ILIAC ARTERIES. 



84 



to be pursued must be very much influenced 

 by the convenience of the moment; but it 

 would seem the better plan, where a choice can 

 }>e made, to pass the needle first backward 

 between the artery and the external iliac vein, 

 find then inward behind the artery toward the 

 pelvis, by which plan the veins will be more 

 surely avoided, and more space will be ob- 

 tained for seizing the ligature. 



In this as well as every operation upon the 

 iliac arteries, the spermatic vessels must be 

 kept in mind, inasmuch as they require atten- 

 tion as much as the ureter; they are usually, 

 however, like it, removed with the peritoneum. 

 Velpeau suggests the possibility of rupturing 

 the ilio-lumbar artery in isolating the internal 

 iliac, and the risk ought not to be overlooked. 



Ligature of the primitive iliac artery. Any 

 of the methods recommended, whether for the 

 internal iliac or the external at a high point, 

 will answer for the ligature of tl>e primitive 

 iliac, (iuthrie gives the preference to that 

 upon Aberi'elliv's lirst plan in this as in the 

 case of the internal iliac ; but it appears to me 

 that here, at all events, the method of Houx or 

 the modification of Cooper's operation is to be 

 preferred ; for, beside that there does not exist in 

 this case the reason for approximating the line of 

 incision to tha aperture of the pelvis, which 

 applies to the internal iliac artery, the situation 

 of the aneurismal tumour in front must render 

 the direct line of incision less convenient than 

 a lateral one, and by the adoption of the for- 

 mer there must be incurred a great exposure 

 of the peritoneum without a commensurate 

 advantage ; the necessity also of stripping the 

 membrane from all or a great part of the front 

 of the aneurism, incurred by this plan, must 

 be very objectionable. The length of incision 

 recommended by Guthrie is five inches at the 

 least, and may be required of even greater 

 extent ; thus Mott was obliged to extend it in 

 his case upward and backward, about half an 

 inch within the ilium, to eight inches : he 

 adopted the principle of Cooper, commencing 

 his first incision " just above the external ab- 

 dominal rin<;, and carrying it in a semicircular 

 direction half an inch above Poupart's liga- 

 ment until it terminated a little beyond the 

 anterior superior spinous process of the ilium, 

 milking it in extent about five inches." It is 

 likely that a longer incision may be net 

 in this method when applied to the primitive 

 iliac than in that recommended by Guthrie ; 

 the greater length of the external incision is 

 doubtless an objection of secondary impor- 

 tance; but it is probable that, when the pri- 

 mitive, artery is to be tied, little will be gained 

 by commencing the incision so low as was 

 done by JVIott, and that it would be more ad- 

 vantageous to carry it upward rather than 

 downward ; such appears to have been the 

 design of I'rampton in the operation per- 

 formed by him for the ligature of the primitive 

 iliac, in which the line of incision was cnned, 

 concave toward the umbilicus, and extended 

 from the anterior extremity of the last lib down- 

 ward beyond the superior anterior spinous 

 process of the ilium, and since unnecessary 



VOL. II. 



division of the abdominal parietes is of course 

 to be avoided, and the leaving them entire at 

 the lower part must be attended with two good 

 results, viz. avoidance of the aneurism and less 

 subsequent danger of pecuniary protrusion, 

 I cannot but regard this plan as a desirable 

 addition to the methods of proceeding when 

 the primitive iliac is the vessel to be tied. 

 In passing the ligature the difference of the 

 relation between the vein and artery of the 

 opposite sides is to be borne in mind, the 

 former being external to the artery on the right 

 and internal on the left, on both sides however 

 being upon a posterior plane. 



The obstruction to the course of the opera- 

 tion caused by the protrusion of the viscera is 

 to be expected ; in that of Mott it is described 

 as very great, while no mention is made of it 

 in Crampton's. This difference was probably 

 the consequence of the difference in the site 

 of the wounds. The separation of the artery 

 and vein is more easily effected than in the case 

 of the external iliacs, because their investment 

 is less thick and resisting. 



The diversity presented by the arteries of 

 the opposite sides suggests a difference as to 

 greater practicability and probability of success 

 on one as compared with the other ; the artery 

 of the right side being longer than the left 

 presents greater room for the application of a 

 ligature at a sufficient distance, whether from 

 the seat of the disease or from the origin of the 

 vessel, while that of the left being more per- 

 pendicular in its course and nearer to the left 

 side of the body ought to be more easily ex- 

 posed ; but it is to be recollected that this dis- 

 position is not uniformly present. 



Before undertaking an operation upon any 

 of the iliac arteries it will be advantageous to 

 determine, so far as possible, the relation of 

 the vessel, which is to be the subject of it, to the 

 superficial points of the abdominal wall. This 

 must be understood to be intended only as an 

 approximation, but by attention to the follow- 

 ing circumstances it will prove sufficiently 

 close to serve the desired purpose. The mean 

 point, at which the aorta divides and the pri- 

 mitive iliac commences, is half an inch below 

 the umbilicus at its left side, and th.it at which 

 the external iliac terminates is midway between 

 the symphysis pubis and the superior anterior 

 spinous process of the ilium : of course a line 

 connecting these points will define the general 

 course of the primitive and external iliac arte- 

 ries. The length of the primitive iliac being 

 from two to three inches, the extent of its 

 course may be determined by the subdivision 

 of this line. The point of demarcation be- 

 tween the primitive and external iliacs, and 

 which will serve to mark the origin of the in- 

 tiTnal and external, as well as the termination 

 of the primitive, may be further determined by 

 a line extending from the crest of the ilium 

 about one inch and a half behind its anterior 

 Miperior spinous process to a similar point on 

 the other side; such a line will traverse the 

 snc id-vertebral articulation posterior to the di- 

 vision of the primitive iliac, and by its ii 

 sation with that before mentioned will mark 



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