so as to form a portable book of reference. The publication will answer the purpose for which it was designed, but for the reasons already stated, its interest in this country is much diminished by our unfortunate familiarity with the complaint.

V.

TRAITE THE ORIQUE ET PRATIQUE DE LA LIGATURE DES ARTERES. Par J. P. Manec, M.D. Premier Prosecteur à l'Amphithéatre Général des Hospitaux Civils de Paris, &c. &c. Paris. Libraire Me

dicale de Crochard, Rue de l'Ecole de Medicine, No. 13. 1832.

Ir is somewhat singular, that, whilst the Medical School of England and the Continent have all afforded valuable works on anatomy, the subject of the present volume, at least as far as relates to its important illustrations, has been so much neglected. Whilst the greatest pains have been taken to represent the most minute, and comparatively, unimportant point in anatomy, and no expense has been spared to render these publications as correct as possible, as far as regards their immediate bearing on surgery, a blank still remained. It can be of little use to know the exact situation of parts individually, or indeed of their relation to one another, unless with this knowledge is connected a similar acquaintance with their relation to the skin which covers them; and although in some works on operative surgery, rules are given as to the directions in which incisions are to be made, and the parts which are to serve as guides to these incisions, still something more was required; and that, as applicable to the ligature of arteries, is here supplied by M. Manec, a man who had acquired some reputation as an anatomist, from his beautiful plates of the sympathetic nerve.

The work commences by an introduction, containing much new and instructive matter on the structure of arteries, particularly on that of their fibrous coat, together with a general history of the ligature of arteries from the time of Desault until the present. The author next devotes considerable space to a consideration of the different effects and comparative dahger of various ligatures-of the value of torsion of these vessels as a therapeutic agent, considered relatively to the effects of ligature-of the modeof placing a ligature on a vessel when affected by disease, whether of steatomatous or ossific deposits-and terminates by some general considerations on wounds of arteries, and the means adopted by nature to effect their occlusion. The operations of ligature was illustrated by very excellent plates, to which are appended, descriptions of the various means which may be adopted for tying any vessel, although but one mode is represented in the drawing. Without any further preface, we will proceed to a more detailed examination of the work, in the form of analysis.

The

To take a view of the structure of arteries will be an excellent preparatory step to the consideration of the application of ligatures to them. Of its primary, arterial system has been not incorrectly compared to a tree.

secondary, tenary, and quarternary branches, none, with the exception of the mesenteric and vertebral interlace, but the anastomoses increase in number in proportion as we reach their ultimate subdivisions. The structure of arteries is not the same universally; or, if the same elements enter into their composition, they are singularly modified according to the capacity of the vessels. Arteries consist of three coats, a cellular, a fibrous (peculiar to arteries), and an internal, (similar to the internal tunics of veins). But besides these, the large arterial trunks are enclosed in a species of cellular tube, called their proper sheath. The external part of this sheath is blended with the surrounding cellular tissue; its internal is distinct from the cellular tunic of the arteries themselves. By extending an artery longitudinally, a separation is effected between it and the cellular sheath. But to vessels of the fourth or fifth order, we find that this sheath no longer belongs, e. g. the radial, ulnar, tibial arteries, &c.

EXTERNAL CELLULAR MEMBRANE.

In the large trunk this tunic lies in contact with the proper sheath, in the less, with the surrounding cellular membrane. Its internal surface adheres closely to the middle coat, the difference in their structure being the only line of separation; their union is effected by means of small cellular filaments passing from the outer coat to be inserted between the fibres of the middle coat. In examining some human aortæ, I have seen an intermediate tunic between the outer and middle, the nature of which I have not yet satisfactorily ascertained, although I should suspect, from its similarity to a structure in the same situation in the ox, that it is essentially glandular. The filaments of the cellular tunic are similarly interlaced to those of felt. Its vascular supply is of double origin-from surrounding vessels and from the artery itself. Extremely minute branches of the sympathetic nerve may be detected in it, by maceration for a few days in dilute nitric acid. We thus find that there is nothing peculiar in this membrane; not so in the next, or

MIDDLE FIBROUS TUNIC.

