mal ligation of the femoral had been done previously, and in these cases
the ojieration was performed once for failure and in the other for inflam-
mation of the sac.
Excision of the sac has been performed four times, and each operation
was followed by a successful result, notwithstanding that in one instance
the vein was tied.
Aneurysms of the Groin.
The external iliac proceeds from the bifurcation of the common iliac
opposite the lumbo-sacral articulation, along the inner margin of the
psoas muscle to the middle of Pou])art's ligament, after passing beneath
which it becomes the femoral. The external iliac lies immediately
beneath the peritoneimi. The accompanying vein lies to its inner side,
and the genito-crural nerve upon the anterior surface of its sheath. The
common femoral is continuous with the external iliac beneath the middle
of PoujKirt's ligament. It descends through the upper part of Scarpa's
triangle for from one to two inches, to divide into its sujierficial and deep
branches. Within this short distance numerous branches are given off.
Lesions. â€” Aneurysms presenting in the groin may arise from the
external iliac or the common femoral artery, or from either of the two
main divisions of the latter close to their origin.
Aneurvsms situated so high upon the sujierficial or deep femoral as
to prevent their treatment by measures addressed to the affected vessels
' Delbet, "Traitement des Ati^v. ext.," Rcvuf de Chi,:, 1SS8-S9. - liUl, he. cit.
themselves are included in this grouj), not solely because they occur in
tlie groin, hut also l)ecause their niauagenient is practically identical with
that of aneurysms involving the external iliac or common femoral.
Of these arteries, aneurysms sj)ring most fre(juently from the common
femoral, next from the external iliac, and least often from the superficial
and deep femf)rals. They are usually globular in shape, and tend to en-
large anteriorly when situated in Scarpa's triangle. When confined to
the iliac fossa the shape varies greatly. The overlying skin may ulcer-
ate and the tumor rujiture externally. It may bm-st into the iliac fossa
or into the ])eritoneal cavity. Arthritis of the hip has been excited by
this form of aneurysm, and ostitis of the i)elvis has been observed.
Compression of the vein will give rise to oedema of the limb.
Inguinal aneurysm has not infrequently been found to be associated
with aneurysms of other arteries. Among Xorris's 10(J cases, 4 were
found to have other aneurysms.
Etiology. â€” Inguinal aneurysm occurs most commonly in males.
Among 100 cases collected by Norris,' 95 were in men and but 5 in
women, Kirmisson- found among 45 cases that 19 occurred between
the ages of thirty and forty years, and 80 between twenty and thirty
There is no especial diiference between the right and left sides in
point of frequency. Arteritis, due to syphilis, rheumatism, gout, nephri-
tis, or alcoholism, is the primary factor in the production of the aneurysm
here as in other positions. The exposed position of the vessels in ques-
tion is possibly an important contributory cause. In one or two cases
suppuration in the neighboring lymph-nodes, leading to erosion of the
artery, apjiears to have been the cause of the aneurysm ; and in several
cases compression or ligation of the artery, made to cure an aneurysm at
a lower point, has been followed by the formation of an aneurysm at the
site of compression or ligature.
Symptoms. â€” In some cases the first symptom is a sudden sharp pain
in the groin, following a blow or hyperextension of the hi]) or violent
nuiscular effort, which appears to mark the beginning of the affecti(m.
After a variable time in such cases, but more commonly without such a
history, a small tumor makes its appearance and increases rather rapidly
The point at which the aneiuysm first develops is important from a
diagnostic standjioint, fiir after it has reached some size the place of origin
becomes difficult of recognition.
The tumor usually possesses the common aneurysmal characteristics â€”
expansile pulsation and bruit. It ceases to pulsate if compression of the
atFerent artery can be efl^ected, and the sphygmograph shows the aneur-
Gangrene has occasionally been observed as a consequence of inguinal
aneurysm, and ])ressure upon the femoral vein has given rise to fcdema
of the limb. Infiammatiou, supjiuration, or necrosis of the sac may
occur, and produce tleath by hemorrhage or gangrene.
Finally, erosion of the pelvis or arthritis of the hip may give
' Xorris, Am. Jnurn. Med. Sci., 1847, xiii. p. 20.
- Kirmisson, Bull, et Mem. de la Soc. de Chir., ii., June, 1884, p. 478.
ANEURYSMS OF THE GROIN. 413
Prognosis. â€” S]>oiitanemis cure has been very rarely seen in inguinal
aneurysms. The tendeney is to progress rather raiiidly to rupture and
Treatment. â€” C'ompressiun by various methods lor the cure of inguinal
aneurysm has yielded a large jDercentage of failures. Among 31 eases
collected by Delbet,' there are 5 cures recorded. In 5 cases flexion
resulted in no cures ; on the contrary, 2 of the patients so treated died of
ruj>ture or inflammation of the sac.
