Part 3

The spring lancet was initially described by Lorenz Heister in 1719.[67] Another early description appeared in 1798 in the first American edition of the _Encyclopedia or Dictionary of Arts and Sciences_, in which the spring lancet was called a "phleam."[68]

The spring lancet for use on humans was a rather tiny instrument. Its casing was about 4 cm long and 1.5 to 2 cm wide. The blade added another centimeter in length. Larger size instruments, often with a metal guard over the blade, were made for use on animals. Eighteenth- and early nineteenth-century spring lancets are found in a wide variety of shapes. Mid- and late nineteenth-century spring lancets are more uniform in shape, most having the familiar knob-shaped end. In most lancets the blade was released by a lever, but in the late nineteenth century, the blade of a more expensive model was released by a button.

[Illustration: FIGURE 6.--Spring lancet, 19th century. (NMHT 321636.01; SI photo 73-4236.)]

[Illustration: FIGURE 7.--Interior of spring lancet. (NMHT 308730.10; SI photo 76-13535.)]

In general, German, American, and Dutch surgeons preferred the spring lancet to the simple thumb lancet. In contrast, the French tended to prefer the thumb lancet. Ristelhueber, a surgeon in Strasbourg, maintained in 1819 that the simple lancet was preferable to the spring lancet both in terms of simplicity of design and application. While allowing German surgeons some credit for attempting to improve the spring lancet, Ristelhueber remained firm in his view that the spring lancet was too complicated and performed no better than the thumb lancet. The only advantage of the spring lancet was that it could be used by those who were ignorant of anatomy and the art of venesection. Untutored bleeders could employ a spring lancet on those veins that stood out prominently and be fairly confident that they could remove blood without harming other blood vessels. The bagnio men (bath attendants), who routinely bled the bathers in public baths, preferred the spring lancet.[69] It was more difficult to sever a vein with a spring lancet and thereby cause serious hemorrhaging. However, since the spring lancet was harder to clean because of its small size and its enclosed parts, it was more likely to induce infection (phlebitis).

While the French and British surgeons remained critical of the spring lancet, it became popular in the United States. John Syng Dorsey, a noted Philadelphia surgeon, wrote in 1813:

The German fleam or spring lancet I prefer greatly to the common English lancet for phlebotomy; it is now in some parts of the United States almost exclusively used. In a country situated like the United States, where every surgeon, except those residing in our largest cities, is compelled to be his own cutler, at least so far as to keep his instruments in order, the spring-lancet has a decided preference over the lancet; the blade of this can with great ease be sharpened by any man of common dexterity, and if not very keen it does no mischief, whereas a dull lancet is a most dangerous instrument; and no one can calculate with certainty the depth to which it will enter. To sharpen a lancet, is regarded by the cutler as one of his nicest and most difficult jobs; it is one to which few surgeons are competent.

The safety of using the fleam is demonstrated by daily experience; there is no country in which venesection is more frequently performed than in the United States, and perhaps none where fewer accidents from the operation have occurred, of those few, I beg leave to state, that all the aneurisms produced by bleeding, which I have seen, have been in cases where the lancet was used. Among the advantages of the spring-lancet economy is not the least. A country practitioner who is constantly employing English lancets, and who is particular in using none but the best, must necessarily consume half the emoluement derived from the operation, in the purchase of his instruments. One spring-lancet, with an occasional new blade, will serve him all his life.[70]

This popularity is also reflected in various medical dictionaries of the eighteenth and nineteenth centuries that described the instrument and in the wide variety of spring lancets in the Smithsonian collection.

One American user of the spring lancet, J. E. Snodgrass of Baltimore, was inspired to compose a poem about the instrument, which appeared in the _Baltimore Phoenix and Budget_ in 1841. He wrote:

To My Spring-Lancet

Years have passed since first we met, Pliant and ever-faithful-slave! Nobly thou standest by me yet, Watchful as ever and as brave.

