About 'phlebotomy equipment'|Fixing bad blood tests
Vocabulary Antiphlogistic- Pertaining to counteracting inflammation Apoplexy- Condition resulting from a crippling or serious injury Plethoric- Red, red-faced Pleurisy- Inflammation of the pleura of the lungs, with or without exudate Quincy- Unknown Scarifier- Brass box or cylinder that contained many small knives (1-20) averaging 12 blades that were activated by a spring mechanism. Spirit heater- Torch soaked in spirits of wine and lighted with a candle Spitting blood- Tuberculosis Suppuration- Producing and exuding pus The Evolution of Phlebotomy Technique and Equipment The practice of bloodletting is one of the oldest therapeutic treatments known. Medical lore, bloodletting, magic and religious ceremonies have been tightly intertwined throughout human history. The practice of medicine first began during the late Stone Age, known as the Neolithic age. The people of the time had a view of medicine and magic as different parts of the same practice, deeming disease to be a curse cast upon the sick, injured, and unlucky. Disease was attributed to one cause with variable symptoms. It was believed that the skull contained the evil spirit or demon that caused disease, and which could be drawn out. To this end priests, witch doctors, or sorcerers used flint tools in trepanning the skull in an effort to release the demon. Given the beliefs of the time the logic was sound, but it was based on an erroneous theory, and so history goes on. Bloodletting originated in a similar manner, with the objective of cleansing the body of bad blood and releasing, or driving out, the evil spirit. It has been theorized that the practice was developed through observation of the menstrual cycle and its' apparent restorative properties. Also, it was believed that the process of bloodletting would rid the body of poorly defined impurities and an overabundance of fluid. Dating from 1400 B.C., several Egyptian wall paintings exhibit the use of leeches in drawing blood. Tools implemented in the early history of blood letting included thorns, sharp pieces of flint or shell, pointed bones or sticks, and sharks teeth. Archeology digs in both South America and New Guinea yielded miniature bow and arrow devices, while tiny crossbows were found in Greece and Malta. Blood letting first became a wide spread practice in Egypt 1000 B.C. The practice spread around the Mediterranean and became widely accepted throughout western civilization. Hippocrates (460-377 B.C.), a Greek, observed the ill and recognized that specific disease states had corresponding symptoms. He, with Galen, developed the concept of balance between the four body humors, consisting of blood, phlegm, and black or yellow biles. The theory became the foundation of many extreme therapies including bleeding, purging, sweating, vomiting, and blistering. Blood was thought to be the seat of the soul, carrying the vital force of the body. It was also the easiest to manipulate and provided the practitioner with the reassurance of an immediate effect. The blood from fallen gladiators was sought after in the hope of consuming the warriors' strength. There exists a later story of an epileptic girl that drank the blood of a cat. She then, reportedly, took on the characteristics of a cat climbing roofs, jumping, scratching, howling, and gazing into a hole in the floor for hours at a time. All insanity and body weakness was thought to be due to some defect of the blood. General bloodletting consisted of venisection and arteriotomy, the intent being to take a large volume of blood from a vein or artery so that the vascular system became noticeably diminished. The average blood loss in general bloodletting was 16-30 oz. creating decreased tension on the walls of the blood vessels and the heart. Bloodletting was also indicated in patients subject to phlebitis, obesity, spitting blood, quinsy, pleurisy, falling sickness, apoplexy, madness, gout, and the wounded in an attempt to, "prevent the inflammation, which is to be feared." Venisection was the most common method of bloodletting. The median basilic vein was the most frequently utilized. Venisection was most often employed in febrile patients with a full pulse, red skin, and agitated state. The doctor could render the patient pale, cool, and calm which was considered an improvement. However, this treatment often resulted in cardiovascular collapse, shock, and death. Various tools were used throughout the history of phlebotomy. Among them were the thumb lancet, spring lancet, scarifier, fleam, blood stick, and the artificial leech. The thumb lancet was small with a sharp double-edged point. It was the principle instrument for humans as the doctors' preference. The instructions for use of a thumb lancet were to apply a