The Esmairli Ijandage, supplemented by indirect compression applied
to the external iliac, has been used in 7 cases, with 2 cures. Of the
failures, 3 were simple ; 1 rapidly relapsed after ajiparent cure ; and in
1 case rupture of the sac occurred.
Indirect c(im]>ression has been employed in 16 cases, three times suc-
cessfully, but -with no dangerous consequences in the others.
Altiiiingii ligation of tlie common femoral has been condenmed as an
operation fraught with great risk and its abandonment advised In- high
authority, the conclusions have been reached upon conditions which no
longer exist Thus, Barwell ^ gives 58 per cent, as the projiortion of sec-
ondary hemorrhages and 51.6 per cent, as the mortality of deligation of
the common femoral. These cases, eom]M-ising as they do cases ope-
rated upon liefore the era of asepsis, are misleading. There is no good
ground for belief that, with careful asepsis and the use of absorbable
ligatures, ligations of several vessels, now rarely practised, may not
become successful procedures. Proximal ligature must then be applied
to the external iliac.
Delbet's ^ statistics comprise the results of 67 cases in which ligation
of the external iliac was performed. Of these 67 cases so treated, 42
were cured, and in 25 cases failure was noted. Among the 25 failures
there were 13 deaths, and of these 11 were ascribed to the operation or
its consequences and 2 to accidental and disconnected diseases. The
mortality, then, is 16.9 per cent. Of the remaining 12 failures, 5 were
simple, no change ensuing in the aneurysm ; in 5 suppuration of the sac
occurred, and resulted in cure ; in 1 gangrene necessitated amputation ;
in 1 secondary hemorrhage required the application of a second ligature
and ended in cure.
Kirmisson's * group of 40 cases reported between 1874 and 1883 gives
a mortality of 12.5 per cent.
Where the point of origin of the aneurysm is uncertain, or its size
and position art' such as to render ligation of the external iliac by the
extraperitoneal method undesirable, or where doid)t exists concerning the
exact place of application of the ligature, the transperitoneal method may
This method has several advantages over the extraperitoneal opera-
tion. It avoid.s tile extensive strijiping up of the subjieritoncal tissues, and
consequently inqilies a smaller wound and one M'hich more directly ex-
poses the site of ligature. It allows of choice in the point to be ligated,
and that it may be successfully accomplished in the case of the common
' Delbet, " Traitement des An^vrysraes externes," Revue de Chii:, 1888-89.
- Barwell, Internat. EncycL, Ashhurst, vol. iii., art. "Aneurisms."
' Delbet, Inr. cil.
*Kirmisson, Truite de Chir., Duplay et Reclus, viii. p. 993.
iliac or either of its branches tiie cases of Banks,' of Stinison,^ and of
Dennis^ will attest.
Extirpation of the sac has heen undertaken twice. The first case was
that of Rose/ who operated npon an anenrvsni ret'nrrinj;; two years after
ligature of the external iliac The vein was opened, but a successful
result was secured. The other case is that of Bazy,'' who extirpated a
large aneurysm with success after tying numerous large afferent arteries.
Delbet' gives 9 ojjcrations after th" method of Antyllus. Of the
9, 3 died. Of the 3 deaths, 1 occurred where the aneurysm had burst
into the hip-joint and simultaneous resection of the joint was done.
Gangrene supervened and the limb was amputated at the hip. In
another instance the sac, having inflamed as a eonse(pience of ligation of
the external iliac, was incised and the patient succumbed to jjyEcmia. In
the third case hemorrhage required the ligation of the external iliac,
with fatal result. Delbet very properly excludes the first 2 cases, leav-
ing 7 in which the operation was primary, with 1 death â€” a mortality of
14.3 per cent.
The small percentage of cures following compression as the treatment
of inguinal aneurysm, together with the possibility of dangerous acci-
dents consequent on its use, would seem to place this method among those
to be onlv exceptionally employed. Ligation of the external iliac has
vielded (32.6 per cent, of successes and a mortality of lfi.8 per cent.
(Delbet), 12.5 per cent. (Kirmisson). The method of Antyllus, in the
small number of cases reported, is successful in 71.4 per cent., while its
mortality is 14.3 per cent.
Ligation of the external iliac continues to be the operation of choice,
while incision or excision of the sac may jiroperly he confined to relapses
or failures after ligation of the external iliac or compression.
