BLEED, BLISTER, VOMIT AND PURGE

THE DOCTOR'S BAG

the blog about 19th century Medicine and Surgery

Keith Souter  aka Clay More

Heroic medicine
I have mentioned heroic medicine in several of the posts over the past two years. It is the name given to the practice of medicine that involved using very aggressive treatments that almost seemed to 'kill or cure.' It was a towering edifice of medical practice that had its roots back in the humoural theory of Hippocrates. It was essentially the orthodox practice of medicine until the end of the Civil War.

In England in the 18th century Dr John Lettsom (1744-1815) was one of the foremost physicians of the day. He was born in the British virgin Islands t a Quaker family and trained in medicine at Edinburgh University in Scotland. He became a distinguished physician and abolitionist. Among his achievements he was the founder of The London Medical Society, which is the oldest medical society in the UK.


He was a great advocate of heroic medicine and even wrote humorously about himself:

I, John Lettsome,

Blisters, bleeds and sweats 'em.

If, after that, they please to die,

I, John Lettsome.

John Coakley Lettsom (1744-1815)

Essentially, he advocated bleeding, blistering, emesis and purgation. Throughout his career he had a running battle with several practitioners who were considered quacks and charlatans. This is interesting, since nowadays bleeding, blistering and purgation would all be placed firmly in the area of quackery as they have been replaced by scientific medicine. Such is the way that science progresses.

On the either side of the Pond heroic medicine found its greatest advocate in Dr Benjamin Rush (1745-1813). As we saw in an earlier post (On the Trail with Dr Rush's Bilious Pills), he advised Lewis and Clark to take copious medical supplies of calomel as a purgative to treat anyone who fell ill on their expedition. Calomel was a mercuric medication that produced a profuse evacuation of the bowels. Recently, archaeologists have been able to trace the latrines used during their expedition across the land, because the ground is still contaminated with mercury from Dr Rush's bilious pills. Yet it has to be said that the two year expedition lost only one man, and that was from appendicitis.

Dr Benjamin Rush (1745-1813)

George Washington was the victim of heroic medicine. He died at Mount Vernon on 14th December 1799, aged 67 years. The illness that ended in him to have aggressive heroic medicine started with  a chill after getting soaked to the skin when he was taking measurements of the front of Mount Vernon. He rapidly fell ill with fever and inflammation of the throat, which may have been peritonsillar abscess or even epiglottitis.

The methods of Dr Rush were highly influential on the doctors of the day. When the president fell ill three doctors were sent for. These were, his own physician, Dr James Craig, Dr Gustavus Brown, a physician with a good diagnostic reputation, and Dr Elisha Dick. He was treated with blistering, enemas and four blood-lettings. Dr Dick was against the excessive blood-letting and advised performing a tracheotomy (an operation to make an opening in the throat to by-pass the obstruction to his breathing), but the other two over-ruled him. He was given further blistering poultices and purged with Calomel. 

Realising that he was going to die, George Washington thanked all three doctors before lapsing into coma and death.

The components of heroic medicine
The aim of the heroic approach was to remove the excessive bad humours that were causing illness. 
These humours were thought to be the four vital fluids that were associated with the four major organs of the body. They were also associated with the four elements of earth, air, fire and water, and the four qualities of cold, hot, dry and wet. These also made up the four temperaments of sanguine, choleric, melancholic and phlegmatic.

The diagram shows the inter-relationships that were taught. So you can see that sanguine people had an excessive amount of blood, which was wet and hot. Choleric types had excessive yellow bile and were angry. Melancholic types had too much black bile and tended to be depressed and gloomy. And phlegmatic types mad excess phlegm and had respiratory troubles, which they phlegmatically put up with. 

