Blackwell Science, LtdOxford, UKTRFTransfusion0041-11322006 American Association of Blood BanksFebruary 2006462166168EditorialEDITORIALEDITORIAL EDITORIAL Hemotherapy: from bloodletting magic to transfusion medicine M edicine began thousands of years ago with the hemotherapy of bloodletting as its major magic. The obverse practice of blood transfusion began only 200 years ago and was perfected as a major supportive therapy within the past 50 years. That transition in hemotherapy was a significant result of the religious, scientific, philosophical, and political changes in which today’s practice of medicine evolved.1 With this issue, TRANSFUSION is inaugurating a new series to be called Transfusion Medicine History Illustrated. Those who enjoy the Journal’s cover illustrations and the short clinical feature called Transfusion Medicine Illustrated have expressed appreciation for their educational value. That concept is being extended to show the story told here of hemotherapy from bloodletting to transfusion medicine. The artifacts left by our predecessors can often explain such long-term changes much better than can written history. Some early artifacts of hemotherapy do exist from the hundreds and even thousands of years during which superficial bloodletting and venesection evolved from a beginning in magic to become a therapy in medicine. Writers report with their own bias and every repetition embellishes a story. Television documentaries produce a story that fits the narration to the available film footage. Still photographs and illustrations must stand alone with minimal explanation. TRANSFUSION is soliciting the submission of unique pictorial material for Transfusion Medicine History Illustrated that will highlight our past, explain our present, and suggest the future. BLOODLETTING Bloodletting by the use of needles for the release of malevolent spirits was described in Chinese medical texts composed in the fourth century B.C. Later that treatment moved to distant sites along “meridian lines” and achieved status as the medical therapy of acupuncture.2 In one form or other, bloodletting appeared independently in cultures all over the world. Early Roman medicine practiced actual venesection, credited in the second century by Galen to Hippocrates and Greek medicine. The Galenic writings on TRANSFUSION 2006;46:166-168. 166 TRANSFUSION Volume 46, February 2006 bloodletting to balance the four humors that determined health formed a system of medical theory that persisted for 1000 years.1 When the Dark Ages descended on Europe, Galen’s writings were preserved in Baghdad and were translated into Arabic. Most Arabic physicians, like the Chinese, were averse to dissection and surgery and their use of bloodletting became superficial. An independent literature, the Leech Books, written in the tenth century Anglo-Saxon language described the duties of a medical practitioner known as the laece,3 a word that then gave name to the bloodsucking leech. With the availability of such manuscripts, the monasteries became the centers of health care throughout Europe, providing bloodletting, tooth extraction, and minor surgery along with herbal remedies. A ruling from Rome in the twelfth century limited the ministrations of the monks to the care to the soul, leaving bloodletting and dentistry for the barber surgeons.1 The itinerant barber surgeon wrapped his bloody bandages around the walking stick that he carried for protection against highwaymen and used the stick also as a rest for the arm of his patient during phlebotomy. That stick became the sign of the trade that today is the barber pole. With the resurgence of European civilization in the thirteenth century, Galen’s writings returned from Baghdad to the medical school at Salerno in Italy. European physicians again championed venesection based on bedside experience and the new findings of the anatomists. Bloodletting became more medical than magical as knowledge of the body was spread by the printing press and medicine joined in the information revolution of the sixteenth century. The barber surgeons together with the surgeons of the short coat and the surgeons of the long coat joined with the learned university physicians in a mania for bloodletting as a therapy. Their tools for superficial bloodletting were the scarificator, the vacuum cup, and the hungry leech. For venesection they used the fleam and the lancet, and as often as not, the blood was collected into shaving bowls or measured into bleeding bowls. Those artifacts exist today4 and some will be shown in Transfusion Medicine History Illustrated. BLOOD TRANSFUSION Shortly after Harvey described the circulation of the blood in the seventeenth century, trials of human transfusion were performed in Paris and London with the blood of EDITORIAL animals. Transfusions with lamb and calf blood were performed at a time when religion and magic were still mixed with medicine for the entertainment of spectators. The early transfusions were performed after removing the blood containing the ill temperament of man in exchange for the blood of a calmer animal. In the words of diarist Samuel Pepys, the idea gave him “pretty wishes, as of the blood of a Quaker to be let into an Archbishop, and such like.”5 Despite legal prohibitions that arose because of the assault on the recipient’s soul as well as body, transfusion from animal to man continued as a sporadic magic entertainment for another 150 years. Meanwhile, bloodletting by venesection and leeching continued. The name of the most important medical tool of the bloodletter was taken by what remains a most respected medical journal today, The Lancet, founded in 1823. In the midst of the continuing rise of the sea of shed blood, an event was recorded that links the art of bloodletting to the science of transfusion. John Henry Leacock published his dissertation in medicine at the University of Edinburgh in 1816 in which he proposed the transfusion of human blood as treatment for both a “deficiency” in the blood and a loss of blood. He wrote that if bloodletting was therapeutic, “what is there repugnant to the idea of trying to cure diseases arising from an opposite cause by an opposite remedy, to wit, by