The Decline of Therapeutic Bloodletting and the Collapse of Traditional Medicine

K. Codell Carter

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351483964
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Over the course of a single generation, without significant discussion or debate, a key practice of traditional medicine was almost completely abandoned in mid-nineteenth-century Europe. K. Codell Carter's book describes how and why bloodletting was abandoned, noting that it was part of a process in which innovation was required so that modern scientific medicine could begin. This book is a masterful study on the collapse of a traditional medical practice. Bloodletting had been a prominent medical therapy in early nineteenth-century Europe and can be traced back to Greek and Roman physicians. The Hippocratic corpus contains several discussions of bloodletting. Galen, the most famous physician in classical antiquity, wrote tracts explaining and defending the practice. It was employed in ancient Egypt and is the most commonly mentioned therapy in the Babylonian Talmud. Indeed, it was practiced in virtually every part of the ancient world. Even though the practice abruptly ceased, there was little argument against it or reason to believe it ineffective. In reality, bloodletting actually worked. However, the rise of modern medicine required not just a change in how disease and causation were conceived, but also a change in the role of medicine in society. It has been claimed that the collapse of traditional medicine was a precondition for the rise of modern medicine, but there has been little support for this assertion before now. Carter provides this missing support. The result is a fascinating study in the history of medical practice and social expectations.

1

Bloodletting and Inflammation

Bloodletting, “the single greatest error in the history of medicine,” was abandoned only after “the claim that it is beneficial was tested and refuted.”

—Joseph Agassi (1969)

Whatever explanation may be given of the effects of bloodletting, there is no doubt of its multiplied results in the treatment of disease.

—James Wardrop (1833)

At 9:00 p.m. on July 13, 1824, a twenty-one-year-old sergeant in a French regiment of infantry was stabbed through the chest while engaged in single combat. His right carotid artery was punctured, and within minutes, he was unconscious from loss of blood. The bleeding was controlled by “very forcible compression,” and the sergeant was quickly transported to a local hospital. At half past nine, “the patient was placed in bed, his head and shoulders being raised by pillows. He was immediately bled from the arm to 20 ounces.” At one o’clock in the morning, “a second bleeding was ordered to the amount of twelve ounces,” and two hours later, another twelve ounces were taken. The chief physician, Professor Jacques Mathieu Delpech, arrived at seven in the morning; he ordered an immediate bleeding of ten ounces and five more bleedings of eight or ten ounces each followed at regular intervals through the next fourteen hours. Altogether, in the first twenty-four hours after admission, in addition to the blood lost on the field of battle, his medical attendants systematically removed ninety ounces of the sergeant’s blood. The specific gravity of blood is 1.060, so sixteen ounces of blood are almost one pint. Thus, in the first day of treatment, more than half the sergeant’s normal supply of blood (about ten pints) was deliberately drained away. Two days later, on July 16, eighteen more ounces were taken; on each of the next two days, he was bled a further eight ounces and on July 24, another twelve ounces. The wound remained sore and swollen, and by July 29, it was evident to Delpech that “suppurative inflammation had commenced.” He ordered twelve leeches applied to the most sensitive part of the wound, and, later in the day, twenty more leeches were applied to the same area. The next afternoon, “four ounces of blood escaped [from the wound] in a large jet”; in response to this accident, four more ounces were drained and more leeches were applied. Over the next three days, a total of forty more leeches were applied to the most painful part of the wound. “Towards the end of September, the strength of the patient had very much returned; he left his bed and could take a little exercise.” He was discharged from the hospital on October 3. Delpech concluded that “by the large quantity of blood lost, amounting to 170 ounces [nearly eleven pints], besides that drawn by the application of [a total of seventy-two] leeches [perhaps another two pints], the life of the patient was preserved.” By contemporary standards, two hundred ounces of blood taken over the space of a few months was a large but by no means exceptional quantity of blood; the medical literature of the period contains many similar accounts—some successful, some not. Delpech found this case novel enough to warrant publication, not because of the massive bleedings, but because digitalis had been used as a sedative “in much larger doses than have ever been tried in this country” (Delpech, 1825). How are we to understand such medical treatment? What could the medical attendants possibly have been thinking?

Bloodletting can be explained on at least two levels. In this chapter, we will consider the practice in relation to what were called inflammatory symptoms; this explanation, while relatively superficial, will be sufficient to answer some basic questions about how bloodletting was used and why it was deemed to be effective. In chapter 2, we will examine the practice in a broader context and present a more comprehensive justification of its use.

