Phlebotomy

Phlebotomy (pronounced fluh-bot-uh-mee)

(1) The act or practice of opening a vein for letting or drawing blood as a therapeutic or diagnostic measure; the letting of blood and known in historic medicine as "a bleeding".

(2) Any surgical incision into a vein (also known as venipuncture & (less commonly) venesection).  It shouldn’t be confused with a phlebectomy (the surgical removal of a vein).

1350–1400: From the earlier flebotomye & phlebothomy, from the Middle French flebotomie, from the thirteenth century Old French flebothomie, (phlébotomie the Modern French) from the Late & Medieval Latin phlebotomia, from the Ancient Greek φλεβοτόμος (phlebotómos) (a lancet used to open a vein), the construct being φλέψ (phléps) (genitive phlebos) (vein), of uncertain origin + tomē (a cutting), from the primitive Indo-European root tem- (to cut).  The form replaced the Middle English fleobotomie.  The noun phlebotomist (one who practices phlebotomy, a blood-letter) is documented only as late as the 1650s but may have been in use earlier and operated in conjunction with the verb phlebotomize.  The earlier noun and verb in English (in use by the early fifteenth century) were fleobotomier & fleobotomien.  The Latin noun phlebotomus (genitive phlebotomī) (a lancet or fleam (the instruments used for blood-letting)) was from the Ancient Greek φλεβότομος (phlebótomos) (opening veins), the construct being φλέψ (phléps) (blood vessel) +‎ τέμνω (témnō) (to cut) +‎ -ος (-os) (the adjectival suffix).  The alternative spelling was flebotomus.  The noun fleam (sharp instrument for opening veins in bloodletting (and this in the pre-anesthetic age)) was from the late Old English, from Old French flieme (flamme in Modern French), from the Medieval Latin fletoma, from the Late Latin flebotomus, from Greek φλεβοτόμος (phlebotómos) (a lancet used to open a vein).  The doublet was phlebotome and in barracks slang, a fleam was a sword or dagger.  Phlebotomy & Phlebotomist are nouns, phlebotomize is a verb and phlebotomic & phlebotomical are adjectives; the noun plural is phlebotomies.

Phlebotomy describes the process of making a puncture in a vein cannula for the purpose of drawing blood.  In modern medicine the preferred term is venipuncture (used also for therapy) although the title phlebotomist continues to be used for those who specialize in the task.  One of the most frequently performed procedures in clinical practice, it’s commonly undertaken also by doctors, nurses and other medical staff.  Although the origins of phlebotomy lie in the ancient tradition of blood letting, it’s now most associated with (1) the taking of blood samples for testing by pathologists and (2) those carried out as “therapeutic phlebotomies” as part of the treatment regimen for certain disorders of the blood.  The inner elbow is the most often used site but in therapeutic medicine or in cases where the veins in the arms are not suitable, other locations can be used.

Bleeding the foot (circa 1840), oil on canvas following Honoré Daumier (1808-1879).

It’s an urban myth the Hippocratic Oath includes the clause: “First, do no harm” but by any reading that is a theme of the document and while the Greek physician Hippocrates of Kos (circa 460-circa 375 BC) wouldn’t have been the first in his field to regard illness as something to be treated as a natural phenomenon rather than something supernatural, he’s remembered because of his document.  His doctrine was one which took a long time to prevail (indeed there are pockets where still it does not), holding that treatment of ailments needed to be based on science (“evidence-based” the current phrase) rather than devotion or appeals to the gods.  His influence thus endures but one of his most famous theories which persisted for decades resulted in much lost blood for no known benefit and an unknown number of deaths.  Drawing from the notion of earlier philosophers that the basis of the universe was air, earth, water & fire, the theory was that there were four “humors” which had to be maintained in perfect balance to ensure health in body & mind, the four being flegmat (phlegm), sanguin (blood), coleric (yellow bile) & melanc (black bile) which were the source of the four personality types, the phlegmatic, the sanguine, the choleric & the melancholic.  Had Hippocrates and his successors left the humors in the realm of the speculative, it would now be thought some amusing fragment from Antiquity but unfortunately surgical intervention was designed to ensure balance was maintained and the mechanism of choice was bloodletting to “remove excess liquids”.

George Washington in his last illness, attended by Doctors Craik and Brown (circa 1800) engraving by unknown artist, Collection of The New-York Historical Society.

