Toby A. Appel

“ 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 petite size, careful construction, beautiful materials, and elegant design. ”

“ One marvels at spring lancets made of silver, thumb lancets with delicate tortoise shell handles, and sets of hand-blown cups in the compartments of a mahogany container with brass 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. ”

“ The story of nineteenth-century attempts to improve cupping technology is an interesting one, in that a great deal of effort was expended on comparatively short-lived results. For those who were adept at cupping, the cups, torch, and standard scarificator were quite adequate. Innovations were thus aimed at making the operation more available to the less practiced. The new gadgets could not rival the traditional instruments in the hands of an experienced cupper, and, moreover, they were usually much more expensive. ”

“ 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 ”

“ In America, there were five patents on scarificators, of which the Smithsonian possesses three patent models. The most significant American patent was that of George Tiemann in 1846. Tiemann’s scarificator had a flattened base and an ebony handle, which contained a coiled spring. The blades were moved by a rack and pinion mechanism, and triggered by a knob at the end of the handle. The advantages claimed by the inventor were ease in handling, ease in cleaning, and the diagonal cut of the blades that allowed the blood to flow more freely and the wounds to heal more readily. ”

“ One of the characteristics of nineteenth-century technology was the attempt to replace natural materials and processes by imitations and mechanisms. Considering the properties of the natural leech, it is no wonder that very early in the nineteenth century inventors began to seek a mechanical substitute. The disadvantages of the leech were many. [Pg 37] Wrote one inventor of an artificial leech:
In the first place the appearance of the animal is repulsive and disgusting, and delicate and sensitive persons find it difficult to overcome their repugnance to contact with the cold and slimy reptile. ”

“ August Bier, professor at the University of Bonn, developed another sophisticated theory supporting the use of blood-suction devices, known as the theory of hyperemia, meaning “excess of blood.” According to the doctrine, lesions are always accompanied in nature by hyperemia, “the most widespread of auto-curative agents.” [162] If we, therefore, wish to imitate nature, we create an artificial hyperemia. Bier recommended several means of increasing the blood supply of an affected part, including hot-air baths, suction devices such as Junod’s boot, and dry cupping. ”

“ 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. ”

“ 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 Brass Box, with a Steel Spring.” ”

“ One of the most popular counter-irritation devices commonly associated with cupping instruments in catalogs of surgical goods, was Baunscheidt’s Lebenswecker, sold by most American surgical supply houses in the second half of the nineteenth century. The Lebenswecker, or “Awakener of Life,” was the mainstay of the mystical medical system known as Baunscheidtismus, after the founder of the device, Carl Baunscheidt of Prussia (1809-1860) . ”

“ Early in the nineteenth century, breast pumps, just as glass cups for bleeding, were attached to brass syringes, and were often included among the variety of cups in cupping sets provided with syringes. Read’s and Weiss’s patent syringe as well as Thomas Machell’s cupping device were adapted for breast pumping. With the invention of vulcanized rubber, the breast pump was frequently attached to a large rubber bulb. A glass protuberance was often added to pumps exhausted by syringes or rubber bulbs, in order to collect the milk so that it could be fed to the infant. ”

“ 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. ”

“ 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 [Pg 2] centuries, many others turned eagerly to the latest gadget on the market. ”

“ Only a skilled physician would thus know when it was proper to bleed a patient. Venesection could be extremely dangerous if not correctly administered, but in the hands of a good physician, venesection was regarded by Galen as a more accurate treatment than drugs. While one could measure with great accuracy the dosages of such drugs as emetics, diuretics, and purgatives, Galen argued that their action on the body was directed by chance and could not easily be observed by the physician. ”

“ Breast pumps were small glass cups with fluted edges made to accommodate the nipple. While some surgeons, as the American Samuel Gross, recommended using a bottle with a long neck in which the air had been rarified by means of hot water, [165] most breast pumps were exhausted by mechanical means. For reasons of modesty, the pumps were usually designed so that the woman could draw her breasts herself. Perhaps the simplest design of a breast pump was a glass cup having a long spout extending in such a way that the woman could perform suction herself. ”

