Phlebotomy

“ What is to limit bleeding? 2. Qualities of an able phlebotomist; 3. Of the choice of instruments; 4. Of the band and bolster; 5. Of porringers; 6. Circumstances to be considered at the bleeding of a Prince.
Simon Harward's "Phlebotomy, or Treatise of Letting of Bloud; fitly serving, as well for an advertisement and remembrance to all well-minded chirurgians, as well also to give a caveat generally to all men to beware of the manifold dangers which may ensue upon rash and unadvised letting of bloud," published in the year 1601, contains much interesting matter on the subject of which it treats. ”

“ But if all things be as they are now represented, we shall feel ourselves at liberty to calculate the quantity of the blood, and to reason on its circular motion. Should any one, for instance, in performing phlebotomy, suffer the blood to flow in the manner it usually does, with force and freely, for some half hour or so, no question but that the greatest part of the blood being abstracted, faintings and syncopes would ensue, and that not only would the arteries but the great veins also be nearly emptied of their contents. ”

“ From the veins, therefore, the blood flows more freely in phlebotomy when the body is warm than when it is cold. We also observe the signal influence of the affections of the mind when a timid person is bled and happens to faint: immediately the flow of blood is arrested, a deadly pallor overspreads the surface, the limbs stiffen, the ears sing, the eyes are dazzled or blinded, and, as it were, convulsed. ”

“ There was one major difference between bleeding a man and bleeding a horse or cow, and that was the amount of strength required to open a vein. The considerable force needed to pierce the skin and the tunic of the blood vessel made the operation much more difficult to perform than human phlebotomy. ”

“ The practitioners of phlebotomy, and the fees paid for the operation, have differed widely. In the middle of the last century a woman used the lancet with great benefit to her own pocket, if not to her patients, in Marshland, in the county of Norfolk. ”

“ I was once, I remember, called to a patient who had received a violent contusion in his tibia, by which the exterior cutis was lacerated, so that there was a profuse sanguinary discharge; and the interior membranes were so divellicated, that the os or bone very plainly appeared through the aperture of the vulnus or wound. Some febrile symptoms intervening at the same time (for the pulse was exuberant and indicated much phlebotomy) , I apprehended an immediate mortification. To prevent which, I presently made a large orifice in the vein of the left arm, whence I drew twenty ounces of blood; ”

“ A thrombus forms, the vein wall suppurates, is softened and in part destroyed, and the clot becomes purulent. No bleeding occurs when the vein ruptures, as a barrier of clot keeps back the blood stream. The clot of suppurative phlebitis cannot be absorbed and cannot organize.
Septic phlebitis causes pyemia, and the infected clots of pyemia cause phlebitis. The symptoms of phlebitis are pain, which is at once felt in the limb along the track of the inflamed vein, and tenderness along the same area; the overlying skin is red, hot, and tender, and the lymphatic nodes in the groin swell ”

“ The incomes that have been realized by blood-letting alone are not less than those which, in the present day, are realized by the administration of chloroform. An eminent phlebotomist, not very many years since, made a thousand per annum by the lancet.
About blood-letting—by the lancet, leeches, and cupping (or boxing, as it was called in Elizabeth's days, and much later) —the curious can obtain many interesting particulars in our old friend Bulleyn's works.
To open a vein has for several generations been looked on as beneath the dignity of the leading professors of medicine or surgery. ”

“ These return the lymph to the blood-current for future use. Nature "gathers up the fragments" here as elsewhere, and sees that the lymph or excess of the blood-supply is once more garnered into the vital stream of the circulation. If we ask how this lymph-flow is maintained from all parts of the body toward the great vein in the neck where the lymph joins the blood, we again light upon the question of high pressure in one side of matters and low pressure in the other side. ”

