judgment in omitting those particulars which to me did not seem important.

As I wished that every one who reads these accounts should be unbiassed in drawing his own inferences from the facts, I have studiously avoided interweaving any reflections of mine own. Such as have occurred to me in my attendance on these cases, I shall now briefly state.

To lay bare the right subclavian artery before it reaches the scaleni, will not be found difficult by any surgeon possessed of a steady hand, and a competent knowledge of anatomy; but I fear, that, with the utmost dexterity, much difficulty will be experienced in passing and tying the ligature, even in the most favourable cases. The instrument delineated in Mr Ramsden's book appears to me well calculated for the purpose, and yet it is not free from objection. I should fear that the coats of the artery might be cut by the sharp edges of the flexible steel plate as it is passing round the vessel. Some means similar to those I have mentioned must be adopted, to prevent the artery from being raised out of its bed while the surgeon is tying the knot.

This operation, difficult on the right, must be deemed absolutely impracticable on the left subclavian artery: For the great depth from the surface at which this vessel is placed,-the direct course which it runs in ascending to the top of the pleura,

-the sudden descent which it makes from this to sink under the protection of the clavicle, and the danger of including in the same ligature the eighth pair of nerves, the internal jugular vein, or the carotid artery, which all run close to and nearly parallel with this artery; these all constitute such a combination of difficulties, as must deter the most enterprising surgeon from undertaking this operation on the left side.

Even on the right side this operation will be very seldom required; for it can only be called for in injuries or diseases of that small portion of this artery which lies between the scalenus and the clavicle. It is scarcely necessary to observe here, how frequently such a case will be complicated with diseases of the great trunks of the arteries nearer to the heart, or how difficult it must be to discover the existence of those internal affections. When examining any pulsating tumour near the top of the tho rax, the surgeon should bear in recollection the remark made by Mr Astley Cooper, as quoted by Mr A. Burns, in his Surgical Anatomy of the head and neck, "that aneurism of the aorta may assume the appearance of being seated in one of the arteries of the neck." The quantity of blood lost by the haemorrhage, which yet we presume was the immediate cause of death in this

case, was very inconsiderable, being infinitely less than I had ever before known to prove fatal.

The operation of tying the subclavian artery on the acromial side of the scaleni muscles is one which will be much more frequently required, and which can be performed with equal facility on the artery of either side. The most striking and most unfavourable circumstance of this operation is, the great length of time required to perform it, although the ultimate and essential steps of it had been executed with so much facility.

This delay is by no means unavoidable. Indeed, any man who will take the trouble of reflecting on the anatomy of the parts concerned, or who will himself perform this operation on the dead subject, must be convinced that it may be executed in as short a time as the operation for femoral aneurism. The causes of delay in this instance were, first, the almost unprecedented nature of the operation; the caution with which we tread upon untried ground rendering every incision more slow, and every step more deliberate. Next, the great anxiety to secure every vessel, even the smallest branch of an artery, or a vein, lest our view should be obscured, or our progress obstructed by any quantity of blood flowing into the wound, was a principal source of this delay. By referring to the account of the operation, the reader can readily estimate what loss of time was occasioned by this object. I do not mean to say that we should pass through the various stages of the operation absolutely regardless of the flow of blood; but I am confident that we have no occasion to tie up any but the larger veins, and the suprascapular artery, if it should chance to be wounded. The curved spatulas, while they hold aside the lips of the wound, will at the same time serve to stop the bleeding. I cannot forbear to recommend, in the strongest manner, the use of these instruments, not merely in this, but in every other operation where the depth of the wound is considerable, compared with its length, and where it is of importance for the surgeon to distinguish the parts which lie at the bottom of such a cavity.

The necessity for removing any portions of fat can occur only in very corpulent subjects.

In passing the needle round the artery, it will be found absolutely necessary to have the scalenus muscle held back by one of these spatulas, otherwise it will be impossible to pass the ligature without including along with the artery some portion of the muscular fibres.

The facility with which the ligature was passed round the artery was in the highest degree gratifying to every one present. This inestimable advantage will be secured by an attention to

the following points: First, To extend the wound out towards the acromion, by which the form of it is changed from a deep cavity to a superficial wound; next, To introduce the needle on the outer or acromial side of the artery; and, lastly, to se lect the most favourable part of the artery. This, on inspection, will be found to be where it has just passed through the scaleni. How necessary this selection is, will appear by a perusal of the account of Mr Ramsden's operation; for he, by attempting to secure this vessel near to the first rib, or rather, as he says, at the lower edge of the first rib, found it almost impossible to turn the needle round the artery in the very narrow space between this bone and the clavicle.

Cases in which this operation may be necessary, will not be very unfrequent. In wounds of the axillary artery, either while it runs in front of the thorax, or while it lies along the humerus, this operation will be preferable to following the course of the wound by cutting through the pectoral muscles in the one case, or entangling ourselves in the brachial plexus, when the artery is wounded in the axilla. The pain and difficulties of the operation above described are trifling, when compared to those which must occur in following the course of these wounds.