O, were the power of language thine, To tell all thou hast seen and done, Methinks the curious would incline, Their ears to dwell they tales upon!

I love thee, bloodstain'd, faithful friend! As warrior loves his sword or shield; For how on thee did I depend When foes of Life were in the field!

Those blood spots on thy visage, tell That thou, thro horrid scenes, hast past. O, thou hast served me long and well; And I shall love thee to the Last!

A thousand mem'ries cluster round thee In all their freshness! thou dost speak Of friends far distant-friends who found thee Aye with thy master, prompt to wreak

Vengeance on foes who strove to kill With blows well aim'd at heart or head-- Thieves that, with demon heart and will, Would fain have on they vials fed.

O, They have blessed thee for thy aid, When grateful eyes, thy presence, spoke; Thou, anguish'd bosoms, glad hast made, And miser's tyrant sceptre broke.

Now, when 'mong strangers, is our sphere, Thou, to my heart, are but the more Endear'd--as many a woe-wring tear Would plainly tell, if from me tore!

There was little change in the mechanism of the spring lancet during the nineteenth century, despite the efforts of inventors to improve it. Approximately five American patents on variations of the spring lancet were granted in the nineteenth century. One patent model survives in the Smithsonian collection. Joseph Gordon of Catonsville, Maryland, in 1857 received patent No. 16479 for a spring lancet constructed so that three different positions of the ratchet could be set by the sliding shield. The position of the ratchet regulated the force with which the blade entered the vein. This also had the advantage of allowing the blade to enter the vein at the same angle irrespective of the depth to which it penetrated.[71]

_The Decline of Bleeding_

Throughout the seventeenth, eighteenth, and nineteenth centuries, most physicians of note, regardless of their explanations of disease, including Hermann Boerhaave, Gerard Van Swieten, Georg Ernst Stahl (phlogiston), John Brown and Friedrich Hoffmann (mechanistic theories), Johann Peter Frank, Albrecht von Haller, Percival Pott, John Pringle, William Cullen, and Francois Broussais, recommended bloodletting and adjusted their theories to provide an explanation for its value. At the end of the eighteenth century and in the early nineteenth century, the practice of bloodletting reached a high point with the theories of F.-J.-V. Broussais (1772-1838) and others. After 1830, however, the practice gradually declined until, by the end of the century, it had all but disappeared.

This decline occurred even though many medical theories were brought to the defense of bleeding. A French medical observer commented in 1851 that "l'histoire de la saignee consideree dans son ensemble, constituerait presque a elle seule l'histoire de toutes les doctrines medicales" (the history of bloodletting, considered in its totality, would constitute almost by itself the history of all medical doctrines).[72] There was no crisis of medical opinion, and no one event to account for this decline. The French physician, Pierre Louis's statistical investigation (numerical method) into the effect of bloodletting in the treatment of pneumonia has often been cited as a cause for the downfall of venesection,[73] but the results of Louis's research showed only that bloodletting was not as useful as was previously thought. Louis's work, however, was typical of a new and critical attitude in the nineteenth century towards all traditional remedies. A number of investigators in France, Austria, England, and America did clinical studies comparing the recovery rates of those who were bled and those who were not.[74] Other physicians attempted to measure, by new instruments and techniques, the physiological affects of loss of blood. Once pathological anatomy had associated disease entities with specific lesions, physicians sought to discover exactly how remedies such as bloodletting would affect these lesions. In the case of pneumonia, for example, those who defined the disease as "an exudation into the vessels and tissues of the lungs" could not see how bloodletting could remove the coagulation. John Hughes Bennett, an Edinburgh physician, wrote in 1855: "It is doubtful whether a large bleeding from the arm can operate upon the stagnant blood in the pulmonary capillaries--that it can directly affect the coagulated exudation is impossible."[75] Bennett felt that bloodletting merely reduced the strength of the patient and thus impeded recovery.