broad tape tourniquet above the elbow, compressing the vein without diminishing the arterial pulse. The blade was grasped between the thumb and forefinger, using the remaining three fingers to steady the hand. Next, the vein was anchored with the left thumb below the draw site. The lancet was then introduced at an oblique direction (vague description) until blood rose up the point. The front edge of the lancet was pulled up in as straight a line as possible to increase the size of the skin wound to the size of the wound in the vein. The anchoring thumb was then removed, allowing room for the blood to flow into the bowl for measurement. The spring lancet was used by laymen. Some referred to it as a fleam. The device had a single blade scarificator. The lancet case resembled a pocket lighter in appearance. The case was made of silver or tortoise shell and it had folding guards of tortoise shell, ivory, or pearl. The handle was made of brass or white metal with a release lever. It was spring loaded and difficult to control. Major concerns with use of a spring lancet included transfixation of a vein, artery, tendon, or nerves as the depth of cut could vary from 5-8 cm. "Fleam" was a name applied to several bloodletting tools. The name principally indicated a bloodletting instrument with several shafts that fold into a case, similar to a folding pocket knife. Blade sizes were variable, but all were oriented at a 90˚ angle to the shaft. The blades were brass and some handles were constructed of animal horn. There were small blades for humans and large ones for domestic stock. The fleam was primarily a farrier's tool, as they not only cared for the horses' feet, but also acted as veterinarian. The fleam was preferred over the lancet for horses because it gave a larger wound more easily, preventing escape of the animal due to pain response, or insufficient blood flow from a shallow cut. The fleam gave a predictable depth of cut. The blade was held firmly against the long axis of the vein where the handle was struck with the bottom of the fist to drive the blade through skin and vein. A blood stick could be used to replace the fist in striking the fleam. The blood stick was a small hardwood club with a lead weight at one end. The force of the fist or blood stick determined the depth of the cut. Spring fleams were also available. Arteriotomy was an uncommon procedure which was thought to be necessary when veins felt empty relative to fullness of the arteries. The artery of choice was a superficial temporal artery or one of its branches. The doctor would partially cut the vessel with a single transverse incision. When the bleeding was complete the practitioner would sever the artery completely in the hope that the ends might contract into the tissue, arresting the hemorrhage. Afterwards a dry lint compress, composed of shredded linen, and a roller bandage were applied to the wound. Local bloodletting consisted of leeches, dry cupping, and wet cupping. The word leech comes from the old English "laece" meaning physician. The 1600's veterinarian was known as a "horse-leech". The treatment so was popular in Mideval Europe that the medicinal leech nearly became extinct by the mid 18th century. This development stimulated the population to begin the practice of leech farming. The medical leech is an annelid of the Hirudinea class native to Sweden. The scientific name is Hirudo medicinalis. The Swedish leech averages an uptake of about four times the blood of the American leech, which makes it the popular candidate for hirudotherapy. Leech saliva contains the anticoagulant hiruden (natural heparin), a vasodilator, and an anesthetic. These components work together to create a wound that is bleeds freely and painlessly for extended periods of time. Captive leeches were first kept in glass jars, but later porcelain jars with perforated lids became the norm. The spring water in the jars was frequently changed out and the jar was given a cool placement. Leeches were used for bloodletting placement where cupping glasses or horns couldn't go. Sites included hemorrhoid veins, the cervix or mouth of the womb, the gums, lips, nose, eyelids, or fingers. When leeches were to be applied near an orifice, a cotton plug had to be applied to prevent the animal from escaping through the hole of the nose, ear, eye, anus, or cervix. Leeches near an orifice required constant monitoring as they could escape in a very short time. Ambrose Paré said that leeches handled with bare hands become angered and would not bite. Rather, use a clean white linen cloth and let the leech dry for 30 minutes before use. The skin had to be prepared to encourage leech to take hold. Common procedures included scarifying the skin or smearing it with blood, milk, or milk and sugar. To attach a