Apparently, bloodletting was practiced by the ancient Egyptians some 3000 years ago and it’s not impossible it was among the medical (or even religious) practices of older cultures and From there it’s known to have spread to the Middle East, Rome, Greece and West & South Asia, physicians and others spilling blood in the quest to heal and the evidence suggests it was advocated for just about any symptom.  The very idea probably sounds medieval but in the West that really was the nature of so much medicine until the nineteenth century and even well into the twentieth, there were still some reasonably orthodox physicians advocating its efficacy.  Still, in fairness to Hippocrates, he was a pioneer in what would now be called “holistic health management” which involved taking exercise, eating a balanced diet and involving the mind in art & literature.  He was an influencer in his time.  All the humors were of course good but only in balance so there could be too much of a good thing.  When there was too much, what was in excess had to go and apart from bloodletting, there was purging, catharsis & diuresis, none of which sound like fun.  Bloodletting however was the one which really caught on and was for centuries a fixture in the surgeon’s bag.

Blood self-letting: Lindsay Lohan as Carrie from the eponymous film, Halloween party, Foxwoods Resort & Casino, Connecticut, October 2013.

Actually, as the profession evolved, the surgeons emerged from the barber shops where they would pull teeth too.  The formal discipline of the physician did evolve but they restricted themselves to providing the diagnosis and writing scripts from which the apothecary would mix his potions and pills, some of which proved more lethal than bloodletting.  The bloodletting technique involved draining blood from a large vein or artery (the most productive soon found to be the median cubital at the elbow) but if a certain part of the body was identified as being out-of-balance, there would be the cut.  The mechanisms to induce blood loss included cupping, leeching & scarification and with the leeches, they were actually onto something, the thirsty creatures still used today in aspects of wound repair and infection control, able often to achieve better results more quickly than any other method.  Leeches have demonstrated extraordinary success in handing the restoration of blood flow after microsurgery and reimplantation and works because the little parasites generate substances like fibrinase, vasodilators, anticoagulants & hyaluronidase, releasing them into the would area where they assist the healing process by providing an unrestricted blood flow.  Of course the leeches don't always effect a cure.   When in 1953 doctors were summoned to examine a barely conscious comrade Stalin (1878-1953; Soviet leader 1924-1953), after their tests they diagnosed a haemorrhagic stroke involving the left middle cerebral artery.  In an attempt to lower his blood pressure, two separate applications of eight leeches each were applied over 48 hours but it was to no avail.  Had he lived he might have had the leeches shot but they probably lived to be of further service.

A Surgeon Letting Blood from a Woman's Arm, and a Physician Examining a Urine-flask (in some descriptions named Barber-Surgeon Bleeding a Patient), eighteenth century oil on canvas, attributed to school of Jan Josef Horemans (Flemish; 1682-1752); Previously attributed to Richard Brakenburg (Dutch; 1650-1702); Previously attributed to the Flemish School,

Scarification was a scraping of the skin and if the circumstances demanded more, leeches could be added.  Cupping used dome-shaped cups placed on the skin to create blisters through suction and once in place, suction was achieved through the application of heat.  However it was done it could be a messy, bloody business and in the twelfth century the Church banned the practice, calling it “abhorrent” and that had the effect of depriving priests and monks of a nice, regular source of income which wasn’t popular.  However, especially in remote villages far from the bishop’s gaze, the friars continued to wield their blades and harvest their leeches, the business of bloodletting now underground.  In the big towns and cities though the barbers added bloodletting to their business model and it’s tempting to wonder whether package deals were offered, bundling a blooding with a tooth pulling or a haircut & shave.  From here it was a short step to getting into the amputations, a not uncommon feature of life before there were antibiotics and to advertise their services, the barber-surgeons would hang out white rags smeared in places with blood, the origin of the red and white striped poles some barbers still display.  To this day the distinctions between surgeons and physicians remains and in England the Royal College of Physicians (the RCP, a kind of trade union) was founded by royal charter in 1518.  By the fourteenth century there were already demarcation disputes between the barber surgeons and the increasingly gentrified surgeons and a number of competing guilds and colleges were created, sometimes merging, sometimes breaking into factions until 1800 when the Royal College of Surgeons (RCS) was brought into existence.  It's said there was a time when fellows of the RCP & RCS, when speaking of each-other, would only ever make reference to "the other college", the name of the institution never passing their lips. 

Bloodletting tools: Late eighteenth century brass and iron “5-fingered” fleam.

Unfortunately, while doubtlessly lobbying to ensure the fees of their members remained high, the colleges did little to advance science and the byword among the population remained: “One thing's for sure: if illness didn't kill you, doctors would”.  It was the researchers of the nineteenth century, who first suggested and then proved germ theory, who sounded the death knell for most bloodletting, what was visible through their microscopes rendering the paradigm of the four humors obsolete.  By the twentieth century it was but a superstition.