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At the heart of general practice since 1960

The decay of bloodletting

From the substance of a Presidential address delivered at the Harveian Society of London in 1909.

On looking up the names of my predecessors in this chair for the purpose of seeing what they had done, and how they had promoted the objects with which the Harveian Society of London was established in the year 1831, I got no further in the list than the names of your first two Presidents. The more illustrious of the two was Dr. Marshall Hall.

The medical politician remembers him as the outspoken champion of the one-portal system of admission to the medical profession, which has not yet been, and perhaps never will be, adopted in this kingdom. The historian of medicine and the general practitioner know him as one who weaned the profession from the pernicious habit of blood letting, not because he disbelieved in its efficacy, but because he endeavoured to lay down rules for its rational employment.

It is with regard to this aspect of his work on blood letting that I wish to consider him, because I like to think that this stupendous revolution in practice, which has no doubt saved hundreds of thousands of lives in this country alone, was inaugurated at the very time when he was president of this Society in 1832.

Blood letting was in full swing, both in London and throughout the kingdom, indeed through the whole civilised world. It was accepted so much as a routine treatment that Marshall Hall, writing in the Cyclopaedia of Practical Medicine in 1833, says: "General blood letting is, of all our remedies the most powerful; its employment requires the utmost consideration. If we neglect the remedy in cases, in which its use is required, we allow the disease to make a dangerous progress."

In 1844, Copland's Medical Directory, the next great encyclopaedia of medicine, omits all reference to blood letting, and, although the practice lingered a few years longer in the more remote parts of the country, this great and universal method of treatment, for upwards of two thousand years, fell into complete disrepute in the course of these twelve years.

It is interesting, therefore, to ascertain why a remedy, thought to be so trustworthy, fell so quickly into disrepute. All unwittingly, Marshall Hall gives the full answer to the question. He says, "If our diagnosis were early and certain, perhaps the lancet would never be required." His Researches principally relative to the Morbid Effects of Loss of Blood, published in 1830 is striking in the very deficient diagnosis of disease which was then common. The physical examination was not very thorough, and no instruments of precision were in use. There was no clinical thermometer, although it was used at Guy's Hospital at least as early as 1780, almost in its present form, but without an index. The stethoscope, invented by Laennec, was known to those who had studied in Paris, but was as yet very little valued, and it was a long time before it came into general use. The laryngoscope, the ophthalmoscope, and test glasses for ametropia were absolutely unknown. Morbid anatomy itself had made but very little progress, and, even in our largest hospitals, the arrangements for post-mortem examinations were most inadequate. The general practitioner treated symptoms, and if a disease could be labelled inflammation, or its equivalents peritonitis, bronchitis, pleuritis, or arachnitis, the patient was bled. The medical profession had not advanced in the treatment of inflammation one whit beyond Thomas Cogan, who, in his Haven of Health, published in 1588, said, "I thinke there is none so blind or so impudent but will grant that a pleurisy is present death without bloodletting." Dr. Marshall Hall says definitely, "in the case of inflammation, no one would think of trusting the safety of the patient to any other remedy than blood letting."

Dr. Marshall Hall published his researches principally relative to the morbid and curative effects of loss of blood, in 1830, and it is evident that his remarks caused the more thoughtful physicians to reconsider their position in regard to blood letting. In 1835, Ch. A Louis published in Paris his Recherches sur les Effets de la Saignée dans quelques Maladies inflammatoires, and dedicated it

"a Monsieur Marshall Hall, Professor de Médecine pratique à Londres." Louis arrives at the conclusion that inflammation cannot be cut short by bleeding, and that bleeding exercises very little influence upon the progress of the disease in which he had studied it.

The views held by Louis were of much greater importance than those of any other teacher of his generation, except perhaps Andral and Chomel. He was the father of the modern method of note taking. Louis was Perpetual President of the Society for Medical Observation, at Paris, which had been established, in 1832, by a few of his pupils. His lectures, given in the Paris Amphitheatre at this time, were delivered to an audience of two or three thousand students, drawn from all parts of Europe and America. When Louis, stimulated by the work of Marshall Hall, had pronounced against blood letting, the whole question was actively canvassed. When serious attention was drawn to the matter, it soon became a thing of the past. How quickly this happened can be shown by the bill for leeches at St Bartholomew's Hospital: no less than 97, 300 were used in 1832; only 48,100 were required in 1842. Last year 400 were bought, and the annual purchases, for some years past, have never exceeded 1,000.

By D'Arcy Power F.R.C.S. Surgeon to, and Lecturer on Surgery at, St Bartholomew's Hospital

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