Five Quarts: A Personal and Natural History of Blood (2 page)

It is this conquering of one’s worst fears that I’ve always found satisfying, in tales spun on a grand scale and, more so, in those played out on the mortal plane. I’ve certainly known times when I’ve been paralyzed by fear or self-doubt but was still able to dig down and push through. These kinds of struggles almost always have unexpected results, as Perseus also discovered. Before his weary eyes, the thin layer of Gorgon’s blood began to ripple and, suddenly, an immaculate, white-and-gold creature leapt out, the winged horse Pegasus. It spread its magnificent wings and flew off to join the Muses, where it would come to serve as the spirit of poetic inspiration. But the pool of blood held one last surprise. Out crawled a foul giant brandishing a sword, the warrior Chrysaor, who’d go on to sire a three-headed monster and a man-eating daughter. The story of Perseus and the Gorgon has thus inspired mine, a personal odyssey through the history of hematology, from the classical age to the modern and, along the way, into my own past. With blood as the mirror, I look at my life and see what emerges.

T
WO

Vital Spirits

AT THE GYM, TWENTY-FOUR MINUTES INTO A RUN, THE speed set at 7.1, incline at 5 percent, my feet barely tap the treadmill as I hit mile three. I am in the silence between songs on my Walkman, then Björk’s “Enjoy” begins. Shoulders thrown back, heart pounding, a shiver runs up my spine as I push against the resistance. All five quarts of blood pulse and churn and, without being able to pinpoint the exact moment, I transcend, riding a wave of endorphins. Outer and inner rhythms merge and I turn up the volume. I enter a kind of cardiovascular nirvana where my soul seems to burst from my chest. Music and breath, blood and sweat, this is the closest I come to God.

Even after stepping off the machine, I am six inches above ground, as clear and weightless as the air I’m devouring. This divine conjunction of sound and movement comes only once or twice a month, if I’m lucky. Far more than an “endorphin high”—that euphoric sensation exercise can induce—it is difficult to re-create. And when I get into this groove, I cannot say for sure where it comes from, whether I’m drawing upon energy from deep within my being or responding to a force outside myself.

Steve knows the exact sensation, though he has a harder time nowadays physically attaining it. A man who’s nothing if not fearless with his metaphors, Steve told me a couple of years back that one of the clearest descriptions of this feeling, this quasi-spiritual energy surge, could be found in a comic book. I was dubious, but as he told me about a character called the Flash, I began to see how perfectly it did fit. You see, he explained, this superhero is able to run superfast because he taps into a field of energy called the Speed Force.

I wanted to know what it looks like in the comic, how the Flash finds it, that sort of thing.

“It just exists,” Steve said, matter-of-fact. “He’s able to ‘feel’ it.” He smiled and shrugged, adding, “He can also share his speed with other people, share his power.”

The strength Steve and I have drawn from each other over the past decade has certainly gotten us through some rough times as he has battled AIDS. Of course, love and support are just a part of our arsenal. His survival has depended, to a great extent, on superb doctors. And the “miracles” we’ve experienced in our life—the powerful new drugs approved just in time, the wholly unexpected positive blood work, Steve’s Lazarus-like return from dire illness—seem more a product of the pharmaceutical industry than the intervention of a divine being. While things are currently not great, they’re not terrible, either. We’re in a holding pattern of hope, anxious but not desperate. We have placed our faith in science.

But faith does not preclude questioning. I’ve never missed joining Steve at a doctor’s appointment, and we always arrive with a list of questions to raise, whether about symptoms, drug side effects, or medications in the pipeline. The three of us go through Steve’s blood work test by test to assess how his regimen is working. When his doctor recommends a new drug, we then do our own research in treatment journals and online before filling the prescription. The scrutiny to which new medications are subjected today is easy to take for granted. It’s mind blowing, by contrast, to look into the history of a long-lived remedy for which the most extravagant claims were made when no conclusive proof of its value ever existed: bloodletting. The practice of withdrawing blood to treat a spectrum of ailments, everything from insomnia to hemorrhage, only died out in the United States in the 1920s. It had endured throughout much of the world for more than twenty-five centuries—twenty-five centuries!—making it, in my view, the longest-running clinical trial in medicine, one that involved millions of patients and persisted on nothing but anecdotal evidence.

The earliest and most influential surviving texts on bloodletting were written by a Greek doctor named Galen (
A.D
. 129–200), who began his career tending to wounded gladiators and rose to become the Western world’s supreme authority on medicine. Galen’s views were considered medical gospel for fourteen hundred years, and I can understand why. He makes an illogical practice sound downright reasonable. His writing voice is so clear and commanding, it is almost a summons.