The interrelationship between the elements, the qualities and the humours

The four temperaments

Thus:
blood was associated with the heart and circulation
phlegm was associated with the lungs and respiratory passages
yellow bile was associated with the liver
black bile was associated with the spleen

to treat these excessive humours the following treatments were used:

• bleeding to remove blood. The word exsanguinate, meaning to drain of blood comes from this concept.
• emesis to cause vomiting to get rid of yellow bile. It would be observed that when vomiting was induced bile would often come up.
• purgation to cause evacuation of the bowels, to get rid of black bile. This would be done with purgatives (laxatives) and enemas.
• blistering with poultices to get rid of phlegm
• diaphoresis or the inducement of a perspiration reaction to get rid of phlegm

In practice, however, patients were often given a mix of treatments to get rid of all humours. Thus they could be bled, blistered, purged and made to vomit. If that didn't bring improvement blistering or diaphoresis could be added. It is likely that different doctors and their own favoured approaches and combination of treatments.

Virtually any condition was considered treatable with these methods. In days when people died from all manner of infections heroic treatment would probably hasten many people to an early grave, yet since these methods were advocated and practiced by the medical profession, death of a patient would have been attributed to the virulence of the bad humours causing the illness and not the ministrations of the heroic doctor.

Phlebotomy, the art of Bleeding
Over the centuries a whole art of phlebotomy  developed. The word comes from the Greek phlebo, meaning blood vessel and -tomy, meaning incision or cutting into. A whole series of different points of the body were delineated, specifically so that bleeding certain veins could drain a part that was causing pains.

In general it would be a vein that was opened, not an artery. A vein is a blood vessel that returns blood from the body to the heart. Opening a vein would result in blood flowing out to be collected in a cup of dish. An eatery is a blood vessel carrying blood from the heart to the tissues, so that opening one would result in blood spurting out forcefully with every beat of the heart. The patient could quickly bleed to death if an artery was opened. 

                                Points for blood-letting, Field book of wound medicine, 1517

A range of instruments were used for phlebotomy.

The lancet

One of the foremost medical journals in the world is the British journal The Lancet, which was founded in 1823 by Thomas Wakley, and English surgeon. It is named after this instrument used for bleeding a patient.

A lancet is a double edged surgical instrument with a sharp point. They usually had wood or ebony handles. They were used to nick and cut into a vein. 

In the late 18th and early 19th centuries physicians and surgeons used spring lancets. These were little gadgets that were spring-loaded so that the blade could be released quickly to slash along the vein.

Doctors prided themselves on the skill with which they performed their phlebotomy. It was considered good practice to open a vein along its length for a half inch, rather than cutting across it. The reason is that if the vessel was cut along it would bleed, but it would after a time, with pressure applied, sea itself. A cut across vein would continue to bleed and would not seal itself off. It would be harder for the cut across vein to heal and the dressings used would have to be bulkier. essentially, a physician who could control the bleeding by skilful phlebotomy would garner a good reputation while the clumsy phlebotomist would accrue a less favourable reputation and would be much less sought after.

One of only three known photographs of blood-letting. Taken c 1860, from The Burns Archive

The fleam

This was an instrument used by both veterinary surgeons and doctors, for many treated both humans and animals. It consisted of several blades of different sizes and of different shapes. They often had a thumb plate so that the blade could be controlled by it. 

A three bladed fleam

Scarification

This was a technique using a device called a scarification. These were much in vogue at the turn of the 19th century. Many were English in design and consisted of a brass box containing a dries of spring loaded blades which could be released to slice through the skin and veins. The depth of the cut could be controlled. The lever was pulled back to lock the springs, then the box was placed on the skin and at a push of the button the blades were released.

This 'scientific' looking device made bleeding an easy matter, since it would be bound to produce blood. It could be used on younger people with the blades not cutting too deeply.

French designed scarifications were much more elegant looking, contained in ornate circular boxes. 

Bleeding receptacles

Most doctors carried their own bleeding bowls, usually pewter ones which were measurable in ounces, so that a half pint, a pint or however many were to be taken, could be easy measured. 

When a scarification was used a cup of glass, metal or horn  would be placed over the bleeding points to accumulate the blood. Sometimes a cup would be used with a bulb at one end so that suction could be applied to draw the blood out to accumulate in the cup.

