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1 2 3

U^U^-^. H.R

VENESECTION IN CARDIAC AND ARTERIAL DISEASE.

By Henri A. Lafleur, M. D., Resident Physician Johns
Hopkins Hospital.

[From The Johns Hopkim Hospital Bulletin, No. 15, August, 1891.]

[From The Johns Hopkiru Hospital Bulletin, No. 15, August, 1891.]

VENESECTION IN CARDIAC AND ARTERIAL DISEASE.

By Henri A. Lafleur, M. D., Resident Physician Johns
Hopkins Hospital.

(Read before the Hospital Medical Society, April 21st, 1891.)

One is almost expected to offer an apology foe bringing the
subject of venesection before a r Heal society at the present day,
owing to the discredit into whici. the practice has fallen during
the last thirty years. Such an apology exists in the fact that an
interest in the subject has quite recently been revived, and vene-
section has been discussed at meetings of various medical societies
and in current medical literature. Special reference may be
made to a paper by Dr. Pye-Smith, abstracted in the British
Medical Journal, January 'si, 1891, on "The Therapeutical
Value of Venesection ; its Indications and its Limits," read and
discussed at a meeting of the Royal Medical and Chirurgical
Society of London. In this paper were recorded nearly fifty cases
in which venesection has been practised in many different forms
of disease, including bronchitis, broncho-pneumonia, croupous
pneumonia, miliary tuberculosis of the lungs, thoracic aneurism,
valvular disease of the heart, pericarditis, Bright's disease,
apoplexy and epilepsy. The writer considered the indications for
venesection in the order of their importance, to be: first, cyano-
sis with dilatation of the right side of the heart, whether from
pulmonary or from some other form of obstruction to the circula-
tion ; secondly, the intense pain of thoracic aneurism ; thirdly,
uraemic and prolonged epileptic convulsions. Reference was also
made to bleeding in fevers and inflammatory disorders. In the
discussion which followed, tlie opinions expressed were in the
main corroborative of the conclusions reached by the writer of

the paper.

Since the opening of the Johns Hopkins Hospital in May
1889, we have had occasion to practise venesection on five patients,
an account of which is subjoined.

Case I. — Thoracic AneAirimn — venesection for urgent dyxpmea
with cyanosis — temporary relief— death from exhaustion.

William W., aged 73, was admitted to the Johns Hopkins
Hospital on May 18, 1889. He had been ailing for some months
frura cough, shortness of breath and pain in the right side of the
chest and right shoulder and on admission was found to pre-
sent the signs of aneurism of the ascending arch of the aorta. He
complained especially of shortness of breath and of intense pain over
the right breast and down the right arm. With rest in bed and the
use of iodide of potassium he improved slightly and the intense
pain was somewhat alleviated, but at night he still suffered very
much from dyspniea and cough, for which morphia had to be used
freely. On the evening of May 29th he had a more than usu-
ally severe attack of shortness of breath accompanied by marked
cyanosis and distention of the cervical veins. As his heart was
beating strongly and regularly, it was considered that venesection
would give him at least temporary relief, and accordingly four-
teen ounces of blood were withdrawn from his right arm. This
afforded him temporary relief; both the cyanosis and the dys-
pnoea became less, and he spent a more comfortable night.
Shortly after the bleeding he had a profuse perspiration. He died
from exhaustion two days later. The autopsy revealed a large
saccular aneurism compressing the right lung, which was the seat
of a chronic interstitial pneumonia.

Case II. — Chronic Nephritis ivith dilated heart— extreme cyan-
osis — venesection with temporary relief— death.

