Branches.—The two large branches to the wall of the abdomen, the epigastric and the circumflex iliac, rise a few lines above Poupart's ligament. Their position is unfortunately apt to vary upwards, to the extent of an inch and a half or even two inches, and they are important, as, besides being liable to be cut during the operation, their position very materially modifies the prognosis, as, if too high up, they interfere with the proper formation of the coagulum.

Operation.—Various plans of incision through the skin have been recommended by various operators, the chief difference being with regard to the part of the artery aimed at; the plan known as that of Mr. Abernethy, with various modifications, being intended to expose the artery pretty high up, and enable the surgeon to reach it from above; while the method going by the name of Sir Astley Cooper's exposes the lower part of the artery, and enables the surgeon to reach it from below. Though the latter is in some respects easier, the former method is generally to be preferred, being further from the seat of disease, and especially more out of the way of the epigastric and circumflex arteries.

The higher operation (Abernethy's modified).—An incision must be made through the skin about four inches in length, but longer in proportion to the amount of subcutaneous fat, and the depth of the pelvis, extending from a point one inch to the inside of the anterior superior spine of the ilium, to a point half an inch above the middle line of Poupart's ligament. It must be slightly curved, with its convexity looking outwards and downwards.³

The subcutaneous cellular tissue and the tendon of the external oblique may then be divided freely in the same line. Then at some one point or other (generally easiest below), the internal oblique and transversalis muscles must be cautiously scraped through with the aid of the forceps, till the transversalis fascia is reached; they may then be freely divided by a probe-pointed bistoury (guarded by the finger pushed up below the muscles) to the required extent. The muscles being held aside by flat copper spatulæ, the fascia transversalis must be carefully scratched through near the crest of the ilium, and thus the operator will be enabled to push the peritoneum inwards, and by the forefinger will easily recognise the pulsation of the artery lying on the soft brim of the pelvis.

A branch of the circumflex iliac artery will very likely be cut in dissecting through the muscles, and must be secured, as also any branches of the epigastric which may be divided in the incisions through the abdominal wall (ut supra, p. 5).

The operator should then, by pressing the peritoneum and its contents gently inwards, endeavour to see the vessel; if, from the depth of the pelvis, this cannot be done, the sense of touch will be in most cases sufficient to enable him to isolate the artery by the point of his finger-nail, or by the blunt aneurism-needle, from the vein. The ligature should be passed from the inner side to avoid including the vein, and thus there will be less chance of wounding the peritoneum from the convexity of the needle being applied to it. If possible, the genito-crural nerve should not be included in the ligature, but probably such an accident would do no great harm.

It is of much more consequence to avoid injuring the peritoneum. This is sometimes very difficult, from the adhesions which are set up between the peritoneum, the artery, and especially the aneurism, as the result of pressure and inflammation. The accident of wounding the peritoneum has happened to Keate, Tait, Post, and others, and in some cases with perfect impunity. However, the peritoneum should be displaced as little as possible from its cellular connections, as such displacement increases the risk of diffuse inflammation of that membrane; and the vessel itself should be raised and disturbed as little as possible, lest destruction of the vasa vasorum cause ulceration of the weak coats and secondary hæmorrhage.

The operation from below (Plate I. fig. 4), Sir Astley Cooper's, is thus described by Mr. Hodgson:⁴—"A semilunar incision is made through the integuments in the direction of the fibres of the aponeurosis of the external oblique muscle. One extremity of the incision will be situated near the spine of the ilium; the other will terminate a little above the inner margin of the abdominal ring. The aponeurosis of the external oblique muscles will be exposed, and is to be divided throughout the extent, and in the direction of the external wound. The flap which is thus formed being raised, the spermatic cord will be seen passing under the margin of the internal oblique and transverse muscles. The opening in the fascia which lines the transverse muscle through which the spermatic cord passes, is situated in the mid space between the anterior superior spine of the ilium and the symphysis pubis. The epigastric artery runs precisely along the inner margin of this opening, beneath which the external iliac artery is situated. If the finger therefore be passed under the spermatic cord through this opening in the fascia, it will come in immediate contact with the artery which lies on the outside of the external iliac vein. The artery and vein are connected by dense cellular tissue, which must be separated to allow of the ligature being passed round the former."

In comparing the two methods of operating, we find that while the latter is in some respects easier, and the vessel in it lies more superficial, it has certain disadvantages which more than counterbalance its advantages. Thus, first, the epigastric artery is very likely to be wounded. It may be said, Well, if so, the ends can be tied; but this tying is sometimes very difficult; and, as shown in Dupuytren's case of this accident, involves considerable interference with the peritoneum, and a possibly fatal peritonitis. Besides this, by cutting the epigastric you destroy an important agent which would have carried on the anastomosing circulation, and thus greatly increase the risk of gangrene. By this method, also, the artery is exposed too near to the seat of disease; and if found to be enlarged and involved in the aneurism, considerable difficulty may be experienced in reaching the upper part of the vessel. Again, ligature of the lower third or half of the vessel, which this method implies, is dangerous from the occasional high origin of the circumflex or epigastric, or both, rendering the formation of a clot much more difficult, and secondary hæmorrhage much more likely.

The circumflex iliac vein must also be remembered, as it crosses the artery from within outwards in the lower end of it, just before it goes under Poupart's ligament.

However, the method may occasionally vary with the individual case. In every case of ligature of the great vessels of the abdomen, the bowels should be carefully evacuated before the operation, and the bladder emptied. A properly managed position, with the shoulders raised and the knees semiflexed, will greatly facilitate the gaining access to the vessel.

In sewing up the wounds in the abdominal walls, advantage will be gained by putting in a certain number of stitches so deeply as to include the whole thickness of the muscles, and in the intervals between these deep ones to insert others less deeply, so as accurately to approximate the edges of the skin. This will both facilitate union and also render the occurrence of hernia less probable. This latter accident did occur in a case, otherwise successful, in which Mr. Kirby tied the external iliac.

Both external iliacs have been tied in the same patient with success, on at least two occasions, once by Arendt, with an interval of only eight days between the operations; and a second time by Tait, at an interval of rather more than eleven months.

This operation is in the great majority of cases performed for femoral aneurism, and naturally secondary hæmorrhage is a too frequent result. Wounds of these great vessels generally result in so rapid death from hæmorrhage as to give no time for surgical interference. One case, however, is recorded,⁵ in which the external iliac was cut in a lad of seventeen by an accidental stab, and in which Drs. Layraud and Durand, who were almost instantly on the spot, succeeded in stopping the bleeding by compresses, till Velpeau arrived, who tied the vessel above with perfect success.

Of the first twenty-two cases collected by Hodgson, fifteen recovered—a mortality of 31.81 per cent.; and of 153 in Norris's collection, including Cutter's cases, forty-seven died—a mortality of only 32.5 per cent.,—a very satisfactory result, considering the size of the vessel and the importance of its relations.

Ligature of Gluteal.—This vessel, though one of the branches of the internal iliac, approaches the surface so nearly as to be occasionally wounded. It is also, though very rarely, the subject of spontaneous aneurism. The principle of treatment and the operation to be selected in any given case, depends upon its origin, whether traumatic or spontaneous. For if traumatic, the wound must almost necessarily be accessible from the outside; the neighbouring part of the artery is probably healthy, and hence the case can be treated by the old operation, slitting up the tumour, and tying the vessel above and below the wound. When the aneurism is spontaneous, there is no guide to tell us where the aneurism may have first originated; it may be that it is high up in the pelvis, and that the visible tumour is only its expansion in the direction of least resistance, or the coats of the vessel may be extensively diseased. The only chance is ligature of the internal iliac.

1. The old operation, or ligature of the gluteal artery in the hip.

Anatomical Note.—The gluteal is the largest branch of the internal iliac, and leaves the pelvis by the great sacro-sciatic notch just at the upper edge of the pyriformis muscle. After a very short course, it divides into superficial and deep branches opposite the posterior margin of the glutens minimus, between it and the pyriformis muscles.

Very precise rules have been given to enable the operator to hit on the exact spot where the artery leaves the pelvis. These, though perhaps interesting anatomically, are quite useless in a surgical point of view, for the only reasons which could possibly induce a surgeon to cut down upon the gluteal in the living body, are the existence either of a wound of the vessel or an aneurism. In the first the flow of blood, in the second the tumour, would give sufficient guidance.

