Dr. Ian Halim: The Yin and Yang of Bloodletting

.....Somerville Bagel Bards member and physician-humanist, Ian Halim, writes about how medicine relates to everything from ethics to botany—aiming to make science accessible to a wide and varied audience. This article will also appear in The Somerville Times.

For centuries, doctors would drain their patients’ blood on purpose in order to try to help them. The ancient but misguided theory was that the body consisted of different fluids, and that health required the right balance of these fluids—humors, as they used to be called. These humors were believed to be responsible not only for health, but even personality and temperament. We get the phrases “ill humor” and “sense of humor,” from this old idea. Black bile was one such humor and gives us the modern word melancholy for sadness (from the Greek “black” melan- and “bile” chol-). Removing blood from the sick was a wrongheaded way to try to correct the supposedly-disease-causing imbalance in the different humors.

This was a theory without evidence. In reality, bloodletting is an assault on the body, starving it of nutrients and the power to supply the tissues with oxygen. When a patient is already sick, bleeding them makes them sicker—and more likely to succumb to disease.

These days, we know that controlled bloodletting is only a good treatment for a couple of rare diseases.


Polycythemia vera is a rare disease of red blood cell excess often caused by a genetic mutation. The treatment, intuitively enough, is removing these excess red blood cells—a kind of modern bloodletting. This is done by using a syringe to draw off blood. As usual, the term for this is from Greek—from words meaning “vein” (phleb-) “cutting” (tom-). In modern hospitals, phlebotomy also refers (in a much more general sense) to the team that handles all blood draws. When you order laboratory studies for a patient, they are added to the “phlebotomy queue.”

Hemochromatosis is another disease treated by phlebotomy. It can result from an inherited problem in the way our bodies process iron, and it's a disease not of red blood cell excess per se, but of iron overload. Iron is a necessary ingredient in the hemoglobin pigment that colors our red blood cells and allows them to carry oxygen. But too much iron is not good. As the saying goes, the dose makes the poison. Over time, if hemochromatosis is untreated it can cause liver failure, diabetes, heart failure, arthritis, and a telltale bronzing of the skin. One of the main places that our body stores iron is in our red blood cells, making removing blood via phlebotomy the best, simplest way to lower the body’s stores of iron and treat the disease.

Except for polycythemia and hemochromatosis, though, losing more than a little blood is usually harmful.




Nowadays, doctors are well practiced at tracking the amount and rate of blood loss. Blood pressure, heart rate, hemoglobin levels, and hematocrit levels are all invaluable ways to track blood loss.




Imagine a balloon filled with water, taut and stretched out. The pressure on it is great. If it is drained, the pressure will drop, and the surfaces will sag and tent inwards. This is a rough approximation of what happens in blood loss. The body can compensate by narrowing blood vessels and using the heart to pump the blood harder and faster. But eventually, if the blood loss is too rapid or too great, these compensatory strategies will fail and the blood pressure will start to drop.




When a patient comes into the emergency room after suffering a car crash or a stab wound, or after starting to vomit blood, having a way to track blood loss is critical. Nearly the first thing that happens when a patient like this comes into the hospital is their vital signs are taking—temperature, heart rate, blood pressure, and the oxygen saturation of their blood. A drop in blood pressure with an increase in heart rate is classic for blood loss (although not unique to blood loss), and will immediately raise concern about the patient, depending on how much the blood pressure has dropped and how much the heart rate has risen. As the balloon grows flaccid—in our model—the heart pumps harder and faster to counteract this. Without adequate blood pressure, tissues will not be getting enough oxygen-rich blood. And eventually, if too much blood is lost, no matter how hard the heart works to counteract it, the blood pressure will continue to drop.




Another way that doctors monitor blood loss is by measuring the hemoglobin and hematocrit—H &H for short. When someone is actively bleeding, the H&H might be taken at regular intervals, to monitor the rate of blood loss. The hematocrit is the relative volume of red blood cells within a given amount of blood. Hemoglobin is the metal protein complex that transports oxygen within our red blood cells, making up the bulk of their non-water weight. If the body loses blood, it will try to retain fluid to maintain total blood volume, but it may not be able to keep up with making enough red blood cells to replace those that are lost—resulting in a relatively dilute blood, and therefore lower amounts of hemoglobin and hematocrit in a given volume of blood.




Hemoglobin, hematocrit, blood pressure, and heart rate are all very useful ways for doctors to monitor blood loss. The clinical situation is very important too, of course, and the idea is to figure out why someone is losing blood, and to stop it. The urgency of intervening will often depend upon the rate of blood loss, and the total amount of blood loss, which can be estimated with our four objective measures. These objective measures are especially meaningful when combined with clinical information about what’s happened to the patient, since other things can cause a high heart rate and a low blood pressure, for example, such as an infection.




