by Bill Hayes
As scientific bunglings go, Galen was in good company. No less a genius than Leonardo da Vinci (1452–1519) made some spectacular ones in his notebooks of anatomical drawings. Leonardo, who dissected cadavers and sketched directly from them, set out with the express goal of being faithful only to the evidence of his eyes. Unlike Galen, he held a lifelong aversion to verbiage and believed that drawing was the only uncontestable means of expression. That being said, Leonardo still could not escape Galen’s lingering influence. This groundbreaking artist who rendered with astonishing accuracy the chambers of the heart, for example, and the fetus in utero, nevertheless added fictitious plumbing to the human body—canals, ducts, and veins—to accommodate humoral theory. Likewise, he drew the spleen cartoonishly large, proportional to its inflated role in secreting the illusory black bile. Another fallacy perpetuated by Galen and then by Leonardo was the kiveris vein, which resolved the biological puzzle of why pregnant women stopped menstruating. The answer: Menstrual blood was converted into mother’s milk, of course, and this “milk vein” conveyed it from the uterus to the breasts. Uniquely male anatomy was fictionalized, too. In cross sections of the penis, Leonardo added a phantom vein for “vital impulse,” the life-giving oomph ejected alongside sperm. Of all Leonardo’s fabrications, the cleverest, I think, was his explanation for crying. A slender vessel carried tears from the heart, the organ of the emotions, up to the eyes. (One last phantom vessel of note is the vena amoris, the “love vein,” first described by the ancient Egyptians and absorbed into Christian ceremony in the fourth century. The vena amoris, it was believed, carried blood straight from the fourth finger of the left hand to the heart, which accounts for the enduring custom of wearing one’s wedding band on this finger.)
I take it that, in the past, it was easier to believe in the unseen, the unproven. To feel certain that universal forces were reflected in the human body. Modern medical technologies all but dash these notions. Still, I share Galen’s and Leonardo’s conviction that real answers can be found within, even though they don’t show up on MRIs, CAT scans, or blood assays. I do pin my hopes on intangibles, from my simplest expectations to my most fervent dreams.
But that faith is tested. Every three months Steve gets his blood drawn. Where, historically, the removal of blood was a remedy for disease, in modern-day phlebotomy it’s done for diagnostic purposes and to gauge how a treatment is working. Nothing brings Steve and me more down to earth than the reality of bad blood counts. Nothing launches us higher than when the results say his virus is “undetectable,” which has lately been the trend. That it’s found to be undetectable is a delicious oxymoron. What this means technically is that so few “copies” of HIV exist in his bloodstream that it cannot be measured. The virus, in essence, is neutralized, not rapidly replicating and therefore less capable of inflicting harm. It also speaks to the limits of present technology. The amount of virus Steve has simply falls below the radar. While, in truth, an undetectable virus is as much of an illusion as Galen’s Vital Spirits, the word nonetheless carries tremendous weight. Right now, it’s the closest we have to “cure.”
To the extent that one can manage a life-threatening disease, Steve has been unusually successful, adhering without fail for years to a difficult regimen of pill taking. “Comply or die” is his motto, though I doubt ACT UP will make a T-shirt of it. Since starting on protease inhibitors in late 1995, he’s had no AIDS-related illnesses, although painful nerve damage caused by earlier drugs (a condition called peripheral neuropathy) persists. Along with his meds, he does everything he can to keep his mind, body, and blood as healthy as possible. I would fault his one bad habit—an overly fond attachment to Diet Mountain Dew—were I not similarly addicted.
Steve has blood drawn about two weeks before his scheduled doctor’s appointments, so that the results will be waiting when he arrives. The logistics are no more complicated than that. It’s a cakewalk compared with how convoluted taking blood became in the Middle Ages. In the fifteenth century, for example, the process depended on a fussy convergence of factors, owing more to celestial bodies than to the patients’. A physician took into account the influence of the sun and moon, the principle being that earthly tides were reflected in the flow of humors. Signs of the zodiac were, in turn, linked to body parts. Aries, for example, was matched to the head, so in late March blood would only be let from the temple. In time, the calculations got so Byzantine that a doctor had to rely on bloodletting calendars and handheld devices adopted from astronomy to determine the right moment to snip a vein.