This is the thickest of the three membranes, but it is subject to variations în vessels of different sizes; it is very remarkable in the large trunks, and insensibly disappears in the small ones. Its colour also varies in different situations; it is yellow in the arch of the aorta; yellowish white in the iliacs and crural, and of a rosy tint in the smaller vessels. Its density is always in exact proportion to its thickness. This tissue (long considered as muscu'ar) is formed of curved fibres, varying in length from one or two "millimétres,"* to two thirds of the circumference of the vessel. The most superficial of these fibres are the longest, their length gradually diminishing as they approach the internal tunic of the vessel, hence concentric layers are formed, the external of which are larger than the internal. This structure is easily detected by examining a transverse section of the aorta, by means of a magnifying glass. It may also be seen that the extremities of

*A millimétre is one thousand part of a metre, which is about 39 inches, English

measure..

the curved fibres do not remain in the layer which is formed by them, but that they are inclined towards the internal tunic, to which they mostly adhere, by passing between the bundles of fibres placed beneath. The superficial fibres alone do not proceed in a direct manner, at least as far as can be well ascertained. They become confounded with the extremities of the deeper fibres, into which they are inserted. The ends of those fibres which form the internal layer of the middle coat, are immediately inserted into the internal tunic, but previously to coming in contact with this membrane they make a turn by which they change from a transverse to a longitudinal course. At the point where this turn is made the separate fibres cross one another so as to form a species of book. It even appears that, after this crossing of the fibres upon each other, one of them takes one direction whilst another proceeds in a contrary course; but I have never been able to follow a fibre throughout the whole of its course, and cannot speak with certainty as to this peculiar construction, although I am inclined to believe that such is the case. At the exterior of the middle coat the fibres are transverse and curved, at the interior they are longitudinal. This structure may easily be seen in the aorta of an ox, after maceration, if a magnifying glass be employed. The interlacement of fibres, just described, renders the internal portion of it very difficult to dissect, and gives to it that closeness of texture which it wants in other parts of its structure. From these observations it is evident, that the external surface of the middle tunic adheres to the cellular coat by the middle of the fibres of which it is formed, whilst its union with the internal coat is effected by means of the extremities of the same fibres. This disposition, whilst it gives great solidity to the internal face of the middle tunic, facilitates very much the movement of reaction which this membrane effects by its elasticity, after having been distended with blood. From some observations made on aneurisms in man, I was induced to make some experiments, which prove that the middle membrane alone can oppose any sanguineous infiltration, when the internal tunic has been by any means obliterated. The experiments consisted in destroying the internal tunic by means of a needle, when it was found that no blood penetrated the middle coat; but when the middle coat was torn by means of the needle, an infiltration took place, in two instances, as far as the surface of the vessel. The peculiar structure of the middle tunic is productive of a double result-1st, an augmentation of the elasticity of the fibres by the insertion of their extremities, the middle being left free; 2d, an insurmountable obstacle, to sanguineous infiltration, even when the internal membrane is destroyed. The rare occurrence of aneurism in connexion with ossification of arteries, may be taken as a further proof of this last deduction; for in this case the blood must come into contact with the middle tissue, and yet aneurism is very rarely produced under such circumstances. The separate fibres of the middle tunic are united by a short cellular tissue which is readily ruptured by the longitudinal traction, but not so easily by torsion. In the very young, some vessels may be traced into this tunic, but it cannot be injected in later life. Nerves cannot be found in it.

INTERNAL TUNIC.