These days, we can set aside the theory of the humors. We know that our red, oxygen-transporting blood is precious life-giving stuff. And we are often in a pretty good position to make sure that someone has enough of it to stay alive.

The Red Letters 3.0: A New Beginning (Perhaps)

The Red Letter Poem Project

NOW ONLINE! I was asked to write an essay for Askold Melnyczuk’s Arrowsmith Journal about what I learned from the first year of the Red Letter Project. It also became a meditation about the relationship between poet and reader. If you’d like to take a look, here is a link –

https://www.arrowsmithpress.com/community-of-voices

-- and you’ll also be able to check out the variety of marvelous literary projects that appear under Askold’s Arrowsmith imprint. Enjoy!



At the outset of the Covid pandemic, when fear was at its highest, the Red Letter Project was intended to remind us of community: that, even isolated in our separate homes, we could still face this challenge together. As Arlington’s Poet Laureate, I began sending out a poem of comfort each Friday, featuring the fine talents from our town and its neighbors. Because I enlisted the partnership of seven local arts and community organizations, distribution of the poems spread quickly – and, with subscribers sharing and re-posting the installments, soon we had readers, not only throughout the Commonwealth, but across the country. And I delighted in the weekly e-mails I’d receive with praise for the poets; as one reader recently commented: “You give me the gift of a quiet, contemplative break—with something to take away and reflect on.”



Then our circumstance changed dramatically again: following the murder of George Floyd, the massive social and political unrest, and the national economic catastrophe, the distress of the pandemic was magnified. Red Letter 2.0 announced that I would seek out as diverse a set of voices as I could find – from Massachusetts and beyond – so that their poems might inspire, challenge, deepen the conversation we were, by necessity, engaged in.



Now, with widespread vaccination, an economic rebound, and a shift in the political landscape, I intend to help this forum continue to evolve – Red Letter 3.0. For the last 15 months, I’ve heard one question again and again: when will we get back our old lives? It may pain us to admit it, but that is little more than a fantasy. Our lives have been altered irrevocably – not only our understanding of how thoroughly interdependent we are, both locally and globally, but how fragile and utterly precious is all that we love. Weren’t you bowled over recently by how good it felt just to hug a friend or family member? Or to walk unmasked through a grocery, noticing all the faces? So I think the question we must wrestle with is this: knowing what we know, how will we begin shaping our new life? Will we quickly forget how grateful we felt that strangers put themselves at risk, every day, so that we might purchase milk and bread, ride the bus to work, or be cared for by a doctor or nurse? Will we slip back into our old drowse and look away from the pain so many are forced to endure – in this, the wealthiest nation on the planet? Will we stop noticing those simple beauties all around us? The poet Mary Oliver said it plainly: “Tell me, what is it you plan to do with your one wild and precious life?” I will continue to offer RLP readers the work of poets who are engaged in these questions, hoping their voices will fortify all of ours.



Two of our partner sites will continue re-posting each Red Letter weekly: the YourArlington news blog (https://www.yourarlington.com/easyblog/entry/28-poetry/3035-redletter-072921), and the Boston Area Small Press and Poetry Scene (http://dougholder.blogspot.com). If you would like to receive these poems every Friday in your own in-box – or would like to write in with comments or submissions – send correspondence to: steven.arlingtonlaureate@gmail.com.



In ancient Rome, feast days were indicated on the calendar by red letters. To my mind, all poetry and art serves as a reminder that every day we wake together beneath the sun is a red-letter day.



– Steven Ratiner







Red Letter Poem #73





Summertime and the livin’ is. . . well yes, easy (though perhaps for only moments at a time) – and then desperate, intoxicating, frantic, beguiling, maddeningly boring, drenched in tears and punctuated by (if you’re lucky) bouts of laughter that erupt like fireworks. It’s not just the long stretch of hot days and lush foliage that propel our moods to their extremes. I believe we’ve been conditioned by years of the school calendar to spend nine months longing for the unreasonable promise of summer, only to be confronted by the fitful and all-too-ordinary reality. Needless to say, the entertainment industry helps to compound the anticipation, plying us with frothy summer pop tunes and Hollywood confections that make us crave those fantasies about love and adventure all the more. And as the Buddha has taught us, expectation is the source of all suffering – and so summer provides that too, often in generous doses.



