3. As the artery ascends in the abdominal wall it gives to either side numerous branches, which are distributed among the structures of the wall, anastomosing externally with branches of the circumflex iliac, of the lumbar and the inferior intercostal arteries, and internally with those of the artery of the other side ; many of these branches ultimately become superficial, passing through the muscles, and through aper tures in the aponeurosis of the external oblique ; they terminate in the superficial structures, anastomosing with the other superficial vessels.
4. Finally, the epigastric artery terminates by two or more long ascending branches, which meet and anastomose with branches from the internal mammary artery.
Methods of operation for the ligature of the iliac arteries.—The methods of operation for the internal and primitive iliacs being but mo difications of those adopted for the external, I propose to detail the latter first.
The operation in each case may be resolved into three stages, viz. 1, the division of the structures of the abdominal wall ; 2, the dis placement of the peritoneum with the inter vening viscera;' 3, the management of the artery and the parts immediately related to it. Several plans have been proposed for exposing the external iliac artery; these may be regarded as, all, modifications of the same; yet their number, the existence of points of difference leading to results of some importance, and the advantage to be derived from a clear appre hension of them, render it desirable to distin guish them so far as they present distinctive characters deserving notice. I propose, there fore, to particularize five methods, between which operators may have occasion to select. In the first the line of incision is straight, and corresponds to the course of the artery. In the second the line of incision is also straight, and inclines away from the course of the artery toward the superior anterior spinous process of the ilium. In the third the line of incision is curved, convex downward toward the thigh, and crosses the course of the vessel. In the fourth the line of incision is straight, and transverse to the artery's course. The fifth, which I would specify, is a modification of the third, by which that plan may be rendered more generally ap plicable. The first is, that which was adopted by Abernethy, by whom the artery was first tied, A.D.1796, and is now generally known as his method, of which the following is his own account :—" I first made an incision, about three inches in length, through the integuments of the abdomen, in the direction of the artery, and thus laid bare the aponeurosis of the ex ternal oblique muscle, which I next divided from its connection with Poupart's ligament, in the direction of the external wound, for the extent of about two inches. The margins of the internal oblique and transversalis muscles being thus exposed, I introduced my finger beneath them for the protection of the peri toneum, and then divided them. Next, with my hand I pushed the peritoneum and its con tents upwards and inwards, and took hold of the artery." The second method seems due to several, and first also to Abernethy. This may seem
doubtful, from the account of his second ope ration originally given by himself, in which he says merely that "an incision of three inches in length was made through the integuments of the abdomen beginning a little above Pou part's ligament, and being continued upwards ; it has more than half an inch on the outside of the upper part of the abdominal ring, to avoid the epigastric artery."t But in his collected worksT. of different dates it is expressly stated of this and his subsequent operations that the incision "began just above the middle of Poupart's ligament, and consequently external to the epigastric . artery, and was continued upwards, but slightly inclined towards the ilium." The plan adopted by Frere differed not much from this. This method appears however more particularly attributable to Roux, who seems to have been the first to give specific instructions for it, recommending that the be ginning of the incision should never be further than half an inch from and a very little higher than the anterior superior spine of the ilium, and that it should be carried very obliquely downwards to the middle of Poupart's liga ment§ The third method is that of Sir A. Cooper, in which the incision is begun just above the abdominal ring, and is extended downward in a semilunar direction to the upper edge of Poupart's ligament, and again upwards to within an inch of the anterior superior spinous process of the ilium. This incision exposes the tendon of the external oblique muscle : in the same direction the above tendon is to be cut through, and the lower edges of the in ternal oblique and transversalis muscles ex posed : the centre of these muscles is then to be separated from Poupart's ligament : the opening by which the spermatic cord quits the abdomen is thus exposed, and the finger passed through it is directly applied upon the iliac artery above the origin of the epigastric and circumflex ilii arteries : the next step of the operation consists in gently separating the vein from the artery by the extremity of a director or the end of the finger ; the aneurismal needle is then passed under the artery.II The fourth is that of Bogros, in which the line of incision is, as I understand it, straight, from two to three inches long, immediately above the crural arch, and has its extremities 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 tire finger; the epigastric vessels, if a guide be necessary, followed toward their origin ; 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.