The abdominal aorta pierces the diaphragna opposite the last dorsal
vertebra and enters the abdomen. It descends upon the anterior surface
of the lumbar spine and bifurcates u]ion the body of the fourtii lumljar
vertelira a little to the left of the middle line. The abdominal aorta
gives off many and large branches, but those more commonly affected by
aneurysm are the coeliac axis, rising from the anterior surface of the
aorta at the margin of the diaphragm, and the superior and inferior
mesenteries, arising from below the level.
The common iliac arteries are formed at the division of the aorta into
its terminal branches upon the body of the fourth lumbar vertebra, and
f)ass ol)liquely downward and outward from this point to the level of the
umbo-saeral articulation, where they divide, forming the external and
internal iliac arteries. The common iliacs lie immediately behind the
peritoneum, the ureters and sympathetic nerves only separating them
from this membrane.
The corresponding vein lies to the right of each artery, but both the
1 Banks, Bnt. Med. Jonni., 1892, ii. 1IG3.
â– ^Stimson, ^Y. 1'. Med. .Jonrn., AnRiist 10, 1889.
â– ' Dennis, Med. Newi^, Phil., 18S6, Ixix. p. .565. â– * Rose, Lancet, Dec. 22, 1883.
5 Bazv, Bull, el Mem. de la Soc. de C'hii:, J.an. 7, 1891. ^ Delbet, loc. cit.
ABDOMIXAL ASEVRYSM. â– 415
rifflit and left conunon iliac voius pass heiiind the right common iliac
arterv before uniting to form the inferior vena cava, to the outer side of
The external iliac arteries skirt tiie l)rini of tliu pelvis along the inner
sides of the psoas muscles from the level of the lumbo-sacral articulation
to Poupart's ligament, where they enter the thighs. Tlie accompanying
vein lies to the inner side of the artery.
The internal iliac artery arises on each side at the bifurcation of the
common iliac, and descends to the upper part ( " the great sacro-scialic
foramen, where it divides into its anterior and posterior branches. The
ureter passes in front of, and the internal iliac vein behind, the artery.
The branches of the anterior division mainly supply the pelvic viscera,
while those of the posterior division are distributed to extrapelvic
Lesions. â€” Aneurysms occurring within the abdominal cavity arise in
most cases from the aorta or the iliac arteries, and more rarely from the
branches of these vessels.
Of 157 cases of aneurysm of the abdominal aorta collected by Sib-
son, lol were seated close to the coeliac axis and 26 arose below this
Aneurysm of the abdominal aorta is usually sacculated, and springs
from the anterior or posterior surface of the aorta, with about the same
frequency. Those aneurysms given off from the posterior wall of the
aoi'ta may erode the bodies of the vertebrae or compress the lumbar
nerves, f)r even the ureter, giving rise to renal colic. Those aneurysms
arising from the anterior surfiice of the aorta by compressing the neigh-
boring viscera or their ducts or interfering with their innervation cause
symptoms referal^le to disturbance of the function of the affected organs.
The common iliac artery is but rarely the site of aneurysm, most of
the aneurysms of the iliac fossa occurring in connection with the exter-
nal iliac, while aneurvsms of the internal iliac are but seldom seen.
Aneurysms of the iliac fossa are occasionally of considerable size and
develop with some rapidity, and that irrespective of their point of ori-
gin, but dependent apparently upon the slight resistance offered by the
Gangi'ene of either extremity may possibly result from clots separat-
ing from an aortic aneuiysm and causing embolism of the arteries of the
limb, and has been observed also as a consequence of iliac aneurysm.
Abdominal aneurysm may burst into the ]X'ritoneum or behind this
membrane, forming a diffuse aneurysm which later ruptures into the
peritoneal cavity, or the sac may rupture into the mesentery, or in the
case of aortic aneurysms situated high u]i rujiturc into the pleural cavity
Etiology. -r-Abdominal aneurysm occurs ofteuest after the age of
thirty years, and oftener in males than in females. Endarteritis, pro-
duced by any of its usual causes, is probably always the antecedent of
aneurysm here as in other situations.
Symptoms. â€” The disturbance of the function of the abdominal
organs consequent upon the development of an aneurysm within the
cavity will (le])end upon the position of the aneurysm. Those aneur-
V-sms arising from the upper part of the aorta may possibly give ri.se to
the .symptoms of dyspepsia or to jauiulice ; tlicy are almost always
accom[)anied by pain, which is ('X])laine(l ]jy irritation of the branches
of the solar j)lexus if the aneurvsin sprino- from tlie anterior snrface of
the aorta, or by erosion of the sj)inal Ixxiies if tiie anenrysm spring from
the posterior surface.
