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peat with confidence what I have frequently affirmed, that it is one thing to suppress the pulse in the lower part of the limb, and another thing to stop the pulse in the great artery. I have tried in great operations, near the trunk of the body, to stop the blood by pressure; but though I could suppress the pulse of the femoral artery with my fore-finger, I could not command its blood with the whole strength of my body.' And in a note he says, 'the fact which I have here affirmed is of too much importance for me not to maintain it with more than common earnestness. I affirm then, that, though the throbbing of an aneurism, or the pulse in the lower part of a limb, be quite suppressed, yet the circulation is not stopped; and I entreat the young surgeon never to trust to any such mark of the compression being effectual.'
“If he wish it to be understood, that the inguinal, or the subclavian artery, cannot be commanded by any pressure, so as to prevent hæmorrhage on their division, it is merely advancing an opinion, that hardly needs a comment; for almost all the medical officers of the British army have, on many occasions, seen both vessels so effectually compressed by moderate pressure, that not one drop of blood has escaped from the orifice of the artery, after it has been divided. I am, therefore, willing to believe that this cannot be his meaning, but that he supposes a certain degree of pressure may stop the pulsation of the artery without suppressing the circulation; an opinion equally as dangerous, and erroneous, as the other; for it tends to keep the mind of the young surgeon in alarm, and thereby obstructs the free exercise of his judgment, during the whole course of many serious operations, when he often requires the greatest firmness to enable him to surmount the dif. ficulties that present themselves. This alarm is most unnecessarily raised, for I have no hesitation in declaring, and I am supported in the assertion by all the surgeons of extensive practice in the British army, that when the pulse is suppressed in a great artery, the flow of blood is completely restrained for every purpose in military surgery. I will even say, that the low of blood shall be entirely suppressed, and yet the pressure upon the subclavian artery above the clavicle, shall
be so moderate, that the instrument will not leave a mark upon the skin discoverable after twenty-four hours. I do not assert this without solid foundation; for I have seen the inguinal and subclavian arteries compressed and divided very many times, and I have had the femoral and axillary arteries as often between my fingers; but I never saw blood projected one inch from the orifice of these vessels without the pulsation or motion of the artery taking place; and I never saw blood flow in a stream from the orifice of any large artery. I have seen, when the sides of these vessels have not been pressed exactly together, so that the inner coats have not been in contact, that a little blood has oozed to the mouth of the artery, and that it has even dropped from it; but the moment this drop became a stream, the pulsation of the artery was sensible to the fingers, and the blood thrown out, came per saltum. I have never found any difficulty in holding the divided end of the femoral or axillary arteries, between my finger and thumb, whilst a ligature has been placed upon them; and I do not, therefore, believe, that the blood is propelled in these arteries with a force that is not readily overcome by moderate pressure; or that in a healthy man, any circulation goes on in an artery, when the pulse of that artery has ceased in consequence of pressure. It is not, indeed, copsistent that it should; for, if the circulation can go on so as to cause a dangerous hæmorrhage, without any pulsation of the artery, the continuance of it in the smaller arteries in a state of health, would almost appear unnecessary. If it be said that it is not circulation, but merely a little blood that passes between the sides of the vessel that are not exactly in contact; I would reply, that if such an oc. currence did take place, the quantity must be so small as to be unworthy the attention of the surgeon; for, if it were in greater quantity, it would be attended by pulsation of the artery.
“I do not mean, in the slightest degree, to doubt the correctness of Mr. Bell's statements of his inability to suppress the circulation in the cases of aneurism he has adduced. I mean to assert only, that the passage of the blood through a healthy artery can be effectually prevented by inoderate pressure; that when the pulse has ceased in a large artery in consequence of this pressure, the circulation is suppressed for every purpose in surgery; and that the surgeon may, therefore, divest himself of all fear of hæmorrhage. It is, indeed, a fact so notorious in the medical department of the army, that I need pot have noticed it thus particularly, if I did not think the great authority of Mr. Bell's opinion might prevail when the practice of the peninsular war shall be forgotten.”
The various doctrinal and practical discussions in which Mr. Guthrie engages, are illustrated and enlivened by a variety of cases, and observations of the highest interest.
Such a book, in short, as this, was wanted; and we now have one which ought to be in the hands of every military surgeon.
