure 4). Cervantes used this type of bowl as the "Helmet of Mambrino" in Don Quixote.[32] Special bowls to catch the blood from a vein were beginning to come into fashion in the fourteenth century. They were shaped from clay or thin brass and later were made of pewter or handsomely decorated pottery. Some pewter bowls were graduated from 2 to 20 ounces by a series of lines incised around the inside to indicate the number of ounces of fluid when filled to that level. Ceramic bleeding bowls, which often doubled as shaving bowls, usually had a semicircular indentation on one side to facilitate slipping the bowl under the chin. Bowls to be used only for bleeding usually had a handle on one side. Italian families had a tradition of passing special glass bleeding vessels from generation to generation. The great variety in style, color, and size of bleeding and shaving bowls is demonstrated by the beautiful collection of over 500 pieces of Dr. A. Lawrence Abel of London and by the collection of the Wellcome Historical Museum, which has been cataloged in John Crellin's _Medical Ceramics_.[33] These collections illustrate the stylistic differences between countries and periods.

The barber-surgeons' pole represented the stick gripped by the patient's hand to promote bleeding from his arm. The white stripe on the pole corresponded to the tourniquet applied above the vein to be opened in the arm or leg. Red or blue stripes appeared on early barber poles, but later poles contained both colors.[34]

The dangers posed by untutored and unskilled bleeders were noted periodically. In antiquity Galen complained about non-professional bleeders, and in the Middle Ages, Lanfranc (1315), an outstanding surgeon, lamented the tendency of surgeons of his time to abandon bloodletting to barbers and women.[35] Barber-surgeons continued to let blood through the seventeenth century. In the eighteenth and nineteenth centuries, the better educated surgeon, and sometimes even the physician, took charge of bleeding.

_Bloodletting and the Scientific Revolution_

The discovery of the blood's circulation did not result in immediate changes in the methods or forms of bloodletting. William Harvey, who published his discovery of circulation in 1628, recognized the value of investigating the implications of his theory. Harvey could not explain the causes and uses of the circulation but he believed that it did not rule out the practice of bloodletting. He claimed that

daily experience satisfies us that bloodletting has a most salutary effect in many diseases, and is indeed the foremost among all the general remedial means: vitiated states and plethora of blood, are causes of a whole host of disease; and the timely evacuation of a certain quantity of the fluid frequently delivers patients from very dangerous diseases, and even from imminent death.[36]

The English scientist Henry Stubbe brought to the surface what would appear to be an obvious dilemma: How could one bleed to produce local effect if the blood circulated? Stubbe commented in 1671:

I do say, that no experienced Physician ever denied the operation of bloodletting though since the tenet of the Circulation of the Blood the manner how such an effect doth succeed admits of some dispute, and is obscure. We the silly followers of Galen and the Ancients do think it an imbecility of judgement, for any to desert an experienced practice, because he doth not comprehend in what manner it is effected.[37]

In the early nineteenth century the physiologist Francois Magendie (1783-1855), who argued against bloodletting, showed that the physiological effects of opening different veins was exactly the same, and therefore the choice of which vein to bleed did not affect the procedure.[38]

The first serious modern challenges to bloodletting were made in the sixteenth and seventeenth centuries under the leadership of the German alchemist Paracelsus and his Belgian follower, Van Helmont. The medical chemists or iatrochemists espoused explanations for and treatments of diseases based on chemical theories and practices. They believed that the state of the blood could best be regulated by administering the proper chemicals and drugs rather than by simply removing a portion of the blood. Iatrochemistry provided a substitution in the form of medicinals to quell the flow of blood for therapeutic purposes.[39]

The revival of Hippocratic medicine in the late seventeenth and eighteenth centuries also led to questioning the efficacy of bloodletting. The Hippocratic treatises, while they occasionally mentioned bloodletting, generally stressed nature's power of cure. This school of medicine advocated a return to clinical observation and a reduction of activist intervention. Treatments such as bloodletting, it was felt by the neo-Hippocratists, might merely serve to weaken the patient's strength and hinder the healing processes of nature.[40]

A rival group of medical theorists also flourished in this period. The iatrophysicists, who concentrated on mechanical explanations of physiological events, remained adherents of bloodletting. Their support of the practice ensured its use at a time when the first substantial criticism of it arose.

