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10 To let blood by incising a vein is no novelty; what is novel is that there should be scarcely any malady in which blood may not be let. Again, to let blood in young women who are not pregnant is an old practice; but it is not an old practice for the same to be tried in children and in the elderly and also in pregnant women: for indeed the ancients were of opinion that the first and last years could not sustain this kind of treatment, and they were persuaded that a pregnant woman, so treated, would abort. Practice subsequently showed indeed that in these matters there is no unvarying rule, and that other observations are rather to be made, to which the consideration of the practitioner ought to be directed. For[p. 157] it matters not what is the age, nor whether there is pregnancy, but what may be the patient's strength. So, then, if a youth is weakly, or a woman, although not pregnant, has little strength, it is bad to let blood; for any remaining strength dies out if it is thus stripped away. But a strong child, or a robust old man, or a pregnant woman in good health, may be so treated with safety. It is mostly, however, in such cases that an inexperienced practitioner can be deceived, because at the above ages there is usually a less degree of strength; and a pregnant woman has need also, after the blood-letting, of forces to sustain, not merely herself, but also her unborn child. Not that we should be in a hurry to do anything that demands anxious attention and care; for in that very point lies the art of medicine, which does not count years, or regard only the pregnancy, but calculates the strength of the patient, and infers from that whether possibly or no there is a superfluity, enough to sustain either a child or an old man or simultaneously two beings within one woman. There is a difference between a strong and an obese body, between a thin and an infirm one: thinner bodies have more blood, those of fuller habit more flesh. The more easily, therefore, do the former sustain this sort of depletion; and the more quickly is he who is over-fat distressed by it; hence it is that the body's strength may be estimated better by its blood-vessels than by its actual appearance. And the foregoing are not the sole considerations, but there is also the kind of disease, whether a superabundance or a deficiency of bodily material has done the harm, whether the body is corrupted or sound. For if the material[p. 159] of the body is either deficient, or is sound, blood-letting in unsuitable; but if the harm is its copiousness, or the material has become corrupted, there is no better remedy. Therefore severe fever, when the bodily surface is reddened, and the blood-vessels full and swollen, requires withdrawal of blood; so too diseases of the viscera, also paralysis and rigor and spasm of sinews, in fact whatever strangulates the throat by causing difficulty of breathing, whatever suppresses the voice suddenly, whenever there is intolerable pain, and whenever there is from any cause rupture and contusion of internal organs; so also a bad habit of body and all acute diseases, provided, as I have stated above, they are doing harm, not by weakness, but by overloading. But it may happen that some disease demands blood-letting, although the body seems scarcely able to bear it; if, however, there appears to be no other remedy, and if the patient is likely to die unless he be helped even at some risk — that being the position, it is the part of a good practitioner to show that without the withdrawal of blood there is no hope, and to confess how much fear there may be in that step, and then at length, if the attempt is demanded, to let blood. In such a case there should be no hesitation about it; for it is better to try a double-edged remedy than none at all; and in particular it should be done: when there are paralyses; when a man becomes speechless suddenly; when angina causes choking; when the preceding paroxysm of a fever has been almost fatal, and it is very probable that a like paroxysm is about to set in which it seems impossible for the patient's strength to sustain. Further although it is least proper to let blood whilst food is[p. 161] undigested, yet that is not an invariable precept; for the case will not always wait for digestion. Thus if a man falls from a height, if there is contusion, or something else happening suddenly has caused vomiting of blood, although food may have been taken but a short while before, yet at once the bodily material should be depleted, lest, if it forms a congestion, it should harm the body; and the same rule will hold good also in other sudden accidents which cause suffocation. But if the character of the affection permits, it should be done then only when there remains no suspicion of undigested food; and therefore the second or third day of the illness may seem the most fitting for the procedure. But whilst there is sometimes a necessity for blood-letting even on the first day, it is never of service after the fourth day, for within that interval the material itself has both been sucked up and corrupted the body, so that then depletion can make it weak but cannot make it sound. But if there is the oppression of a vehement fever, to let blood during the actual paroxysm is to cut the man's throat; the remission is therefore to be awaited: if the fever does not decrease, but merely stops increasing, and there is no hope of remission, then also the opportunity, bad as it is, as it is the only one, should not be missed. When the measure is necessary it should generally be divided between two days; on the first it is better to relieve, and later to deplete the patient, rather than perchance to precipitate his end by dissipating his strength all at once. But if this answers in the case of pus, or of the water in dropsy, all the more necessarily should it answer in the letting out of blood. If the cause affects the body as a whole, blood should be let from the arm;[p. 163] if some part, then actually from that part, or at any rate from a spot as near as may be, for it is not possible to let blood from everywhere, but only from the temples, arms and near the ankles. Nor am I ignorant that some say blood should be let from a place the furthest away from the damaged part, for that thus the course of the material of the disease is diverted, but that otherwise it is drawn into the very part which is damaged. Yet this is erroneous, for blood-letting draws blood out of the nearest place first, and thereupon blood from more distant parts follows so long as the letting out of blood is continued; when put a stop to, no more blood comes to the part diseased, because it is no longer drawn to the opened vein. Practice itself, however, seems to have taught that for a broken head blood should be let preferably from the arm; when the pain is situated in one upper limb, then from the arm opposite; I believe because, if anything goes wrong, those parts are more liable to take harm which are already in a bad state. Blood is also at times diverted when, having burst out at one place, it is let out at another. For bleeding from a place where it is not desired ceases after something is applied to stop it there, when the blood is given another exit. Now blood-letting, whilst it may be very speedily done by one practised in it, yet for one without experience is very difficult, for to the vein is joined an artery, and to both sinews. Hence should the scalpel strike a sinew, spasm follows, and this makes a cruel end to the patient. Again, when an artery is cut into, it neither coalesces nor heals; it even sometimes happens that a violent outburst of blood results. As to the actual vein, when completely divided by a forceful cut, its two ends[p. 165] are pressed together, and do not let out the blood. Yet if the scalpel is entered timidly, it lacerates the skin but does not enter the vein; at times, indeed, the vein is concealed and not readily found. Thus many things make difficult to one who is unskilled what to one experienced is very easy. The vein ought to be cut half through. As the blood streams out its colour and character should be noted. For when the blood is thick and black, it is vitiated, and therefore shed with advantage, if red and translucent it is sound, and that blood-letting, so far from being beneficial, is even harmful; and the blood should be stopped at once. But this cannot happen under that practitioner who knows from what sort of body blood should be let. It more often happens that the flow of blood continues as black as on the first day; although this be so, nevertheless, if enough has flowed out, blood-letting should be stopped, and always an end should be put to it before the patient faints, and the arm should be bandaged after superimposing a pad squeezed out of cold water, and the next day the vein is to be flicked open by the tip of the middle finger so that, its recent coalescence being undone, it may again let out blood. Whether it be on the first or on the second day that the blood, which has at first flowed out thick and black, begins to become red and translucent, a sufficient quantity has been withdrawn, and the rest of the blood is pure; and so at once the arm should be bandaged and kept so until the little scar is strong, and this, in a vein, becomes firm very quickly.
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