Jeremiah B., aged 41, was admitted to the Johns Hopkins Hos-
pital February 5, 1890. His illness had commenced six months
before with shortness of breath, and three months later he had
noticed that his legs were swollen. During November he had
improved slightly, but since that time both the dropsy and the
shortness of breath had gradually increased, until it had involved
his abdomen and arms. He had not noticed any change in the
quantity or appearance of his urine. The condition of the patient
on admission was as follows : Very plethoric and stout; general
anasarca; respirations a little labored, 44; pulse 108, regular;
no increase in tension ; slight lividity of lips and tips of fingers
and ears ; venules of the cheeks and nose distended. There was
a diminution of the area of lung resonance in the lower thorax in

front, in the axilla and behind, and the breath-sounds at both
bases were enfeebled. Cardiac dulness began at the third rib, but
the inferior and lateral limits could not be made out. There was
gallop rhythm ut ihe apex, a moderately intense systolic murmur
in the anterior axilla with accentuation and reduplication of the
second sound at the pulmonary cartilage. The abdomen was
very large ; but there was so much fat that it was not possible to
demonstrate any ascites. Tlie urine was diminished in amount,
sp. gr. 1028, and contained albumen and fatty hyaline and gran-
ular casts. The patient was freely purged with salts and given
half an ounce of the infusion of digitalis every four hours. Dur-
ing the next three days the urine progressively increased in
amount, the dropsy was slightly diminished, and the heart-sounds
became more distinct, though the pulse remained rapid. At mid-
day January 10th, after coughing up some bloody sputum during
the morning, he had a severe attack of dyspnoja, and when seen a
few minutes later he was extremely cyanosed ; the veins of the
neck were distended ; the breathing feeble and shallow, while the
pulse could not be counted at the wrist. The heart-sounds were
rapid and indistinct, and there was tremor and jactitation of the
extremities. Venesection was deferred until 2:15 p. m., when
eighteen ounces of blood were withdrawn. The relief was imme-
diate, the breathing becoming easier, and the cyanosis disappear-
ing almost entirely. There was no return of the cyanosis or dys-
pnoea, but the patient died on the morning of the next day. An
autopsy could not be obtained : it is probable that there were ex-
tensive hemorrhagic infarctions in the lungj.

Case III.— M<ra^ regurgitation ivith dilated and irregular heart
— cya7iosis and dijfqmrca — venesection, ivith marked relief — sudden
death from syncope six days later.

Mark W., aged 22, was admitted to the Johns Hopkins Hos-
pital June 17, 1890. He had had three attacks of inflammatory
rheumatism, the first occurring four years ago, but had not shown
any symptoms of cardiac mischief until three months previous to
admission, when he began to be short of breath and to have pal-
pitation on slight exertion. He had also suffered from vertigo and
slight cough ; his legs had been swollen for some days, and he was
passing less urine than usual. Condition on admission : Face
pale, slight bluentss of finger nails, tiedema of legs ; there was or-
thopucea, R. 27. The pulse was intermittent, 36 per minute, only

two out of a series of three boats of til e heart reaching the radial
pulse. There was slight inipairnient of resonance at the base of
the right lung with enfeel)leil breath-sounds. The whole of the
left side of the chest was lifted with tlu; cardiac systole, and there
was throbbing in the neck and at the epigastrium. The apex im-
pulse was forcible and diffused in the sixtii intercostal space out-
side the nipple line The area of cardiac duiluess was increased
in both diameters. There wius irregularity in the rhythm and in-
tensity of the cardiac beats, a lou<l whiffing systolic nuirmur at
the apex, and marked accentuation of the second sound at the
pulmonary orifice. There was marked albuminuria without tid)e-
casts. Tiie patient was ordered sulph. sitryohnia, gr. ^^ tor die,
and ten days later, sparteine gr. J was substituted for this. There
was some improvement in the pulse and the anlema partially dis-
appeared. On July 4th there was considerable cyanosis of tlie
hands and lii)s ; not much dysjmcea, and free j)erspinition. The
pulse was very small and in marked contrast to the heaving im-
pulse in the praecordial region. The heart's action was very irreg-
ular. Fifteen ounces of blood were drawn from the left arm. On
the following morning the color of the patient was much better.
The pulse was 96, of fairly good volume; tlio heart's action only
slightly irregular, and there was no longer such disproportion be-
tween the cardiac systole and the pulse. The improvement con-
tinued until six days later, when the patient died suddenly in a
syncoj)al attack. An autopsy could not be obtained.