Steve’s quarterly blood draw has always been a joint ritual, in which I drive the car and provide companionship. After all these years, it’s still nerve-wracking, yet, thankfully, we’ve come a long way from the time when the results were so consistently poor that his doctor stopped testing his blood altogether. For the past ten years Steve has used a lab called Immunodiagnostic Laboratories, located in a downtown medical building. The door to IDL looks like a private eye’s office in a film noir: hand-painted black lettering on thick mottled glass, a dark oak frame, a well-worn mail slot. Unless you had business within, you’d be hard-pressed to guess what’s behind it. The tiny waiting room inside is narrow and dim, an overheated den dominated by old magazines.
Same magazines, different location: the old-fashioned barbershop, alive and well today in small-town America, with its trademark candy-cane pole out front. This, like IDL, is a descendant of medieval bloodletting establishments. Back in thirteenth-century Europe, venesection was the specialty of the “Surgeons of the Short Robe,” who were also called barbers. (“Surgeons of the Long Robe” performed more elaborate operations.) Barbers also cut hair, stitched minor wounds, gave enemas, and extracted teeth. At this stage of worldly enlightenment, it was considered healthy for an individual to be bled a couple times a year just to remove the buildup of toxic humors. Think of it as opening the window of a stuffy room. To advertise his services, the barber posted a striped pole outside his door. When I was a boy, this pole was a reminder of the candy I’d earn if I didn’t fidget. The truth is far more ghoulish. The red stripe symbolized blood; the white stripe, the bandages; the blue stripe, the vein; and the pole itself represented the stick the patient gripped to facilitate blood flow. Barbers continued to perform venesection up through the seventeenth century, and early colonists transported the practice to America.
Although Steve never makes an appointment for a blood draw, he almost never has a wait at IDL. He needs to fast for certain tests, so we’re there first thing in the morning. Seriously groggy, Steve is like a big sedated dog that’s followed me into the waiting area. The receptionist’s window slides back, a courteous hello rings out, and Steve hands over his lab write-up. Usually, once he’s called inside, I sit down and use the time to catch up on ancient celebrity gossip. Today, with the permission of lab manager Rosemary Cozzo, I’ll be a fly on the sterile office wall.
IDL’s inner offices are as bright as a new refrigerator and divided into cool, white compartments. Steve, a foot taller than Rosemary, squeezes into one of the draw-station chairs as she studies the lab form. There’s not much room for spectating. I could easily get in her way. Fortunately she is someone over whose shoulder I can actually look, my five-eight to her five-one. As if someone has just said Go, she starts plucking empty vials, three purples, two yellows, and assembles the other equipment she’ll need.
Rosemary, who’s in her late fifties, could illustrate the dictionary definition for nurse (see also, efficiency). In her starched white, monogrammed lab coat, skirt, and low pumps, the only thing she’s missing is an old-fashioned nurse’s cap bobby-pinned to her no-fuss hair. She has a heart-shaped face and a warm smile. As she snaps on latex gloves, my eyes are drawn to a prominent vein on her left temple, a blue squiggle under her ivory skin. If Galen were here, I can’t help thinking, he would want to bleed from it. He devoted tremendous attention to mapping the body’s veins as sites for letting, everywhere from behind the ears to t
he roof of the mouth to the ankle. These days, by comparison, blood is almost always drawn from a vein in the crook of an elbow. If one is difficult to access—say, if a patient is obese—a vein on the leg might be used. There’s no such problem with Steve, who has lean, muscular arms and the big, ropy veins of a gladiator. Rosemary looks pleased, as does Steve, though for a different reason. Some days a newly trained staff person draws his blood, and that rarely goes well. Even before the needle is unsealed from its packet, Steve’s told me in the past, he can tell just how new a novice is.