Galen first made a name for himself at the Coliseum in Pergamum, a small kingdom in what’s now western Turkey. There, as the chief physician to the gladiators, Galen was the ancient equivalent of an ER doctor, treating the freshly butchered in his trauma ward in the basement of the stadium. Just as a modern physician might hear the distant wail of an ambulance and know a body was on its way, Galen may have had his own alarm system in the collective gasps and muffled yelps of the crowds overhead. This gifted twenty-eight-year-old, who’d begun studying the healing arts at fourteen, had an impressive first year on the job: Not a single gladiator died of injuries, which was unheard of, given that the combatants fought with brutal-looking tridents and two-foot-long swords. The position also gave him an unprecedented scientific advantage: rare, close-up views inside still-living bodies.

Neither of Galen’s most distinguished predecessors, Aristotle (384–322
B.C.
) and the Greek physician Hippocrates (460–375
B.C.
), had ever dissected a human body. And those who had performed dissections noted that the corpse’s arteries were empty (because, as a modern pathologist would explain, blood drains back into the veins once the heart stops). This led the great thinkers to the false conclusion that the arteries contained only an air-like substance. Hence
artery,
derived from a Greek word meaning “air duct.” Galen, with virtual human vivisections at his disposal, was able to correct this error. Clearly, the arteries were filled with blood. Further, he accurately traced the course of blood from the right side of the heart to the left via the pulmonary artery and lungs. The most crucial discovery, however—that the arteries, veins, and heart work together as a circulatory system—would not be made until the 1600s.

Despite his new insights, the foundation of Galen’s medical philosophy did not change. He embraced the ancient Hippocratic theory that a person’s state of health was determined by four fluids, or humors—blood, phlegm, yellow bile, and black bile—which had to be in perfect balance within the body for good health to prevail. When one or more of these fluids was overabundant or insufficient, the body’s inner scales tipped and disease resulted. The humor called black bile deserves special mention because, as modern medical historians point out, it is a fictitious substance, though Galen firmly believed it existed. Conceptually, there
had
to be four humors—not three, not five—because the body was seen as a microcosm of the universe, which was organized in patterns of four: the basic elements (earth, air, fire, water) and their cosmological correlates (the Earth, sky, sun, sea); the four seasons; and what were known as the Aristotelian “qualities” (cold, damp, hot, and dry). All of these aspects were interrelated, sometimes overlapping, in an elaborate system that Galen would later codify in his medical books. Phlegm, for example, was cold, damp, watery, and wintry, while blood was hot, damp, air-, and spring-like. That the microcosm mirrored the macrocosm was a defining part of Galen’s diagnoses. After patching up a gladiator who’d lost a large amount of blood, for instance, he would likely have prescribed a huge increase in the man’s dietary intake. In the doctor’s view, the liver—the body’s hot, damp organ—was “the principal instrument of sanguification”; it converted digested food into blood. The patient, by gorging himself, would restore his humoral balance. Were another gladiator unable to fight because of, say, a high fever, Galen would have diagnosed “plethora,” an excess of humors in his body. As treatment, Galen would have turned to copious bloodletting.

With only a slight shift in thinking, I can understand Galen’s rationale. Since physical appearance was one of the few diagnostic tools available to him, it’s not wholly absurd that Galen would’ve concluded from a flushed, fevered face that the patient was suffering from superfluous blood. Or, similarly, that a sallow complexion meant that the gallbladder—the hot, dry organ—was producing too much yellow bile. To have explained to Galen that things floating in the blood actually caused disease would’ve made as much sense to him in his day as saying his fax needed paper. In second-century medicine it wasn’t the quality of blood that was at issue, but the quantity. One could have too much of a good thing.

Doctors in Galen’s time had other methods for cutting off the body’s production of fresh blood: getting the patient to stop eating for several days or inducing vomiting (after all, who doesn’t look a bit bloodless after throwing up?). But Galen preferred the immediacy of
venesection,
opening a vein. He used a pointed, double-edged metal scalpel, an instrument of the period called a
phlebotom
(from the Greek
phlebos,
for “vein,” and
tome,
meaning “to cut”), from which came the medical term for drawing blood,
phlebotomy.
Few of these original devices survive to the present day, but one found in the ruins of Pompeii was probably typical: a slim, three-inch-long bronze blade mounted in a decorative handle.

When Galen put a phlebotom to a vein, he was continuing a medical tradition that had existed since at least 2500
B.C.
, the approximate date of an Egyptian tomb painting showing a noble being bled at the foot and neck, the earliest-known depiction of phlebotomy. Of course, this is not meant to suggest that there hadn’t been two and a half millennia of naysayers, just that scant records survive. What is known is that, from Hippocrates’s day forward, the critics of bloodletting were as passionate as the advocates. Galen discovered this firsthand when he moved to Rome, the big city, in the year 162. A local celebrity in Pergamum, the thirty-three-year-old found that his specialty made him an outsider here, and he immediately butted heads with the Roman medical establishment. His biggest opponent, strangely enough, was a man five hundred years dead, the Greek physician Erasistratus (300–260
B.C.
), who’d taught at the celebrated medical center in Alexandria and had been vehement in condemning venesection. He had a legion of vocal followers, known as Erasistrateans.

