Part 6

A second advantage of leeches over cupping was that leeches could extract blood more readily. Not only was dexterity not required in order to apply a leech, but also it was soon noticed that leech bites continued to bleed even after the leech let go, while scarificator incisions often coagulated before any blood was obtained. In 1884 it was shown by John Berry Haycroft, a Birmingham chemist, that this phenomenon was due to an anti-coagulant, now called "hirudin," that the leech injected into the blood.[181]

To apply a leech, the animal was first dried with a bit of linen, and the skin of the patient was prepared by washing with warm water and then shaving. To direct it to the right spot, the leech was often placed in a small wine glass that was inverted over the area to be bitten. Since leeches were sometimes perversely unwilling to bite, they were enticed by the placement of a bit of milk or blood on the patient's skin. Small children were given one or two leeches, and adults 20 or more. Broussais employed up to 50 leeches at one time.[182] The leech was usually allowed to drop off of its own accord when it had satiated itself, which took about an hour. Sometimes the tail of the leech was cut off so that it would continue to suck. Once used, leeches could not be reused for several months unless they were made to disgorge their meal by dropping them in salt water or weak vinegar. A healthy leech drew one or two fluid drachms of blood, and as much would flow after the leech had dropped off. Thus a good Swedish leech could remove about an ounce of blood. This quantity could be increased by employing a cupping glass over the bite.[183]

Leeches were kept in a glass container of water covered with gauze or muslin and placed in a cool, dark room. The water had to be changed frequently, as much as every other day in summer. Pebbles or moss were placed in the bottom of the vessel to aid the leech in removing the slimy epidermis that it shed every four or five days. In the nineteenth century leeches were often sold in drug stores from large, elegant containers with perforated caps. Actually, only the day's supply of the pharmacist's leeches was kept in the attractive storefront jars; the rest were kept out of sight. While most leech jars were simple white crockery pieces with "leeches" lettered in black on the front, some leech jars were over two feet tall and decorated with elegant floral and scroll work. Among the most ornate leech jars were those made in Staffordshire, England.[184] (Figure 20.)

_Artificial Leeches_

One of the characteristics of nineteenth-century technology was the attempt to replace natural materials and processes by imitations and mechanisms. Considering the properties of the natural leech, it is no wonder that very early in the nineteenth century inventors began to seek a mechanical substitute. The disadvantages of the leech were many. Wrote one inventor of an artificial leech:

In the first place the appearance of the animal is repulsive and disgusting, and delicate and sensitive persons find it difficult to overcome their repugnance to contact with the cold and slimy reptile. This is especially the case when it is a question of their application about or within the mouth. Then again, their disposition to crawl into cavities or passages results sometimes in very annoying accidents. Another source of annoyance is that they are often unwilling to bite--the patience of all concerned being exhausted in fruitless efforts to induce them to take hold.

The expense, too, of a considerable number is by no means trifling.[185]

[Illustration: FIGURE 20.--Staffordshire leech jars, 19th century. (NMHT 263554 [M-11504]; SI photo 73-4231.)]

In addition, leeches were often difficult to obtain, and the rural physician could not easily carry them about. Leech bites could have unfortunate consequences, for many times the bleeding could not be stopped. For these and other reasons, several inventors in Europe and America sought to create a mechanical or artificial leech.[186] Such artificial leeches are often difficult to distinguish from cupping devices, because both sorts of instruments employed some form of scarification and suction. Artificial leeches however, were usually adaptable to small areas of the anatomy, and the puncture wound generally attempted to imitate a leech bite.

Perhaps the earliest instrument offered as a substitute for leeches was Sarlandiere's "bdellometer," from the Greek _bdello_, "leech." Sarlandiere, a French manufacturer, introduced his instrument in 1819 and, incidentally, had the prototype sent to New Orleans. The bdellometer consisted of a glass bell with two protruding tubes, one perpendicular for performing scarification, and the other oblique, for attaching the aspirating pump. A plug could be removed to allow air to enter the bell after the operation was completed, and a faucet allowed for drainage of blood without having to remove the apparatus from the body. A curved cannula could be attached to the bdellometer for bleeding in the nasal passages, the mouth, the vagina, and the rectum. For internal bloodletting, the disk, with lancets, normally used for scarification, was replaced by a small brush of hog bristles.[187] Sarlandiere's bdellometer attracted sufficient attention in America to be included in the numerous editions of Robley Dunglison's medical dictionary,[188] but it was ultimately no more successful than the complicated cupping devices discussed in the previous chapter.