“A newbie looks at your arms with a great deal of indecision, as if weighing a dozen options. But there are really only two: right arm or left,” he’s pointed out. “And when the person starts poking at your veins, self-narrating about which one looks best, this one, no, maybe this one, that’s when I think, This isn’t gonna be pleasant. It’s also a bad sign when the person rubs the alcohol on your arm like they’re trying to remove a tattoo.”
There have been mornings when I’ve been able to tell how rough a blood draw was by how damp Steve’s T-shirt is. “Three times,” he’d say, for instance, joining me in the waiting room. “Three times to get the needle in right.” Or sometimes he’d say nothing and just flash me his two bandaged arms.
With Rosemary, no uncertainty is betrayed, and this translates into a confident spearing of his vein. “It’s like cracking an egg without smashing the shell or breaking the yolk,” Steve has said; “swift and decisive.” I now watch her technique. The needle and housing come packaged like a vending-machine sandwich; Rosemary pops open the seal. She then ties a tourniquet to his left arm, swabs the distended vein, and, in the blink of an eye, slips in the three-quarter-inch needle. Steve doesn’t flinch. (I do.) He’s had this procedure done at least fifty times in the past dozen years; he’s used to steeling himself against discomfort and potential bad news. That he’s had to learn this skill, I find heartbreaking. In this context I appreciate Rosemary’s gentleness and competency. Unlike some phlebotomists, she always uses a “butterfly,” a needle stabilized against the skin with tapered “wings” and connected to a narrow, eight-inch tube. At the end of this tubing is a barrel into which consecutive vials are inserted. The vacuum in each vial sucks Steve’s burgundy-black blood up through the thin hose. He loves butterflies. Without one, each vial has to be jammed directly into the base of the needle, which tends to rip up the vein. Butterflies are expensive, so not all labs use them.
Every piece of equipment Rosemary employs has evolved from basic bloodletting tools. The pressurized vials, which look like test tubes with color-coded caps, are a counterpart to bleeding bowls, large clay or pewter basins placed below the incision site to catch the blood. These were often graduated like measuring cups so the phlebotomist could tally the amount removed before discarding it. The modern syringe has a mixed heritage: Its housing is descended from the small glass cups used for suctioning blood from tiny cuts made in the skin. “Cupping” has a history almost as long as bloodletting. In practice these cups, heated over a flame, were applied to different parts of the body; a partial vacuum held them in place. Doctors used cupping for localized pain or if a patient was too young or weak to be bled properly from a vein. The syringe needle actually has the most ancient origins, reaching all the way back to the earliest human’s use of a thorn or animal tooth to break the skin. Jumping forward to the early eighteenth century, the preferred implement for piercing a vein was the new spring lancet, as compact as nail clippers, with a trigger-activated blade. One Baltimore bloodletter so adored his spring lancet that he was driven to poetry. “I love thee, bloodstain’d, faithful friend!” one stanza began.
The most cringe-inducing tool of the bloodletter was the leech, although nothing in Rosemary’s work space is remotely related, thank God. Like cupping, leeches had been used since antiquity as an auxiliary to venesection. Placed on the skin, these bloodsucking creatures, close kin to earthworms, fed on a patient until sated. After about an hour, they’d drop off. A doctor would typically employ five to ten at a time, although to be covered with fifty wasn’t unheard of. Leeches were handy for hard-to-reach spots, such as up the anus, down the throat, or inside the vagina. Tiny thread leashes kept the leeches from getting lost. The leech of choice was the European Hirudo medicinalis, exported worldwide from Sweden and Germany. In 1833 alone France imported 41.5 million of the suckers. A standard part of medical practice, leeches were kept close by in water-filled clay or glass jars.
