IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
 
 
 1.0 
 
 I.I 
 
 1.25 
 
 !f ilM IIIIIM 
 
 ^ ■- ill 22 
 
 ^ 1^ IIIIIM 
 
 1.4 
 
 1.6 
 
 V] 
 
 <^ 
 
 /2 
 
 '<^. 
 
 
 7. 
 
 '^^ ^% > 
 
 
 /A 
 
 riiuujgiajjiuij 
 
 ^Sdences 
 Corporation 
 
 23 WEST MAIN STREET 
 
 WEBSTER, NY. MS80 
 
 (716) 872-4503 
 
 ,v 
 
 ;\ 
 
 
 S. 
 
 ■^ 
 
 \\ 
 
 
 6^ 
 
 .<^ 
 
 ^' 
 
 -%" 
 

 '^ 
 
 r/u 
 
 7^ 
 
 \ ^O 
 
 > 
 
 CIHM/ICMH 
 
 Microfiche 
 
 Series. 
 
 CIHM/ICMH 
 Collection de 
 microfiches. 
 
 Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiques 
 
 ■<?.'• 
 
Technical and Bibliographic Notes/Notes techniques et bibliographiques 
 
 The Institute has attempted to obtain the best 
 original copy available tor filming. Features of this 
 copy which may be bibiiographically unique, 
 which may alter any of the images in the 
 reproduction, or which may significantly change 
 the usual method of filming, are checked below. 
 
 
 
 D 
 D 
 
 D 
 
 D 
 
 Coloured covers/ 
 Couverture de couleur 
 
 I I Covers damaged/ 
 
 Couveiture endommagde 
 
 □ Covers restored and/or laminated/ 
 Couverture restaur^e et/ou pelliculde 
 
 □ Cover title missing/ 
 Le titre de couverture manque 
 
 □ Coloured maps/ 
 Cartes giographiques en couleur 
 
 Coloured ink (i.e. other than blue or black)/ 
 ere de couleur (i.e. autre que bleue ou noire) 
 
 I I Coloured plates and/or illustrations/ 
 
 Flanches et/ou iliustratioris en couleur 
 
 Bound with other material/ 
 Relid avec d'autres documents 
 
 Tight binding may cause shadows rr distortion 
 along interior margin/ 
 
 Lareliure serr6e peut causer de I'ombre ou de la 
 distortion le long de la marge int^riejre 
 
 Blank leaves added during restoration may 
 appear within the text. Whenever possible, these 
 have been omitted from filming/ 
 11 se peut que certaines pages blanches ajout^es 
 lors dune restauration apparaissent dans le texte, 
 mais, lorsque cela itait possible, ces pages n'ont 
 pas 6t6 filmdes. 
 
 Additional comments:/ 
 Commentaires suppl6mentaires: 
 
 L'Institut a microfilm^ le meilleur exemplaire 
 qu'il lui a 6t6 possible de se procurer. Les details 
 de cet exemplaire qui sont peut-dtre uniques du 
 point de vue bibliographique, qui peuvent modifier 
 une image reproduite, ou qui peuvent exiger une 
 modification dans la m6thode normale de filmage 
 sont indiqu^s ci-dessous. 
 
 I I Coloured pages/ 
 
 Pages de couleur 
 
 Pages damaged/ 
 Pages endommag6es 
 
 □ Pages restored and/or laminated/ 
 Pages restaurdes et/ou pellicul6es 
 
 \/ 
 
 D 
 
 Pages discoloured, stained or foxed/ 
 Pages d^color^es, tacheties ou piqu^es 
 
 I I Pages detached/ 
 
 Pages ddtach^es 
 
 Showthrough/ 
 Transparence 
 
 Quality of prir 
 
 Qualitd in^gale de {'impression 
 
 Includes supplementary materis 
 Comprend du matdriel supplementaire 
 
 Only edition available/ 
 Seule Edition disponible 
 
 rri Showthrough/ 
 
 I I Quality of print varies/ 
 
 I I Includes supplementary material/ 
 
 I I Only edition available/ 
 
 Pages wholly or partially obscured by errata 
 slips, tissues, etc., have been refilmed to 
 ensure the best possible image/ 
 Les pages totalement ou partiellement 
 obscurcies par un feuillet d'errata, une pelure, 
 etc., ont 6x6 film^es 6 nouveau de facon k 
 obtenir la meilleure image possible. 
 