I

As is illustrated in the account of the infantry sergeant’s treatment, bloodletting occurred in two forms: sometimes, using a special instrument called a lancet, physicians opened a vein or an artery and simply allowed the patient’s blood to flow into a receptacle. This approach, which was called venesection, phlebotomy, or general bloodletting, was usually selected when a patient was feverish or was judged to be at risk to become so. The sergeant in the previous account was repeatedly bled in this way presumably to prevent the onset of fever. In other cases, those in which a patient had a local inflammation on the surface of the body, physicians removed blood directly from the inflamed tissues. This was called local bloodletting, and it could be done either by abrading the skin and applying suction in one way or another or by applying leeches to the inflamed tissues. In the sergeant’s case, when his wound became inflamed, leeches were applied directly to the surface of the wound.

Bloodletting, local, general, or a combination of both, was central to a broader therapeutic strategy called the antiphlogistic regimen. The name comes from the word phlogiston which, in a now antiquated and discarded theory of physics, referred to the hypothetical essence of fire, heat, or inflammability. When nineteenth-century physicians observed fever or inflamed tissues, it seemed reasonable to suppose that the patient was generally or locally overheated; the antiphlogistic regimen was conceived of as removing excess heat, and a central part of the process was removing blood. Beyond bloodletting, the regimen could also include such measures as purging, blistering, dietary restrictions, and the use of cooling lotions. Since a large number of medical problems involved fever or inflammation, the antiphlogistic regimen and bloodletting in particular were central to much of medical practice.

One four-volume medical encyclopedia, which included articles by fifty of England’s most celebrated physicians and which went through several editions beginning in 1830, recommended the antiphlogistic regimen, and bloodletting in particular, for about two-thirds of the diseases identified in the index. These included acne, apoplexy (now called stroke), asthma, beriberi, cancer, cholera, chorea, coma, convulsions, croup, diabetes, difficult teething, dropsy, dysentery, eczema, emphysema, epilepsy, gangrene, gout, hemorrhoids, hepatitis, herpes, hiccup, hydrophobia (now called rabies), indigestion, insanity, jaundice, laryngitis, leprosy, ophthalmia, palpitations of the heart, paralysis, phthisis (now called tuberculosis), plague, pleurisy, pneumonia, rheumatism, scurvy, smallpox, softening of the brain, spinal meningitis, suppression of urine, tetanus, tonsillitis, and whooping cough, as well as eleven different forms of hemorrhage and about seventy other assorted disorders (Forbes, Tweedie, and Conolly, 1849). “Even during surgical operations, doctors viewed bleeding (artificial or hemorrhaging) as beneficial in preventing febrile symptoms and local inflammation .… Before amputations it was common to bleed patients to the extent that the loss of blood would equal the amount estimated to circulate in the limb” (Haller, 1982, p. 49). And, of course, there is the revealing fact that the medical journal Lancet, which was founded in 1823 and which remains one of the world’s most prominent medical journals, was named after the instrument by which venesection was performed.

How extensive was therapeutic bloodletting in the early decades of the century? In 1859, one American physician estimated that, over the course of his career, he had removed more than one hundred barrels of blood (Haller, 1982, p. 49). The number of leeches in use also gives some indication of the extent of bloodletting: during this period, in addition to all the leeches that could be produced and harvested domestically (and the harvesting was so thorough that some physicians feared that leeches might actually become extinct), British physicians imported more than seven million leeches each year from such countries as France, Germany, Silesia, and Poland, and even from Turkey, Egypt, India, and Australia (Carter, 2001). (For purposes of comparison, in the 1830s, the population of Great Britain was about ten million.)

General bloodletting or venesection was relatively straightforward. It was simply a matter of opening a vein or an artery and allowing blood to flow. Of course, there were some risks. For one thing, there was always the danger of taking too much blood. This problem was generally controlled by bleeding patients while they were sitting erect in bed or even standing—the thinking was that as long as a patient could sit or stand erect, he or she had not yet lost so much blood as to be in danger; once the patient passed out, it was time to stop. However, it was widely recognized that, by accident, patients were sometimes literally bled to death. This was suspected to have happened, for example, both to George Washington and to his contemporary, King George III of England. Another related problem was that it was sometimes difficult to stop the flow of blood once it had begun. Practitioners were cautioned to be prepared to arrest the flow of blood by stitching the opening together with a needle and silk thread or by employing cauterizing agents, ligatures, or plaster of Paris.

