The history of bloodletting has been marked by controversy. The extensive
literature on bloodletting contains numerous polemical treatises that both
extol and condemn the practice. Bloodletting was no sooner criticized as
ineffective and dangerous than it was rescued from complete abandonment by
a new group of zealous supporters.
From the time of Hippocrates (5th century B.C.)--and probably before,
although no written record is available--bloodletting had its vocal
advocates and heated opponents. In the 5th century B.C. Aegimious of Eris
(470 B.C.), author of the first treatise on the pulse, opposed
venesection, while Diogenes of Appolonia (430 B.C.), who described the
vena cava with its main branches, was a proponent of the practice.
Hippocrates, to whom no specific text on bloodletting is attributed, both
approved and recommended venesection.[3]
The anatomist and physician Erasistratus (300-260 B.C.), was one of the
earliest physicians to leave a record of why he opposed venesection, the
letting of blood from a vein. Erasistratus, who practiced at the court of
the King of Syria and later at Alexandria, a celebrated center of ancient
medicine, recognized that the difficulty in estimating the amount of blood
to be withdrawn and the possibility of mistakenly cutting an artery,
tendon, or nerve might cause permanent damage or even death. Since
Erasistratus believed that only the veins carried blood while the arteries
contained air, he also feared the possibility of transferring air from the
arteries into the veins as a result of venesection. Erasistratus was led
to question how excessive venesection differed from committing murder.[4]
Through the writings of Aulus Cornelius Celsus (25 B.C.-?), the Roman
encyclopedist, and Galen (ca. A.D. 130-200) venesection was restored as a
form of orthodox medical treatment and remained so for the next fifteen
hundred years. By the time of Celsus, bloodletting had become a common
treatment. Celsus remarked in his well-known account of early medicine:
"To let blood by incising a vein is no novelty; what is novel is that
there should be scarcely any malady in which blood may not be let."[5] Yet
criticism of bloodletting continued, for when Galen went to Rome in A.D.
164 he found the followers of Erasistratus opposing venesection. Galen
opened up discussion with these physicians in two books, _Against
Erasistratus_ and _Against the Erasistrateans Dwelling in Rome_. These
argumentative dialectical treatises, together with his _Therapeutics of
Venesection_, in which he presented his theory and practice of
venesection, established Galen's views on bloodletting, which were not
effectively challenged until the seventeenth century.[6]
The fundamental theory upon which explanations of health and disease were
based, which had its inception in ancient Greek thought and lasted up to
the eighteenth century, was the humoral theory. Based on the scientific
thought of the Pre-Socratics, the Pythagoreans, and the Sicilians, this
theory posited that when the humors, consisting of blood, phlegm, yellow
bile, and black bile, were in balance within the body, good health ensued.
Conversely, when one or more of these humors was overabundant or in less
than adequate supply, disease resulted. The humors were paired off with
specific qualities representing each season of the year and the four
elements according to the well-accepted doctrine of Empedocles, in which
all things were composed of earth, air, fire, and water. Thus, yellow
bile, fire, and summer were contrasted to phlegm, water, and winter, while
blood, air, and spring were contrasted to black bile, earth, and autumn.
When arranged diagrammatically, the system incorporating the humors,
elements, seasons, and qualities appears as shown in Figure 1. The
earliest formulation of humoralism was to be found in the physiological
and pathological theory of the Hippocratic treatise, _On the Nature of
Man_.[7]
Plethora, an overabundance of body humors, including blood, which
characterized fevers and inflammations, was properly treated by
encouraging evacuation. This could be done through drugs that purged or
brought on vomiting, by starvation, or by letting blood. During starvation
the veins became empty of food and then readily absorbed blood that
escaped into the arteries. As this occurred, inflammation decreased. Galen
suggested that instead of starvation, which required some time and
evacuated the system with much discomfort to the patient, venesection
should be substituted to remove the blood directly.[8]
Peter Niebyl, who has traced the rationale for bloodletting from the time
of Hippocrates to the seventeenth century, concluded that bloodletting was
practiced more to remove excess good blood rather than to eliminate
inherently bad blood or foreign matter. Generally, venesection was
regarded as an equivalent to a reduction of food, since according to
ancient physiological theory, food was converted to blood.[9]
[Illustration: FIGURE 1.--Chart of elements, seasons, and humors.]