Case IV. — Arterial aclerosis — cardiac hypertrophy and dilata-
tion — venous engorgement with slight cyanosis — stupor and de-
lirium — venesection — recovery.

David B., aged 50, was admitted to the Johns Hopkins Hos-
pital December 10, 1890, suffering from cough, shortness of
breath and dropsy. His illness dated from fourteen weeks before
entering the Hospital. At that time he had been seized suddenly
at night with shortness of breath and cough, and latterly the dys-
pnoea had been constant with progressively increasing dropsy
and decrease in the quantity of urine passed daily. There had
also been slight transitory mental disturbance. There was no his-
tory of rheumatism or syphilis. On admission he presented the
following condition : Oedema of lower extremities and of the right
side of the trunk (he had been lying for some time on the right
side); pulse 116, regular ; tension increased; respirations 4-1, of

the Cheyne-iStokes type. There were bronchial rules at the bases
of both liiiif^s, but no dulnens. The upex beat waa neither visi-
ble nor palpable, and the sui)erficial area of cardiac dulness waa
not increased. There was fietal heart rhythm at the ajiex, and gal-
lop rhythm at the fourth ril). No accentuation of the aortic second-
sound. Tlie urine contained a small percentage of albumen with
a few hyaline and granular casts. With the use of digitalis, free
purgation with salts and an occasional hot bath, the (edema ra-
pidly subsided and the pulse became slower and of better volume.
He still suffered from dys|)n(ea, however, and was very restless
and slightly delirious at night. On December 'iord ho was not
so well. His tongue was dry, his pulse more rapid and occasion-
ally intermittent, and there was drowsiness with rambling even in
the day time. There was in addition considerable venous en-
gorgement of all the superficial veins with slight cyanosis and ex-
tension of the cardiac dulncss to the right of the sternum. At 3
p. m., sixteen ounces of blood were taken from his left arm, which
lessened the venous engorgement in a marked degree. He was
restless until three o'clock in the morning, when he fell asleep.
On the next day he was (juite rational ; there was still some dys-
pnoea, but the pulse was 9(5 and regular. During three days fol-
lowing the bleeding he passed a very large quantity of urine. On
January 7th he was quite free from drojisy. his mind was quite
clear, he slept and ate well, and his jnilse was regular, ranging
from ()0-70. He was discharged on this day at his own request.
Three months later he called at the hospital and stated that he
felt quite well and was at work.

Case V. — Mitral regtirgitation with dilated and irregular heart
— extreme cyanosis — venesection — recovery,

John B., aged 44, was admitted to the Johns Hopkins Hospital
April 13, 1891 , suffering from dropsy and shortness of breath. In
the autunm of 1889 he had suffered severely for three months
from inflammatory rheumatism, all his larger joints having been
swollen and very painful, and at the same season in 1890 he had
had an attack of typhoid fever. He gave no history of venereal
disease. Four weeks before his admission to the Hospital he had
noticed that his feet were swollen. The dropsy increased rajjidly
and two weeks later he was quite short of breath, so much so
that if he attempted to lie in bed he would choke. He had not
complained of palpitation, his bowels were regular, and he passed