In a colonnaded hall opposite the Forum, Galen joined others in giving public lectures during his first year in Rome. In the spirit of self-promotion, he held forth on a range of topics, including, notoriously, his enthusiasm for bloodletting and his disdain for the teachings of Erasistratus. The Erasistrateans in attendance were not pleased, although their heckling probably just drew larger crowds. Galen relished stirring up controversy. He was also eager to drum up business. Unlike the majority of Roman physicians, he proclaimed himself to be above all sects, the leader of his own school of thought. He ingratiated himself to the audience, which swelled over time as word spread of the brash, charismatic healer. Bored with chariot races at the nearby Circus Maximus, dignitaries dropped by to see the theatrical young man who, for example, demonstrated vivisection with a squealing pig. Shorthand writers transcribed his speeches and, within months of his arrival, Galen’s views on bloodletting were published in the book
Against Erasistratus,
the title alone like a gauntlet thrown down.

A modern reader of the book and its sequel,
Against the Erasistrateans Dwelling in Rome,
gets a vivid sense of this renegade doctor, a man whom one nineteenth-century historian described as a “quarrelsome, self-willed spiteful brawler, who goes for his adversary foaming at the mouth.” Nonetheless, Galen’s words lift from the page and, like a gentlemanly participant in a cross-time debate, he reiterates his opponent’s positions before dissecting them, even quoting the dead Erasistratus verbatim. This is fortunate since Erasistratus’s words survive only within the works of others.

Galen starts off on a conciliatory note: The two physicians would not have disagreed, he admits, about what causes illness—humoral imbalance—or about the final goal of treatment, the “evacuation” of the plethos. They parted ways when it came to the means. “The easiest and promptest course of action is to open a vein,” Galen states. “In this way, we evacuate the actual inflammatory materials themselves. And nothing else.” It’s a remedy that was “esteemed by the ancients.” By contrast, the main Erasistratean solution, starvation, “apart from the long time it requires, evacuates the whole system indiscriminately.” Even now, I can almost hear Galen’s
tsk-tsk,
as well as the grumbling of the Erasistrateans gathering at the back of the crowd.

In addition, starvation, Galen warns, is accompanied by a host of evils: severe fatigue, nausea, heartburn, constipation, and perhaps the most serious side effect, turning the other humors “bilious and painful,” thereby exacerbating rather than alleviating the imbalance. Pausing, I imagine, to let the crowd absorb these grim facts and to allow the stenographers to catch up, Galen then adds, “Yet Erasistratus sees none of these.” He and his adherents are “like blind men, who although a smooth, broad, and direct road is near, often take a narrow, rough, and long one, and go by a circuitous route.”

A surgeon by training and temperament, Galen next attacks their use of powerful laxatives and purgatives as a foolhardy reliance on fate. “The flow to the stomach cannot be stopped in the way you can immediately put an end to the bleeding by putting your finger to the divided vein.” He then brings this argument home: A “grave disturbance of the entire body [may occur] as a result of being evacuated either insufficiently or to excess,” whether it be loss of consciousness or “pulselessness.” Indeed—pause for dramatic effect—“the ultimate misfortune often ensues in this state.”

What’s fascinating is that Galen’s own last remarks could equally have been used to denounce his beloved bloodletting. Erasistratus held that it was impossible to determine precisely how much excess blood a patient had and therefore how much should be let. Further, he had seen the handiwork of incompetents who’d slashed through tendons, nerves, and arteries in their hunt for a vein, leaving behind lifelong damage if not death. The practice was so fraught with risk that Erasistratus viewed bloodletting as tantamount to committing murder. But Galen felt himself beyond reproach. He well understood that a patient could die quickly if an artery were severed, which was the primary reason he rarely attempted opening these thicker vessels with their greater blood volume. (They were also harder to access, anatomically speaking.) As for patient safety, Galen again placed himself above Erasistratus, who “paid little attention to examining patients, but stayed at home and wrote down mere opinions.” Adamant that only an experienced physician should perform phlebotomy—he, of course, being best suited—Galen advised cutting parallel to a vein, never across it, and keeping puncture holes small. Bloodletting sounds ghastly, but, in fact, the amount Galen drained at one sitting was modest—about a pint at most, no more than you’d give today at a blood bank. However, the doctor often chose to repeat the procedure day after day after day.