Local bloodletting was a more complex procedure and one whose success depended on the mastery of some rather specialized techniques—techniques that were continually being scrutinized and perfected in the early decades of the nineteenth century. One way of bleeding locally was by abrading the skin to expose inflamed tissues and by applying mechanical devices that created enough suction to withdraw blood. However, the most effective and most popular means of bleeding locally was by the application of leeches. When brought into contact with a living animal, a leech punctures its victim’s skin with a bite that resembles the emblem on a Mercedes-Benz. It then secretes various anesthetic, anticoagulant, and diffusing agents, and for about half an hour, it sucks the blood that flows from its host. Tests conducted in the early nineteenth century indicated that a leech would consume about half an ounce of blood before detaching itself. However, the use of leeches was not as simple as one might expect. In 1804, G. Wilkinson recommended that the area to which leeches were to be applied should be washed with soap and water, rinsed thoroughly, and, when appropriate, shaved very close to the skin: “I have found the sharp points of the incised hairs so greatly to annoy them, as to prevent their fixing.” He observed that leeches could best be controlled by placing them in a wine glass; this was useful not only “for observing their motions, circumscribing their limits, retaining them in the proper place assigned for their bite, but it also tends to support them when filling and thereby prevents their separating from the parts sooner than they otherwise would do.” If leeches were reluctant to bite, they could be encouraged by rubbing the target area with sugar water, milk, or, most effective of all, a small quantity of fresh blood. A few years later, one practitioner reported that submerging leeches in diluted wine or, very briefly, in warm full-strength porter would cause them to bite and suck vigorously (Wilkinson, 1848). If a leech became attached at the wrong site (or “what is equally bad” on the practitioner’s fingers), it could be made to release its hold by sprinkling table salt on its mouth.

Leeches were deemed especially useful in removing blood from areas of the body that were too constricted to allow for the application of mechanical suction—areas such as in and around the nose and ears, inside the mouth, and within the rectum and vagina. They were sometimes also used to achieve the benefits of general bloodletting in infants or in patients who were too weak to withstand venesection. When substituting for general bleeding, the usual procedure was to place one or more leeches as near as possible to the focus of the morbid process: for headache, on the temples; for gastrointestinal inflammation, on the abdomen; for bladder troubles, on the shaved pubis; and for menstrual disorders, on the thighs, the groin, and the vulva.

Through the early nineteenth century, there was considerable interest in improving techniques for removing blood from different parts of the body. William Brown observed that while morbid accumulations of blood in the head or in the lower belly were often relieved, by nature, through repeated spontaneous bleeding from the nose or from the rectum, physicians needed to develop alternative methods for use when these “efforts of nature” were inadequate. He recommended the following procedure for taking blood from the hemorrhoidal veins—a procedure he described as well-established in many parts of Europe. The patient

is seated on a perforated chair, which only uncovers the anus itself; the operator, stooping or kneeling, by means of a taper, sees the part to which the leech is to be applied; and, provided with a small round wide-bottomed bottle with a long neck, just large enough to contain one leech, he allows the animal to draw out and fix itself on the part intended. The operator having applied one leech, withdraws the bottle, and proceeds to fix one after another till the desired number have been applied; a basin is placed under the chair into which the blood flows (Brown, 1818, p. 140).

Brown pointed out that this technique was useful in most abdominal inflammations “such as hepatitis, enteritis, [and] puerperal fever, [as well as] in suppressed menses, lochia, etc.”

Since the mucous membranes often became inflamed, it seemed desirable to apply leeches to these tissues as well. Philip Crampton reported applying leeches directly to inflamed tonsils, but this procedure involved obvious risks: for one thing, the leeches could become detached and accidentally suffocate the patient. He explained that to avoid such an accident, he passed a single thread of silk

through the body of the leech, at about its lower third, the ligature being made fast to the finger of the operator, the leech … was introduced into the mouth, and its head, directed by a probe, was brought into contact with the inflamed tonsil. The animal fixed itself to the part in an instant, and, in less than five minutes, being gorged with blood, it fell upon the tongue, and was withdrawn (Crampton, 1822, p. 229).

A later physician reported that passing threads through leeches, “far from incapacitating them from action, causes them to bite with increased ardor, and, in fact, [the procedure] may be used to stimulate torpid leeches.” Crampton reported that when leeches were applied directly to the tonsils, “relief [to the patient] was immediate.” He also found that the application of leeches to the internal surface of the nostrils provided the greatest possible relief in cases of “undue determination of blood to the brain” or in cases of habitual nosebleed.

A decade later, in 1833, John Osborne praised Crampton’s pioneering work and recommended several improvements of his own. In bronchitis, he observed, “the application of leeches to the larynx and to the trachea in the triangular space between the mastoid muscles, has appeared … to be the most decisive and immediately successful remedy of all those I have ever applied.” This use of leeches was also effective in laryngitis and was “of singular efficacy in stopping the cough of phthisis [a disorder now classified as a form of tuberculosis], in so much that by resorting to it … we have enabled to secure sleep at night, and during the day to keep the phthisical patients so free from cough that a superficial observer might readily believe that we had cured the disease.” Osborn also noted that leeches would continue to suck when submerged in water “at a temperature considerably above 100 degrees.” This meant that a patient could be placed in a warm bath for treatment; when the leeches finished sucking and dropped off, the warm water ensured that the bites continued to bleed so that even more blood was extracted.

