Sunday, February 16, 2014

Bloodletting (Venesection) During the Civil War

By Dr. Michael Echols

After reviewing an inventory list of medical supplies from a N.Y. military hospital at the end of the War, the presence of scarificators in the inventory lead to this investigation of evidence in the military literature of bloodletting being in use during the War.   From examination of the literature gathered from the Medical and Surgical History citations, venesection was indeed practiced during the Civil War, but was rapidly being abandoned as the War years progressed and knowledge of medicine and bleeding wounds increased.

In eighteenth- and nineteenth-century America, many symptoms of illness were believed to be caused by an excess of blood: the removal of some was therefore thought to alleviate the condition. There were two main methods of bloodletting: using leeches and venesection (i.e. cutting open a vein).  Bloodletting is achieved by fleams, scarificators, cupping glasses, leeches, and assorted instruments.

Venesection (or phlebotomy) was the technique of lancing open a vein to remove blood, which could be drained into a bowl. It could also be removed by suction using a bloodletting cup in which was burned a small amount of alcohol to create a vacuum.   Leeches are annelid worms that inhabit fresh water. They are injurious to animals and people from whom they suck blood. They attach themselves by means of their strong mouth adapted to sucking. The medicinal leech, Hirudo medicinalis, was employed on "bleeding" patients. It is still used for some medical purposes and is a source of the anticoagulant, hirudin.

If you search for 'bloodletting' in the Medical and Surgical History of the War of the Rebellion not that much shows up.  However if you search for 'venesection', then many citations pro and con as well as actual cases are found.

There is abundant evidence reported of the earlier use of bloodletting and bleeding in the History, but only two cases of actual "bloodletting".  The problem is with the term: bloodletting.  The term used by surgeons at the time was 'venesection', not the older term 'bloodletting'.  Most of the information is in defense or rebuke of the process, not the actually use nor which instruments were used unless reference was made to a specific procedure like cupping or leeches.

Examples in the defense of bloodletting or venesection is found thorough out the various medical reports, much of which is from pre-War literature.  Of note is the adamant advice from the Confederate medical leaders that bloodletting should be avoided for various treatments.

The bottom-line is bloodletting or venesection was practiced through out the Civil War, because when the War started, bleeding was an accepted practice in the medical community.  As the war progressed, evidence based treatment was leaning against the use of bleeding for various medical or surgical problems as reported in the Medical and Surgical History.

Edited from the medical text book Handbook of Surgical Operations, 1863, (in this collection)  written during the Civil War by Stephen Smith, M.D.:

BLOODLETTING: The abstraction of blood is divided into general and local bleeding.

General Bleeding.—In general bleeding, blood may be drawn from the veins, when the operation is called venesection; or from the arteries, when it is known as arteriotomy.

Lancets differ as to their points; some are very blunt, others are very acute- the more obtuse are generally used when the vessel is superficial, and the more acute when it is deeply seated.

Venesection.—Blood may be taken from any of the superficial veins, but those of the neck, the bend of the arm, and at the ankle, are generally selected. The patient may be seated or recumbent, but in general the position should be chosen which most enlarges the vessels. The operation should commence by stopping the flow of blood to the heart by a ligature applied around the part on the proximal side of the point selected for the operation, sufficiently firm to close the veins and still leave the arteries unobstructed. The veins now become prominent unless the person is very fleshy, when the position of the vein must be determined by its corded feel. The operation is performed by placing the thumb of the left hand firmly on the vein (Fig. 40), a little to the distal side, to prevent the vessel from rolling aside on the attempt to puncture it. The lancet, held-between the thumb and index finger of the right hand, the blade at an obtuse angle with the hand, is plunged into the vein obliquely to its transverse diameter, and the hand being fixed, the point of the lancet is elevated so as to cut its way out.

