Bloodletting Instruments in the National Museum of History and Technology Part 1

Bloodletting Instruments in the National Museum of History and Technology.

by Audrey Davis and Toby Appel.

ABSTRACT

Davis, Audrey, and Toby Appel. Bloodletting Instruments in the National Museum of History and Technology. _Smithsonian Studies in History and Technology_, number 41, 103 pages, 124 figures, 1979.--Supported by a variety of instruments, bloodletting became a recommended practice in antiquity and remained an accepted treatment for millenia. Punctuated by controversies over the amount of blood to take, the time to abstract it, and the areas from which to remove it, bloodletters employed a wide range of instruments. All the major types of equipment and many variations are represented in this study of the collection in the National Museum of History and Technology.

OFFICIAL PUBLICATION DATE is handstamped in a limited number of initial copies and is recorded in the Inst.i.tution's annual report, _Smithsonian Year_. COVER DESIGN: "Phlebotomy, 1520" (from Seitz, 1520, as ill.u.s.trated in Hermann Peter, _Der Arzt und die Heilkunst_, Leipzig, 1900; photo courtesy of NLM).

PREFACE

Among the many catalogs of museum collections, few describe objects related to the practice of medicine. This catalog is the first of a series on the medical sciences collections in the National Museum of History and Technology (NMHT). Bloodletting objects vary from ancient sharp-edged instruments to the spring action and automatic devices of the last few centuries. These instruments were used in a variety of treatments supporting many theories of disease and therefore reflect many varied aspects of the history of medicine. Beginning with an essay sketching the long history of bloodletting, this catalog provides a survey of the various kinds of instruments, both natural and man-made, that have been used throughout the centuries.

It is a pleasure to thank the Smithsonian Research Foundation, the Commonwealth Foundation, and the Houston Endowment for their financial support of this project.

Miss Doris Leckie, who did much of the preliminary research and organized part of the collection that led to a draft of this catalog with special emphasis on the cupping apparatus, receives our highest grat.i.tude. Her public lectures on the topic drew much praise. The usefulness of this catalog is due in no small part to her devoted efforts.

For photographing the Smithsonian objects so well we thank Richard Hofmeister, John Wooten, and Alfred Harrell of the Smithsonian Office of Printing and Photographic Services. For a.n.a.lyzing selected objects and answering our requests promptly we thank Dr. Robert Organ, chief; Barbara Miller, conservation director; and Martha Goodway, metallurgist, of the Conservation a.n.a.lytical Laboratory.

To those who helped us to solve specific problems we extend appreciation to Dr. Arthur Nunes; Dr. Uta C. Merzbach, curator of mathematics, NMHT (especially for finding the poem by Dr. Snodgra.s.s); and Silvio Bedini, deputy director, NMHT, whose enthusiasm and unmatched ability for studying objects has sustained us throughout the period of preparation.

While it is traditional to add a reminder that various unnamed people contributed to a publication, it is imperative to state here that numerous people are essential to the collection, conservation, preservation, and exhibition of museum objects. Without them no collection would survive and be made available to those who come to study, admire or just enjoy these objects. We hope this catalog brings out some of the joy as well as the difficulties of maintaining a national historical medical collection.

BLOODLETTING INSTRUMENTS IN THE NATIONAL MUSEUM OF HISTORY AND TECHNOLOGY

AUDREY DAVIS and TOBY APPEL[A]

Introduction

Bloodletting, the removal of blood from the body, has been practiced in some form by almost all societies and cultures. At various times, bloodletting was considered part of the medical treatment for nearly every ailment known to man. It was also performed as punishment or as a form of wors.h.i.+p to a Superior Power or Being. It still retains therapeutic value today, although only for an extremely limited range of conditions. In early attempts to extract blood from the body, the skin was penetrated in various places with a sharp instrument made of stone, wood, metal, bristle, or any other rigid material. When it was recognized that a vein visible on the surface of the skin as a blue-green stripe contained blood, the vein was incised directly. To facilitate "breathing a vein" and to provide greater safety, more refined and sharper instruments were devised.