single leech, the tail was held to position the animal over the prospective site. Multiple leeches were applied with a cupping glass inverted over the site. To get the leech to suck more blood, the practitioner would cut the tail off after attachment. It would continue sucking because the blood ran right out of the opening. To remove them, people used salt, ashes, or powder of aloe on their heads. To gauge the amount of blood removed one would sprinkle powdered salt on them and they would bring up their stomach contents. The wound would continue to bleed for a while, as the anticoagulant lasts hours. After removal of the leech, all clots must be removed and the site cleansed. If the patient were bleeding continuously the attendant would apply a half bean to the wound until it sticks. An alternative to stem the flow was a burnt rag and ligature. Leeching was largely abandoned by 20th century, but interest in it was revived in the 1960's. There was an old time artificial leech, which consisted of a pointed lancet in a glass syringe cylinder or "sucker". The devices suffered coagulation problems, as the blood would clot before drainage was complete. Cupping was done with a glass, gourd, or horn. The cupping glass was also known as a cucurbitula, which means gourd. Glass cups were dome-shaped, often wine or beer glasses and could be designed with a small hole in the bottom for attaching a hose and syringe, allowing for manual suction control. The hollow, distal section of an animal horn was useful. The wide end was placed on the skin and the mouth was applied to the smaller, pointy end to produce suction. Once suction was established wax was used to plug the hole. The favored cupping method was heat applied to a glass or gourd. Dry cupping was done over intact skin. The practitioner would sponge the site with warm water to increase vascularity and dry it with a towel. The cup was passed over the spirit heater for one second, taking care not to heat the edges of the glass, causing blistering of the skin. The air would cool, developing suction, causing the skin to redden and swell. The purpose of cupping was to draw underlying blood and fluid away from the site of inflammation, to the skins' surface relieving congestion without removing fluid. A fingernail under the edge of the cup was sufficient to break the vacuum. Wet cupping would often take place after dry cupping. Once the site was prepared by the dry cup a scarifier was used to cut into the capillary bed. The cup was then reheated and applied over the fresh wound. On average 3-5 oz of blood was extracted using this method, a much smaller quantity of blood than was removed through general bloodletting. After cup removal the wound was dressed with lint and plaster. There were standardized procedures to cupping. For instance, the incision was to correspond to the direction of the muscular fibers. If the blades were set too deep then fat protruded through the skin and prevented blood flow. The intent of cupping was to apply it to a fleshy part of the body to draw out "corrupt blood and windy matter." It was thought that if skin was scarified before cupping it drew blood, but if the skin were intact it drew spirit. Phlebotomy was used to treat disease, cancer, trauma, obesity, and mental disturbance. Severely wounded soldiers were bled to syncope. Surgery from 1100-1500 A.D. was crude. Astrology played a major role in a physicians' practice in the 14th and 15th centuries. There was thought to be a specific relationship between the zodiac and each part of the body. Bloodletting and surgery were regulated by the signs of the Zodiac and the positions of the planets as dictated in the phlebotomy table of 1480 A.D. Bloodletting was performed at particular times for specific areas of the body. As medicine and religion were still closely linked, priests and monks were the primary practitioners of bloodletting. At a monastery in Scotland, where the monks bled each other regularly, a find at the monastery was a blood stratum of an estimated 300,000 pints. Then, in 1163 the Council of Tours issued a church edict prohibiting any but the barber-surgeons from performing bloodletting. The Council stated that, "The church abhors bloodletting." Barbers duties were to lance veins and abscesses, as well as to perform tooth extractions and amputations. During this time educated doctors avoided surgery. This set the stage for later conflict when surgery became respectable. The barber pole signified a barber who did both hair-cutting and surgery. The red was for blood, white for bandages, and the pole was for the rod squeezed by the patient during extraction. Shaving bowls often pulled double duty as a blood collection vessel. The bowls were designed with a semicircular notch after 1500 A.D. This design