Galen defined the criteria for bloodletting in terms of extent, intensity,
and severity of the disease, whether the disease was "incipient,"
"present," or "prospective," and on the maturity and strength of the
patient.[10] Only a skilled physician would thus know when it was proper
to bleed a patient. Venesection could be extremely dangerous if not
correctly administered, but in the hands of a good physician, venesection
was regarded by Galen as a more accurate treatment than drugs. While one
could measure with great accuracy the dosages of such drugs as emetics,
diuretics, and purgatives, Galen argued that their action on the body was
directed by chance and could not easily be observed by the physician.[11]
However, the effects of bloodletting were readily observed. One could note
the change in the color of the blood removed, the complexion of the
patient, and the point at which the patient was about to become
unconscious, and know precisely when to stop the bleeding.
Galen discussed in great detail the selection of veins to open and the
number of times blood might be withdrawn.[12] In choosing the vein to
open, its location in respect to the disease was important. Galen
recommended that bleeding be done from a blood vessel on the same side of
the body as the disease. For example, he explained that blood from the
right elbow be removed to stop a nosebleed from the right nostril.[13]
Celsus had argued for withdrawing blood near the site of the disease for
"bloodletting draws blood out of the nearest place first, and thereupon
blood from more distant parts follows so long as the letting out of blood
is continued."[14]
Controversy over the location of the veins to be opened erupted in the
sixteenth century. Many publications appeared arguing the positive and
negative aspects of bleeding from a vein on the same side
(derivative--from the Latin _derivatio_ from the verb _derivare_, "to draw
away," "to divert") or the opposite side (revulsion--from the Latin
_revulsio_, "drawing in a contrary direction") of the disordered part of
the body. This debate mirrored a broader struggle over whether to practice
medicine on principles growing out of medieval medical views or out of
classical Greek doctrines that had recently been revived and brought into
prominence. The medieval practice was based on the Moslem medical writers
who emphasized revulsion (bleeding from a site located as far from the
ailment as possible).[15] This position was attacked in 1514 by Pierre
Brissot (1478-1522), a Paris physician, who stressed the importance of
bleeding near the locus of the disease (derivative bleeding). He was
declared a medical heretic by the Paris Faculty of Medicine and derivative
bleeding was forbidden by an act of the French parliament. In 1518,
Brissot was exiled to Spain and Portugal. In 1539, the celebrated
anatomist, Andreas Vesalius, continued the controversy with his famous
_Venesection Letter_, which came to the support of Brissot.[16]
Only with the gradual awareness of the implications of the circulation of
the blood (discovered in 1628) did discussion of the distinction between
derivative and revulsive bloodletting become passe.[17] Long after the
circulation of the blood was established, surgical treatises such as those
of Lorenz Heister (1719) recommended removing blood from specific parts of
the body--such as particular veins in the arm, hand, foot, forehead,
temples, inner corners of the eye, neck, and under the tongue. In the
nineteenth century this practice was still challenged in the literature as
a meaningless procedure.[18] (Figure 2.)
_How Much Blood to Take_
According to Galen, safety dictated that the first bloodletting be kept to
a minimum, if possible. Second, third, or further bleedings could be taken
if the condition and the patient's progress seemed to indicate they would
be of value. The amount of blood to be taken at one time varied
widely.[19]
Galen appears to have been the first to note the amount of blood that
could be withdrawn: the greatest quantity he mentions is one pound and a
half and the smallest is seven ounces. Avicenna (980-1037) believed that
ordinarily there were 25 pounds of blood in a man and that a man could
bleed at the nose 20 pounds and not die.[20]
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]
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: