Bloodletting Instruments in the National Museum of History and Technology Part 3

The French physician, Pierre Louis's statistical investigation (numerical method) into the effect of bloodletting in the treatment of pneumonia has often been cited as a cause for the downfall of venesection,[73] but the results of Louis's research showed only that bloodletting was not as useful as was previously thought. Louis's work, however, was typical of a new and critical att.i.tude in the nineteenth century towards all traditional remedies. A number of investigators in France, Austria, England, and America did clinical studies comparing the recovery rates of those who were bled and those who were not.[74] Other physicians attempted to measure, by new instruments and techniques, the physiological affects of loss of blood. Once pathological anatomy had a.s.sociated disease ent.i.ties with specific lesions, physicians sought to discover exactly how remedies such as bloodletting would affect these lesions. In the case of pneumonia, for example, those who defined the disease as "an exudation into the vessels and tissues of the lungs" could not see how bloodletting could remove the coagulation. John Hughes Bennett, an Edinburgh physician, wrote in 1855: "It is doubtful whether a large bleeding from the arm can operate upon the stagnant blood in the pulmonary capillaries--that it can directly affect the coagulated exudation is impossible."[75] Bennett felt that bloodletting merely reduced the strength of the patient and thus impeded recovery.

Bloodletting was attacked not only by medical investigators, but much more vehemently by members of such medical sects as the homeopaths and botanics who sought to replace the harsh remedies of the regular physicians by their own milder systems of therapeutics.[76]

As a result of all this criticism the indications for bleeding were gradually narrowed, until at the present time bloodletting is used in only a few very specific important instances.

In England and America, in the last quarter of the nineteenth century, a last serious attempt was made to revive bloodletting before it died out altogether. A number of Americans defended the limited use of bleeding, especially in the form of venesection. The noted American physician, Henry I. Bowditch, tried in 1872 to arouse support for venesection among his Ma.s.sachusetts Medical Society colleagues. He noted that venesection declined more than any other medical opinion in the esteem of the physician and the public during the previous half century. At the beginning of his career, he had ignored the request of his patients who wanted annual bloodlettings to "breathe a vein" to maintain good health.

He eventually found that to give up the practice entirely was as wrong as to overdo it when severe symptoms of a violent, acute cardiac disease presented themselves. Lung congestion and dropsy were other common disorders that seemed to him to be relieved, at least temporarily, by venesection.[77]

In 1875 the Englishman W. Mitch.e.l.l Clarke, after reviewing the long history of bloodletting and commenting on the abrupt cessation of the practice in his own time, wrote:

Experience must, indeed, as Hippocrates says in his first aphorism, be fallacious if we decide that a means of treatment, sanctioned by the use of between two and three thousand years, and upheld by the authority of the ablest men of past times, is finally and forever given up. This seems to me to be the most interesting and important question in connection with this subject. Is the relinquishment of bleeding final? or shall we see by and by, or will our successors see, a resumption of the practice? This, I take it, is a very difficult question to answer; and he would be a very bold man who, after looking carefully through the history of the past, would venture to a.s.sert that bleeding will not be profitably employed any more.[78]

An intern, Henri A. Lafleur of the newly founded Johns Hopkins Hospital, reported on five patients on whom venesection was performed between 1889 and 1891. Lafleur defended his interest in the subject by calling attention to other recent reports of successes with bleeding, such as that of Dr. Pye-Smith of London. He concluded that at least temporary relief from symptoms due to circulatory disorders, especially those involving the pulmonary system, was achieved through venesection.

Pneumonia and pleurisy were the primary diseases for which venesection was an approved remedy.[79] It had long been believed by bloodletters that these complaints were especially amenable to an early and repeated application of the lancet.[80] Austin Flint had explained in 1867 that bloodletting "is perhaps more applicable to the treatment of inflammation affecting the pulmonary organs than to the treatment of other inflammatory affections, in consequence of the relations of the former [pulmonary organs] to the circulation."[81] Thus, while bloodletting for other diseases declined throughout the nineteenth century, it continued to be advocated for treating apoplexy, pneumonia, and pulmonary edema.[82]

The merit of phlebotomy for those afflicted with congestive heart failure was emphasized again in 1912 by H. A. Christian. This condition led to engorgement of the lungs and liver and increased pressure in the venous side of the circulation. Articles advocating bloodletting continued into the 1920s and 1930s.[83]

Bloodletting is currently being tested as a treatment for those suffering from angina or heart attacks. Blood is removed on a scheduled basis to maintain the hematocrit (the percentage of red blood cells in the blood) at a specified level. Keeping the hematocrit low has provided relief to those being tested.[84] Other benefits of removing blood, including the lowering of blood pressure, can be obtained by the use of antihypertensive drugs. Thus the valid indications for bleeding are being supplanted by the use of modern drugs that accomplish the same end.