Situated lower down upon the aorta or one of the iliac arteries, the
aneurysm gives rise to groups of symptoms dependent upon the organs
enci'oached upon, but it is only when the iliac fossa comes to be occu-
pied by the aneurysm that (cdcma of tiie corresponding extremity or
symptoms of palsy are developed.
The tumor formed by the aneurysm is usually readily recognized,
and possesses no uncommon features other than those due to its position
within the abdomen. Several conditions, however, must be kept in
mind in determining the nature of an abdominal tumor suspected of
being an aneurysm. In many persons whose abdominal walls are thin
the aorta may readily be seen pulsating, and not infrequently in such
cases, on compressing the vessel with the stethoscope, a distinct bruit is
audible, but this is never the harsh aneurysmal rasp, nor is a tinner
Solid or cystic tumors of moderate size overlying the aorta, and
indet'd fecal masses, sometimes ccmvey the pulsations of the aorta and
simulate aneurysms ; but a purge entirely removes the impacted fteces,
and examination of the abdomen, with the patient upon his hands and
knees, will serve in most cases to decide between aneurysmal and other
jMucli has been said in reference to the distinction between pulsating
sarcomata of the pelvic bones and aneurysms, and while, in many cases,
the differentiation is attended witii difficulty, in most instances the pres-
ence or absence of the aneurysmal pulse in the corresponding dorsalis
pedis will decide the diagnosis.
The point of origin of the aneurysm is not always easy to recognize ;
but in addition to the facts furnished liy the history of the patient it
may be said that aneurysms above the level of the umbilicus arise from
the aorta or one of its branches, while tliose below this level may, rarely,
be connected witii the aorta, but probably sjjring from one of the iliac
Prognosis. â€” Occasionally spontaneous cure has been found, at au-
topsies made upon persons who had died of other diseases, to have oc-
curred in aneurysms whose existence was not susjK'cted during life.
Recovery has followed treatment, but the tendency of the disease is to
progress to a fatal issue by rupture of the sac in one or other of the
directions above indicated.
Treatment. â€” The method of Valsalva has yielded a few successful
results, and, unless special conditions exist which do not admit of delay,
may be used as the first step in the treatment, esjjecially of aneurysms
above the umbilicus. In those situated high in the abdomen this
method until recently constituted almost the only eligible plan of
The rest should be al)solute, and the heart-action reduced to a min-
imum by restriction of diet, administration of iodide of potassium or
other .sedative drug, and by venesection if the patient be at all plethoric.
ABDOMINAL ANEURYSM. 417
This plan is tedious, sometimes occupying weeks or months, and often
fails to cure the aneurysm or e\'en stay its growth, although symptoms
are frequently ameliorated.
Distal pressure has not yet l)een successful.
Proximal compression was first successfully practised by Alurray,'
though originally suggested by Holmes,^ and has now been emploj-ed
in a considerable number of cases,^ some of them being cured ; but in a
few cases disastrous results have occurred, due to injury of the intestine.
Pressure is made by some form of abdominal tournicjuet, and of
these the instruments of Lister and of Pancoast are the iiest.
The bowels are emptied by eatiiartics, and the compressor applied
over the artery, with the abdominal wall relaxed by Hexiou of the
thighs, and screwed down till pulsation ceases in the' aneurysm, or at
least in the femorals.
The pain incident to compression for any length of time makes anaes-
thesia by some means necessary, but to avoid vomiting the anaesthesia
should not be pi'ofound. The lower extremities, entirely without circu-
lation, require warm covering. The suggestion that the intestines be
gently kneaded from beneath tlie pad as the latter is screwed down seems
plausil)le, but is really impracticable.
In Murray's case pressure was maintained for ten antl a half hours
without interruption, but in other cases solidification has been produced
in a much shorter time. The patient's condition during this time must
be carefully observed, and any failure of heart-action or respiration
counteracted or the treatment suspended.
If success is to be achieved, dimiiuition of the tumor and increased
density of its walls will l)e recognized ; liut even if such do not occur at
the end of a reasonable period or the patient's general condition inter-
rupts the treatment, a second attempt may prove rapidly curative,^ or
slow clot-formation may go on within the sac as the consequence of
changes elfected by the temporary interruption of the current through
While the successful cases of abdominal aneurysm treated by this
method have been but few, this numl)er includes instances not only of
aortic but also of iliac aneurysm.