_Instrumentation and Techniques_

Sharp thorns, roots, fish teeth, and sharpened stones were among the early implements used to let blood.[41] Venesection, one of the most frequently mentioned procedures in ancient medicine, and related procedures such as lancing abcesses, puncturing cavities containing fluids, and dissecting tissues, were all accomplished in the classical period and later with an instrument called the phlebotome. _Phlebos_ is Greek for "vein," while "tome" derives from _temnein_, meaning "to cut." In Latin, "phlebotome" becomes "flebotome," and in an Anglo-Saxon manuscript dating from A.D. 1000, the word "fleam" appears. The phlebotome, a type of lancet, was not described in any of the ancient literature, but its uses make it apparent that it was a sharp-pointed, double-edged, and straight-bladed cutting implement or scalpel similar to the type later used for splitting larger veins.[42]

Several early Roman examples of phlebotomes have been collected in European museums. One, now in the Cologne Museum, was made of steel with a square handle and blade of myrtle leaf shape. Another specimen, made of bronze, was uncovered in the house of the physician of _Strada del Consulare_ of Pompeii. This specimen, now in the Naples Museum, is 8 cm long and 9 mm at the broadest part of the blade, and its handle bears a raised ring ornamentation.[43] A number of copies of Roman instruments have been made and some have passed into museum collections. Some of the copies were commissioned by Sir Henry Wellcome for the Wellcome Historical Medical Museum collection and the Howard Dittrick Historical Medical Museum in Cleveland. They emulate the size, color, and aged condition of the originals and make it very difficult for the inexpert to distinguish an original from its replica. It is, however, impossible to fully duplicate the patina of ancient bronze.[44] Seventeenth-century and later bloodletting instruments usually have not been copied.[45]

From the earliest examples of the fleam, such as the specimen found at Pompeii, this instrument has been associated with the veterinarian. Since early practitioners, particularly the Roman physician, performed the duties of the surgeon as well as those of the veterinarian, it is possible that they used the same instrument to open blood vessels in humans and animals.[46]

In the seventeenth and eighteenth centuries a type of fleam (German _fliete_, French _flamette_), which had a pointed edge at right angles to the handle, was in use in Germany, Holland, and Vienna, Austria.[47] Since the specimens found in museums vary in size, it is likely that this type of fleam was used on both animals and humans.

In about the fifteenth century the thumb lancet, also called a _gladiolus_, _sagitella_, _lanceola_, _lancetta_, or _olivaris_, was introduced.[48] It soon became the preferred instrument for opening a vein in any part of the body. The double-edged iron or steel blade was placed between two larger covers, usually made of horn or shell, and all three pieces were united at the base with a riveted screw. The blade could be placed at various angles of inclination when in use. The shape of the blade, whether broad or narrow, determined the ease with which the skin and vein could be penetrated. A long slender blade was essential to pierce a vein located below many layers of fatty tissue.[49] These tiny and delicate thumb lancets were often carried in small flat cases of silver, tortoise shell, shagreen, or leather with hinged tops and separate compartments for each lancet. (Figure 5.)

A surgeon was advised to carry lancets of various sizes and shapes in order to be prepared to open veins of differing sizes and in different locations. Even Hippocrates had cautioned bloodletters not to use the different size lancets indiscriminately, "for there are certain parts of the body which have a swift current of blood which it is not easy to stop."[50] For vessels that bled easily, it was essential to make narrow openings; otherwise it would be difficult, if not impossible, to stop the flow of the blood. For other vessels, lancets that made larger openings were required or the blood would not flow satisfactorily.

The blood as it spurted from the vein would be collected in a container and measured. When enough blood was removed, the bleeding would be stopped by a bandage or compress applied to the incision.

[Illustration: FIGURE 5.--18th-19th century lancets and lancet cases. The cases are made of mother-of-pearl, silver, shagreen, and tortoise shell. (NMHT 308730.10. SI photo 76-9116.)]

Teaching a medical student how to bleed has had a long tradition. Before approaching a patient, the student practiced opening a vein quickly and accurately on plants, especially the fruits and stems.[51] The mark of a good venesector was his ability not to let even a drop of blood be seen after the bleeding basin was removed.[52]

It required some degree of skill to strike a vein properly. The most common vein tapped was in the elbow, although veins in the foot were also popular. The arm was first rubbed and the patient given a stick to grasp. Then a tourniquet would be applied above the elbow (or, if the blood was to be taken from the foot, above the ankle), in order to enlarge the veins and promote a continuous flow of blood. Holding the handle between the thumb and the first finger, the operator then jabbed the lancet into the vein. Sometimes, especially if the vein was not close to the surface of the skin, the instrument was given an extra impetus by striking it with a small mallet or the fingers to insure puncturing the vein.[53] The incisions were made diagonally or parallel to the veins in order to minimize the danger of cutting the vein in two.[54]

