ILIAC ARTERIES* 



845 



equidistant, the external from the spine of the 

 ilium, and the internal from the symphysis of 

 the pubis. The aponeurosis of the external 

 oblique muscle having been laid open -in the 

 direction of the crural arch upon a grooved 

 director, the spermatic cord with the cremaster 

 is to be drawn upward beneath the superior lip 

 of the wound ; the deep ring dilated with the 

 point of the finger ; the epigastric vessels, if 

 a guide be necessary, followed toward their 

 oriain ; the cellular structure and lymphatic 

 glands situate above the arch upon the artery 

 separated ; and the vessel exposed and 

 isolated.* 



In the fifth method, which is but a modi- 

 fication of Cooper's, the outer extremity of 

 the incision as directed by him is prolonged 

 to, or beyond the superior spinous process of 

 the ilium in proportion to circumstances. 



Before these methods be contrasted with 

 each other, a few additional remarks seem re- 

 quired in reference to the operation however 

 performed. 



1. The posture of the patient should be such 

 as will most relax the abdominal muscles in 

 order to prevent as much as possible their 

 pressure upon the viscera, and to allow the 

 more easy separation of the edges of the wound. 

 The shoulders should be raised and the legs 

 bent upon the pelvis. 



2. It seems desirable that unless the super- 

 ficial wound be longer than has been stated, 

 the division of the aponeurosis of the external 

 oblique should be of equal extent. 



3. The recommendation to divide that apo- 

 neurosis upon a director appears judicious as 

 a means both of facility and safety. 



4. Where it can be used the finger seems a 

 safer instrument with which to separate the 

 internal oblique and transversalis muscles from 

 the structures beneath, for it will be readily 

 understood that the extremity of a director 

 might be easily thrust through the peritoneum 

 in the execution of this step. 



5. It must be borne in mind that between 

 the muscles and the artery there are to be ex- 

 pected beside the peritoneum two other struc- 

 tures : 1. the fascia transversalis; 2. the im- 

 mediate investment of the vessels. The fascia 

 transversalis may either be treated in the manner 

 directed by Cooper, viz. by dilating the deep 

 ring, or be lacerated with the nail, as recom- 

 mended by Guthrie, but it is to be recollected 

 that a prolongation of the fascia descends upon 

 the spermatic cord, and that therefore there 

 exists no opening, and that the fascia varies 

 in strength, and may at times be found so 

 strong as to require more force to lacerate it 

 than it may be deemed proper to exert. In 

 such case an opening may be made through it 

 with the knife, and enlarged upon a director 

 if necessary. This may be effected by either 

 of two methods, viz. either by dividing the 

 prolongation of the fascia, which descends 

 upon the spermatic process, " having been first 

 raised with a forceps, to a sufficient extent to 

 admit the forefinger to pass upon the cord into 



* Archives Gentrales de Med., t. iii. p. 408. 



the internal abdominal ring," a proceeding 

 adopted by Mott, and which offers a safe mode 

 of opening that structure ; or by cutting the 

 fascia upon the outside of the ring, in the di- 

 rection toward the superior spine of the ilium, 

 to such an extent as may allow the introduction 

 of the director or the finger : the section can- 

 not be attempted safely inward, because of the 

 vicinity of the epigastric artery, which is so 

 near to the inner side of the deep ring that it 

 must in such case be exposed to imminent 

 danger, situate as it is between the fascia 

 and the peritoneum ; on the other hand the 

 more close attachment of the fascia to the latter 

 membrane in proportion as it recedes from the 

 crural arch forbids the section of the fascia di- 

 rectly upward ; while the existence of the tri- 

 angular interval, which has been described, 

 between the fascia and the peritoneum imme- 

 diately above the arch renders the membrane 

 safe from injury in a division outward near to 

 the arch : it must however be recollected that 

 in approaching the arch the circumflex ilii 

 artery is also approached and endangered, so 

 that the incision should not be brought too 

 near to that part, but made in the direction 

 mentioned, nor in any case be larger than will 

 suffice for the introduction of the finger or the 

 director. 



6. The immediate investment of the vessels 

 frequently opposes great resistance to the sepa- 

 ration of the artery and vein, and to the iso- 

 lation of the former; this impediment is due 

 not merely to the strength of the investment, 

 but also to the absence of a resisting support 

 behind the vessel as it recedes from the pubis, 

 in consequence of which it yields to the pres- 

 sure exerted to separate it. In such case the 

 nail, the director, or the knife has been recom- 

 mended for the division of the expansion; 

 Abernethy made a slight incision on either side 

 of the artery. The nail does not seem the best 

 instrument in this instance, because, by the 

 use of it the vessel must be a good deal dis- 

 turbed, a circumstance to be avoided when- 

 ever it can be ; the knife again must be attended 

 with risk unless used with great caution and 

 in steady hands, and the risk is the greater 

 when the incision is made at one side of the 

 artery, since the vein is thereby endangered ; 

 it would seem a safer proceeding and one less 

 likely to disturb the artery unnecessarily, if, 

 when it can be done, the investment were 

 pinched up with a forceps over the middle of 

 the artery and then divided to the extent to 

 which it may have been raised, after which, 

 with the director or the blunt aneurism- needle, 

 the artery may be isolated with facility while 

 the investment is drawn to either side with the 

 forceps. 



7. It is to be borne in mind that one or 

 more lymphatic glands usually lie in front of 

 the artery imbedded in the cellular structure 

 which forms its investment, and that these 

 may be to be displaced. 



8. In operations upon the iliac arteries, more 

 particularly when performed after the method 

 of Abernethy, or upon the internal or primi- 

 tive vessels, a protrusion or bearing down of 