about the same quantity of urlju! ns usual. When seen shortly
after liis udinission to tlin ward he was found to bo cyanosed, sit-
ting up in bed and somewhat breatldes-s. His pulse was 90-100,
small and irregularly intermittent. There was a wide area of
heaving cardiac impulse, the apex beat being three fingers breadth
outside the letl nipple. A loud blowing systolic murmur was
present at the apex and was transmitted into the letl axilla. The
second sound was accentuated at the left border of the sternum.
The lungs were clear with the exception of a few mucous rdles
at the bases. There was enlargement of the liver without ascites,
and considerable (t'dema of the lower extremities. The urine was
scanty, highly colored and albuminous; it contained some hyaline
and finely granular casts. A milk diet, free purgation with salts,
and tr. digitalis m. xv. every 4 hours, were ordered. At mid-
night he was very cyanotic and breathing heavily. The railial
pulse was just perceptible, only one heart-beat in every four or
five being felt at the wrist. The pr.-ecordial impulse was heaving
and irregular, and the heart-sounds were loud. A bleeding of
eighteen ounces produced inunediate relief; the dyspudnx disap-
peared almost entirely, the cyanosis diminished, the pulse at the
wrist increased in volume and frequency, and the patient was rel-
atively comfortable for the rest of the night. The next morning
he was looking well and sitting up in bed. There was still a little
shortness of breath and blueness of the lips and finger tips. ^ The
pulse was 96, of fairly good volume but still irregularly inter-
mittent. The upper limit of the cardiac dulness was at the third
rib, and transversely it extended from the right border of the ster-
num to the apex impulse in the sixth intercostal si)ace. There
was some engorgement of the veins at the root of the neck. The
auscultatory signs of the heart and lungs were as described above,
and there was a slight elevation of temperature. The digitalis
was discontinued and was again given on the following day in
smaller doses; and two days later strychnia and stroi)hanthus
were substituted for it. From April 15 to May 1st there was
irregularity in the volume of the individual beats, but not inter-
mitteucy, and the urine was free from albumen and casts. On
Mav (), after having been up and about for a week, he was feeling
quite well ; there was no uidema, lividity or shortness of breath,
and he ate and slept well. The radial pulse was 80, small, irreg-
ular and once more occasionally intermitting. There was still a
marked contrast between the force of the ventricular contraction

an.l the volmno of the pubo. The physical «ignH >vore not inate-
ruilly .litterent from th.me ..haerve.l the .hiy alter the blee<lni«.
He was discharKca from the hosi.ital on this day.

The above cnaes illustrate the value of blee.ling as a means
both of aironlin. ten.porary relief from .lintresHinK ^7"l>^;;';;j^'«
to.li.turlmnces of the cireulation, ami also of saving bte ami even
rcstorin-' i.atientrt to ccmijuirative health. ...

There" is little to 1,0 a.Ule.l to Dr. Pye-Snnth's eonelusmn. as e-
ganls the indications for veneneetion and it. relative value .n the
various clash's of cases which require its performance. Our ex-
perience has been, with one exeepti<.n. lin.ited to cases of primary
cardiac or arterial disease, which arc undoubtedly those in which
most good may be expected from its use.

Hvichard' advocates sn.all blee.lin.'s from time to time m the
fi,-st stages of arterial sclerosis and thinks that in t us way it may
be possible to lessen and even delay the evilsresultmg from pro-
Ionised high vascular tension. He insists particularly on the value
of ;enesection in the later stages of the same disease when the le
ventricle is im longer able to cope with the increased periphe ml
resistance and volume of blood, and the heart is in dange^ of u^-
den arrest. This may occur even when there is but little a- kma
or cyanosis, though there is usually engorgement ot the right sue
of the heart and of the veins. In addition to its purely mechan.ca
ell-ect venesection removes from the blood a considerable amount
of toxic material which has accumulate.! in it owing to the mi-
perfect performance of the functions <.f the kulneys and liver.
Lse viscera being usually more or lessatfected by the general ar-

terial sclerosis. , „,.forinl

The contra-indicati.)ns to venesection in cardiac and aiterm
.license are few. Even when death is imminent, the rapia
Z^tr I? some ounces .>f blood -t iniVenueMly saves
the patient. It is obvious that when marke.l ascites or pleural
eflu ion co-exists wiM. cyanosis and distressed breathing the abdo-
men or the pleura should be tapped and venesection delaye. unti
t is apparent whether either ot these procedures do or do not
aftbrd relief. Large hemorrhagic infarctions of the lungs and ex-
e. ive disease ofUie myocardium or of ^^^ ^^^^^^^^ ;;^^
could such conditions be definitely ascertained -ouUl 1 bab^
be a contra-indication as even temporary relief could hanlly be
expected under such circumstances.

1 Huchard : Muladies du coeur et des vaisseaux, Paris, 1889.

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