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]

The annual physical examination today includes taking a small amount of blood from the finger or a vein in the elbow. This blood is then analyzed for the presence of biochemical components of such diseases as diabetes, anemia, arteriosclerosis, etc. A tiny sterile instrument called a blood lancet may be used by the technician who draws the blood, who is still called by the historical name, phlebotomist.

Cupping

"Cupping is an art," wrote the London cupper Samuel Bayfield in 1823, "the value of which every one can appreciate who has had opportunities of being made acquainted with its curative power by observing its effects on the person of others, or by realizing them in his own."[87] The curious operation of taking blood by means of exhausted cups had been part of Western medicine since the time of Hippocrates, and has been found in many other cultures as well. It is still practiced in some parts of the world today.

Since antiquity medical authors have distinguished two forms of cupping, dry and wet. In dry cupping, no blood was actually removed from the body. A cup was exhausted of air and applied to the skin, causing the skin to tumefy. In wet cupping, dry cupping was followed by the forming of several incisions in the skin and a reapplication of the cups in order to collect blood. It was possible to scarify parts of the body without cupping--through the nineteenth-century physicians recommended scarifying the lips, the nasal passages, the eyes, and the uterus. In order to remove any sizeable amount of blood, however, it was necessary to apply some sort of suction to the scarifications, because capillaries, unlike arteries and veins, do not bleed freely. (Figure 8.)

Cupping was generally regarded as an auxiliary to venesection. The indications for the operation were about the same as the indications for phlebotomy, except that there was a tendency to prefer cupping in cases of localized pain or inflammation, or if the patient was too young, too old, or too weak to withstand phlebotomy. "If cutting a vein is an instant danger, or if the mischief is still localised, recourse is to be had rather to cupping," wrote the encyclopedist Celsus in the first century A.D.[88]

As noted above, the ancients usually recommended cupping close to the seat of the disease. However, there were several examples in ancient writings of cupping a distant part in order to divert blood. The most famous of these examples was Hippocrates' recommendation of cupping the breasts in order to relieve excessive menstruation.[89]

As was the case for phlebotomy, the number of ills that were supposedly relieved by cupping was enormous. Thomas Mapleson, a professional cupper, gave the following list of "diseases in which cupping is generally employed with advantage" in 1801:

Apoplexy, angina pectoris, asthma, spitting blood, bruises, cough, catarrh, consumption, contusion, convulsions, cramps, diseases of the hip and knee joints, deafness, delirium, dropsy, epilepsy, erysipelas, eruptions, giddiness, gout, whooping cough, hydrocephalus, head ache, inflammation of the lungs, intoxication, lethargy, lunacy, lumbago, measles, numbness of the limbs, obstructions, ophthalmia, pleurisy, palsy, defective perspiration, peripneumony, rheumatism, to procure rest, sciatica, shortness of breath, sore throat, pains of the side and chest.[90]

_Early Cupping Instruments_

Mapleson believed that cupping was first suggested by the ancient practice of sucking blood from poisoned wounds. In any case, the earliest cupping instruments were hollowed horns or gourds with a small hole at the top by which the cupper could suck out the blood from scarifications previously made by a knife. The Arabs called these small vessels "pumpkins" to indicate that they were frequently applied to a part of the body in which the organs contained air or that they were vessels that had to be evacuated before they could be applied.[91] The use of cattle horns for cupping purposes seems to have been prevalent in all periods up to the present. When Prosper Alpinus visited Egypt in the sixteenth century, he found the Egyptians using horns that were provided with a small valve of sheepskin to be maintained in place by the cupper's tongue and serving to prevent the intake of air once the cup was exhausted.[92]

In nineteenth-century America, at least one physician still recommended horns as superior to glass cups for rural medical practice. A Virginia physician, Dr. W. A. Gillespie, disturbed by the high cost of cupping instruments, suggested to his readers in _The Boston Medical and Surgical Journal_ for 1834 that since glass cups were often broken when carried from place to place, "an excellent substitute can be made of a small cow horn, cornicula, which may be scraped or polished until perfectly diaphanous or transparent."[93]

