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 Abernetby, 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 lie 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 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 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 tho 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 bis 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 epigastrie 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, unless there be something peculiar in the par ticular case to justify its adoption. The ad vantages of the second method have been partly stated ; to these is to be added that the line of incision will be made to correspond more to that of the artery than by the last method, and consequently the wound will be less oblique in depth, whence probably there will be less difficulty experienced in holding aside the parts which intervene between the surface and the vessel ; and certainly the operator, who may be apprehensive of injuring the epigastric and circumflex iliac arteries or the spermatic process, will do well to adopt it. Still for some reasons I feel disposed to prefer the last, for 1, it re quires less disturbance of the peritoneum ; 2, it appears to me that the exposure of the vessel must be greatly facilitated by carrying the lower extremity of the incision across the course of the artery to its inner side, which is not accom plished by the second method ; 3, a semilunar line of incision furnishes a wound of greater length, and capable of being more widely opened than a straight one, while caution will secure the spermatic process and the epigastric artery from injury ; and if a branch of the circumflex ilii be, as it is likely to be, divided, it may be tied with ease. This was the me thod adopted by Mott in the operation, in which he tied the primitive iliac artery ; a ease which sufficiently establishes the adequacy of this plan for the high ligature of the vessel, at the same time that it displays in a strong light the difficulties for which the operator must be prepared. In such cases the method of di viding the internal oblique and transversalis used by Mott may be adopted with advantage, viz. after having opened the fascia transversalis to insinuate the finger between it and the peri toneum, and guided by it to divide both mus cles at once from within. It must not be forgotten that it is not uncommon to find the ureter crossing the internal iliac artery, upon the right side, near its origin.