The success of the operation is determined by the flow; if this should be slight, it may be due to too small an orifice, which should then be enlarged; or to a mass of protruding fat, which may be pushed aside. If an increased flow is required the patient should be directed to grasp repeatedly the staff, or the operator may rub the limb from the wrist towards the elbow.

When the proper amount of blood is drawn the band should be removed, and a small compress being placed over the wound, a figure-of-eight bandage is applied;. to prevent air entering the circulation in bleeding from the jugular, pressure on the wound should be made before the compress is removed.

Venesection is generally performed either on the external jugular, the median basilic or cephalic, or the internal saphena.

External Jugular.—A compress is placed over the vein in the supra-clavicular fossa, and firmly retained by a bandage passed over it and under the opposite axilla; the index finger of the left hand is placed upon the vein above, and the incision is made upwards and outwards across the platysma myoides.

Median Basilic and Cephalic.—The cephalic vein may be selected on account of its isolation. The basilic is the largest, but the brachial artery passing directly under it is in danger of being wounded. The position of the artery must first be determined. A band is then passed firmly around the arm, above the elbow, and with his band the patient grasps a staff. The operator, standing in front of the patient, grasps the arm with the left hand, placing the thumb on the distended vein, and the fingers on the back of the elbow, and holding the lancet in the right, opens the vessel.

Internal Saphena.—The foot is first placed in a vessel of warm water to distend the veins; a band is then passed around the leg, just above the malleoli; the thumb being placed on the vein it is opened just above the inner ankle, with an oblique incision.

Arteriotomy.—The temporal artery is that on which this operation is practised. It may be opened just over the zygoma, in front of the tragus, before its division into the anterior .and posterior branches, but the anterior branch is generally selected. The position of the artery is determined by its pulsations; the skin being made tense a straight incision is made with a scalpel, involving a part of the caliber of the vessel; when a sufficient amount of blood has been withdrawn the artery should be completely divided, and compression made on either side of the incision with small graduated compresses, firmly retained with a bandage.

Local Bleeding.—The local abstraction of blood is effected by leeching, cupping, scarification, and punctures.

Leeching.—Leeches should not be applied to parts liable to infiltration of blood, and discoloration, as the eyelids, scrotum, prepuce, or where a wound would disfigure, as their bites sometimes leave scars, nor over the track of a superficial vein. They are best applied by placing them in a small glass vessel, and inverting it over the inflamed part; blood, or sweetened milk, is often put on the skin. A single leech can take about an ounce of blood. When removed, the parts may be fomented to increase the flow; if it is desired to stop the blood the bites may be sprinkled with flour, starch, or other absorbent material; if the flow of blood continues astringents are used, of which the best is the persulphate of iron.

Cupping.—Cupping requires a scarificator and cupping-glass. The scarificator is an instrument containing eight or twelve blades, moved by a single spring, and so arranged as to be readily graduated as to the depth which they shall penetrate. They cover but the small space of an inch and a half or two inches square, and make eight, twelve, or more parallel cuts. The cupping-glass .may be simple tin or glass, of the proper size and shape, and applied by exhausting  air within by burning a few drops of alcohol; or it may have an exhausting pump attached to the top ; or, finally, it may have an india-rubber top, which requires only to be squeezed to produce a vacuum. The latter cups have but lately come into use, and are preferable to any other.

Scarification.—In making scarifications, the lancet, scalpel, or bistoury should be used, and the cuts should be made only partially or entirely through the skin, as may be necessary to promote the local abstraction of blood. The incisions should generally be made the entire length of the inflamed part, and within an inch of each other. The flow of blood may be greatly increased by warm fomentations.

Puncturing.—Punctures are made with a straight sharp-pointed bistoury, or a common lancet. The instrument is thrust into the inflamed tissues, to a depth varying from an eighth of an inch to an inch, carefully avoiding vessels and nerves. They should' be repeated until the entire surface is relieved of tension. Warm fomentations will increase the depleting effect.

IMAGE: Cupping & lancet instruments shown in the c.1867 Tiemann catalogue



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