Five Quarts: A Personal and Natural History of Blood

by Bill Hayes

  “The Queen sent for me about 3, and I had to tell her the whole story of the illness,” he wrote in a letter to his sister, dated January 17, 1892. “She was sitting in an ordinary chair at a writing table, and of course I had to stand. I was there almost exactly an hour and a quarter.” Though he betrays not a whit of emotion in this retelling, the royal visit did go well. Soon thereafter he was appointed Physician Extraordinary to Queen Victoria.

  William Broadbent held the queen’s wrist. Now a queen holds mine: one named Ernesto, the physician’s assistant in my doctor’s office. Up to this point on a recent visit, nothing extraordinary has occurred. A good forty minutes after my arrival, Ernesto flung open the inner office door and sang out, “Willlllllyaaaammm!” He then weighed me in the hallway, led me into a stuffy cubicle, quizzed me about why I’d come, and just as I was beginning to regret making the appointment—to broach the topic of anti-anxiety medication, no less—something relatively pleasant happened: The room went quiet. It was time for Ernesto to check my pulse.

  At that moment it seemed as if a tiny Dr. Broadbent perched atop Ernesto’s hooped earring, whispering instructions in his ear: “Three fingers should be placed on the artery, and it will not be amiss to observe the old-fashioned rule of letting the index finger always be nearest to the heart; the different points with regard to the pulse should then be ascertained, each by a distinct and separate act of attention.”

  Ernesto’s technique is flawless: his grip, firm yet gentle; his bare hand warm. Utterly focused, he studies his wristwatch. He stands so close to me, I can feel his pillowy belly at my arm. I have the sensation of being anchored by this heavyset man as he listens with his fingers to my heart. I stop thinking about what brought me here and what Dr. Knox might say. For thirty seconds I am absolutely grounded in present tense.

  Then Ernesto looks up from his watch, releases his grip. “Sixty-eight. Heart rate’s sixty-eight,” he says. “Perfectly normal.”

  At which point I feel tempted to compliment him back: How fashion-forward of you to be wearing white clogs, for instance. But no, I could never say that with a straight face. Anyhow, the moment is lost. He’s already jammed a thermometer into a plastic sleeve and has placed it under my tongue. My pulse appears on my chart as a scribbled number at which Dr. Knox will scarcely glance. Dr. Broadbent would’ve been disappointed.

  Today pulse palpation is a central part of an exam only in cases of serious cardiovascular disease. What’s more, in hospitals and many doctors’ offices, beats-per-minute is often obtained not by hand but through a monitor attached to the blood pressure cuff or a sensor clipped like a clothespin to the index finger. These digital devices, sensitive enough to detect the heart rate through capillaries in the skin, operate just like the pulse calculators built into sports watches, stationary bikes, and so forth. They’re used in the interest of speed, accuracy, convenience, and, I’m told, patient comfort. Some people do not like to be touched. While there’s no such high-tech revolution yet under way at Dr. Knox’s office, Steve’s doctor visits are different. In an office gone digital, the haste with which his body is stripped of its secrets—weight, body temperature, heart rate—is dizzying. Every second shaved from an exam is, of course, money saved by an HMO. But at a time when patients are encouraged to turn to WebMD with the questions their family doctor didn’t have time to answer, it strikes me that pulse taking by hand remains an uncorrupted tradition, one with strong roots in the classical age.

  In ancient Greece the art of feeling the pulse (sphygmopalpation, from the Greek sphygmos, for “throb”) was first taught by the physician Praxagoras, a contemporary of Hippocrates, one of the earliest fathers of Western medicine. Praxagoras’s star pupil, Herophilus (335–280 B.C.), was the first physician to methodically time the pulse. He used a primitive water clock that had been invented to time the speeches of orators. Erasistratus, Galen’s phantom bloodletting rival, is credited with incorporating the pulse into clinical exams. His first diagnosis: lovesickness, in a young man whose pulse quickened dangerously whenever his crush drew near. The attention paid the pulse at that time is all the more impressive given that the ancients were missing huge pieces of the puzzle. Though these healers knew they had their fingers on the pulse of the body’s innermost workings, they did not understand the actual role of the heart in circulating blood any better than they knew the distinction between veins and arteries.