A second French invention, also given a pretentious name, was Damoiseau's "terabdella" (meaning "large leech"), or pneumatic leech. This invention, introduced some time before 1862, met with skepticism at the outset on the part of the reviewers at the French Academy of Medicine. It consisted of two pistons attached to a plate to be placed on the floor and held down by the feet of the operator. Each piston was connected by a tube to a cup, and the whole apparatus was operated by means of a hand lever connected with both pistons. More a cupping device than an artificial leech, the terabdella met with little success beyond the French province where Damoiseau practiced.[189] (Figure 21.)

Perhaps the most successful of the mechanical leeches was known as Heurteloup's leech, after its inventor, the Frenchman, Charles Louis Heurteloup (1793-1864). Sold in most late nineteenth-century surgical catalogs for as much as $15.00, the device consisted of two parts, one a spring scarificator that made a small circular incision (about 5 mm in diameter) and the other, a suction pump, holding an ounce of blood, whose piston was raised by means of a screw. For the treatment of eye ailments, one of the major purposes for which the device was invented, it was applied to the temples.[190] A similar two-part mechanical leech was sold under the name "Luer's Leech."

One of the most interesting leech substitutes, sold by George Teimann & Co. as its "Patent Artificial Leech," employed ether in exhausting the glass "leeches." Patented by F. A. Stohlmann and A. H. Smith of New York in 1870, the "leech" consisted of a glass tube, either straight or with a mouth on the side so that the tube would hang somewhat like a living leech. To expel air from the tube, a few drops of ether were placed in it, after which it was immersed to its mouth in hot water until the ether vaporized. The tube was then applied to the skin and allowed to cool, thus sucking blood from a wound made by the scarificator, a long metal tube that was rotated to make a circular incision. One of the patentees explained the advantages of the device:

In all previous attempts at an artificial leech the vacuum has been produced by the action of a piston. This renders the instrument too heavy to retain its position, and necessitates its constantly being held. This precludes the application of any number at once, even if the cost of half-a-dozen such instruments were left out of the account. But in the case of this leech, the tubes, being exceedingly light, attach themselves at once, remaining in position until filled; and as the cost of them is but a few cents, there is no limit to the number which may be applied.[191]

To take the place of leeches in the uterus, quite a number of uterine scarificators were sold. These were generally simple puncturing instruments without spring mechanisms. If insufficient blood flowed from the scarification, Thomas's Dry Cupper, a widely available vulcanite syringe, could be inserted into the vagina to cup the cervix before puncturing.[192] At least one attempt was made to combine puncture and suction in a device for uterine application. This was Dr. William Reese's "Uterine Leech," introduced in 1876. It consisted of a graduated glass cylinder 190 mm long and 12 mm in diameter containing a piston and a rod with a spear point. The rod was surrounded by a spring that withdrew the blade after it punctured the cervix. Several American companies, including George Tiemann & Co., offered the device for sale.[193]

[Illustration: FIGURE 21.--Damoiseau's terabdella. (From Damoiseau, _La Terabdelle ou machine pneumatique_, Paris, 1862. Photo courtesy of NLM.)]

Despite all the efforts to find a suitable substitute, the use of natural leeches persisted until the practice of local bloodletting gradually disappeared in America. By the 1920s leeches were difficult to find except in pharmacies in immigrant sections of large cities like New York or Boston. One of the last ailments to be regularly treated by leeches was the common black eye. Leeches commanded rather high prices in the 1920s, if they could be found at all. One Brooklyn pharmacist, who deliberately kept an old-fashioned drugstore with the motto "No Cigars, No Candy, No Ice Cream, No Soda Water, But I Do Sell Pure Medicines," wrote in 1923:

Here in this atmosphere free from the lunch room odor my armamentarium consists of drugs and preparations from the vegetable, mineral and animal kingdoms. Among the latter are leeches, prominently displayed in a number of glass jars in different parts of the store, including one in the show window. Anything moving, anything odd, arouses the curiosity of the public, and my reputation as a "leecher" has spread far beyond the "City of Churches." Besides, this leech business is also profitable, as they are retailed at $1.00 per head without any trouble; in fact patients are only too glad to be able to obtain them.[194]

Veterinary Bloodletting

The same theories and practices that prevailed for human medicine were applied to the treatment of animals. Not only were horses routinely bled, they were also cupped and leeched.[195] Manuals of veterinary medicine gave instructions for the bleeding of horses, cows, sheep, pigs, dogs, and cats.[196]

There was one major difference between bleeding a man and bleeding a horse or cow, and that was the amount of strength required to open a vein. The considerable force needed to pierce the skin and the tunic of the blood vessel made the operation much more difficult to perform than human phlebotomy.[197] As in the case of cupping, the simplest instruments, those most often recommended by experts, were not easy to use by those without experience. Although a larger version of the thumb lancet was sometimes employed, most veterinarians opened the vein of a horse with a fleam, that is, an instrument in which the blade (commonly double beveled) was set at right angles to the blade stem. These are enlarged versions of the fleam employed in human bloodletting. The fleams sold in the eighteenth and nineteenth centuries consisted of one or more blades that folded out of a fitted brass shield. In the late nineteenth century fleams with horn shields were also sold. The largest blades were to be used to open the deeper veins and the smaller blades to open the more superficial veins.

To force the fleam into the vein, one employed a bloodstick, a stick 35-38 cm long and 2 cm in diameter. The blade was held against the vein and a blow was given to the back of the blade with the stick in such a way that the fleam penetrated but did not go through the vein. Immediately the fleam was removed and a jet of blood came forth that was caught and measured in a container. When enough blood had been collected, a needle would be placed in the vein to stop the bleeding.

Horses were most frequently bled from the jugular vein in the neck, but also from veins in the thigh, the fold at the junction of breast and forelegs, the spur, the foreleg, the palate, and the toe.

Since applying the bloodstick required a degree of skill, the Germans attempted to eliminate its use by adapting the spring lancet to veterinary medicine. The common veterinary spring lancet (which sometimes was also called a "fleam" or "phleme") was nothing but an oversized version of the brass, nob end spring lancet used on humans. Sometimes the lancet was provided with a blade guard that served to regulate the amount of blade that penetrated the skin. Although the veterinary spring lancet was quite popular in some quarters, the French preferred the simple foldout fleam as a more convenient instrument.[198] (Figure 22.)

[Illustration: FIGURE 22.--Knob end spring lancet used on humans compared to a knob end lancet used on horses and cattle. Note the blade guard on the veterinary spring lancet. (NMHT 302606.09 and NMHT 218383 [M-9256]: SI photo 76-7757.)]

In contrast to the few attempts made to modify the human spring lancet, there were a large number of attempts to modify the veterinary spring lancets. Veterinary spring lancets can be found with a wide assortment of shapes and a wide variety of spring mechanisms. In the enlarged knob end spring lancet, pushing upon the lever release simply sent the blade forward into the skin. By a more complex mechanism, the blade could be made to return after it was injected, or the blade could be made to sweep out a curve as do the blades of the scarificator. Perhaps one of the earliest attempts to introduce a more complex internal mechanism into the veterinary spring lancets is found in John Weiss's "patent horse phlemes" of 1828. The first model invented by Weiss was constructed on the principle of the common fleam and bloodstick. As in the knob end spring lancet, the spring acted as a hammer to drive the blade forward. In a second improved "horse phleme," Weiss mounted the blade on a pivot so that the blade swept out a semicircle when the spring was released.[199]

The Smithsonian collection contains a number of different types of veterinary spring lancets. Perhaps this variety can best be illustrated by looking at the two patent models in the collection. The first is an oval-shaped lancet patented in 1849 by Joseph Ives of Bristol, Connecticut.[200] By using a wheel and axle mechanism, Ives had the blade sweep out an eccentric curve. The lancet was set by a detachable key (Figure 23).

