Monday, February 6, 2017

1875: Bleeding STILL recommended to cure your asthma

No one knows for sure why this was ever practiced, yet for thousands of years in the annals of human medical history, diseases were treated by a remedy called bleeding, or venesection.  This involved intentionally slitting a vein with a sharp object to induce bleeding.  It was the ideal remedy when all else failed, even for asthma or difficult breathing.

Hippocrates generally recommended subtle remedies for asthma, although when all else failed, bleeding remained an option.  So assuming Hippocrates picked up his medical wisdom from the stone tablets at the Aesclepeon of Cos, the practice must have been known to the priests of Ancient Greece since the early days.  And considering the Greeks gained much of their medical wisdom from the ancient Egyptians, it probably goes back much further.

Historian Edward Withington, in his 1894 book "Medical History from its earliest times" proposed an interesting theory regarding bleeding.  He postulated the idea that it may have been picked up by primitive humans, the same humans who would eventually settle in Mesopotamia and Egypt.  He wrote:
Ever since vital activity has existed on the earth, it has, in all probability, been liable to those perturbations which we call disease; wounds and injuries must have occurred wherever there were weapons to inflict them, and fragments of diseased fossil bone are to be found in our museums. We may well suppose that the earliest efforts of intelligent beings were directed towards the avoidance or cure of these disorders, and the older writers amused themselves by searching for instances of medical or surgical practice which they thought might be derived from animals. Thus the most ancient and widely spread of surgical operations, that of bleeding, is said to have been taught mankind by the hippopotamus. "That intelligent animal," says Pliny, "finding himself plethoric, goes out on the banks of the Nile, and there searches about for a sharp-pointed reed, which he runs into a vein in his leg, and having thus got rid of a sufficient amount of blood, closes the wound with clay."  Similarly the use of emetics is said to have been learnt from the dog, that of hellebore from the goat, while the assertion that stags healed their wounds by means of the herb dittany is supported by many authorities, including Aristotle himself. Nor are these stories to be entirely rejected, for have we not lately been told that Count Mattei* discovered the basis of his alleged remedies by observing the plants eaten by a mangy dog in the Apennines? (2, page 7)
Of course Withington was just speculating, yet his theory is interesting.  If nothing else, his theory shows just how far back the practice of bleeding goes back.

Primitive people had no concept of anatomy or diseases, so they probably bleed as a means of purging evil spirits or demons from sick people.  It may also have been a means of pleasing the gods through sacrifice.

S.D. Gross, in his 1875 article "The lost art of medicine," said there was a variety of methods of blood letting, which included, but were not limited to: (1, page 430)
  1. Venesection:  Slitting open a vein 
  2. Cupping:  Placing cups on he skin that cause blistering and bleeding
  3. Leeches:  The leeches to the work of sucking out blood
  4. Scarification
  5. Puncture
  6. Arteriotomy:  Due to difficulty, few practice it.
Gross estimated that the diseases hat benefited the most from bleeding were those of inflammation.  For example, he noted that "Hippocrates and his immediate followers bled largely in pneumonia and pleurisy; and Sydenham, Rush, Louis, Drake, and many others often took immense quantities of blood in the treatment of these maladies."  (1, page 430)

