846 



~ ILIAC ARTERIES. 



the abdominal viscera is to be expected which 

 has been found a great obstruction to the 

 operation : this will be most effectually pre- 

 vented by the use of purgatives previous to the 

 operation; by posture, the abdominal muscles 

 being thereby relaxed as much as possible; 

 and during the operation, if it occur, by the 

 use of curved spatulas of considerable width 

 and curve, as used by Mott, with which the 

 viscera may be supported. 



9. In the passage of the ligature it will 

 always be necessary to be assured that the 

 genito-crural nerve is not included ; but it may 

 be avoided without difficulty, and can seldom 

 require to be divided. Its situation should be 

 borne in mind, viz. above external to the artery, 

 below external or anterior. 



Lastly, it would seem the safer plan to pass 

 the needle and ligature from within outward, 

 inasmuch as the vein is internal to the artery. 

 In Cooper's Lectures edited by Tyrrell, it is 

 directed to pass the needle from without; by 

 so doing there is less risk that the genito-crural 

 nerve shall be included, and in high operations, 

 since the vein is situate so much beneath the 

 artery at the superior part of their course, it 

 will not be thereby much endangered, but at 

 the lower part the vein must certainly be more 

 exposed by that mode of passing the ligature 

 than by the contrary one, while the nerve may 

 be avoided without difficulty. 



We shall next consider the comparative 

 merits of the several plans of operation. In 

 the method of Abernethy the direction of the 

 line of incision is attended with the following 

 consequences. 1 . It requires a more extensive 

 division of the oblique and transversalis mus- 

 cles, and hence is more likely to be followed 

 by weakness of the abdominal wall. 2. Fal- 

 ling, as first performed by him, nearly upon 

 the course of the epigastric artery, it exposes 

 that vessel to be divided, though in the me- 

 thod adopted by him in his latter operations 

 this risk must be very much diminished, if not 

 removed. 3. The extent to which it is neces- 

 sary to divide the internal oblique and trans- 

 versalis muscles must expose the peritoneum 

 lining the anterior wall of the abdomen to be 

 lacerated or divided during their separation. 

 4. The parallelism of the vessel and the wound 

 must render it necessary to expose a greater 

 length of the former, in order to effect its 

 separation from the contiguous parts and to 

 pass a ligature round it. 5. It is therefore 

 necessary to detach the peritoneum in all cases, 

 and to a greater extent than may be necessary 

 or required by a different method. 6. The 

 peritoneum must be detached to an equal ex- 

 tent from both walls of the abdomen from the 

 anterior as much as, or it may be more than, 

 from the posterior. 7. The protrusion of the 

 viscera must be more likely to occur. 



It is asserted by some* that the spermatic 

 cord is more exposed to injury in this method; 

 but it appears to me that it cannot be more so 

 than in others, and that it ought to be more 

 safe. 



* Velpeau. 



The second method is free from many objec- 

 tions to which others, and especially the first, 

 are exposed. 1. It does not endanger any 

 vessel but the superficial epigastric. 2. It does 

 not endanger the spermatic cord. 3. Probably 

 it does not tend to weaken the abdominal wall 

 as much as the first method. 4. It renders 

 necessary a much less extensive detachment of 

 the peritoneum, since the line of incision falls 

 so much nearer to the inferior reflection of the 

 membrane. Add to these that by it the artery 

 may be reached at as high a point as by the 

 first, and no doubt can remain that it is to be 

 preferred to it ; and in cases requiring a high 

 ligature of the vessel there is none, save the 

 modification of Cooper's method, which can 

 be considered equally eligible. It is still, 

 however, subject to the same conditions with 

 the first, only in less degree. In the method of 

 Cooper, on the contrary, the internal oblique 

 and transversalis muscles are divided to but an 

 inconsiderable extent, and the division of the 

 aponeurosis of the external oblique approaches 

 more to the course of its fibres. The direc- 

 tion of the incision being transverse to that of 

 the artery, the vessel may be exposed, and a 

 ligature passed round it without stripping it to 

 a great extent and with little disturbance of it. 

 Again, for the same reason and because of the 

 vicinity of the incision to the crural arch, the 

 vessel may be exposed either without dis- 

 placing the peritoneum at all, or displacing it 

 but little ; and when it is necessary to displace 

 the membrane, that may be effected with the 

 least possible disturbance of it, inasmuch as, 

 because of the propinquity of the line of in- 

 cision to the reflection of the membrane, it is 

 not necessary to detach the latter from the 

 anterior wall of the abdomen. It must also 

 be less exposed to the protrusion of the viscera, 

 and when the vessel is tied below, the reflection 

 of the peritoneum must be exempt from it. 

 This method permits the artery to be reached 

 at from an inch to an inch and a half above the 

 crural arch. 



On the other hand this method endangers 

 the epigastric artery and spermatic cord more 

 than the others ; the former because the line 

 of incision crosses the vessel's course, com- 

 mencing internal to it, and the latter because 

 the line of incision crosses and sweeps over 

 tne cord in describing its curve. Velpeau con- 

 siders that there is greater danger to these parts 

 in the method of Abernethy, but I cannot 

 concur in this opinion, for the lower extremity 

 of the incision alone can fall upon the situation 

 of the cord, and in the mode adopted by him 

 in the majority of his operations, the line of 

 incision was external to that of the epigastric 

 artery. Experience too proves that there is 

 greater danger of dividing the epigastric artery 

 in the method of Cooper, since the accident 

 has occurred more than once in it, and in the 

 most dexterous hands; thus Averill relates that 

 the artery was wounded by Dupuytren, and 

 Guthrie also states that he has seen the artery 

 divided in the performance of this operation, 

 while I am not aware of an instance in which 

 the trunk of the artery has been divided in the 