The second patent lancet was even more singular in appearance, having the shape of a gun. This instrument, patented by Hermann Reinhold and August Schreiber of Davenport, Iowa, in 1880, featured a cocking lever that extended to form a coiled spring in the handle portion of the gun. Also attached to the cocking lever was an extended blade with ratchet catches, so that by pulling on the cocking lever, the blade was brought inside the casing and the spring placed under tension. Pushing upon the trigger then shot the blade into the vein.[201] (Figure 24.)

Physical Analysis of Artifacts

The Conservation Analytical Laboratory of the Smithsonian Institution analyzed selected bloodletting instruments and one drawing from the Museum's collection. Instruments were chosen on the basis of their unique appearance and as representative examples of the major types of instruments in the collection. Six lancets and cases, two scarificators, and one pen and ink drawing were analyzed.

[Illustration: FIGURE 23.--Patent model, J. Ives, 1849. (NMHT 89797 [M-4292]: SI photo 73-4211.)]

[Illustration: FIGURE 24.--Patent model, Reinhold and Schreiber, 1880. (NMHT 89797 [M-4327]; SI photo 73-4210.)]

X-ray fluorescence analysis, response to a magnet, reaction to nitric acid, and the Vickers pyramid hardness test were among the methods of analysis used that involved no damage to the objects.

The instrument for X-ray fluorescence analysis has been modified to permit analysis of selected areas on the objects. This instrument produces, detects, and records the object's X-ray fluorescence spectrum, which is characteristic of its composition. X-rays produced by a target in the instrument strike the object and cause it, in turn, to fluoresce, or emit, X-rays. This fluorescence is detected by a silicon crystal in the detector and dispersed into a spectrum, which is displayed on an oscilloscope screen. The entire spectrum--from 0 to 40 Ke V--can be displayed or portions of it can be expanded and displayed at an apparently higher resolution that permits differentiation between closely spaced fluorescent peaks, such as those from iron and manganese. The spectrum may be transferred from the oscilloscope to a computer for calculation of the percentage of composition and for comparison with spectra of other samples. During analysis the objects can be supported and masked by sheets of plexiglas or metal foils to limit the radiation to a certain area of the object. Masks also prevent scattering of radiation off other parts of the object and off the instrument itself, which otherwise might be detected and interpreted as less concentrated components in the object.

Brass was the most common metal used in the fabrication of eighteenth- and nineteenth-century lancets and scarificators. Upon analysis the brass was found to contain 70%-75% copper, 20%-30% zinc, and other trace elements. The blades, cocking levers, and button releases of lancets and scarificators were found to be made of ferrous metal (iron or steel). In addition to the typical brass pieces, a number of "white metal" pieces were analyzed. (The term "white metal" is used to designate any undetermined silver-colored metal alloy.) Those white metal pieces dating from the eighteenth century (a Swiss or Tyrolean fleam and an English veterinary spring lancet) were found to be composed entirely of ferrous metal. The hardness of the fleam metal indicated that it was carburized sufficiently to be made of steel. Two of the spring lancets, dating from the late nineteenth century, were found to be made of a silver-copper composition that was not rich enough in silver to be sterling silver. These lancets were probably typical of the lancets advertised as silver in the late nineteenth-century trade catalogs. About 1850 an alloy imitating silver began to be widely used in the making of surgical instruments. This was German silver or nickel-silver, an alloy containing no silver at all, but rather copper, zinc, and nickel. A patent model scarificator dating from 1851 was found to contain about 63% copper, 24% zinc, and 13% nickel. This alloy is presently called "nickel-silver 65-12" alloy. The French made scarificators out of their own version of nickel-silver that was called "maillechort." The French circular scarificator was found to contain copper (55%-70%), nickel (10%-20%), zinc (20%-30%), and tin (less than 10%). The cases in which the lancets and scarificators were carried were covered with leather, despite the fact that several appeared to be covered with paper. X-ray analysis revealed that several cases contained tin, leading to the possibility that a tin salt was used in the dye-mordant for leather. The clasps on the cases were made of brass. One case was trimmed in gold leaf.

The most difficult item to analyze was the pen and ink drawing in black and red of a bloodletting man purported to be a fifteenth-century specimen (1480) from South Germany. The text is in German (Figure 25).