He wrote:
In chronic inflammation, blood-letting is often an indispensable remedy. Even the most ultra advocate of the stimulant method of treatment will hesitate to employ it when destructive action is gradually but surely undermining structure and function. The abstraction of five eight, or even ten 'ounces of blood in chronic pneumonia and pleurisy, especially when associated with severe pain and obstructed respiration, often acts like a charm, relieving suffering and promoting the beneficial action of other measures. (1, page 430)
He continued:
To draw blood to the greatest possible advantage, the quantity should be measured, not by ounces, but by the impression it makes upon the system, as denoted by the pallor of the countenance, the reduction of the heart's action, the softened state of the pulse and skin, the abatement of pain and of other symptoms, as headache, thirst, and restlessness, so universally present in all severe inflammatory attacks. To insure this result in the mor. speedy and decided manner, the blood should be drawn from a large orifice in a large vein at the rate of two and a half to three ounces in the minute, while the patient is in the erect or semi-erect posture. If the body be recumbent during the operation, a much larger quantity of blood will be required to be drawn to produce the desired effect than whet the reverse is the case. While, therefore, the bleeding should be spoliative, care should be taken not to waste the fluid unnecessarily.
 To prevent undue reaction after the operation, the bleeding should not be carried to complete syncope, but merely to an approach to this condition, the effect of the operation being carefully watched by a reference to the countenance and the pulse, lest it should exceed the proper limits, and thus do harm instead of good. Violent reaction, however, in any case, after the abstraction of blood, may generally be effectually prevented by a full dose of some diaphoretic anodyne, as ten grains of Dover's powder with one-fourth of a grain of morphia, given immediately after the operation.  (1, page 430)
He further explains he mode at which bleeding helps with inflammation:
In the first place, the abstraction acts spoliatively, diminishing, as the name implies, the quantity of blood, both in the part and system. Secondly, it weakens the power of the heart, and thereby prevents it from sending the blood with the same force and velocity into the suffering structures. Thirdly, it unlocks all the emunctories, and thus promotes secretion. Fourthly, it disgorges the vessels at the seat of the disease, restores the circulation, and places the absorbent vessels in a better condition for the removal of effused matter. And, last, but not least, it favours the action of other remedies, as purgatives, diaphoretics, diuretics, and anodynes.
So experts had bleeding down to a science, so to speak.

Now, say you were short of breath in ancient Greece, desperate for a solution, and your priest/ physician is pent on cutting your skin to make you bleed. This may not have sounded so irrational to you, as your priest/ physician was equally ignorant of anatomy and disease as you were.  By now there was the belief that such a practice would somehow help to balance the humors of your body to heal your ailing lungs.

The practice was heavily used among all the healers of the world -- from the primitive medicine man, to the ancient priest and priest/ physician, to the medieval physicians, surgeons and barbers -- until it was given a black eye of sorts in the minds of commoners due to certain abuses.

According to historian Fielding Hudson Garrison, the remedy perhaps was used to extremes in France around the time of Napolean, after his war surgeon, Francois Joseph Victor Broussais, recommended all sickness be treated by covering the body with leeches.  Yet when Pierre-Charles-Alexandre Louis realized leeching was useless during a diptheria epidemic, the remedy of Broussais faded away.  Louis later became the first to prove that bleeding had no effect for pneumonia, and this stopped bleeding for pneumonia, at the very least. (3, pages 340-342)

Gross suspected the end of the practice may have been a result of lost faith among the public and medical professions due to overuse.  He wrote: 
The indiscriminate employment of the lancet in former days did much to bring blood-letting into discredit, not only with the better thinking class of physicians, but the public at large. 'We cure the sick,' says Gui Patin, a professor in the Royal College of France,' when over eighty years old, by blood-letting, and also infants of not more than two or three months, with as much success and as little inconvenience.' (Benjamin) Rush, the great champion of this operation on this side of the Atlantic, bled indiscriminately and remorselessly at all periods of life, the young, the middle-aged, and the old; in all kinds of diseases, in the eruptive fevers, in fever and ague, in puerperal fever, in inflammations, in injuries, in hemorrhages, and even in anaemia, often taking immense quantities of blood, and repeating the operation six, eight, or even a dozen times in the same patient. In short, he and his followers used to bleed in every possible disorder until, in many cases, no more blood would flow, because there was none left That such a practice would at length work out its own destruction is what might reasonably have been expected. It rang its own knell. (1, page 429)
He continued:
I have said that general bleeding can be successfully practised only at the beginning of an inflammatory attack, a fact which, I repeat it, is not to be lost sight of in weighing the propriety of such a procedure. Let it be borne in mind also that bleeding is not to be practised indiscriminately, but judiciously, and with proper regard to the condition of the system. Our fathers grievously erred, because they bled in every stage of disease, and in all states of the system, the plethoric and the anaemic, the strong and the weak. Of course there were exceptions, but as a rule this was the practice; the harm, hence, as a natural consequence of the abuse, the abandonment of the treatment. (1, page 431) 
By the middle of the 19th century old medical theories were replaced by scientific method, and bleeding was basically phased out, going the same way as dilapidated medical theories.  However, there remained a few physicians (as there always are) who refuse to let go of old fallacies, ones who wish to continue using old ideas and remedies regardless of lack of evidence to their usefulness.  One of these physicians was S.D. Gross, who recommended bleeding even into the 1870s.