Osborn felt that his own most valuable contribution to leechcraft was in solving a problem that had long vexed physicians: “In treating intestinal inflammation, the application of leeches to the anus had little effect, and to apply them internally is often difficult, on account of the violent contractions of the sphincter.” Osborne overcame this difficulty by the use of a grooved metal rod (with an elegant leather handle), which he designed and ordered to be constructed especially for the purpose. In using the rod, Osborn explained, one first passed a thread through the tail of the leech (as Crampton had recommended a decade earlier). The leech was then placed in the groove of the instrument and,

the operator, holding the ends of the threads, introduces the instrument into the rectum, and pushes it up so as to cause it to draw up the leeches along with it into the rectum. When they have thus been conveyed up beyond the sphincter, the instrument is withdrawn, and the leeches are suffered to remain till gorged with blood and loosened from their hold, when they are drawn out by means of the threads which the operator retains outside the anus. (Osborne, 1833, p. 339f)

Osborne observed, “I have never used more than four leeches at once, in this way, fearing lest too great a hemorrhage might be produced.” He noted that such devices also allowed leeches to be applied directly to enlarged prostate glands.

Leeches were regularly introduced into the vagina to stimulate menstrual flow and to treat various feminine disorders. One obstetrician, Samuel Ashwell, observed that leeches applied directly “to the os uteri … [were] decidedly more beneficial than any other local depletion” (Ashwell, 1852). He pointed out that “the speculum tube may be introduced into the vagina prior to their application; and if the cervix be brought fully into view, neither the vagina nor any other part than this portion of the congested viscus will be fixed on by the leeches.” Ashwell recommended that this indelicate use of leeches be “confined to married women” and that “a clever nurse should be taught to apply them.”

Treating a single disease episode usually required only a few leeches; however, sometimes many more seemed to be indicated. “A gentleman [who] fell from his horse and severely bruised the elbow-joint” was treated by the application of 118 leeches over the course of four days (Wardrop, 1833–4). Between July 22 and August 3, 1824, 130 leeches were applied to the inflamed testicles of a patient with gonorrhea (Tyrrell, 1824). In four days, 160 leeches were applied to the abdomen of one woman in an unsuccessful attempt to save her from puerperal fever (Editor’s Note, 1828–9); however, one year earlier, a case of severe metritis “was subdued by the application of 220 leeches and two venesections within ten days” (White, 1819).

Various difficulties and risks were associated with the use of leeches. Leech bites, an obvious indication of recent medical treatment, could be embarrassing. Referring to treatment of testicular inflammation, Astley Cooper, a prominent surgeon, observed that in private practice, he saw “persons in whom it is of the greatest consequence that a bleeding from these parts should be concealed” (Cooper, 1823–4). Cooper recommended that in treating such persons, rather than leeching, one should use a lancet to carefully open a few veins in the scrotum. As in general bleeding, leeching also sometimes led to the removal of too much blood. One physician, “desirous of being enabled to get about among [his] patients as speedily as possible, applied sixty leeches to his own sprained ankle which he then soaked in hot water.” “The consequence,” he reported, “was not merely a faintness, like death, from which no measures could for half an hour or more restore me, but an excessive degree of general debility, from which I did not recover entirely for months” (Grower, 1831–2).

An equally serious hazard was that leeches applied to the throat could suffocate patients, or be swallowed and then attach themselves within the lower esophagus, “thereby causing extensive mischief” (Editor’s Review, 1842–3). Another problem was that leech bites sometimes bled so profusely as to become life-threatening. Anthony White reported that a two-year-old girl had died from the loss of blood induced by a single leech (White, 1819), and similar deaths were occasionally reported throughout the early decades of the century. Physicians recommended that, where possible, leeches should be applied over solid internal tissue, such as a bone, so that pressure could be applied to stop the bleeding. Physicians were also cautioned to be prepared to stop the flow of blood by the same methods that could be used if too much blood was released in venesection.

Another risk was that the leech bite could itself become the focus of subsequent morbid processes. One physician advised against applying leeches to the eyelids, or to the scrotum or penis, because he had seen “very violent inflammation, and even gangrene, result from it, … an accident by which the reputation of the surgeon cannot fail to suffer” (Lisfranc, 1836). He also observed that leech bites could give rise to erysipelas and other inflammatory processes. In another essay, the same physician argued...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Introduction
• 1 Bloodletting and Inflammation
• 2 Bloodletting and Social Norms
• 3 Disease and Causes of Disease in Early Nineteenth-Century Medical Thought
• 4 The Early Nineteenth-Century Conception of Quackery
• 5 The Edinburgh Bloodletting Controversy
• 6 Ignaz Semmelweis and the Adoption of Etiological Concepts of Disease
• 7 The Collapse of Traditional Medicine and the Rise of Medical Science
• 8 The Current Crisis in Epidemiology
• References
• Index