By the twentieth century the lancet was replaced in some quarters by safer devices for removing blood and injecting fluids into the bloodstream.

Heinrich Stern improved Strauss's special hyperdermic needle. In 1905 Stern designed a venepuncture or aspirating needle that was 7 cm long with a silver cannula of 4 cm. Attached to the handle was a thumb-rest and a tube for removing or adding fluids and a perforator within the cannula. He recommended that the forearm be strapped above the elbow and that the instrument be thrust into the most prominent vein. This streamlined vein puncturing implement reduced the possibility of injecting air and bacteria into the blood.[85] It was, and continues to be, used to withdraw blood for study in the laboratory, to aid in diagnosis of disease, and to collect blood for transfusing into those who need additional blood during an operation or to replace blood lost in an accident or disease. The blood is collected in a gla.s.s or plastic graduated container and stored under refrigeration. The study of blood donors has, incidentally, given insights into the physiology of bloodletting since the volume customarily removed from a donor is about the same in volume as that taken by a bleeder (one pint or 500 cc).[86]

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

Cupping

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

Since antiquity medical authors have distinguished two forms of cupping, dry and wet. In dry cupping, no blood was actually removed from the body.

A cup was exhausted of air and applied to the skin, causing the skin to tumefy. In wet cupping, dry cupping was followed by the forming of several incisions in the skin and a reapplication of the cups in order to collect blood. It was possible to scarify parts of the body without cupping--through the nineteenth-century physicians recommended scarifying the lips, the nasal pa.s.sages, the eyes, and the uterus. In order to remove any sizeable amount of blood, however, it was necessary to apply some sort of suction to the scarifications, because capillaries, unlike arteries and veins, do not bleed freely. (Figure 8.)

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

As noted above, the ancients usually recommended cupping close to the seat of the disease. However, there were several examples in ancient writings of cupping a distant part in order to divert blood. The most famous of these examples was Hippocrates' recommendation of cupping the b.r.e.a.s.t.s in order to relieve excessive menstruation.[89]

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

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

_Early Cupping Instruments_

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

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

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

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

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

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

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

(Figure 10.)

[Ill.u.s.tration: FIGURE 9.--Persian spouted cupping gla.s.s, 12th century.

(NMHT 224478 [M-8037]; SI photo 73-4215.)]

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

The custom which appears to have become prevalent of resorting to these Bagnios, or Haumaums, to be bathed and cupped, appears to have superseded the practice of this operation by the regular surgeons.

Falling into the hands of mere hirelings, who practiced without knowledge, and without any other principle than one merely mercenary, the operation appears to have fallen into contempt, to have been neglected by Physicians, because patients had recourse to it without previous advice, and disparaged by regular Surgeons, because, being performed by others, it diminished the profits of their profession.[100]

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

After a period of neglect, cupping enjoyed renewed popularity in the late eighteenth and early nineteenth centuries. In that period a number of professional cuppers practiced in the cities of Europe and America. Both Guy's and Westminster Hospitals in London employed a professional cupper to aid physicians and surgeons. Of these hospital cuppers, at least four, Thomas Mapleson, Samuel Bayfield, George Frederick Knox, and Monson Hills published treatises on the art of cupping, from which we gain the clearest account of cupping procedure.[101] Knox, who succeeded Mapleson as Cupper at Westminster Hospital, was pet.i.tioned by 59 medical and surgical students to write his practical and portable text.[102]

_Instruments of the Professional Cupper_

Cupping instruments in the eighteenth and nineteenth centuries were generally simple dome-shaped gla.s.s cups provided with thick rims so that the cups would be less painful when applied and removed. Cups were sold in various sizes, ranging from about 45 mm to 75 mm high. Some were made with a smaller diameter and a larger belly for cupping on parts of the body with a limited surface area. For the same reason, cups with an oval rim were recommended. (Figure 11.)