  Not until the intellectual watershed of the Renaissance did this begin to change. A major upheaval in how the body was viewed required first the systematic dismantling of the hallowed teachings of Galen. A key figure in this deconstruction was the Belgian anatomist Andreas Vesalius, who, in his illustrated seven-volume masterwork of 1543, soundly disproved two hundred of Galen’s factual errors. No, the liver did not distribute blood throughout the body. No, blood did not “sweat” from the right side of the heart to the left. No, animal anatomy wasn’t interchangeable with human. And on and on. Vesalius, among others, paved the way for Great Britain’s William Harvey, who in 1628 turned the world on its ear: Blood circulates, he announced in his historic An Anatomical Essay on the Movement of the Heart and Blood in Animals. For its role in launching the modern era of medicine, contemporary historians have called Harvey’s book one of the three greatest works in the English language—all three, curiously, dating from the early 1600s—alongside the King James version of the Bible (1611) and the First Folio Edition of Shakespeare’s plays (1623). By comparison with these other two works, Harvey’s tour de force is small in size (five by seven inches), short in length (seventy-two pages), and written in deceptively simple language.

  “The movement of the blood in a circle is caused by the beat of the heart,” he declared, summing up in one sentence his entire theory of the circulatory system. Then, as if to head off any But what about . . . ? from the unconvinced, Harvey added, “This is the only reason for the motion and beat of the heart.”

  Through animal vivisection, human dissections, and observations of living patients, Harvey poked more holes in Galenism. Blood did not ebb and flow within the same vessels, as the Greek physician had taught. Instead, the arteries carry it away from the heart, and the veins bring it back. Valves inside the veins help the depleted blood make the return trip. Further, although he couldn’t explain how, Harvey theorized that blood passes via some unknown mechanism from the arteries into the veins. The crude new microscopes of his day were not nearly powerful enough to reveal the minute bridging vessels now known as capillaries. In a final slap to Galen, Harvey also proved that the arteries themselves did not contract and dilate like blacksmith bellows, thereby producing the pulse. “The pulsation of the arteries,” Harvey wrote, “is nothing else than the impulse of the blood within.”

  William Harvey

  Accomplishments notwithstanding, Harvey was not necessarily a “better” scientist than Galen, contemporary writer-physician Jonathan Miller contends. “The difference between the two men is not one of ingenuity and skill—in fact, if these were the sufficient conditions of scientific progress, Galen rather than Harvey might have been the discoverer of the circulation of the blood.” Instead, the difference between them was one of “metaphorical equipment,” Miller argues in his book The Body in Question (1978). Galen likened the heart to a common household item of his time, the oil lamp: The organ heated and transformed blood from a dusky fuel to a flaming scarlet stream, illuminated by Vital Spirits. In his reckoning, however, that was the extent of the heart’s role. “Galen’s inability to see the heart as a pump was due to the fact that such machines did not become a significant part of the cultural scene until long after his death,” Miller states. By the end of the sixteenth century, though, mechanical pumps began to be widely employed in mining, firefighting, and civil engineering, such as in the design of ornamental public fountains. Therefore, when Harvey conducted his experiments (among them, watching as hearts slowly failed during animal vivisections), he was able to see the organ for what it was: a pump, re
sembling the marvelous inventions in use around him.

  With the medical community electrified by Harvey’s discovery, a new interest was sparked in injecting substances directly into the bloodstream. But a simple means for such a procedure did not exist. Enter: British architect Christopher Wren. In 1656 Wren fashioned a crude syringe from a hollow feather quill fastened to a bladder and was able to pump opium straight into a dog’s vein, thus creating a method for IV therapy as well as one very mellow pooch. Wren’s success inspired others to infuse animals with not just medications but also wine, beer, milk, urine, anything liquid—often with fatal results—and eventually to try blood. In 1665 the British anatomist Richard Lower performed the first successful blood transfusion in animals, linking one dog’s artery to a recipient dog’s vein with a quill piping. The transfused dog had first been bled almost to death, so its fast return to vim was hugely dramatic, bordering on miraculous. The floodgates were now thrown wide open.

  The next step: animal-to-human blood transfusions. Over the following couple of years, a spate of attempts were made, though none for what we’d now consider logical or medically appropriate reasons—to treat hemorrhage, say, or to bolster red blood cells in acute anemia. The physiological unknowns at the time were considerable. Neither the component parts of blood nor its role in transporting oxygen, nutrients, hormones, and pathogens had yet been discovered. Interestingly, the idea of blood compatibility was considered, though not in the modern sense of the phrase. (Blood typing did not arise until the early 1900s.) Rather, a transfuser had to be cautious when mixing blood because it contained qualities. As perfume was the essence of a flower, so blood was a concentrate of traits, whether in man or beast. A fearless soldier had brave blood, for instance. A raging bull had angry blood. In theory, then, a transfusion had the potential to restore strength to the weak, calm to the crazy, and so on. Hence in 1667 French scientist Jean-Baptiste Denis introduced the docile blood of a calf into the circulatory system of a raving madman. But did it work? Well, Denis thought he had triumphed. The recipient had vomited profusely and urinated what looked like liquid coal—he was being purged of his lunacy! From a modern take, however, we know the man was suffering a severe transfusion reaction and was lucky to have survived. But the story didn’t end there. Before a follow-up transfusion could be performed, tragedy intervened. The man’s long-suffering wife had finally had enough and administered a lethal dose of arsenic, thus bringing both the marriage and the experiment to a close.