As theories supporting bloodletting grew more complex, so too did the instruments.

Spontaneous forms of bleeding, including nosebleed, menstruation, and those instances produced by a blow to any part of the body, apparently inspired the earliest human bloodletters. The Egyptians claimed that the hippopotamus rubbed its leg against a sharp reed until it bled to remove excess blood from its body.[1] The Peruvians noted that a bat would take blood from the toe of a sleeping person when the opportunity presented itself. A deer, and goat, would pick a place near its diseased eye for relief.[2] The methods employed by animals increased interest in using artificial methods for letting blood in man.

The devices man has employed to remove blood from the body fall into two major categories: (1) those instruments used for general bloodletting, that is, the opening of an artery, or more commonly a vein, and (2) those instruments used in local bloodletting. Instruments in the first category include lancets, spring lancets, fleams, and phlebotomes. a.s.sociated with these are the containers to collect and measure the blood spurting from the patient. In the second category are those instruments a.s.sociated with leeching and cupping. In both of these methods of local bloodletting, only the capillaries are severed and the blood is drawn from the body by some means of suction, either by a leech or by an air exhausted vessel.

Instruments in this category include scarificators, cupping gla.s.ses, cupping devices, and many artificial leeches invented to replace the living leech.

Much effort and ingenuity was expanded, especially in the eighteenth and nineteenth centuries, to improve the techniques of bloodletting. In the eighteenth century, delicate mechanical spring lancets and scarificators were invented to replace the simpler thumb lancets and fleams. In the nineteenth century, as surgical supply companies began to advertise and market their wares, many enterprising inventors turned their hand to developing new designs for lancets and scarificators, pumps, fancy cupping sets, rubber cups, and all manner of cupping devices and artificial leeches. If we also consider treatments related to bloodletting, in which blood is transferred from one part of the body to another, without actual removal from the body, then we can add the many inventions devoted to dry cupping, irritating the body, and exhausting the air around limbs or even the entire body. Although many physicians continued to use the traditional instruments that had been used for centuries, many others turned eagerly to the latest gadget on the market.

Bloodletting instruments, perhaps the most common type of surgical instrument little more than a century ago, are now unfamiliar to the average person. When one sees them for the first time, one is often amazed at their pet.i.te size, careful construction, beautiful materials, and elegant design. One marvels at spring lancets made of silver, thumb lancets with delicate tortoise sh.e.l.l handles, and sets of hand-blown cups in the compartments of a mahogany container with bra.s.s and ivory latches and a red plush lining. Those finding such instruments in their attic or in a collection of antiques, even if they can determine that the instruments were used for bloodletting, often have no idea when the instruments were made or how they were used. Frequently a veterinary spring lancet or fleam is mistaken for a human lancet, or a scarificator for an instrument of venesection. Almost nothing has been written to describe these once common instruments and to place them in historical context. Historians who study the history of medical theory usually ignore medical practice, and they rarely make reference to the material means by which a medical diagnosis or treatment was carried out. It is hoped that this publication will fill a need for a general history of these instruments. This history is pieced together from old textbooks of surgery, medical encyclopedias, compilations of surgical instruments, trade catalogs, and the instruments themselves.

The collection of instruments at the National Museum of History and Technology of the Smithsonian Inst.i.tution contains several hundred pieces representing most of the major types of instruments. Begun in the late nineteenth century when medical sciences were still part of the Department of Anthropology, the collection has grown steadily through donations and purchases. As might be expected, it is richest in bloodletting instruments manufactured in America in the nineteenth century. One of its earliest acquisitions was a set of four flint lancets used by Alaskan natives in the 1880s. A major source for nineteenth-century instruments is the collection of instruments used by the members of the Medical and Chirurgical Faculty of Maryland, a medical society founded in 1799. The Smithsonian collection also includes patent models of bloodletting instruments submitted to the U.S. Patent Office by nineteenth-century inventors and transferred to the Smithsonian in 1926.