modification allowed the bowl to be pressed against the neck or antecubital fossa. The contents of the bowl were often measured. The Barber-Surgeon Company flourished in England for many years, until it was dissolved in 1744. There was a clear separation between barbers and surgeons for several years prior to the dissolution. Surgery was brought into prominence by a 17th century French Master Barber-Surgeon by the name of Ambrose Paré. He became known as the Father of Surgery. Paré described the reasons for bloodletting in 1634, concluding that phlebotomy was necessary in five respects. The first was to lessen the abundance, "as in plethoric bodies and those troubled with plentitude." The second reason was to divert the blood to another location. An example was to open the vein of the right arm to stay bleeding of the left nostril. Third was to draw allure, or draw down the blood, as in opening the ankle vein to draw down menstrual flow in women. The fourth purpose was to alter the blood, or introduce another quality to it. This was linked with sharp fevers, the objective being to breathe out blood that has been heated in the vessels, and cooling the remaining blood. The fifth and final reason presented was to prevent illness. The doctors were particularly busy during the spring and autumn, as it was the fashion to change out the body humors for the season. Patient preparation included a "gentle clyster" or suppository, as it was thought that the mesenteric vein would draw impurities into the blood directly from the bowel. The patient was bled while standing or sitting up until they fainted. Babies were bled till their lips turned blue. Domestic stock were bled until either their gums turned white or they fainted. Anton Van Leeuwenhoek discovered "animalcules" (microscopic life) in 1674. Buchan in the 1784 edition of Domestic Medicine stated that blood is in a systemic circuit. Therefore, he contended that there was little significance in the site chosen. In the U.S. Benjamin Rush, MD was very active in Philadelphia's 1793 yellow fever epidemic. It was during his treatment of these patients that he developed a deadly therapeutic procedure called "heroic therapy". He wrongly believed that the body held 25 lbs of blood and 20 lbs of that could be safely drained. Under this assumption he routinely bled patients of up to 75% of their blood volume. He was admired by some for staying at such personal risk. On average he bled more than 100 patients per day. In 1799 Dr. Rush treated George Washington for acute laryngitis. Washington was bled heavily four times in two days. Rush only relented when Washington requested to die without further medical intervention. He did. In early 19th century England bloodletting reached its zenith, as the public was convinced of the necessity for all of the population, healthy and ill. It was considered preventative medicine and very routine. It was said that folks "bled as regularly as went to market." The descriptions of the time were vague, the terminology confusing. Some examples include heart veins, breast veins, head veins, spitting blood, dropsy, fits, decay, fever, excitability, quinsy, pleurisy, falling sickness, apoplexy, and madness. Doctors based their medical therapies on personal experience and impressions, not on case histories or statistics. Bleeding patients gave the physician a sense of control over the course of the patients' health. Physicians used an antiphlogistic approach as it was believed that redness, heat, and swelling were abnormal responses to be treated. "Laudable" pus was thought necessary for good healing. Bloodletting was thought to counteract the redness, heat, and swelling by relieving congestion in the vessels. This method was used widely in 1830 and subsequent cholera and influenza epidemics. It was discovered that bloodletting didn't work and was not the magic bullet in curing illness. The tide began to turn. In the mid 1800's Ignaz Sammelweis theorized a connection between physicians conducting bare handed autopsies and then delivering babies without washing their hands. He introduced the concept of antiseptic handwashing using a chlorine wash. John Snow proved the effectiveness of breaking the chain of infection in an 1854 cholera outbreak in London. He tracked the infection to its source, a well contaminated with cholera bacteria through human waste. He was the first to exercise biohazard containment by removing the handle of the pump. Oliver Wendell Holmes (1809-1894) said, "The lancet was the magicians' wand of the dark ages of medicine." In the 1858 edition of Practice of Physic it was stated that the object of general blood-letting was to diminish the whole quantity of blood, thus lessening the force of the hearts' action. The object of local bleeding, most times, was