Leeches 

In days gone by doctors were somewhat derogatorily referred to as leeches. This is a good example of the way that names become changed and slip into common parlance. In fact in Anglo-Saxon England the Anglo-Saxon word for a physician was Laece, which became leche. Later i was assumed to be leech.

King Alfred the Great (849-899 AD) ordered all medical texts to be translated from Latin into English. As a result the medical textbooks came to be called leech books. Further, physicians were by law entitled to claim a leech fee for professional services.

Most doctors would have a covered leech jar in their office

The application of leeches to reduce bruising has been practiced since antiquity. The writers Theocritus advocate them in the second century BC, Nicander wrote about them a century later, as did Horace in the first century BC.

Doctors kept a supply of leeches in a jar or bottle. They would be applied to a fresh bruise and would suck up to a drachm of blood. The results around bruises to the eyes were remarkable. 

The leech is basically a tubular creature that looks the same at both ends. The head end, however, has teeth which it fastens onto the skin with. Doctors would use a leech-glass to apply them. A leech would be held delicately by the tail and inserted into the glass tube or leech-glass. The skin would be cleansed as well as possible then the glass applied to encourage the leech onto the exact site. They were not always keen to bite and latch on, so the skin was often moistened with some milk or cream. A healthy leech would remove about a fluid drachm of blood. 

Emesis
This comes from the Greek for vomiting. These were given when there was ingestion of poison of any sort. Indeed, this is still done today in cases after deliberate or accidental overdoses. 

Simple remedies to provoke vomiting include mustard or salt water. A doctor would preside ipecacuanha or tartar emetic. 

Tartar emetic was a salt derived from tartaric acid with potash and antimony. It could be grandly known as tartrate of antimony and potash. It would come in the form of colourless crystals that dissolve rapidly in water to produce an odourless liquid that tasted sweet and metallic.

It could also be given as 'antimony wine,' produced by dissolving forty grains of tartar emetic in a pint of sherry. 

The dose given was two grains of tartaric emetic dissolved in water. If the wine was given, then the dose was a fluid ounce. A vomiting reaction would occur in twenty minutes to half an hour.

Tartar emetic was also given in lower doses, insufficient to produce vomiting, in cases of chest infection and pneumonia. Five drops of the antimony wine would be given together with effervescing ammonia mixture. 

Purgation
Laxatives are drugs or fruits that produce a fairly gentle evacuation of the bowel. Purgatives have the same effect, but are much more aggressive.

Calomel, a mercury based drug was a multi-purpose purgative. For more information, see the posts on Dr Rush's Bilious Pills and A Primer about some of the drugs a doctor could make up.

Enemas
These are methods of administering a fluid into the rectum. There were various types of enema used, depending upon the purpose they were intended for.

If the aim was to introduce a medicine into the body - almost invariably opium - then a small quantity of fluid was to be used, otherwise it would not be retained. Firstly, starch or arrowroot would be mixed to produce a thick fluid. About two to three ounces would be the amount. To this the opium would be added and mixed thoroughly. When it was cooled it would be taken up into a glass syringe with a rounded nozzle. This would be gentle introduced into the back passage and slowly injected from the syringe. Some doctors would use an India rubber syringe in which an air ball could be used to pump the fluid inside. 

More commonly the enema was given with the purpose of opening the bowels. The enema simplex usually consisted of soap and water or gruel. Te patient was usually lying on the left side. About a pint or a pint and a half would be used. The patient was then advised to attempt to retain the enema for as long as possible in order to get the maximum effect. 

If it was needed to get a vigorous evacuation then a purgative would be mixed with the fluid used. Olive oil or castor oil would be appropriate. Turpentine would have a much greater purgative effect, as would substances like asafoetida or Epsom salts. 

Poultices and Blistering
Poultices were often used on the skin to relieve pain. It was basically a efficient way of applying heat or cold to the intact skin.