This is connected with the middle coat by a tissue having no analogy with

common cellular membrane. Its internal surface is similar to serous membranes, excepting that it has a somewhat velvety appearance. Its organization differs also from that of serous membranes, inasmuch as it is destitute of the extremely delicate interlaying filaments which characterize them. It is evidently formed of globular molecules, having all, one with another, the same connexions. Serous membranes are also composed of globular molecules, but arranged in such a manner as to form elementary fibres. The organization of serous membranes is of a higher character than that of the internal tunic of arteries; this latter is extremely small and readily torn, and cannot be regarded as a membrane, the end of which is to strengthen the parietes of the vessel; such is evidently not its purpose; it is merely to afford a more ready passage to the blood, and this is effected by an unctuous matter which moistens the internal surface. In experiments which I have tried on various animals to ascertain the function of the artery in secreting this substance, I have isolated a portion of an artery between two ligatures and allowed the blood to escape. After a certain number of hours, I have found a collection of this unctuous substance, varying in quantity and quality in proportion to the age and state of health of the animal, and very much influenced by the animal employed. In some other experiments, I denuded a portion of a vessel of part of its internal coat, thus leaving the middle coat naked in one or more places; from this, also, a secretion of unctuous matter took place, varying in quantity and quality according to the time which the experiment had lasted-thus, six or eight hours after the experiment, the whole of the unctuous matter was of a similar character; but in 36 or 48 hours this similarity no longer existed, and the matter presented a different aspect and different qualities, according as it was situated over the middle or internal membrane; over the former it was larger in quantity, adhered more firmly to the membrane, and was much more consistent than at any other part. Hence, we may conclude, 1st, that the internal membrane alone does not afford unctuous matter; 2d, that the middle tunic contributes to its production: 3d, that when formed by the middle membrane it appears more plastic and coagulable. It is not improbable, from the plastic nature of this effusion from the middle tunic, that the internal coat may be re-produced by it, when by any cause it has been destroyed. Neither vessels or nerves can be detected in this internal coat, in its physiological state. Of the three tunics of the arteries, the internal and middle are the most readily torn by moderate traction or pressure; the external alone resists the immediate action of constrictive force, and does not give way to longitudinal traction until some time after the others have been torn through.

After having devoted so much attention to the intimate structure of arteries, the author next proceeds to the more immediate subject of his work.

The phenomena presented by an artery to which a ligature has been applied, are dependent on, 1st, the size, form, and nature of the instrument employed; 2d, the size and condition of the vessel. The introduction of, and improvement in, the use of the ligature have gradually followed the plan employed by Desault to stop the current of the blood in an artery. The principles on which this effect is now produced were not at that time understood, and a variety of means were employed by celebrated surgeons, such as Bichat and Scarpa, without much success. No satisfactory improvement

took place in this branch of surgery until 1805, when Dr. Jones published a valuable work on the means which nature adopts for the suspension of hæmorrhage. Various ligatures had been employed before the publication of this work, in which it was proved that the one in which the greatest confidence might be placed, was a small round ligature. Abernethy, Astley Cooper, and other eminent English surgeons adopted the practice, and with great success. It was not known in France until 1814, and was then so slightly spoken of by Roux, as to fall into disrepute. M.M. Béclard and Breschet repeated Jones's experiments, and with results so favourable that it was adopted and approved of by Duputren and Larrey; many, however, still continued to employ the broad, flat ligature, and do so even at the present day. It is to decide this question that M. Manec has paid a lengthened attention to, and tried numerous experiments on the subject, and in the hope that his endeavours will prove of service to mankind, and an assistance to the judgment of his professional brethren.

GENERAL PRINCIPLES.

In effecting the obliteration of an artery, the first indication is to suspend the passage of the blood; this may be effected in various manners-1st, by simply compressing the vessel and bringing its internal coat into close contact, in all its parts; 2d, by the same contact with more or less extensive rupture of the inner and middle coats; 3d, a uniform compression of the artery, with a neat and regular section of its internal and middle coats.

M. Manec here enters into a description of the operation for ligature, as usually performed, and of the instruments which are necessary. The points particularly insisted on, are, the necessity of making the first incision sufficiently long (it is better that it should be too long than too short, because, in the latter case, the operation is more dangerous and tedious from the difficulty of reaching and of isolating the vessel; there is, also, much more cause to fear the effects of suppuration); the impropriety of opening the sheath more than is absolutely necessary to separate the artery from its accompanying vein and nerve; the necessity of avoiding all violent traction. of the artery in surrounding it by its ligature, in which case its vessels of supply may be cut off, and death of the part take place. When the separation has been effected with violence, the artery at that part is only kept alive by continuity with itself; and if the patient be not young and strong, and the operation has been laborious, there is great probability that union will not take place between the artery and its sheath, but that a suppurative inflammation will ensue. Even if suppuration do not take place, still the violent separation of the vessel retards the succession of phenomena which should succeed one another before a perfect cure is effected. When an artery which is to be tied is situated close to a vein, the needle carrying the ligature should be introduced between the two vessels and carried outwards; the chance of wounding the vein is here very much less than it would be, were the needle passed in an opposite direction. If the vein be behind the artery, the latter should be gently elevated, and the needle carefully slid along its posterior surface. The same precautions are necessary in separating the artery from any nerves with which it may be in contact. A precautionary measure of great importance is, that when the knot is tied in the