A woman self-medicating with leeches, as depicted in a seventeenth-century woodcut
One would think that the huge gains made in understanding human biology from the Renaissance forward would’ve curtailed the popularity of bloodletting. But no. In fact, the practice reached its height in the eighteenth and nineteenth centuries. The Western world’s most powerful people, receiving what was considered the very best of care, were needlessly bled, cupped, and leeched. Retired president George Washington’s death in December 1799 was hastened by excessive bloodletting, for example, historians conclude. The president, sixty-seven and suffering from a severe throat inflammation, was tended by three top physicians who could have saved their patient’s life had they had access to two things not yet invented: antibiotics and steroids. Instead, they bled Washington four times within a twelve-hour period, a total of 2.5 quarts. He died that day. It sounds like manslaughter to me, but the doctors’ actions were considered both medically appropriate for the time and even heroic. Under less grave circumstances, the rule of thumb for a single letting session was to keep the vein open until the patient passed out. “Bleeding to syncope,” this was called. In a statement of near Galenic aplomb, the English physician Marshall Hall wrote in 1830: “As long as bloodletting is required, it can be borne; and as long as it can be borne, it is required.” Dr. Hall and his fellow physicians were, of course, a few facts shy of our modern understanding. A healthy person can, in fact, replace a lost pint of blood in about an hour, but it takes weeks for the oxygen-carrying red blood cells to return to normal levels. Thus, frequent and copious lettings served only to create in patients an endless cycle of chronic anemia. These days the amount of blood a phlebotomist withdraws for testing is minor, about half an ounce per vial. And rarely more than seven vials are collected. If a patient does faint, more than likely it’s from a touch of hemophobia, fear of the sight of blood and/or needles.
Rosemary became a licensed phlebotomist in 1965 and thinks of herself as an old-timer in the field. “I started in a little mom-and-pop lab across the hall,” she recalls, gesturing the direction with a tilt of her head. “In those days I’d both take blood and perform basic tests. Everything was done manually—cholesterol levels, blood sugar, enzymes, pregnancy tests.” Wistfulness is just a flash in her eyes. Of course, she explains, the whole field changed virtually overnight with AIDS. Safety procedures tightened. New tests were introduced, others replaced, most now performed with computers at a facility across the Bay. The patients changed, too. For the past fifteen years the majority of Rosemary’s clients have been gay men, like Steve.
“You must have lost a lot of patients,” I say quietly.
Without glancing up from her work, Rosemary considers this. “Oh, gee,” she begins, then changes course. “I’ve gotten to know a lot of patients,” she replies with a smile to Steve.
“Okay, you’re about done for today,” she adds, watching the last vial fill.
Rosemary withdraws the needle while pressing down with a wad of cotton so large it looks like a chunk of pillow. “Hold that, will you?” she tells him. She deposits the butterfly and tubing into a Sharps container, a receptacle for used needles, and then affixes the clump of cotton to the site with half a foot of tape. And that’s that. The whole procedure has taken no more than five minutes. I back out of the cubicle, Steve rises, and, while the three of us small-talk for a moment, I am struck by this tableau: Rosemary stands between us cradling in her hands the vials of his blood. That’s a part of his body, I think; it
has passed through his heart. Those five finger-shaped vials must still be warm, like she’s holding his hand in hers. We say goodbye as she gingerly places each one inside a shipping container emblazoned with BIOHAZARD signs.
THREE
Biohazard
PRIOR TO IDL, STEVE HAD REGULARLY HAD HIS BLOOD drawn at a SmithKline Beecham lab near his doctor’s old office. He stopped using this lab in 1994 and we didn’t give it another thought until one day five years ago when I brought in the mail, which included a special-delivery packet from the blood lab.
“Nothing good ever comes by certified mail,” Steve muttered, frowning, as he tore open the manila envelope and pulled out a letter from SmithKline Beecham’s president, dated May 27, 1999. According to the letter, a phlebotomist who’d worked at the lab Steve frequented had reused needles from blood draws (butterfly needles, it turned out). The woman had admitted to doing this “occasionally,” thereby possibly exposing uninfected patients to HIV, hepatitis, and other illnesses. (It was unclear whether her actions were intentionally criminal or inexplicably ignorant, but a year later she would be indicted on multiple felony charges of assault with a deadly weapon—dirty needles.) Records showed that Steve might have been one of her patients, the letter suggested; she wasn’t named, so Steve wasn’t sure himself. Those who wished to get tested for possible exposure could do so and receive counseling at SmithKline Beecham’s expense.