“ When blood escapes from a blood-vessel it comes into contact with a foreign surface, either a tissue or the damaged walls of the cut vessel. Very speedily this contact results in the discharge of thrombogen and thrombokinase, the former from the white blood corpuscles and also possibly from the platelets, the latter from the platelets or from the tissue with which the blood comes in contact. The interaction of these two bodies next results in the formation of prothrombin, which, combining with the calcium of any soluble lime salt present, forms thrombin or fibrin-ferment. ”

“ Tested with nitric acid and ammonia, it is found to contain a protein substance which is called fibrin.
Blood plasma, then, is made up of a fluid portion of serum, and fibrin, which, although in a fluid state in the blood vessels within the body, coagulates when blood is removed from the blood vessels. This coagulation aids in making a blood clot. A clot is simply a mass of fibrin threads with a large number of corpuscles tangled within. The clotting of blood is of great physiological importance, for otherwise we might bleed to death even from a small wound. ”

“ Thus we see a living plasma is not necessary for the blood corpuscles: they flourish in a dead one. The blood plasma is not alive.
In the days of venesection we were taught that the last act of vitality in blood when drawn from the body was its coagulation, but is this really any more a vital process than the clotting of sour milk? I think not.
In the same category with milk and blood plasma, we must place lymph, the fluids in the pleura, pericardium, peritoneum and synovial sacs, and also the cerebro-spinal fluid; none of them is alive. ”

“ Function of Lymph.—The tissues and organs of the body are traversed by a network of tubes which carry the blood. Inside these tubes is the blood proper, consisting of a fluid plasma, the colorless corpuscles, and the red corpuscles. Outside the blood tubes, in spaces between the cells which form tissues, is found another fluid, which is in chemical composition very much like plasma of the blood. This is the lymph. It is, in fact, fluid food in which some colorless amœboid corpuscles are found. Blood gives up its food material to the lymph. ”

“ If the wound is aseptic, the fate of the foreign body varies with its character. A substance that is absorbable, such as catgut or fine silk, is surrounded and permeated by the phagocytes, which soften and disintegrate it, the debris being gradually absorbed in much the same manner as a fibrinous exudate. Minute bodies that are not capable of being absorbed, such as particles of carbon, or of pigment used in tattooing, are taken up by the phagocytes, and in course of time removed. ”

“ Hunter was more nearly right than his successors.’
[906] ‘Inflammation of the veins, originally studied by Hunter, has of late years attracted the attention of many distinguished Continental and British pathologists.’ Erichsen's Surgery, London, 1857, p. 475. ‘No subject more amply illustrates the essential services which the science and art of medicine have derived from pathological anatomy than that of phlebitis. By this study many a dark point in the phenomena of disease has been either thoroughly elucidated, or, at all events, rendered more comprehensible. ”

“ The fluid should be diluted one-half for the first part of the injection, and sufficient fluid used to reach all parts of the circulatory system. It will be well to add fluid equal to the amount of blood and fluid taken from the vein to your normal injection in a body the size of the one to be operated on. A complete cavity injection should be given. For transportation, govern yourself according to the provisions of the transportation rules. ”

“ Larger bodies, such as needles or bullets, which are not capable of being destroyed by the phagocytes, become encapsulated. In the granulation tissue by which they are surrounded large multinuclear giant-cells appear (“foreign-body giant-cells”) and attach themselves to the foreign body, the fibroblasts proliferate and a capsule of scar tissue is eventually formed around the body. The tissues of the capsule may show evidence of iron pigmentation. Sometimes fluid accumulates around a foreign body within its capsule, constituting a cyst. ”

“ Every organ must be standardized. Placenta is only useful so long as it is not decomposed by the serum of carcinomatous subjects, or of individuals with salpingitis, tuberculosis, and the like. Carcinoma is correctly prepared if it is not attacked by the serum of pregnant individuals.
Above all, the organ should be tested by means of cases which contain ferments acting against the components of the red blood corpuscles. Cases of blood effusion are excellent testing agents for the absence of blood in the prepared organ. ”