  Emblematic representations of the four temperaments associated with each of the humors of the body. A slight excess of one humor determined whether your natural disposition was sanguine (surplus blood), choleric (yellow bile), phlegmatic (phlegm), or melancholic (black bile). Engravings by sixteenth-century German artist Virgil Solis

  News of Denis’s initial “success” emboldened scientists to consider human-to-human blood transfusions. To the great minds of the seventeenth century, William Harvey included, this seemed like sound science because a belief in humoral theory was still widespread. A person in good health always had slightly more of one humor than the other three, and this excess determined the kind of person you were. Extra yellow bile made you choleric—a disagreeable sort. A tad more blood and you were sanguine—cheerful, optimistic. Remnants of this Doctrine of Temperaments, as it was known, survive to this day in the related words melancholic and phlegmatic. In an extrapolation of these factors, a German surgeon named Johann Elsholtz proposed in 1667 the use of transfusion as a remedy for marital discord. Would not the mood of a melancholic husband be lightened by transfusing him with the blood of his effusive and sanguine wife? And, flowing the other way, might not the wife become more temperate? The mutual exchange of blood between mates could heighten understanding between them—seventeenth-century couples therapy without all the talking.

  Elsholtz never had the chance to move beyond the hypothetical, however. Magistrates throughout Europe could not ignore the reality that transfusions were killing people, and a ban was implemented in 1668. (In fact, it would be another 250 years before safe, effective human-to-human transfusions would be performed.) Though relegated to a minor historical footnote, Elsholtz was nevertheless on to something, I choose to believe, if only by a shiny thread of whimsy.

  WITH THE POTENTIAL FOR DISEASE FACTORED OUT, TO BE INFUSED with what runs in Steve’s veins would mean being imbued with, among other qualities, his innate sanguineness and his long-lived love of comic books. The latter started in the summer of 1975 at Lefti’s corner store in East Hanover, New Jersey, where he grew up. Steve was twelve when he picked up an issue of Fantastic Four. It was about a family, he thought, albeit an unconventional one—three guys and a girl, two of them related by blood, united in fighting on the side of good. Steve, one of four kids himself, found it fun, but another title in the Marvel Comics Universe really grabbed him: X-Men. With his first issue, Giant Size X-Men #1, he was hooked. That it was a number one played a part. Like everyone else in his family, Steve was a collector—Wacky Pack gum cards and Flintstones jelly glasses were favorites. Now he had the starting point for a new collection, one that would grow over the years to thousands of issues currently stored in long boxes in all our closets.

  From its inception, what made X-Men different from other comics was that it introduced the idea of mutants into the superhero pantheon. These characters weren’t the victims of freakish science experiments gone wrong or of sudden exposure to mysterious biohazards; they were born that way—they had a genetic quirk in their DNA, an X-factor. Their powers, though, often didn’t manifest until their teen years. You woke up one morning to find your body was starting to change. The intended parallel was to puberty, but to any readers who saw in themselves something shameful, the X-Men struck a deeper chord. Although they were heroes doing good, the mutant X-Men were grossly misunderstood, despised by society at large, hunted down by the government. Where Superman was lauded in the bright light of day, the X-Men had to stick to the shadows.

  With its monthly tales of prejudice and perseverance, the comic book slowly instilled in Steve a resolve that would make his coming out far less torturous than mine. Not being an only son or raised a devout Catholic also helped ease his way. It seemed perfectly normal to him to keep secret his “identity” while at the same time accepting it as a natural part of himself. Just as mutations occurred in nature, so did homosexuality. He also knew a time and a place would come when he could safely expose this aspect of himself. High school was just not it. He never doubted that a real-world correlate to the X-Men existed, a group somewhere who’d accept him.

  I read the occasional comic book as a kid, yet they were never a constant in my life. While I could’ve named the major superheroes, my taste ran more to Richie Rich and Archie’s Pals & Gals. Now, viewing superhero comics through Steve’s eyes, I see not only how much they’ve evolved but also how, with their godlike heroes and grand-scale drama, they are like the ancient Greek tales I’ve always loved. Superhero comics are the medium of modern myths.