 This item is filmed at the reduction ratio checked below/ 
 
 Ce document est film6 au taux de reduction indiqu6 ci-dessous. 
 
 10X 14X 18X 22X 
 
 26X 
 
 30X 
 
 
 
 
 
 
 
 
 
 
 
 
 
 y 
 
 
 
 
 
 
 ■■■K. .-'*'' jHiH^MH 
 
 
 
 12X 
 
 16X 
 
 20X 
 
 24X 
 
 28X 
 
 32X 
 
The copy filmed here has been reproduced thanks 
 to the generosity of: 
 
 IVIedical Library 
 iVIcGlii University 
 IVIontreal 
 
 The images appearing here are the best quality 
 possible considering the condition and legibility 
 of the original copy and In keeping with the 
 filming contract specifications. 
 
 Original copies in printed paper covers are filmed 
 beginning with the front cover and ending on 
 the last page with a printed or illustrated Impres- 
 sion, or the back cover when appropriate. All 
 other original copies are filmed beginning on the 
 first page with a printed or illustrated impres- 
 sion, and ending on the last page with a printed 
 or illustrated i:Tipression. 
 
 The last recorded frame on each microfiche 
 shall contain the symbol —^(meaning "CON- 
 TINUED"), or the symbol y (meaning "END"), 
 whichever applies. 
 
 L'exemplaire film6 fut reproduit grAce d la 
 g^nirositi de: 
 
 IVIedical Library 
 McGIII University 
 Montreal 
 
 Les images sulvantes ont At6 reproduites avec le 
 plus grand soin, compte tenu de la condition at 
 de la nettet* de l'exemplaire f Ilm6, at en 
 conformity avec les conditions du contrat de 
 fllmage. 
 
 Les exemplaires originaux dont la couverture en 
 papier est imprimte sont fllmte en commenpant 
 par le premier plat at en terminant soit par la 
 derniire page qui comporte une empreinte 
 d'Impression ou d'illustratlon, soit par le second 
 plat, selon le cas. Tous les autres exemplaires 
 originaux sont fllmte en commenqant par la 
 premiere page qui comporte une empreinte 
 d'impression ou d'illustratlon at en terminant par 
 la dernidre page qui comporte une telle 
 empreinte. 
 
 Un des symboles suivants apparattra sur la 
 derni&re image de cheque microfiche, selon le 
 cas: le symbols —»> signifie "A SUIVRE", le 
 symbols y signifie "FIN ". 
 
 Maps, plates, charts, etc.. may be filmed at 
 different reduction ratios. Those too large to be 
 entirely included in one exposure are filmed 
 beginning in the upper left hand corner, left to 
 right and top to bottom, as many frames as 
 required. The following diagrams illustrate the 
 method: 
 
 Les cartes, planches, tableaux, etc.. peuvent dtre 
 filmte d des taux de rMuction diffdrents. 
 Lorsque le document est trop grand pour dtre 
 reproduit en un seul clich6. il est filmA i partir 
 de I'angle supArieur gauche, de gauche d droite. 
 et de haut en bas. en prenant le nombre 
 d'images n^cessaire. Les diagrammes suivants 
 illustrent la m^thode. 
 
 1 2 3 
 
 1 
 
 2 
 
 3 
 
 4 
 
 5 
 
 6 
 
Vt 
 
 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. 
 
 i-Tswi««?«w.T»ii^j!\r*S'ii.r,icXi7J'-3j<»^