“ In slight cases of phymosis, the orifice may be dilated by frequent fomentation, and perseverance in withdrawing the prepuce as far as possible. When ulceration or secretion of matter has occurred, astringent injections, at first mild, and gradually strengthened, should be frequently thrown into the præputial cavity. Suspension of the penis should be enjoined, along with rest—of the whole body, as well as of the affected organ in particular. When much inflammation exists, antiphlogistic remedies must be put in force, followed by fomentations. ”

“ And this goes on until you have left in the clot very little besides corpuscles entangled in a network of fibrin, and all the rest of the blood has been squeezed outside the clot, and is then called serum. Serum, then, is blood out of which the corpuscles have been strained by the process of clotting.
Now I dare say you are ready to ask the question, If blood clots so readily when it is shed, why does it not clot inside the body? Why is our blood ever{48} fluid? This is rather a difficult question to answer. When blood is shed from the warm body it soon gets cool. ”

“ We merely take a sterilized swab of cotton on the end of a wire, rub it gently over the surface of the throat and tonsils, restore it to its glass tube, smearing it over the surface of some solidified blood-serum placed at the bottom of the tube, close the tube and send it to the nearest laboratory. The culture is put into an incubator at body heat, the germs sown upon the surface of the [Pg 234] blood-serum grow and multiply, and in twelve hours a positive diagnosis can be made by examining this growth with a microscope. ”

“ The glands act as filters, arresting not only inert substances, such as blood pigment circulating in the lymph, but also living elements, such as cancer cells or bacteria. As it passes through a gland the lymph is brought into intimate contact with the leucocytes, and in bacterial infections there is always a struggle between the organisms and the leucocytes, so that the glands may be looked upon as an important line of defence, retarding or preventing the passage of bacteria and their products into the general circulation. ”

“ In the ordinary treatment of phlebitis, in addition to the insistence on perfect rest and quiet, fomentations may be applied locally, the limb being kept raised. Massage must not be employed so long as there is any risk of a clot being detached. ”

“ The longer the limb is disused, the more perfect and rapid is the recovery, provided the rest of the cure be properly conducted. In general nothing more than what has been stated is required. But if the limb be moved, or stimulated in any way, early, then necessity will arise for antiphlogistic measures—perhaps venesection, certainly copious and repeated abstraction of blood by leeches, accompanied with fomentations, and the internal exhibition of antimonials, purgatives, &c. ”

“ To this process Metchnikoff gave the name of phagocytosis, and he recognised two forms of phagocytes: (1) the microphages, which are the polymorpho-nuclear leucocytes of the blood; and (2) the macrophages, which include the larger hyaline leucocytes, endothelial cells, and connective-tissue corpuscles. ”

“ This fact, which, taken by itself, might appear of little consequence, assumes considerable importance when considered as one of the inherent properties of the blood, at all times ready, under favourable circumstances, to be called into action in the living body. The conditions under which pus will determine the coagulation of the blood, and those under which it will circulate in the living vessels, require to be accurately ascertained, before we can rightly interpret the discordant evidence which we at present have upon this point. ”

“ The reconstruction of substances of every kind from products that are harmonious to the plasma and the lymph is demonstrated by every growing hair and every growing nail. Every new blood corpuscle tells us of far-reaching transformations; and every secretion—whether produced directly, as in the case of saliva or milk, or manifested when a fistula is produced by surgical means, or whether it forms a so-called internal secretion, choosing the blood or the lymph for its path of action—every one of these gives evidence of powerful disintegrations, integrations, or transformations. ”

“ The white corpuscles become entangled in the upper portion of clot, giving it a pale yellow look on the top, known as the buffy coat. As the clot is attached to the sides of the vessel, the shrinkage is more pronounced toward the center, and thus the surface of the clot is hollowed or cupped, as it is called. This remarkable process is known as coagulation, or the clotting of blood; and the liquid which separates from the clot is called serum. The serum is almost entirely free from corpuscles, these being entangled in the fibrin. ”