Bloodletting Instruments in the National Museum of History and Technology Part 2

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 sh.e.l.l, 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 sh.e.l.l, s.h.a.green, 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.

[Ill.u.s.tration: FIGURE 5.--18th-19th century lancets and lancet cases. The cases are made of mother-of-pearl, silver, s.h.a.green, and tortoise sh.e.l.l.

(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 pa.s.s 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 fas.h.i.+onable 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 const.i.tutional 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 ma.s.sive 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 subst.i.tutes 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 Was.h.i.+ngton (1732-1799), who was bled four times in two days after having contracted a severe inflammation of the throat. Was.h.i.+ngton'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 Was.h.i.+ngton'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 b.u.t.ton 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, bra.s.s, 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 fas.h.i.+on 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 k.n.o.b-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 b.u.t.ton.

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

[Ill.u.s.tration: 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 pract.i.tioner 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. Snodgra.s.s 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 pa.s.sed since first we met, Pliant and ever-faithful-slave!

n.o.bly 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 s.h.i.+eld; 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 cl.u.s.ter 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 s.h.i.+eld. 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, const.i.tuerait presque a elle seule l'histoire de toutes les doctrines medicales" (the history of bloodletting, considered in its totality, would const.i.tute 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.