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Hemotherapy- from bloodletting magic to transfusion medicine

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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.
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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
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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
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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.
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