844 



ILIAC ARTERIES. 



2. The epigastric artery in passing the deep 

 inguinal ring gives a branch, which goes out 

 through the ring in company with the spermatic 

 process, descends to the scrotum and is distri- 

 buted to the structures of the cord, to the 

 tunica vagina] is, and to the cremaster, and anas- 

 tomoses with branches of the spermatic artery ; 

 it is denominated by some the inferior sper- 

 mutic artery. 



3. As the artery ascends in the abdominal 

 wall it gives to either side numerous branches, 

 which are distributed among the structures of 

 the wall, anastomosing externally with branches 

 of the circumflex iliac, of the lumbar and the 

 inferior intercostal arteries, and internally with 

 those of the artery of the oilier side ; many of 

 these branches ultimately become superficial, 

 passing through the muscles, and through aper- 

 tures in the aponeurosis of the external oblique ; 

 they terminate in the superficial structures, 

 anastomosing with the other superficial vessels. 

 4. Finally, the epigastric artery terminates by 

 two or more long ascending branches, which 

 meet and anastomose with branches from the 

 internal mammary artery. 



Methods of operation for the ligature of the 

 iliac arteries.- The methods of operation for 

 the internal and primitive iliacs being but mo- 

 difications of those adopted for the external, I 

 propose to detail the latter first. 



The operation in each case may be resolved 

 into three stages, viz. 1, the division of the 

 structures of the abdominal wall ; 2, the dis- 

 placement of the peritoneum with the inter- 

 vening viscera; 3, the management of the 

 artery and the parts immediately related to it. 

 Several plans have been proposed for exposing 

 the external iliac artery ; these may be regarded 

 as, all, modifications of the same; yet their 

 number, the existence of points of difference 

 leading to results of some importance, and the 

 advantage to be derived from a clear appre- 

 hension of them, render it desirable to distin- 

 guish them so far as they present distinctive 

 characters deserving notice. I propose, there- 

 fore, to particularize five methods, between 

 which operators may have occasion to select. 

 In the first the line of incision is straight, and 

 corresponds to the course of the artery. In the 

 second the line of incision is also straight, and 

 inclines away from the course of the artery 

 toward the superior anterior spinous process of 

 the ilium. In the third the line of incision is 

 curved, convex downward toward the thigh, and 

 crosses the course of the vessel. In the fourth 

 the line of incision is straight, and transverse to 

 the artery's course. The fifth, which I would 

 specify, is a modification of the third, by which 

 that plan may be rendered more generally ap- 

 plicable. The first is, that which was adopted 

 by Abernethy, by whom the artery was first 

 tied, A.D. 1796, and is now generally known as 

 his method, of which the following is his own 

 account : " I first made an incision, about 

 three inches in length, through the integuments 

 of the abdomen, in the direction of the artery, 

 and thus laid bare the aponeurosis of the ex- 

 ternal oblique muscle, which I next divided 

 from its connection with Poupart's ligament, in 



the direction of the external wound, for the 

 extent of about two inches. The margins of 

 the internal oblique and transversalis muscles 

 being thus exposed, I introduced my finger 

 beneath them for the protection of the peri- 

 toneum, and then divided them. Next, with 

 my hand I pushed the peritoneum and its con- 

 tents upwards and inwards, and took hold of 

 the artery."* 



The second method seems due to several, 

 and first also to Abernethy. This may seem 

 doubtful, from the account of his second ope- 

 ration originally given by himself, in which he 

 says merely that " an incision of three inches 

 in length was made through the integuments 

 of the abdomen beginning a little above Pou- 

 part's ligament, and being continued upwards ; 

 it has more than half an inch on the outside of 

 the upper part of the abdominal ring, to avoid 

 the epigastric artery. "f But in his collected 

 worksj of different dates it is expressly stated 

 of this and his subsequent operations that the 

 incision "began just above the middle of 

 Poupart's ligament, and consequently external 

 to the epigastric artery, and was continued 

 upwards, but slightly inclined towards t/n: 

 ilium." The plan adopted by Frere differed 

 not much from this. This method appears 

 however more particularly attributable to Houx, 

 who seems to have been the first to give specific 

 instructions for it, recommending that the be- 

 ginning of the incision should never be further 

 than half an inch from and a very little higher 

 than the anterior superior spine of the ilium, 

 and that it should be carried very obliquely 

 downwards to the middle of Poupart's liga- 

 ment.! 



The third method is that of Sir A. Cooper, 

 in which the incision is begun just above the 

 abdominal ring, and is extended downward in 

 a semilunar direction to the upper edge of 

 Poupart's ligament, and again upwards to 

 within an inch of the anterior superior spinous 

 process of the ilium. This incision exposes 

 the tendon of the external oblique muscle : in 

 the same direction the above tendon is to be 

 cut through, and the lower edges of the in- 

 ternal oblique and transversalis muscles ex- 

 posed : the centre of these muscles is then to 

 be separated from Poupart's ligament : the. 

 opening by which the spermatic cord quits the 

 abdomen is thus exposed, and the finger passed 

 through it is directly applied upon the iliac 

 artery above the origin of the epigastric and 

 circumflex ilii arteries: the next step of the 

 operation consists in gently separating the vein 

 from the artery by the extremity of a director 

 or the end of the finger ; the aneurismal 

 needle is then passed under the artery. || 



The fourth is that of Bogros, in which the 

 line of incision is, as I understand it, straight, 

 from two to three inches long, immediately 

 above the crural arch, and has its extremities 



* Surgical Works, 1830, v. 1, p. 292. 

 t Surgical Observations, 1804, p. 214. 

 } Surgical Works, 1830, p. 396. 

 $ Cooper's Dictionary, and Nouveaux Elcmcns dc 

 Mcd. Op. 



|| Cooper's Lci'Uucs liy Tyrrell, v. 11. 