The watermark of the paper--a horned bull (ox) with crown--is believed to have appeared in 1310 and was used widely for two hundred years. The paper was heavily sized and no feathering of the black ink or red paint appears.

The paper fluoresced only faintly under ultraviolet light and much less brightly than new paper, leading to the conclusion that the paper is not modern. Various stains on the paper fluoresce yellow, which also indicates a considerable history for the document.

The guard strip is vellum. Red stains on this strip may have been made by blood.

The inks (brown and red) may have come from different sources or been applied at different times because of their various compositions and densities. Iron and lead were found in an area of writing on the left foot. Iron is typical of an iron gall ink. Some of the lighter lines contain graphite. The red lines contain mercury and lead suggesting a mixture of vermilion and red lead.

Analysis of the ink and paper indicates that the document has had a varied history and seems not to have been a deliberate production intended to simulate age.

Catalog of Bloodletting Instruments

Several systems of catalog numbers have been employed for instruments in the collections. The earliest instruments were originally collected by the Division of Anthropology and were given a six-digit number in the division catalog (referred to as "Anthropology"). Later objects in the collections have been given a six-digit National Museum of History and Technology (NMHT) accession number, which serves for all items obtained from one source at a given date. Before 1973, the Division of Medical Sciences used a system of numbering individual items by M numbers (e.g., "M-4151"). Since 1973, individual items have been distinguished by adding decimal numbers to the accession numbers (e.g., "308730.10"). Objects on loan have been marked as such and given a six-digit number. Other institutional abbreviations are as follows: SI = Smithsonian Institution; USNM = the former United States National Museum; NLM = National Library of Medicine.

[Illustration: FIGURE 25.--Bloodletting manikin. (NMHT 243033 [M-10288]; SI photo 76-13536.)]

Photograph numbers are labeled "BW" for black and white negative and "CS" for color slide. (Copies of photographs or slides may be purchased through the Office of Printing and Photographic Services, Smithsonian Institution, Washington, D.C. 20560.) Abbreviations for dimensions of objects are as follows: D = diameter; L = length; W = width; H = height.

Instruments within each group are arranged chronologically as accessioned by the museum.

_Phlebotomy_

FLINT AND THUMB LANCETS

Flint lancets (4). Pieces of flint used to let blood by native doctors in Alaska in the 1880s. Donated by William J. Fisher late 19th century. L 22 mm, 35 mm, 43 mm, 50 mm. Anthropology vol. 30, catalog no. 127758. Neg. 73-4208 (BW, CS). (Figure 30.)

Thumb lancet, 19th century. Typical thumb lancet with steel blade and tortoise shell shield, engraved with a crown and "Evans/Old Change/London" (manufacturer). Purchased 1898. Shield: L 56 mm. Blade: L 50 mm. Anthropology vol. 30, catalog no. 143079.

Flint lancet. "Indian scarificator" collected by the Section of Ethnology of the Smithsonian 1902. L 44 mm. Anthropology vol. 30, catalog no. 143166.

Thumb lancets (4) with case, 19th century. Lancets are engraved "S. Maw" (manufacturer). The case is made of cardboard covered with brown leather and has four compartments. Used by the donor's father while a missionary in Samoa in the 1830s. Donated in 1936 by the Rev. Robert G. Harbutt. Lancets: L 55 mm. Case: L 60 mm, W 28 mm, H 10 mm. Neg. 73-4230 (BW) four lancets with case; negs. 73-4226, 73-4227, 73-4228, 73-4229 (BW & CS), individual lancets. NMHT 139980 (M-4151). (Figure 38.)

Thumb lancets (2), 19th century. Lancets are typical 19th century thumb lancets. Shell shields are broken. Second lancet is engraved with a crown denoting British manufacture. Owned by S. K. Jennings of Baltimore (1771-1854). Donated by the Medical and Chirurgical Faculty of Maryland 1976. First lancet: L 54 mm; L of blade 46 mm. Second lancet: L 58 mm; L of blade 42 mm. NMHT 302606.062.

Thumb lancets (2), 19th century. Shell shields. One shell is marked "A. L. Hernstein." Purchased 1976. First lancet: L 60 mm. Second lancet: L 70 mm. NMHT 1977.0789.