“ 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. Associated with these are the containers to collect and measure the blood spurting from the patient. ”

“ To expel air from the tube, a few drops of ether were placed in it, after which it was immersed to its mouth in hot water until the ether vaporized. The tube was then applied to the skin and allowed to cool, thus sucking blood from a wound made by the scarificator, a long metal tube that was rotated to make a circular incision. One of the patentees explained the advantages of the device:
In all previous attempts at an artificial leech the vacuum has been produced by the action of a piston. ”

“ A notable improvement was made in the early nineteenth century when John Weiss, a London instrument maker, introduced a 12 blade octagonal scarificator whose blades, arranged on two rods or pinions, were made to cut in opposite directions. This advance was mentioned by Mapleson in 1813 and adopted by London professional cuppers thereafter. The advantage of the innovations was that the skin was thereby stretched, and a smoother, more regular cut could be made. Weiss’s Improved Scarificator also featured blades that could easily be removed for cleaning and repair. ”

“ 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. ”

“ As late as 1915, Heinrich Stern, previously mentioned as a latter-day proponent of bloodletting, had no doubt that application of the boot to the foot would relieve congested states of the abdominal viscera. [161] (Figure 18.)
Americans patented a number of modifications of the arm and boot, and in addition they patented a number of whole body devices called “depurators.” Junod had introduced such a device along with his boot—a metal casing in which a patient would be placed leaving only his face showing. The air inside would then be exhausted by means of a gigantic syringe. ”

“ The improved cups and scarificators, while they had achieved a limited success, had still failed to supplant the common octagonal scarificator and the plain glass cup. As interest in wet cupping declined, medical attention shifted to the therapeutic virtues of dry cupping. Dry cupping offered even greater opportunities for inventors, who sought means to bring the effects of the vacuum to more areas of the body for greater lengths of time. ”

“ Barber-surgeons continued to let blood through the seventeenth century. In the eighteenth and nineteenth centuries, the better educated surgeon, and sometimes even the physician, took charge of bleeding. ”

“ The blood is collected in a glass 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 analyzed for the presence of biochemical components of such diseases as diabetes, anemia, arteriosclerosis, etc. ”

“ 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 [Pg 12] 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 constitutional fear is out of the question, to the opening of a vein, however unskillfully advised.” ”

“ These tiny and delicate thumb lancets were often carried in small flat cases of silver, tortoise shell, shagreen, 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.” ”

“ 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. ”

“ We know today that blood volume is about one-fifteenth to one-seventeenth the body weight of an adult. Thus an adult weighing 150 pounds has 9 or 10 pounds of blood in his body. Blood volume may increase at great heights, under tropical conditions, and in the rare disease polycythemia (excess red blood cells) . After a pint of blood is withdrawn from a healthy individual, the organism replaces it to some degree within an hour or so. ”

“ Upon analysis the brass was found to contain 70%-75% copper, 20%-30% zinc, and other trace elements. The blades, cocking levers, and button releases of lancets and scarificators were found to be made of ferrous metal (iron or steel) . In addition to the typical brass pieces, a number of “white metal” pieces were analyzed. (The term “white metal” is used to designate any undetermined silver-colored metal alloy.) Those white metal pieces dating from the eighteenth century (a Swiss or Tyrolean fleam and an English veterinary spring lancet) were found to be composed entirely of ferrous metal. ”

“ The novel part of the instrument was the tubular blades that were injected into the flesh and then left in place while the blood was being removed, “by which means the punctures are kept from being closed prematurely, as frequently happens with the ordinary device.” [138]
It is unlikely that any of these ingenious devices were marketed in quantity. For those skilled in the art of cupping, the torch, cups, and scarificator were more effective. For those not experienced in the art, the new devices were simply too expensive, inconvenient to carry about, and fragile. ”