There were several common methods for exhausting cups, of which the simplest and most widely used was that of throwing burning lint or tow (the coa.r.s.e part of flax, hemp, or jute) inside the gla.s.s before applying the gla.s.s to the skin of the patient. The professional cuppers vehemently disapproved of this clumsy practice, for the patient could easily be scorched.[103] Various improvements were suggested to avoid burning the patient. Dionis (1708) had recommended placing a small card with lighted candles over the scarifications, and then applying the cup.[104] Other methods included the brief introduction of a wire holding a bit of sponge soaked with alcohol and ignited, or attaching a bit of sponge to the inside of the gla.s.s by means of wax and a piece of wood. All such methods were deemed "clumsy expedients" by professional cuppers,[105] who preferred to employ a lamp or torch especially made for cupping.

Eighteenth-century surgical texts ill.u.s.trated bra.s.s grease lamps with covers to regulate the flame. Probably less difficult to maneuver was the alcohol lamp first introduced in the 1790s. Alcohol lamps for cupping were made of metal, shaped like teapots, and contained a heavy cotton wick protruding from the spout.[106]

[Ill.u.s.tration: FIGURE 11.--Typical gla.s.s cupping cups, late 19th century.

(NMHT 152130 [M-4766-68]; SI Photo 61135-C.)]

Although Mapleson (1813) employed an alcohol lamp, the cuppers writing after him preferred the more recently-introduced cupping torch. This consisted of a piece of hollow metal tubing cut obliquely at one end and provided with a metal bulb or ring at the other end. A cotton wick was stuffed as compactly as possible into the tube so that a small piece of wick protruded from the oblique end. The wick was dipped in alcohol, ignited, and inserted briefly into the cup. The torch was more convenient than the older teapot lamp because it was easier to insert into the cup, and was small enough to hold in the hand at the same time as one held the scarificator.[107]

The introduction of the scarificator represented the major change in the art of cupping between antiquity and the nineteenth century. Unlike later attempts at improving cupping technology, the scarificator was almost universally adopted. Previous to its invention, the cupper, following ancient practice, severed the capillaries by making a series of parallel incisions with a lancet, fleam, or other surgical knife.[108] This was a messy, time consuming, and painful procedure. Ambroise Pare (1510?-1590) was the first to employ the word "scarificator" and the first to ill.u.s.trate a special instrument for scarification in his compendium of surgical instruments.[109] However, a precursor to the scarificator had been suggested by Paulus of Aegina (625-690), who described an instrument constructed of three lancets joined together so that in one application three incisions could be made in the skin. The instrument, recommended for the removal of coagulated blood in the wake of a blow, was considered difficult to use and was not generally adopted.[110] Pare's scarificator had a circular case and eighteen blades attached to three rods projecting from the bottom. A pin projecting from the side may have served to lift the blades and a b.u.t.ton on the top to release them although Pare did not describe the spring mechanism.[111] Pare did not recommend the instrument for cupping, but rather for the treatment of gangrene. Several sixteenth- and seventeenth-century surgical texts made reference to Pare's instrument, among them Jacques Delechamps (1569) and h.e.l.lkiah Crooke (1631).[112]

It is not known who made the first square scarificator and adapted it to cupping. The instrument was not found in Dionis (1708), but it did appear in Heister (1719) and in Garengeot (1725). Thus it appears that the scarificator was invented between 1708 and 1719. Garengeot disliked cupping in general and he had little good to say of the new mechanical scarificator. "A nasty instrument," he called it, "good only for show."[113] The German surgeon, Lorenz Heister, was more appreciative of the innovation. After describing the older method of making sixteen to twenty small wounds in the skin with a knife, he announced that "The modern surgeons have, for Conveniency for themselves and Ease to the Patient, contrived a Scarificator ... which consists of 16 small Lancet-blades fixed in a cubical Bra.s.s Box, with a Steel Spring."[114]

Heister noted that while Pare had used the scarificator only for incipient mortification, it was now "used with good success by our Cuppers in many other Diseases, as I myself have frequently seen and experienced."[115]