  Their unique dynamism, I’ve learned, hinges on a device that’s crucial to this art form: the blank space between panels—the gutter, it’s called. Much happens in these narrow strips of nothing. There, your mind takes two scenes and bridges them, filling in the elements that are not drawn or lettered. A fist is thrown in one panel; the villain careens backward in the next; but you envision the wallop. The moment of impact and the crunch of cartilage are your creations, as is the breadth of emotion. An eerie calm can stretch as long as you decide. This involvement turns you from a mere reader of the comic book into a collaborator, a member of the creative team that makes the story work.

  Time passes at a slower rate in a comic-book universe than in our own. While it’s been almost thirty years since Steve picked up his first superhero comic, in Marvel Time, as it’s called, only a few years have gone by. So when Steve reads the latest issue of Uncanny X-Men, say, he meets up with old friends who’ve hardly aged since he was
a kid. Up till now I’d thought this was the whole appeal, a sweet nostalgia trip for a forty-year-old man battling AIDS, a well-deserved escape from his reality. But it’s clearly more. There’s a powerful draw in a stack of comics. In their pages, overwhelming odds are overcome. Good guys win. Death is not always final. And the question What comes next? is never frightening. It’s exciting.

  The only time he reads comic books, I notice, is at bedtime. It’s shortly after he’s taken his handful of nighttime meds. His stomach roils, sorting out the pills, sending them out through his blood. His feet, pinging like sonar from the pain of his neuropathy, kick at the sheets. His fingers are almost too numb to turn the thin paper. Though the sedating effect of the drugs sets in, he fights to stay awake, to read another page, then another, just one more. I give up before he does and turn out my reading light. Before drifting off, I look over. Steve’s smiling. He’s lost to another world, fighting the good fight in the space between panels.

  FOUR

  Blood Sister

  WHEN I WAS A LITTLE KID GROWING UP IN 1960s Spokane, I associated blood with the rough-and-tumble world of brothers. Though I had no brothers of my own, I could always go to my best friend’s house to be among some. Conversely, Chris Porter came over to mine to be around sisters, for he had just one and I had a surplus—five. I almost never saw blood at our house. My sisters played board games, not ball games. Twister was about as rough as it got. Sure, we had Mercurochrome and a tin of Band-Aids in our medicine cabinet for skinned knees and mosquito bites so scratched over they bled. The Porters, by comparison, had an actual first-aid kit, stocked with pads of gauze the size of sandwich bread, splints, and a tourniquet. A tourniquet! How cool was that? Their house was a two-minute bike ride away, a place expressly outfitted, I now realize, for boys to burn off energy. Outside, Chris and his three brothers had a basketball hoop mounted in a cement-filled tire, a tree fort, and a garage filled with every sort of sports weaponry imaginable—lawn darts, baseball bats, and cracked hockey sticks still good for whacking crab apples into the neighbor’s yard. In the downstairs rec room there was a pool table and a punching bag and a floor so often cluttered with stuff—strips of Hot Wheels track, zillions of Matchbox cars, plastic soldiers, Erector Set buildings, Lincoln Log barricades—that Mrs. Porter routinely used one of those wide janitorial brooms to clear a path for herself to the pantry area, mercilessly toppling the mini metropolises in her way. She had a don’t-mess-with-me severity my mother lacked, an I-don’t-have-time-for-this quality, but the most radical difference between the two of them was that Mrs. Porter worked outside the home, something no other woman in our neighborhood did. She was the part-time nurse to her husband, Dr. Porter, a GP with an office nearby. Though always back home by the time school let out, Nurse Porter was never off duty. She knew back then, for instance, that I had what would now be called “white coat syndrome”—the skyrocketing of blood pressure and anxiety during a doctor’s appointment. I liked Mr. Porter, but Dr. Porter terrified me. To get around this, during a lull in Chris’s and my playing, she would sweep in, strap the blood pressure cuff on my arm, and, before my heart could start racing, she’d have already pumped and squeezed out the result. “See?” she’d say to me. “Perfectly normal.” Oh, she was crafty, that Mrs. P. And unflappable. I remember once being out under the carport with Chris when little Melissa Parker ran up wailing in a voice that could’ve shaken the fort from the tree: “Andy cracked his head open!” Sure enough, her bloodied brother, wheelbarrowed by two friends, soon bounced up the driveway. The Porter boys and I watched, straddling that gulf between horror and fascination, as their mom calmly sprang into action. Alas, so much blood for what ended up needing so few stitches! Time and again, as spectator and sometime recipient, such injuries reinforced in me the same equation: Blood was a guy thing, not a girl thing. Little did I know that there was a tide of female blood in my own home, and it seldom ebbed.