Maceweu â– " has apjilicd his needling method to at least one case of
aneurysm situated high in tlie abdomen and unsuitable for proximal
compression. The symptoms were markedly relieved. This method,
however, is a]iplica])lc only in those cases in which the aneurysm lies in
immediate contact with the abdominal wall â€” a fact demonstrated by
Maceweu in tlie case rejiorted, tiiniugh inflation of the stomach.
Ligature of the aorta has been done 11 times, and each operation has
resulted fatally. In 9 cases the ligature was applied for aneurysm, antl
in 2 cases for wound of the aorta and of the femoral respectively. In 1
case, that of IMonteiro," the jiatient survived the operation, done for a
diffused inguinal aneurysm, and finally died, exhausted by repeated
' JIurray, Mnl.-Cliir. Trims., xlvii. )). 187. '' Holmes, St/.Hl. Surgery, 1st ed.
^ Of 9 cases so treated, 4 were cured, 1 recovered uncured, and 4 died, all of peritonitis.
' Sutherland, lirlt. Meil. .fount., Oct. 5, 1867.
' Maceweu, ibid., 1S9(), ii. pp. 1107-1104.
* Monteiro, Lanrrl, 1842, i. p. 334.
lic'iuorrhagt'S from the nc'iglil)orhootl of tlie ligature. Tlie operation was
extraperitoneal. The recently rejjorted case of Milton,' in which the
aorta was ligatured by the transperitoneal method, resulted in death at
the end of twenty-four hours.
Notwithstanding the gloomy outlodl-; atl'orded l>y examination of the
eleven cases so iar reported, there seems to be some ground for belief
that ligation of tlie aorta, performed upon a patient not yet exhausted by
aneurysmal disease, or as a last resort after rupture of the aneurysm has
occurred, might be successful. That a collateral circulation sufficient to
carry on nutrition of the lower extremities can develop the (;ase of
Monteiro will attest. But witliout further facts the question of the justi-
fiability of ligating the aorta must remain stih juilice.
For iliac aneurysm ligation of either the common iliac or of its
branches may be undertaken with considerable confidence of success;
and of the two metliods, extra- or transperitoneal, the latter is to be pre-
ferred in all but exceptional cases.
The dangers of opening tlie peritoneum may now fairly l)e said to be
no greater than those attendant upon the infiiction of the extensive
wound necessary to reach tiie ct)nniion iliac or the upj)er part of the ex-
ternal iliac by the exti'aperitoneal operation ; indeed, several cases of
peritonitis have developed after ligation by the latter method where the
peritoneum was said not to have been wounded.
Stimson," Banks,' and Dennis* have each reported instances in which
the main iliac and each of its Ijranches liave been tied by the transperito-
neal method with ease and success.
Aneurysm of the Buttock.
The gluteal artery, the continuation of the posterior division of the
internal iliac, emerges from the pelvis throtigli the upper part of the
great sacro-sciatic foramen, and almost immediately divides into super-
ficial and deep branches.
The former passes outward in the interval between the gluteus maxi-
mus and medius, while the latter runs between the medius and minimus.
The sciatic artery, derived from the anterior division of the internal
iliac, escapes from the })elvis through the lower part of the great sacro-
sciatic foramen, along with the sciatic nerves, and, passing downward
for a short distance between the great trochanter and the tuber ischii,
beneath the gluteus maximus, is distributed to the structures of the
Lesions. â€” Aneui'vsm of the buttock may arise from eitlier tlie gluteal
or sciatic artery.
The sac ordinarily does not reach very considcral)le proportions before
rupture occurs â€” an accident to which the position of the aneurysm ren-
ders it peculiarly liable. Many, if not most, of* the recorded cases of
aneurysm of the buttock are instances of traumatic and not of spontane-
In rare cases the sac has reached the size of a child's head or larger
â€¢ Milton, Lancet, 1891, i. p. 85. ^ gtimson, N. Y. Med. Jouni., Aug. 10, 1889.
^ Banks, Bril. Med. Jom-n., 1892, ii. p. 1163.
* Dennis, Med. News, 1886, Ixix. p. 565.
ANEUBYS^r OF THE BUTTOCK. 419
before diiFusion occurred, and iu some cases the aneurysmal dilatation of
the artery has involved its intrapclvic portion to a variable extent. The
tumor, by coni])ressing the branches of the sacral plexus, gives rise to
severe pain in tiie distril)ution of tlie nerves or even i)alsy. The function
of the hip may be impaired or the pelvic bones eroded.
Knpture may occur through tlie skin or into the neigliboring struc-
tures, and wlien the latter happens the blood may be very widely diffused.