For superficial veins, the vein was sometimes transfixed, that is, the blade would be inserted underneath the vessel so that the vessel could not move or slip out of reach. The transfixing procedure ensured that the vein would remain semi-divided so that blood would continuously pass out of it, and that injury to other structures would be avoided. Deep-lying veins of the scalp, for example, could not be transfixed. They were divided by cutting through everything overlying them since there were no important structures to injure.[55]

The consequences of puncturing certain veins incorrectly were discussed by many early writers including Galen, Celsus, Antyllus, and Paul of Aegina.[56] Injury to a nearby nerve, muscle, or artery resulted in convulsions, excessive bleeding, or paralysis.

Bloodletting was at its most fashionable in the eighteenth and early nineteenth centuries. In this period it was considered an art to hold the lancet properly and to support the arm of the patient with delicacy and grace.[57] Many patients had by repeated bloodlettings become inured to its potential danger and unpleasantness. In the mid-eighteenth century one British physician declared: "People are so familiarized to bleeding that they cannot easily conceive any hurt or danger to ensue, and therefore readily submit, when constitutional fear is out of the question, to the opening of a vein, however unskillfully advised."[58] In England in the early nineteenth century people came to the hospital to be bled in the spring and fall as part of the ritual for maintaining good health. At some periods there were so many people undergoing prophylactic bloodletting that they could be seen lying on the floor of the hospital while recovering from the faintness induced by venesection.[59]

The lancet was perhaps the most common medical instrument. _The Lancet_ was the name of one of the oldest and most socially aware English medical journals, founded by Thomas Wakeley in 1823.[60]

In America, Benjamin Rush (1746-1813) promoted vomits, purges, salivation, and especially bleeding. Rush, a signer of the Declaration of Independence, is notorious in medical history for his resorting to massive bleedings during the epidemics of yellow fever at the end of the eighteenth century. Rush told a crowd of people in 1793: "I treat my patients successfully by bloodletting, and copious purging with calomel and jalop and I advise you, my good friends, to use the same remedies." "What?" called a voice from the crowd, "Bleed and purge everyone?" "Yes," said the doctor, "bleed and purge all Kensington."[61]

The alternatives to bleeding in this period included administering mercury (calomel) to promote salivation and tartar emetic to induce vomiting. These substitutes could be as hazardous as bleeding and offered little choice to the patient who had to bear the unpleasant effects. Thus, the late eighteenth and early nineteenth century has been referred to by historians as the era of heroic medicine because of the large amounts of strong medications given and excessive bloodletting.[62]

One of the most notable victims of heroic medicine during this period was George Washington (1732-1799), who was bled four times in two days after having contracted a severe inflammation of the throat. Washington's physician, Dr. Craik, admitted that the removal of too much blood might have been the cause of his death. Additional bleeding was prevented only by Washington's request to be allowed to die without further medical intervention, since he believed that his illness was incurable.[63]

Bloodletting was especially resorted to in times of crisis. One woman, Hannah Green, had been anesthetized in 1848 by chloroform before undergoing a minor operation on her toe. The physician bled her in a futile attempt to revive her, but she died, becoming the first known victim of inhalation anesthesia.[64]

_Spring Lancets_

The great vogue in phlebotomy inspired the invention of ingenious instruments. From Vienna came the automatic or spring lancet, originally called a _Schnepper_ or _Schnepperlein_, which permitted the operator to inject the blade into a vein without exerting manual pressure.[65] It was widely adopted if the variety of models now extant is a proper indication. In the spring lancet, the blade was fixed into a small metal case with a screw and arranged to respond to a spring that could be released by a button or lever on the outside of the case. The blade was positioned at right angles to the spring and case, thus adopting the basic shape of the fleam. The case of the spring lancet was usually made of copper, silver, brass, or an alloy. It was often decorated with engraved furbelows or embossed with political or other symbols depending on the preference of the owner and the fashion of the period. The mechanism of this handsome implement has been described by a modern collector (Figures 6, 7):

The curved projection (1) is the continuation of a heavy coiled spring. When pushed up it catches on a ratchet. A razor sharp blade (2), responding to the pressure of a light spring placed under it, follows the handle as it goes up. A lever (3) acting on a fulcrum (4) when pressed down, releases handle which in turn strikes the lancet down with lightning speed.[66]