Because we have made an effort to survey every major type of instrument related to bloodletting, it is hoped that this publication will serve as a general introduction to bloodletting instruments, and not merely a guide to the Smithsonian collection. With this goal in mind, the catalog of bloodletting instruments has been preceded by chapters surveying the history of bloodletting and describing, in general terms, the procedures and instruments that have been used since antiquity for venesection, cupping, leeching, and veterinary bloodletting. In the course of our research we have consulted several other collections of bloodletting instruments, notably the collections of the Wellcome Museum of London, the Armed Forces Inst.i.tute of Pathology, the College of Physicians in Philadelphia, the Inst.i.tute of the History of Medicine at the Johns Hopkins University, the Howard Dittrick Medical Museum in Cleveland, and the University of Toronto. Ill.u.s.trations from these collections and references to them have been included in the cases where the Smithsonian collection lacks a particular type of instrument.

Sources

While primary sources describing the procedures and presenting theoretical arguments for and against bloodletting are plentiful, descriptions of the instruments and their manufacture are often difficult to find. Before the nineteenth century, one may find ill.u.s.trations of bloodletting instruments in the major textbooks on surgery, in encyclopedias such as that of Diderot, and in compendia of surgical instruments written by surgeons. The descriptions following the drawings are often meager and give little indication of where, when, and how the instruments were produced. Until well into the nineteenth century, the tools used by barber-surgeons, surgeons, and dentists were made by blacksmiths, silversmiths, and cutlers. These craftsmen generally left little record of their work. As the demand for surgical instruments increased, specialized surgical instrument makers began to appear, and the cutler began to advertise himself as "Cutler and Surgical Instrument Maker" rather than simply "Cutler and Scissor Grinder." A few advertising cards dating from the eighteenth century may be found, but the ill.u.s.trated trade catalog is a product of the nineteenth century. Among the earliest compendia/catalogs of surgical instruments written by an instrument maker, rather than by a surgeon, was John Savigny's _A Collection of Engravings Representing the Most Modern and Approved Instruments Used in the Practice of Surgery_ (London, 1799). This was followed a few decades later by the brochures and catalog (1831) of the famous London instrument maker, John Weiss. By the 1840s John Weiss, Charriere of Paris, and a few other instrument makers had begun to form surgical supply companies that attempted to market instruments over a wide area. While there are a handful of company trade catalogs dating from the 1840s, 1850s, and 1860s, the great influx of such catalogs came after 1870. Trade catalogs, a major source of information on the new instruments of the nineteenth century, provide the historian with line drawings, short descriptions indicating the mechanism and the material of which the instrument was composed, prices, and patent status.

For more details on nineteenth-century instruments one must turn to brochures and articles in medical journals introducing the instruments to the medical profession. These sources provide the most detailed descriptions of how the instruments were constructed, how they were used, and why they were invented. For many American instruments, the descriptions available at the U.S. Patent Office offer ill.u.s.trations of the mechanism and a discussion of why the instrument was considered novel.

One finds specifications for many bizarre instruments that never appear in trade catalogs and may never have been actually sold.

A final source of information is the instruments themselves. Some are engraved with the name of the manufacturer, and a few are even engraved with the date of manufacture. Some have been taken apart to study the spring mechanisms and others examined in the Conservation a.n.a.lytical Laboratory of the Smithsonian Inst.i.tution to determine their material content. The doc.u.mentation accompanying the instruments, while sometimes in error, may serve to identify the individual artifact by name, place and date of manufacture, and to augment our knowledge of the historical setting in which these instruments were used.

Bleeding: The History

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 subst.i.tuted 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]

[Ill.u.s.tration: 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,"