In an article fittingly titled "The lost art of medicine," Gross explains not only that bleeding should still be recommended for asthma, he recommends that it be performed with a lancet.  Man, could you imagine going to your doctor because you couldn't breath, and have him have you sit on the examining table as he whipped out a lancet from his closet?  He's sharpen it and say, "Well, I don't want to do this anymore than you, but it has to be done if you want to get better."

Of bleeding for asthma, Gross wrote the following:
For bleeding should not be restricted to the treatment of inflammatory disease... In asthma, bleeding is frequently of inestimable value, in relieving engorgement and spasm of the lungs, the causes of the terrible dyspnoea so often present in the more aggravated forms of the disease. I recall to mind the case of a lady who was the subject of asthma from the age of fourteen up to that of eighty six, when she died of pneumonia, whom I repeatedly bled with the greatest advantage in attacks of this kind, which nothing else could relieve. In another case, that of a tall slender gentleman of this city, nearly eighty years of age, in which a severe attack of asthma was complicated with great congestion and slight inflammation of the lungs, the abstraction of less than ten ounces of blood by the lancet led to a speedy convalescence and a complete cure. I verily believe that if this gentleman had not been bled he would have died.
Gross was confident that bleeding would be recaptured as an art of the medical profession.  He wrote:
I well remember the time when the use of cold water was interdicted as highly improper, especially in the treatment of the so-called eruptive fevers, and when ventilation of a sick man's chamber was considered as fraught with danger.  Bleeding will again come into fashion; history constantly repeats itself, and knowledge runs in a circle. No sensible man can fail to read the signs of the times; but it will not be indiscriminate bleeding, but bleeding performed for a reason, early, and, if need be, freely, to save tissue and promote resolution; in the robust and plethoric, in the young and middle aged, not in the weak, the anaemic, the intemperate, the broken-down, and the decrepit. Practitioners, during the last third of a century, have laboured under a delusion and a dream, from which they are gradually emerging to a sense of their duty; and, although I am not a prophet or the son of a prophet, I venture to predict that the day is near at hand, if, indeed, it has not already arrived, when this important element of treatment, so long and so shamefully neglected, will again become a recognised therapeutic agent, and will thus be instrumental in saving many lives, many an eye, many a lung, many a joint, and many a limb.
So if you were an otherwise healthy individual, Gross firmly believed bleeding should not only be recommended for diseases such as asthma, but that he benefits, as he has witnessed, would offer "great, if not permanent, relief."

Gross was not the only physician to continue to find a medical use for bleeding.  Even the great William Henry Osler noted in his 1894 book, "The Principles and Practice of Medicine," that bleeding was useful for certain medical conditions.  Surely the practice ultimately fell out of favor, although it would be another several years before bleeding truly was "a lost art."

Count Cesare Mattei (1809-1896)

  1. Gross, S.D., "The lost art of medicine," The London Medical Record a review of the progress of medicine, surgery, obstetrics, and the allied sciences, volume III, 1875, London, Smith, Elder and Company,  page 432
  2. Withington, Edward, "Medical History from its earliest times," 1894, London, ,Aberdeen University Press, page 407
  3. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1913, 1st edition, Philadelphia and London, W.B. Saunders and Company, pages 340-342
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