A Treatise on the Puerperal Fever, illustrated by Cases, which
occurred in Leeds and its vicinity, in the years 1809-1812. By William Hey, Jun. Member of the Royal College of Surgeons in London, and Surgeon of the General Informary, and of the House of Recovery, at Leeds. 8vo. pp. 238. London, 1815, Longman and Co.
[From the Edinburgh Medical and Surgical Journal, for October, 1815.]
We have been much interested by the perusal of this very able and instructive volume. It exhibits the most demonstrative evidence of the propriety and success of a simple but decided practice, in this severe and dangerous malady; at least in the particular form of it which occurred at Leeds during the periods specified in the title-page. We say in this particular epidemic, perhaps rather in conformity with established opinions upon this subject, than consistently with the impression which the perusal of this work has left upon us. For when we add the testimony of Mr. Hey to that of Drs. Gordon and Armstrong, and still more, when we examine the nature of several of the cases related by the former in this work, we feel disposed to doubt the propriety of the distinctions made by many writers, between the epidemic and sporadic disease.
It appears to us to be an obvious inference from the different views which practitioners and authors now take of many febrile diseases, either that the older physicians of the last generation were mistaken in their apprehensions of putridity and debility, or that the diseases of this country have actually undergone a considerable alteration in their type and character. We are disposed to believe, indeed, that there is some foundation for both these suppositions. We cannot doubt that the hypothesis of debility, and the practice of stimulation, were carried to a much greater length than sound observation would have justified; and that many of the effects ascribed to debility, were in reality the result of over-excitement, not checked in the outset by evacuations, and rather aggravated than diminished, by the cordial system which was afterwards employed. But, on the other hand, there appears to be suffi. cient evidence of some actual change in the character of febrile diseases since that period, dependent upon other causes than a change of medical treatment, and probably itself in part the cause of this change of medical opinion. It seems to be well ascertained, that petechial fevers have every where in a great measure declined in this country, though thirty or forty years ago they were extremely prevalent in jails, hospitals, and ships, and in the habitations of the poor. At present such fevers are rarely seen, even in the prisons and fever-hospital of London; see Willan on Cutan. Disorders, where he quotes the authority of the surgeon of Newgate, and the physician of the House of Recovery, 2d edit. p. 469; and the experience of practitioners in general will confirm the general fact. Whether these changes are inexplicable upon any known facts, (sor we cannot ascribe them with Sydenham to occult changes in the bowels of the earth); or whether they are ex. plicable upon the general improvement of the country in cleanliness, ventilation, temperance, and a better diet, which increasing wealth has introduced, we do not pretend to determine; but as facts we think they must be received. The con
stitutions of the people seem to have acquired somewhat more of a phlogistic diathesis, and to bear and require less of the stimulant treatment to which they were formerly subjected, and a more general evacuant plan. We wish to persuade ourselves that this view of the subject is true, for the credit of the art; for if it is not, the practice of medicine must be a farce, or the former practice must have been productive of extensive injury. We are certain, at least, that in most of our febrile diseases, the dread of typhus and malignancy is now a bugbear, and that the cordial treatment is generally manifestly injurious.
The judicious author of this treatise has stated, in the most philosophical manner, the series of facts which the occurrence of an epidemic brought under his observation, adopting no theory, and using no hypothetical phrases, respecting the nature and seat of the malady; but giving a plain and inductive comment upon the obvious results of the expedients resorted to, and the natural course of events when these expedients were omitted. Insomuch that, as we have already observed, his evidence amounts as near to demonstration as experiments in pathology will admit of; and we can scarcely dissent from his inference, that much mistake has been committed in supposing that puerperal fever, when epidemic, was to be treated, in any instance, in a different manner.
It would be difficult to do justice to the view, which Mr. Hey has given of the subject, by any analysis of the volume before us, which we recommend to every practitioner to study, who may be liable to be called upon to treat this disease. For the disease is too rapid to admit of delay and hesitation, and must be attacked with as much promptitude as vigour, in order to be combated with success; and therefore the practitioner cannot have premeditated too much on the treatment which he will adopt.
The author begins by proving, in his preface, by quotations from the most distinguished authors on the subject, the extraordinary contrariety of opinion which has always prevailed respecting the disease in question, except with respect to its danger and fatality, which is generally admitted. When the