The action of a poultice is to produce hyperaemia, that is, redness of the skin  by producing dilation of the skin blood vessels. Often it would produce a very mild counter-irritation and would relieve pain. That basically means you produce one type of discomfort over a wide area which will over-ride pain from another source under the skin. Hot poultices were applied for abdominal colic and for chest complaints like pneumonia, pleurisy and bronchitis.

Various poultices were made - linseed, bread, charcoal, yeast, hemlock, potato or ice.  A sort of porridge consistency paste was made of whichever poultice was used, which was then spread on a piece of calico or linen, leaving an inch edge all round. Anther piece of calico or linen was spread on top of it and this was applied to the part and bandaged in place. It would be left until it completely cooled and replaced after several hours.

Blistering was a far more aggressive treatment made to the skin. This involved using one of the so-called blistering agents to produce first hyperaemia, then damage to the skin in the form of blisters to appear. These were done to produce very powerful counter-irritation, so that the pain of the blisters would over-ride the painful condition being treated. They could be applied in rheumatic and muscular conditions, sciatica, neuralgia, but in true heroic treatment were in fact applied in all sorts of inflammatory conditions of the deeper organs. Thus it could be used for pneumonia, liver problems, diabetes and even heart trouble. 

Mustard plasters were used for mildly painful conditions. At its most basic, mustard paste was applied to brown paper or a piece of linen and then applied to the body and bandaged on. This was used for chills or to reduce swelling on inflamed joints. 

More extreme treatments required the use of the 'blistering fluids,' which were called vesicants, meaning of course, that they produced blisters. Capsicum, made from chilli peppers was commonly used.  Capsicum could be applied directly as a tincture, liniment or ointment. The latter was referred to as chilli paste. It would produce a marked redness and slightly raised area, but not a blister. It was also commonly applied as a blister patch and several of them could be used over an area, such as over a joint.

Blister patches applied to the knee to reduce swelling

If a blister was actually wanted, then but the vesicant that saw most service was the famous Spanish Fly! This was a preparation made from dried, powdered Spanish fly, one of the blistering beetles. It was wrongly classified as Cantharis vesicatorum, but is now  correctly named as  Lytta vesicatioria.

When an area was to be blistered it would be surrounded by vaseline to limit the area. Then it would be painted with the blistering fluid, usually Spanish fly. 

Surrounding skin would be protected with vaseline before applying Spanish fly

As soon as the blistering occurs the area was cleansed gently, trying not to break the blister, because the blistering fluid would really hurt raw tissue under the blister. This could result in the development of an ulcer of the tissue. A clean dry dressing would be applied and changed later. 

Large blisters could be snipped to let the blister fluid out, but then had to be carefully tended to prevent excess friction of the separated skin on the delicate lower tissue. If the treatment was more aggressive, as it often was in heroic medicine, then poultices or warm fomentations might be applied to produce further fluid release into the blistered areas. 

From ancient Rome to modern day medicine
This treatment may sound barbaric, yet nowadays rubefacient treatments are still used to help inflammatory and painful musculoskeletal problems. 

The process of inflammation was known about in antiquity. Aulus Cornelius Celsus, a Roman encyclopaedist writing in the first century AD described the four cardinal signs of inflammation in his book De Medicina. The book was written in Latin, of course, and the signs were - calor (warmth), dolor (pain), tumor (swelling) and rubor (heat). We recognise all of them even today.

            

Note the last one, rubor, meaning heat. It is from this word that we derive the term ‘rubefacient.’ It means an agent that produces heat. This seems to be the mechanism that many of these rubbing-on preparations work; they produce local heat or irritation of the skin over the area, which then over-rides pain signals from the deeper tissues. This is actually a quite legitimate mechanism of pain relief called ‘counter-irritation.  

Ancient Rome - OVDO - Olympic Victor’s Dark Ointment

Interestingly, an ancient medical treatise from the same epoch in history has recently been unearthed by the British Museum. It details how to make a remedy which in Latin was called ‘fuscum olympionico inscriptum.’ This translates as ‘Olympic Victor’s Dark Ointment.’ This was purportedly a liquid plaster which had cooling and pain-killing effects, and which reduced inflammation and bruising.

