Bloodletting and Germs: Technology’s Progress Requires Generalists
Thomas C. Rosenthal MD
Emeritus Professor and Chair of Family Medicine
Jacobs School of Medicine and Biomedical Sciences
University at Buffalo
Hippocrates recommended bloodletting two thousand years before Leeuwenhoek found animalcules under his microscope. In 1793 Benjamin Rush claimed patients, if bled aggressively, could survive yellow fever. Technological advances of the nineteenth century saw those traditions of medicine give way to scientific methods as hospitals isolated patients according to symptoms and opinions based on single case reports lost sway. However, discovery is unpredictable. Then and now, it requires generalist physicians, relationship bound to their community and patients, to connect patients to new knowledge, tools, and technology.
It was Hippocrates who in the third century BC encouraged releasing warm, red blood as the most efficient method for reducing the heated flushed-faced condition associated with fever. In the second century AD, Galen theorized that bloodletting rebalanced humors and corrected human moods. In his 1719 novel Daniel Defoe describes Robinson Crusoe undergoing ‘venting’ blood to cure an illness after his rescue. In an 1805 treatise Benjamin Rush claimed that if bled to the point of fainting, no victim of the 1793 Philadelphia yellow fever pandemic died. Rush went further, suggesting a regular spring bleeding and bowel cleansing could prevent illness.
But the nineteenth century’s second quarter new speculations challenged the dogma of traditional medicine. First came Samuel Hahnemann’s homeopathy, followed by Samuel Thomson's herbal and sweating remedies and Sylvester Graham’s wheat germ diet. They offered little in the way of advanced cures, but patients liked the newer, gentler treatments and Dr. Oliver Wendell Holmes was prompted to declare, “I firmly believe that if the whole material medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind and all the worse for the fishes.” But Holmes hedged, warning that new remedies should be adopted cautiously and long held therapies should not be abandoned lightly.
The wedding of science to medicine really began in Europe. In 1836, a mentor of Dr. Holmes, Parisian Pierre Louis, isolated patients with pneumonia in separate wards of a Paris hospital and conducted what may be the first published randomized controlled trial. Louis found that bled patients experienced transient relief of symptoms, but if bled repeatedly they were more likely to die. Reluctant to condemn venesection however, he emphasized proper diet, ample sleep, while declaring physick a humble and limited art.
The conservative nature of physicians and the fits and starts of science made for slow progress. In a series of quarrelsome essays published in the Boston Medical and Surgical Journal in the 1840s, Dr. Joseph Gallup asserted patients suffered mostly inflammatory disease, therefore bleeding and purging was essential to relieve the body of its excesses. Dr. William Tully countered that Gallup was old-fashioned and new information confirmed disease is a state of depletion calling for stimulants, which he defined as alcohol and quinine. But as large hospital wards continued to group patients according to symptoms, patterns of illness became more apparent and the search for external causes took shape.
Encouraged by the New York State Medical Society, village doctors used vaccination to nearly eliminate smallpox by the second quarter of the early nineteenth century. But the introduction of regularly scheduled stagecoach service and the opening of the Barge Canal facilitated community to community spread of typhoid, scarlet fever and measles. Case mapping revealed that the 1832 cholera epidemic spread from Europe, to Montreal, to Albany, then to New York City and Buffalo at the speed of human travel. By 1834 cholera disappeared, only to return in 1849, killing thirty percent of its victims.
Rapidly decreasing printing costs emboldened the highly competitive newspaper and magazine trades to ponder the gentler therapies of homeopathy, shocking graduate doctors out of their complacency about the competition alternatives offered. Medical care had to improve, and medical journals that provided information about physiology, biology, chemistry, epidemiology, and microscopic pathology proliferated. The Civil War forced Army surgeons to work in teams, exposing great differences in skills and technique. When the military tried to standardize procedures, they found little science to support even widely accepted traditional treatments. Army records tracking patient outcomes ignited new investigations, and long held provincial village perspectives were shattered as soldiers and doctors marched through previously unheard-of American communities. Newspapers took on national attentions and railroads made America seem smaller.