transfusion.” He performed animal experiments proving that therapeutic transfusion was possible if species specificity of donor and recipient was matched.6 It was Leacock who first defined transfusion as we think of it today, as a medical therapy. James Blundell had graduated Edinburgh only a few years before Leacock with a dissertation on a study of music and hearing. Later in his London obstetrical practice, Blundell could only watch as women died of uterine hemorrhage, the dreaded “floodings.” He remembered Leacock’s suggestion and convinced himself of the correctness of Leacock’s concept of species specificity by repeating the animal experiments. Blundell then launched the usage of human-to-human transfusion7 that properly has earned him the title of “Father of Blood Transfusion.” In all his publications, Blundell gave credit to Leacock as having provided him with “first notions on the subject.” Blundell published and republished. Leacock made only the one report, left no further record in medicine, and is memorialized only by name on his widow’s tombstone in his native Barbados.6 Blundell’s writings and text lectures on “obstetricy” included detailed illustrations of his tools and were published throughout the world leading to more reports of transfusion throughout the nineteenth century.7 All were “direct” transfusions from donor immediately to patient because there were no satisfactory anticoagulants and defibrination failed as an alternative. Syringe transfusion was documented by the Union armies in the Civil War and transfusion was photographed at Bellevue Hospital in New York in 1873.7, 8 The twentieth century opened with Landsteiner’s accidental discovery of the blood groups while testing for diseases known to result in red cell agglutination. Early surgeons practicing direct transfusion knew of the work but did not use it because “what is apparently true to-day may be contradicted to-morrow.”9 That same caution was applied to the 1915 introduction of the citrate anticoagulants for the “indirect” transfusion used in the trenches in World War I. In 1928, a journal editor complained that every surgeon wished to devise and have a blood transfusion instrument called by his name; in his Nobel lecture, Landsteiner reported that more than 10,000 transfusions were performed annually in New York City alone. Practical difficulties remained and plasma was introduced for management of the new concept of “shock.” Before America joined in World War II, New York sponsored a “Plasma for Britain” program out of six hospitals with Charles Drew as medical director. After America sent troops, the Red Cross collected 14 million pints of blood on the Drew model. At first, the red cells were discarded because of faith in the efficacy of plasma alone, but the war ended with a victory for whole blood. Physicians returned home to demand whole blood for their patients, and the Red Cross, community, and hospital blood banks opened civilian programs. The American Association of Blood Banks was founded in 1947. FROM THE PAST TO THE FUTURE Although progress is not necessarily chronological, blood component and platelet therapy became a reality in the 1960s with the plastic blood containers that were introduced in 1953. In the 1970s, the American donor system became almost all voluntary in response to the danger from hepatitis. The name blood bank became obsolete because it was no longer a system into which donors made deposits for the purpose of making withdrawals. In the 1980s, the appearance of AIDS led to the current exquisite testing for viral contaminants. Meanwhile, the therapeutic plasmapheresis of the 1970s was performed for unexplained disorders in a throwback to the magic of bloodletting. Massive bloodletting persists to obtain samples for test “profiling” by the laboratory. The leech is back as an aid to plastic surgery. Immunohematology that entered the twentieth century as a science because of Landsteiner’s agglutination test is now a technology. Nevertheless, Starobinski’s dictum that “disease is as old as life, but the science of medicine is still young,”1 applies to the hemotherapy that began thousands of years ago. From goals such as the magical release of malevolent spirits and the control of the four humors, hemotherapy Volume 46, February 2006 TRANSFUSION 167 EDITORIAL grew into exchange transfusion to mollify man’s bad character and then became a medical science for the replacement of deficient and lost blood. Hemotherapy is now transfusion medicine, applying molecular biology in immunohematology and using precursor cells in clinical care. Hemotherapy as a science is still young and is still growing. That story and that growth will be depicted in Transfusion Medicine History Illustrated. We would like to invite contributions to this new section. Instructions for authors can be found on the Manuscript Central Web site (http://mc.manuscriptcentral.com/transfusion) in the author center. Paul J. Schmidt, MD Transfusion Medicine Academic Center Florida Blood Services P.O. Box 22500 St. Petersburg, FL 33742 e-mail: [email protected] Paul M. Ness, MD The Johns Hopkins Medical Institutions 600 North Wolfe Street/Carnegie 667 Baltimore, MD 21287 168 TRANSFUSION Volume 46, February 2006 REFERENCES 1. Porter R. The greatest benefit to mankind; a medical history of humanity. New York: W.W. Norton; 1998. 2. Epler DC Jr. Bloodletting in early Chinese medicine and its relation to the origin of acupuncture. Bull Hist Med 1980; 54:337-67. 3. Anglo-Saxon leechcraft: an historical sketch of early English medicine. London: Burroughs Welcome Co.; 1912. 4. Davis A, Appel T. Bloodletting instruments in the National Museum of History and Technology. Smithsonian Studies in history and technology. No. 41. Washington (DC): Smithsonian Institution Press; 1979. 5. Pepys S. Diary for 14 November 1666. 6. Schmidt PJ, Leacock AG. Forgotten transfusion history: John Leacock of Barbados. BMJ 2002;325:1485-7. 7. Schmidt PJ. Transfusion in America in the eighteenth and nineteenth centuries. N Engl J Med 1968;279:1319-20. 8. Schmidt PJ. The first photograph of blood transfusion. Transfusion 2001;41:968-9. 9. Crile GW. Hemorrhage and transfusion. New York: Appleton; 1909.