When an aneurism of the axillary artery shall require this operation, we may indulge a confident hope that the rest of the arterial system is free from disease, as it appears to have been in two of the foregoing cases, that of Levanee, and of the Rev. Mr S.; one, where the disease arose spontaneously, the other, where it could be traced to accidental injury. Although this operation has not yet proved ultimately successful, yet I think we should not despair. The history of surgery furnishes parallel instances of operations, now generally adopted, which, in the few first trials, failed of success.

Stephen's Green, Sept. 6, 1814.

II.

Observations on the Fatal Liver, &c. &c. By JAMES BRYCE, F. R. S. E. Fellow of the Royal College of Surgeons Edinburgh.

IT

T is a circumstance known to all anatomists and physiologists, that the size of the liver, compared with the other vis

cera, or with the body, is much greater before birth, than after that period; and, although the immediate cause of this be readily explained, by comparing the anatomical structure of this organ during the foetal state, with its structure in the adult, yet, for what purpose it is intended by nature that this peculiarity should constantly take place in the foetus, seeing less bile is secreted by the liver before than after birth, is a question which, as yet, has not been explained to the satisfaction of physiologists.

In the following pages I shall attempt to explain some important advantages which the constitution of the new-born infant obtains from the diminution which takes place in the size of the liver immediately after birth, and which, I presume, will appear to be of such consequence to the animal economy at that critical period, as to entitle me to deduce from them the final cause, or the purpose intended by nature to be effected, by the greater size of that organ during the foetal state. For this purpose, we shall first attend to the general situation and connections of the liver, and, from a comparative view of its anatomical structure in the fœtus with that in the adult, point out those circumstances on which its great size before birth seems immediately to depend.

The liver is the largest of all the abdominal viscera, and also the largest gland in the body. It is of a very irregular figure, being convex and smooth above, concave and uneven below. It is situated in the upper part of the abdomen, having its smooth and convex surface contiguous to the arch of the diaphragm, and its concave surface in contact with the stomach and part of the intestinal canal. In the adult, its size is such as, in a healthy state, to be easily contained in the right hypochondrium and epigastric regions; but, in the foetus, it not only fills these completely, but also the left hypochondrium and greatest part of the umbilical region. It is divided into lobes, which, from their situation in the abdominal cavity, have acquired the names of right and left, by a deep furrow on the inferior surface, and by a corresponding membranous ligament above. In the foetus, these lobes are nearly of an equal size; but, in the adult, the right is much greater than the left. Besides this division of the liver into two great lobes, there is, situated upon the right lobe towards its back part, and near the deep furrow already mentioned, a triangular eminence, called, by anatomists, the lobe of Spigelius; and near it another smaller eminence which is anonymous, but to which and the other now mentioned the name of portæ has been applied, because

between these pass the blood-vessels of this organ before entering its substance.

næum.

The liver is connected to the surrounding parts by means of ligaments, which are formed chiefly by doublings of the peritoThe most conspicuous of these is that already mentioned as corresponding with the deep furrow. It is called by some, from its shape, falciform; by others, from the office it seems to perform, suspensory. By this ligament, which, in the foetus, contains the umbilical vein in its duplicature at the lower edge, the liver is connected with the umbilicus, the anterior side of the abdomen, and with the diaphragm. By doublings of the peritoneum are formed the two lateral ligaments, connecting the lateral portions of the liver with the corresponding parts of the diaphragm. And another connection of this viscus, which has improperly obtained the name of ligament, is merely an adhesion of its substance to the tendinous part of the diaphragm.

The liver, even in the adult, is supplied with blood in a very ample manner in proportion to its bulk.

The great trunk of the aorta, having passed through the diaphragm, sends off a large vessel, called cæliac artery, which soon divides into three branches; one of which is distributed on the stomach, and another, passing to the left, goes to the spleen, while the third and largest goes to the right, and, giving off some branches to the adjacent parts, carries blood to the liver, and is then called the hepatic artery. This artery, passing between the portæ, enters the liver, and is, by innumerable ramifications, distributed throughout its whole substance, terminating in the beginnings of corresponding veins. The blood which this artery carries to the liver, as possessing all those qualities fitted for the nourishment of the animal body, is supposed to be destined solely for that purpose with respect to this organ.

Besides the blood thus carried to the liver by the hepatic artery, it also receives, in a manner peculiar to itself, a large quantity of blood by the vena portæ,-a vein apparently performing in the liver the office peculiar to an artery in other parts of the body. This vessel begins by innumerable small branches, and receives the blood from the whole of the other abdominal chylopoietic viscera. These branches unite, in their passage towards the liver, into one great trunk, which, together with the artery already mentioned, is inclosed in a membranous capsule, and, running between the portæ, enters the liver, and, like the artery, is distributed throughout its whole substance. Of the ramifications of the vena portæ, some terminate in corresponding hepatic veins, whereby the blood is conducted into the vena