Chen Chen’s poem plays off those summer tropes, though the expectations he’s wrestling with are familial, societal, and even poetical. But by intensifying the feverish turns of the imagination, he seems to be concocting his escape plan. Or is he? Is that fantasy of ‘falling in love midair’ hinting at how flights of the imagination can somehow rescue us – poet and reader alike – or only another catchy top-40 chorus in search of a guitar riff? But what I’m much more convinced of – reading Chen Chen’s highly-acclaimed inaugural collection, When I Grow Up I Want to Be a List of Further Possibilities (BOA Editions) – is that this poet has found inventive ways to intensify language while defying assumptions about how a poem must sound. Chen Chen creates seemingly playful vignettes that dazzle the imagination and break the heart, often at the same time. Born in Xiamen, China, he grew up in Massachusetts, and sometimes his writing attempts to surf the riptides between cultures. Recipient of the A. Poulin, Jr. Poetry Prize and the Thom Gunn Award, Chen Chen currently teaches at Brandeis University as the Jacob Ziskind Poet-in-Residence. And so, before the new school year rolls around, I’m humming a summer tune under my breath and thinking: one of these mornings, I’m gonna rise up singing. . . not just because the Gershwin lyric promised us that, but because of magic tricks like the one Chen Chen has pulled off with such aplomb. Perhaps, as August wanes, I really will spread my wings and take to the sky. This poet almost makes it look easy.





Summer Was Forever





Time dripped from the faucet like a magician’s botched trick.

I did not want to applaud it. I stood to one side & thought,

What it’s time for is a garden. Or a croissant factory. What kind

of work do I need to be doing? My parents said: Doctor,

married to lawyer. The faucet said: Drip, drop,

your life sucks. But sometimes no one said anything & I saw

him, the local paper boy on his route. His beanstalk frame

& fragile bicycle. & I knew: we would be so terribly

happy. Our work would be simple. Our kissing would rhyme

with cardiac arrest. Birds would overthrow the cathedral towers.

I would have a magician’s hair, full of sleeves & saws,

unashamed to tell the whole town our first date was

in a leaky faucet factory. How we fell in love during jumps

on his tragic uncle’s trampoline. We fell in love in midair.





–– Chen Chen

 

On Seamus Heaney, by R. F. Foster

On Seamus Heaney, by R. F. Foster 228 pages $19.95 (hardcover)

Princeton University Press, 2020 (“Writers on writers” series)

Review by Denise Provost


R.F. Foster needs no attention from me to burnish his reputation, any more than Seamus Heaney needs Foster to add luster to his. On Seamus Heaney, however, adds welcome layers to our understanding of Heaney as a poet and of the kind of public intellectual who attains moral standing in the wider world. This review aims mainly to draw attention to a valuable book possibly overlooked in the chaos of COVID, and to alert US readers to the merit they will find in Foster’s other writings.

Robert Fitzroy (Roy) Foster is currently Professor of Irish History and Literature at Queen Mary University of London. He was formerly, and remains emeritus, Professor of Irish History at the University of Oxford. As this progression indicates, his academic roots are as an historian. Foster, though, is Irish, and Ireland’s history and literature are intertwined to a degree uncommon among nations. With the publication of Foster’s magisterial two-volume biography of William Butler Yeats, his literary sensitivity and insight became as apparent his exacting scholarship.

On Seamus Heaney is a quite different undertaking than the encyclopedic Yeats biography. It benefits, however, from the same basic methodology. Foster sifts through diaries, correspondence, lecture notes, letters, and early drafts of poems to construct a full view of Heaney’s poetic enterprise. Foster braids together Heaney’s biography and writing with the history of his place of origin, giving us a rounded view of how these elements come together in his art.

Foster connects Heaney’s early life on his parents’ farm – along with his classical education as a scholarship student - to the virtuoso ease of his first major poetry collection, Death of a Naturalist. Publication of that collection set up a “remarkable connection between Heaney and his readership,” which later grew more complicated. Foster charts Heaney’s growing success in the North of Ireland, even as violence against civil rights protesters and other targets – including some of Heaney’s own kin - provided painful new subject matter.

Foster notes that Heaney’s friend, the poet Derek Mahon, “claimed in 1970 that Northern poets operated in a milieu of broader relevance than the ‘narcissistic provincialism’ of the South.” Such a claim may seem astonishing, considering that the Republic of Ireland was at that time not yet fifty years past its war of independence and even bloodier civil war. Yet some poets of the North and others excoriated Heaney for his treatment “of ancient, repetitive, sacrificial violence” in subsequent poetry collections.

Insisting on the “privacy and independence” of the poet, Heaney gave up his teaching post at Queens University, Belfast; moved to the Republic of Ireland, and published his galvanizing fourth major work, North. Heaney’s later international acclaim makes it easy to forget that at this point his writing career, some reactions to his work were “viscerally antagonistic.” Foster examines criticism of Heaney from this period, parsing out critiques based on professional jealousy or political disapproval to provide a clear-eyed and fair-minded assessment.