The Smithsonian collection contains a cow's horn from Madaoua, Niger Republic (West Africa), used for drawing blood in the 1960s. The director of the Baptist Mission, who sent the horn, noted that he had often seen Africans sitting in the market place with such horns on their backs or their heads. Scarifications were made with a handmade razor.[94]

[Illustration: FIGURE 8.--Scarification without cupping in Egypt in the 16th century. To obtain sufficient blood, 20 to 40 gashes were made in the legs and the patient was made to stand in a basin of warm water. (From Prosper Alpinus, _Medicina Aegyptorum_, Leyden, 1719. Photo courtesy of NLM.)]

In addition to horn cups, the ancients employed bronze cups in which a vacuum was obtained by inserting a piece of burning flax or linen into the cup before its application to the skin. Most Greek and Roman cups were made of metal.[95] Although Galen already preferred glass cups to metal cups for the simple reason that one could see how much blood was being evacuated, metal cups were used until modern times. Their main virtue was that they did not break and thus could be easily transported. For this reason, metal cups were especially useful to military surgeons. Brass and pewter cups were common in the eighteenth century, and tin cups were sold in the late nineteenth century.

Since the latter part of antiquity, cups have been made of glass. The Smithsonian possesses two Persian opaque glass cups dating from the twelfth century, called "spouted glasses" because of the spout protruding from the side of the cup by which the cupper exhausted the air with his mouth. Similar spouted glasses were illustrated by Prosper Alpinus (sixteenth century), so designed that the blood would collect in a reservoir instead of being sucked into the cupper's mouth. Like the horn cups illustrated by Alpinus, the glass cups were provided with a small valve made of animal skin. It appears that the sixteenth-century Egyptians were not familiar with the use of fire for exhausting cups. (Figure 9.)

Cupping and leeching were less frequently practiced in the medieval period, although general bloodletting retained its popularity.[96] When the eastern practice of public steam baths was reintroduced into the West in the late sixteenth and early seventeenth centuries, cupping tended to be left in the hands of bath attendants (Bagnio men) and ignored by regular surgeons. Some surgeons, such as Pierre Dionis, who gave a course of surgery in Paris in the early eighteenth century, saw little value in the operation. He felt that the ancients had greatly exaggerated the virtues of the remedy.[97] Another French surgeon, Rene de Garengeot, argued in 1725 that those who resorted to such outdated remedies as cupping had studied the philosophical systems of the ancients more than they had practiced medicine. He accused the admirers of the ancients of wishing to kill patients "with the pompous apparatus of wet cupping."[98] (Figure 10.)

[Illustration: FIGURE 9.--Persian spouted cupping glass, 12th century. (NMHT 224478 [M-8037]; SI photo 73-4215.)]

Nineteenth-century cuppers tended to blame the baths for the low status of cupping among surgeons. Dionis had described the baths in Germany as great vaulted halls with benches on two sides, one side for men and the other for women. Members of both sexes, nude except for a piece of linen around the waist, sat in the steamy room and were cupped, if they so desired, by the bath attendants. The customers' vanity was satisfied by making the scarifications (which left scars) in the form of hearts, love-knots, and monograms.[99] Mapleson's complaint against the baths in 1813 was typical of the reaction of the nineteenth-century professional cupper:

The custom which appears to have become prevalent of resorting to these Bagnios, or Haumaums, to be bathed and cupped, appears to have superseded the practice of this operation by the regular surgeons. Falling into the hands of mere hirelings, who practiced without knowledge, and without any other principle than one merely mercenary, the operation appears to have fallen into contempt, to have been neglected by Physicians, because patients had recourse to it without previous advice, and disparaged by regular Surgeons, because, being performed by others, it diminished the profits of their profession.[100]

[Illustration: FIGURE 10.--Cupping in the bath, 16th century. (From a woodcut held by the Bibliotheque Nationale. Photo courtesy of NLM.)]