to empty the engorged and loaded capillaries of the inflamed part. The author believed topical bloodletting diverted the flow, giving the blood a new direction, indirectly relieving inflammatory congestion. However, phlebotomy was sometimes performed directly from the affected part. In the mid 19th century French statisticians compiled patient history and treatment results. It was determined bloodletting does more harm than good. An 1860 author wrote "If the employment of the lancet was abolished altogether, it would perhaps save annually a greater number of lives than in any year the sword has ever destroyed." In the end of the 19th century doctors believed illness was due to an excess or deficiency of some body product. There was little that doctors could do for patients as most all therapies were useless and many were harmful. Cathartics were used to cleanse the bowels, reducing an overexcited nervous system. Diuretics were used to restore system balance. Tonics stimulated a depressed nervous system, and bloodletting reduced fluids and temperature. Louis Pasteur suggested the Germ Theory of Disease in 1862. Robert Koch verified the Germ Theory and put forth Koch's Postulates in 1875. They are still in use in identifying new disease today. The combination of Pasteur and Koch's work a renaissance in therapies occurred, and the histologic reaction to infection (redness, swelling, fever) became a secondary issue to be resolved. In the 20th century the practice of bloodletting died throughout the world. In 1935 Randolph said, "With alternating periods of excess and moderation it is about the only remedy that has held its own throughout our history." In the present day phlebotomy is used in a very limited fashion in regard to treatments. Bloodletting today is used to treat polycythemia vera, hemochromatosis, congestive heart failure, pulmonary congestion, and is the standard of care in hematological diseases and disorders. Blood is also withdrawn from the body to provide blood products for transfusion. The primary use for phlebotomy in contemporary medicine is in diagnosis not treatment, although blood loss for diagnostic testing can still be considerable. The current equipment includes the tourniquet, syringe, needle, ETS, butterfly, and the capillary lancet. The current veins of choice are in the antecubital region. The preferred vein is the median cubital, then the median cephalic, and finally the basilic. From scientific evaluation the body is known to respond more promptly to acute blood loss than to chronic loss of small amounts. Leeches are used today to withdraw blood, control pain, reduce swelling, and keep small vessels open. They are most commonly used in microsurgical procedures, transplants, and skin grafts. There is even a modern day version of the mechanical leech, which was created in 2001 at the University of Wisconsin, Madison. It has a glass vial attached to a suction cup that delivers an anticoagulant, and withdraws blood as intended. The mechanical leech may one day become common phlebotomy equipment. The purpose of the mechanical leech is to make patients more comfortable with treatment and, more importantly, to prevent infection transfer of Aeromonas hydrophila directly from the leech gut into the blood stream causing septicemia. This has been a concern mainly where the water that the leeches are kept in was not changed regularly. Leech therapy shows long-term benefits in pain and mobility treatment, while further side effects consist of slight itching and possible scarring at the site of the bite. Oral and topical medications currently in use for pain treatment can have devastating effects on the stomach, liver, pancreas, kidneys, or skin. They also have a much lower incidence of pain management and increased mobility. It has been said that it is amazing that such a drastic procedure, that provided little relief, was practiced for so long. It has also been stated that "Our current efforts to treat cancer without understanding the underlying etiologic factors will someday, no doubt, appear just as illogical." Keep evolving. (McCormic, 2008) Works Cited Bloodletting. Burns, S.B. . Retrieved on April 14, 2008. McCall, R.E. and Tankersley, C.M. (2003). Phlebotomy Essentials, Fourth Edition. Baltimore, MD: Lippincott Williams and Wilkins. Multiple Editors (2006). Mosby's Dictionary of Medicine, Nursing, and Health Professions, Seventh Edition. St. Louis, MO: Elsevier. Pommerville, Jeffery C. (2004). Alcamo's Fundamentals of Microbiology, Seventh Edition. CANADA: Jones and Bartlett Publishers. Bloodletting Over the Centuries. Seigworth, G.R. MD. Retrieved on April 13, 2008. Leech Therapy for Pain and Venous Congestion. Walsh, N. Retrieved on April 14, 2008. |
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