Foster goes on to examine the influences of Heaney’s religious faith, devotion to Dante, friendships with other poets, and rising international profile in “his remaking of himself in middle age.” In demand as a lecturer, Heaney became a literary essayist. He joined the Field Day cultural cooperative for which he wrote his celebrated play, The Cure at Troy; around this same time, he composed his collection Station Island.

In the long eponymous poem in that volume, Heaney meets the ghost of James Joyce, who says:

“…Your obligation

Is not discharged by any common rite.

What you do you must do on your own




so get back in harness. The main thing is to write

for the joy of it. Cultivate a work-lust

that imagines its haven like your hands at night…”




On Heaney’s poetic and temporal journeys, Foster is a reliable guide. Of the collections The Haw Lantern and Seeing Things, written in these later years, Foster sees “a chastened and profound investigation into the depths of death and life. The roof had lifted off his world, opening it to new intimations.” One of these was Heaney’s arrival in the post of Professor of Poetry at Oxford, which yielded a series of extraordinary and wide-ranging lectures, in which “Heaney demonstrated his analytical command over different modes of poetic expression….”




Years before, Foster reports, “Heaney remarked that he thought it necessary, as an Irish Writer using the English lyric tradition, ’to take the English lyric and make it eat stuff that it had never eaten before.’” Heaney, in turn, later would – metaphorically speaking – eat the Old English epic poem Beowulf, translating it into modern English. By his doing so, Foster observes “Heaney’s work and reputation were now positioned at the center of the English canon, while operating emphatically from a base in Ireland (North and South.)”




In this same period, Heaney was exploring “the line that divides the actual conditions of our daily lives from the imaginative representation of those conditions in literature, and divides also the world of social speech from the world of poetic language.” He also began to speak of the power of poetry to redress the world’s injustices and imbalances. Yet, at the same time, in Heaney’s work, the “tension between public responsibility and artistic freedom is framed over and over again, decisively and defiantly refusing a simple answer.”




Then, in 1995, Heaney was awarded the Nobel Prize in Literature. His remarkable acceptance speech, “Crediting Poetry” was separately published in book form and has become widely read. Foster reflects, however, that its backdrop of “the blood-spattered infliction of tribally decreed violence…has largely faded from consciousness…over the last quarter-century, if indeed it was ever in clear focus.”




Heaney’s tenure as Nobel Laureate expanded his life as a public figure. These demands came at a time of his life about which Heaney wrote: “I think that the political urgency is past for me. This is more the moment of mortality.” It is during the time which Heaney wrote the poems in his extraordinary final collection, Human Chain, a work about which Foster writes with poignant insight.

I credit Foster with finding exactly the right observations in the other writings of Heaney and his contemporaries to illuminate Heaney’s body of poetry from multiple angles. I hope that others who care about our literary inheritance will use On Seamus Heaney as a standard for writing about writing. Its combination of meticulousness and soul can only enrich our understanding.

Rednecks & Weed-eaters

Rednecks & Weed-eaters


B. Lynne Zika


August: I’ve made three more trips since I wrote the following; William never was home. So the weeds are still tossing their curls into the wind.



June: The weed-eater’s not cranking up. My neighbor Bob recommended a fellow down the road who does small-engine repair. Bob said William’s the truest definition of a redneck you’d ever hope to meet, which was saying something since Bob himself sports a goodly twang and two missing front teeth. Don’t get me wrong; I sympathize with dental issues, and Bob’s a good fellow, married to a German woman who’s got the sweetest, trimmest little kitchen garden a backyard ever boasted. And Bob’s the one who found me the used weed-eater to begin with. It worked well… for a while.

So at Bob’s recommendation I called up William and arranged to swing by the following day. After 5:30, which is when he gets home from work.

William lives a block over, almost directly behind me. There’s something about his section of the street that’s just a tad seedy. Nothing you can exactly put your finger on right away, but as I waited… and waited… for someone to answer the door, the details began to fill in.



1. A piece of chain from a child’s swing set wrapped around one of the wrought-iron pillars on the front porch. Meant for a yard dog, obviously, but there was no dog.



2. Next to the chain, a metal water bowl growing mold samples under an inch of water.



3. On the other porch pillar, the industrious homeowner had tied a black plastic flowerpot with a strip from a black plastic garbage bag. This was the mailbox.



4. Two trucks parked on the grass, one sedan in the driveway.



William never answered the door. I left a note, with my phone number, asking him to give me a call to reschedule. Haven’t heard anything, but he may get around to it eventually. I did notice that despite the fact that I knocked several times, I never did hear any dog barking. May be it died and William just hasn’t gotten around to tossing out the chain and bowl. He might get around to that eventually, too.

Wonder what the turnaround is like on repairing a weed-eater—assuming, of course, he’s actually at home one of these days.

Meanwhile, I reckon I’ll sit out on the porch and watch the grass grow.



Roll tide.