ILIAC ARTERIES. 



847 



method of Abernethy. But these objections 

 to the method of Cooper, however serious in 

 themselves, seem of insufficient weight when 

 contrasted with those to which the plan of 

 Abernethy is subject, more especially since 

 they only require caution to be effectually ob- 

 viated, while the others are inseparable from 

 the plan to which they apply. And hence the 

 preference has been given to his method, by 

 the greater number of those* who have had 

 opportunities of experimentally testing the 

 comparative claims of the two in all cases 

 where it is applicable : i. e. in those instances 

 in which the aneurismal tumour has so little 

 encroached upon the crural arch, or in which 

 there is so much reason to consider the artery 

 in a healthy condition immediately above the 

 arch, that it may be with propriety tied near 

 to that part. Sabatier is of opinion that the 

 method of Abernethy should be preferred in 

 every case; but the number of authorities 

 in favour of the other is so great, that we must 

 consider its greater eligibility as a decided 

 question. And the method of Cooper pos- 

 sesses the additional and great recommendation 

 that it may at any time be so modified by the 

 prolongation of the upper extremity of the in- 

 cision, as to be adapted to every case, so that 

 in instances, in which it may be found neces- 

 sary to tie the artery at a greater distance from 

 the arch than the original plan will permit, 

 this modification of it may be adopted even in 

 the course of the operation : for the most part 

 surgical writers recommend a preference of 

 Abernethy 's first plan in such circumstances; 

 but to this all the same objections which have 

 been already stated, apply, and forbid its adop- 

 tion, while another less subject to them and 

 not less efficacious presents for selection. 

 Abernethy's plan certainly promises one ad- 

 vantage, viz. that the line of incision being 

 nearer to that of the artery the depth of it from 

 the surface is likely to be less, unless where 

 the abdomen is very prominent, than in the 

 latter, in which the obliquity of the direction 

 must increase the depth of the wound, and for 

 the same reason it may be more easy to obtain 

 a view of the vessel, and to direct the opera- 

 tion by the sight, which must be more difficult 

 in the latter, and in proportion as the point at 

 which the operator aims is higher ; yet, not- 

 withstanding this circumstance in favour of the 

 method of Abernethy, and the preference given 

 by several to it in such cases, the method of 

 Cooper, modified as has been explained, ap- 

 pears to me still preferable, inasmuch as the 

 greater disturbance of the peritoneum, the risk 

 of injuring it in front, and the greater debility 

 of the abdominal wall likely to be the con- 

 sequence of Abernethy's method, seem to out- 

 weigh its advantages : there is beside another 

 disadvantage attending the latter and a cor- 

 responding advantage attending Cooper's plan, 

 which must be experienced when an aneuris- 

 mal tumour occupies the iliac fossa, viz. that, 

 by the former the peritoneum must be detached 

 from all the front of the tumour, while in the 



* Norman, Todd, Velpeau. 



latter the lower and inner part of it may be 

 left undisturbed, and this I consider a matter 

 of some importance. 



The method of Bogros has been proposed as 

 an improvement upon that of Cooper, under the 

 impression that in the latter the incision, which 

 makes nearly a right angle with the artery, 

 corresponds to the vessel only by its internal ex- 

 tremity, while in the one which Bogros proposes 

 the middle of the incision corresponds directly 

 to the artery ; by this plan he further maintains 

 that greater facility in the operation is ob- 

 tained, and the artery may be exposed nearly 

 an inch above the crural arch without disturb- 

 ing the peritoneum, while in Cooper's the 

 membrane must be always displaced, and the 

 ligature can be applied at only a very short 

 distance from the arch. Bogros plainly under- 

 stands Cooper's incision to commence at the 

 internal abdominal ring, and in such case his 

 objections would be well founded. It is cer- 

 tainly to be regretted that Cooper has used an 

 ambiguous expression, which has led others 

 beside Bogros to mistake his meaning ; but if 

 reference be made to his description of the 

 anatomy of hernia it will be found that by the 

 " abdominal" he intends the superficial in- 

 guinal ring, and if so, that the sole difference 

 between his and Bogros' plan is that in one the 

 line of incision is straight while in the other it 

 is curved, whence the comparative results must 

 be the reverse of those inferred by Bogros, so 

 far as the facility of securing the artery and of 

 reaching it at a greater distance from the crural 

 arch is concerned. If however it be desired to 

 secure the artery immediately above the crural 

 arch, between it and the reflection of the peri- 

 toneum, as may occur in cases of femoral 

 aneurism, the method of Bogros furnishes a 

 plan fully adequate to the intention, free from 

 the necessity of disturbing the peritoneum and 

 easy of execution ; at the same time that it is 

 subject to the objection, that, unless care be 

 taken to prevent it by tracing the vessels to 

 their origin, which must render the operation 

 more complicated and delicate, the artery is 

 more likely to be tied below the origin of the 

 epigastric and circumflex arteries by this than 

 by any other plan, and this upon two accounts 

 had better be avoided, so that all things con- 

 sidered this plan appears to me not so eligible 

 as that of Cooper, in which it is altogether 

 optional with the operator whether he shall 

 disturb the peritoneum or not, or whether he 

 shall tie the vessel immediately above the arch 

 or farther from it, the one method being ap- 

 plicable to all cases, and not requiring, perhaps 

 during the operation, a transition to another, 

 after that the first has been found insufficient. 



The modification of Cooper's plan, which 

 has been enumerated as a fifth method, can be 

 required only in those cases, in which it may 

 be necessary to reach a very high point of the 

 external or the primitive iliac. In such it will 

 be a question whether to adopt Abernethy's 

 original method, the second method, or the one 

 under consideration : for myself it appears to 

 me that the first ought to" be abandoned in 

 operations upon the external or primitive iliacs, 