In 1816, also in Paris, Rene’ Laennec found that a hollow wooden ear trumpet amplified lung sounds. He called his technological breakthrough a stetho-scope (chest-scope). In 1852 Ireland, George Cammann perfected a flexible, bi-aural stethoscope with ear knobs, a bell and diaphragm, and a rubber rim to improve patient comfort. With practice a physician could now localize and isolate sounds, or add a forehead brace to hear fetal heart sounds. Dr. Austin Flint at the University at Buffalo, expanded on Laennec’s work by comparing autopsy findings with premorbid heart sounds. Expanded usefulness and functionality resulted in the stethoscope replacing the mortar and pestle as the iconic symbol of physick.
Post-Civil War America also saw marked improvements in laryngoscopes, otoscopes, ophthalmoscopes, clinical thermometers, speculums, forceps, sphygmomanometers and hypodermic syringes. Much improved microscope optics eased the examination of urine, blood and pus as physicians gathered more and more information beyond the patient’s perspicacity. Unanticipated inter-operabilities emerged, like using the hypodermic syringe to drain tubercular effusions found with a stethoscope. Anesthesia made advances in surgery possible but demanded improved antisepsis to prevent post-operative inflammations. In 1850, New York’s State University coordinated a nationwide study conducted by village doctors who measured humidity and reported patient symptoms daily. The study detected no relationship between illness and miasma. Soon a chemist, Claude Bernard, discovered that chloral hydrate became chloroform in the blood stream and could induce sleep. Then, in 1876, Robert Koch confirmed the infectivity of the anthrax bacillus and established postulates for infectious disease investigations.
Generalist doctors like Jabez Allen, MD who practiced in East Aurora, New York from 1834 to 1884, tackled the whipsaw of scientific advancement with curiosity and study. His Vermont medical college taught him to bleed and purge and his professors voiced both interest and censure about the role of germs just as medical journals began replacing single case stories and opinions with more scientific methodologies. In 1849 the American Medical Association, founded to confront competition from homeopaths and herbalists, encouraged local medical societies to include scientific presentations and promote interactions between community doctors and researchers. These forums gained Dr. Allen an acquaintance with Dr. Flint who needed the practical experience of generalists like Dr. Allen to validate his research on heart auscultation. Collaborations encouraged generalists to gain skills in auscultation and made Dr. Flint’s medical textbook the bestselling textbook of the 1870s.
As more signs, symptoms and data revealed more patterns, diagnostic labels became the language of medicine, further enticing observation science and experimentation to search for external causes. Science and improved training came to distinguish the graduate physician from the quack. Post-Civil War medical colleges adopted the French model that required students to observe, examine and keep notes on large numbers of patients quartered in almshouses or hospitals. These concentrated experiences dramatically improved a graduate’s ability to distinguish normal from abnormal while expanding the medical faculty’s own clinical experience. Faculty taught, conducted research and wrote, but making a living required community physicians to refer their special cases.
The 1878 national AMA meeting was held in Buffalo and germs dominated the dialog. In the 1870s Pasteur had nailed the coffin on spontaneous generation, Tyndall proved that bacterial spores floated in the air, Edinburgh’s Joseph Lister toured America lecturing on the use of dilute carbolic acid to prevent post-operative infections, Koch proved that bacteria caused anthrax, and New York recognized qualified graduate physicians by re-establishing licensure. In the next decade the City of New York Health Department established one of the first laboratories for culturing bacteria, leading directly to the discovery of diphtheria anti-toxin by 1896.
Through it all community doctors administered to patients and families. Physician obituaries included phrases like: “The doctor possessed in a very marked degree the confidence of his numerous patients. His devotion to the welfare of those under his care could scarcely have been surpassed and his generosity in other matters was well known to all his friends.” Every generation has needed a doctor friend who they could trust to sort through the newest technology and select what was best for them.
Today, communication far surpasses the speed of the telegraph and smartphones can access more information than a whole wall of books. It took forty years for science to disprove the miasmic theory of cholera and culture Vibrio cholerae. In 2020 it took only weeks to learn that COVID-19 was caused by a virus, a few more months to understand that remdesivir helped, and just under a year to develop a vaccine. Still the primary care doctor manages patients through a blizzard of discovery, reading the science and making recommendations. Speed challenges practice, but it also excites interest. Discoveries still arrive in fragments, each one battered by diverse opinions. But families will always need a doctor able to match the potential and limits of science with the potential and limits of those suffering illness.
For more about Dr. Jabez Allen and generalism in the nineteenth century see the historical novel: Rosenthal, T. C. (2020). Bloodletting and Germs: A Doctor in Nineteenth Century Rural New York.
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