In cases of traumatic aneurism the operation should be something like the following:—A free incision should be made into the tumour, dividing it in its long direction; the contents should be rapidly scooped out, and a finger placed on the bleeding point, just at the upper corner of the sciatic notch. This will at once stop the hæmorrhage till the vessel can be secured. This sounds easy enough, and has been done several times with success. Thus, John Bell, by an incision two feet long, as he tells us in his hyperbolical language, was enabled to tie the vessel in the case of the leech-gatherer who had punctured the artery by a pair of long scissors. Carmichael of Dublin used a smaller incision, removed one or two pounds of clots, and tied the vessel, in a case of wound by a penknife.⁶

Now, though both of these cases were eventually successful, both patients lost during the operation a very large quantity of blood; John Bell's especially could not be removed from the operating-table for a considerable time after the operation. The period at which the great loss of blood took place was the interval after the incision was made, and before the artery was exposed to view, i.e. the interval in which the surgeon was busy dislodging the clots from the cellular membrane, the sac of the false aneurism. The procedure devised by Mr. Syme to obviate this difficulty, and which was put in practice by him in several very trying cases, is best given in his own terse description of an operation in a case of traumatic gluteal aneurism:—

"The patient having been rendered unconscious, and placed on his right side, I thrust a bistoury into the tumour, over the situation of the gluteal artery, and introduced my finger so as to prevent the blood from flowing, except by occasional gushes, which showed what would have been the effect of neglecting this precaution, while I searched for the vessel. Finding it impossible to accomplish the object in this way, I enlarged the wound by degrees sufficiently for the introduction of my fingers in succession, until the whole hand was admitted into the cavity, of which the orifice was still so small as to embrace the wrist with a tightness that prevented any continuous hæmorrhage. Being now able to explore the state of matters satisfactorily, I found that there was a large mass of dense fibrinous coagulum firmly impacted into the sciatic notch; and, not without using considerable force, succeeded in disengaging the whole of this obstacle to reaching the artery, which would have proved very serious if it had been allowed to exist after the sac was laid open. The compact mass, which was afterwards found to be not less than a pound in weight, having been thus detached, so that it moved freely in the fluid contents of the sac, and the gentleman who assisted me being prepared for the next step of the process, I ran my knife rapidly through the whole extent of the tumour, turned out all that was within it, and had the bleeding orifice instantly under subjection by the pressure of a finger. Nothing then remained but to pass a double thread under the vessel, and tie it on both sides of the aperture."

The bleeding in this case was thus rendered comparatively trifling, and the patient made a speedy and complete recovery. He returned home within six weeks after the operation.⁷

2. In one case, at least, the gluteal artery has been tied with success (for traumatic aneurism) just where it leaves the pelvis, without the tumour being opened. This was in the practice of Professor Campbell of Montreal. The operation was a very difficult one, and while possible only in cases seen very early, and where the tumour is very small, does not appear to have any advantage over the old method.

Cases of spontaneous aneurism of the gluteal artery should be treated by ligature of the internal iliac. Steven's and Syme's cases of ligature of the internal iliac were of this nature.

Manuals of operative surgery occasionally devote pages to the description of special operations for the ligature of such arteries as the sciatic, epigastric, circumflex ilii, and pudic. They do not require ligature, except in cases of wound either of the vessels themselves or their branches; and, according to the modern principles of surgery in such cases, the ligature should be applied to the bleeding point, rather than to the vessel at a distance above it.

Ligature of Femoral.—Under this head we practically mean cases of ligature of the superficial femoral, for the common femoral, or (as called by some anatomists) the femoral, before the profunda is given off, very rarely requires to be tied. If it is wounded, of course the bleeding point must be sought, and the artery tied above and below it, but if an aneurism on the superficial femoral renders ligature of that trunk impossible, experience teaches that ligature of the external iliac gives better results than ligature of the common femoral. Erichsen asserts that out of twelve cases in which the common femoral has been tied, only three have succeeded, the others dying from secondary hæmorrhage. The experience of the Dublin surgeons, Porter, Smyly, and Macnamara, has been more satisfactory, as in eight cases of this operation six were successful.⁸ A ninth case was unsuccessful. Reasons to explain the danger are not far to seek, for the numerous small muscular branches, along with the superficial epigastric, circumflex, and pudic trunks, reduce the chances of a good coagulum in the common femoral to a minimum, even without taking into consideration the shortness of the trunk before the great profunda femoris is given off. For the common femoral artery is only from one to two inches in length, and if there are some rare cases in which it is a little later in its bifurcation, there are others in which it divides nearer to Poupart's ligament.

The superficial femoral is the name given to the main trunk between the origin of the profunda, and the point at which, passing through the tendon of the adductor magnus, it receives the name of popliteal. During this long course it gives off no branch large enough or regular enough to receive a name, except one, the anastomotica magna, which rises in Hunter's canal, close to the end of the vessel, so in that respect it is peculiarly suitable for the application of a ligature. Again, in the upper part of its course, it is superficial, being covered only by skin and fascia. A short notice of its most important anatomical relations is necessary.