           

 This is a fascinating find, since it shows that sports medicine was alive and well in the ancient world. And an effective pain-killing, anti-inflammatory remedy would have been worth its weight in gold to treat injuries in the gladiatorial circus or in the athletics arena.

            

This particular treatise was written by the Greek physician Claudius Galenus of Pergamum (AD131-201), who is known to history as Galen. He worked in a gladiator school, later becoming physician to the emperor Marcus Aurelius. He was the first anatomist and the most influential medical writer for a thousand years. He wrote about OVDO and recommended it as being of great benefit for bruises and black eyes.

           

 Researchers from the British Museum and the University of Copenhagen have reproduced the remedy and tested its efficacy. It consisted of the following ingredients: antimony, cadmia, saffron, frankincense, myrrh, acacia, gummi, opium, pompholyx, aloe indica and raw egg. The various ingredients would help to soothe inflammation and pain, reduce swelling and promote healing, with the egg acting as a binding agent.

           

 The research team found that when they made it up it would have been too gritty to apply to the eye, but that it could have been applied to the face and other parts of the body. It was a semi-liquid which set like a modern spray-on flexible plaster. Amazingly, it was about 25 per cent as effective as a modern pain-relieving patch.  They also found that it delivered pain relief quite rapidly, but also had a slow-release effect, rather like present slow relief plasters. The antimony was a concern, since repeated use of it could result in toxic levels accumulating in the body, but used short term, it would have a cooling and anti-inflammatory effect.

            

I mention this here to illustrate that pain relief and anti-inflammation have been prime concerns of doctors across the centuries, and that even in antiquity they had medicines that were effective.

Modern day - chilli cream

We have rediscovered the benefit of capsicum, or chilli paste.Although the concentration used is less, nowadays doctors can prescribe capsaicin cream, a rubefacient which exerts its effect just the same way that it did in the 19th century. 

It is interesting the way that medicine sometimes progresses in circles.

Diaphoresis - make them sweat bullets 
This may sound an apt type of treatment for a frontier doctor of the Old West. The aim was to stimulate a perspiration reaciotn, whereby the person produced copious drops of sweat, like bullets.

In fact, a diaphoretic is any drug that induced mild perspiration. A drug that produced the most profuse perspiration reaction was called a sudorific.

Tartar emetic and Dover's powders were both commonly used diaphoretics. They would be given to reduce the temperature during a fever, because perspiration removes heat from the body. At the beginning of a fever 1/2 drachm of spirit of nitrous ether with 1/2 ounce of acetate of ammonia every three hours would be given to cool a fever. 

Dover's powder was given in feverish colds. 

Nicotine from tobacco and pilocarpine from the leaves of the South American  Jacorandi plant are sudorifics. Pilocarpine produces extensive salivation and perspiration. 

The leaves of the Jacorandi yields the rug pilocarpine

Diaphoretics are no longer given routinely. Indeed only pilocarpine would be used in conditions that have diminished saliva production, such as Sjogren's syndrome (a connective disorder that causes arthritis, dry eyes and dry mouth) sand in post-radiotherapy situations where the saliva production is lost. Pilocarpine also has a role to play in the treatment of glaucoma today. 

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Some of Clay More's latest releases:

Redemption Trail published by Western Trail Blazer
- a novelette- novella

Sam Gibson used to be a lawman, until the day he made a terrible mistake that could never be taken back. Since then, he has alternated between wishing there were a way he could redeem himself and believing he deserved punishment. 

He’s about to get both… 

REDEMPTION TRAIL

And his collection of short stories about Doc Marcus Quigley is published by High Noon Press

Available at Amazon.com:

ADVENTURES FROM THE CASEBOOK OF DR MARCUS QUIGLEY

And his latest western  novel Dry Gulch Revenge was published by Hale on 29th August.