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Iliac Aneurism Extirpation



Presented is a man, aged forty-six years, who was admitted to the Roosevelt Hospital, in August last, suffering from a painful pulsating tumor of the left groin. Fifteen years before he contracted syphilis, followed by various cutaneous eruptions and moderate alopecia. Two years ago he first noticed a small lump in the left groin, which was not painful or tender. Shortly after that it was felt to pulsate. The tumor gradually increased in size, but, up to two months before admis sion, did not cause any marked inconvenience. At that time he noticed shooting-pains in the leg, and a disagreeable sense of throbbing, on exertion. Later, there appeared an oedema of the foot, which has gradually increased in amount and extent.

A few days before admission, the pain was so severe that he was obliged to give up his work. On examination, his general physical condition was fair, old syphilitic scars on the lower legs, and a presystolic and systolic murmur of the apex, with an accentuated second sound of the heart. There was an oval swell ing in the left groin, almost filling the space between the anterior superior spinous process and the spine of the pubis, reaching about three or four inches above and from one to two inches below Poupart's ligament. The tumor was fairly well defined below, but above seemed to fade off into the deeper parts without any distinct line of demarcation. On palpation, distinct expan sile pulsation was present. The sensation imparted to the hand, at one point, suggested the presence of only a thin wall of tissue between the skin and blood current. Auscultation revealed a loud systolic murmur synchronous with heart-beat. No impulse on coughing. Skin movable. No pulsation in posterior tibial artery. Leg oedematous and cold ; superficial veins enlarged. Temperature, 99.2° F. ; pulse, 112.

Under ether anaesthesia, an incision was made midway be tween the anterior superior spinous process and the umbilicus, parallel with the fibres of the external oblique muscle. The muscular fibres were then separated without division down to the peritoneum, which was retracted from the iliac fascia until the common and external iliac arteries were exposed. The latter was easily ligated with chromicized catgut and the wound closed in the usual manner. The entire leg was then enveloped in cotton batting and bandaged, and the patient placed in bed.

Practically, no reaction followed the operation. The wound healed primarily. The evidences of circulatory disturbance in the leg were remarkably light, the foot seeming warm and well nourished from the first. Twenty-three days later, the patient was again anaesthetized, and a vertical incision made over the entire extent of the tumor. The femoral artery, issuing from the lower extremity of the aneurism, was ligated ; afterwards, the profunda and its several branches, together with the super ficial epigastric and circumflex iliac and superficial external pudic.

The walls of the aneurism were then carefully separated from the vein and nerve, and the entire sac removed. The inci sion was then closed with silkworm gut, and the same dressings were applied. Following this operation, there was a considerable lowering of the temperature of the foot and leg, and other evi dences of impaired circulation.

The patient remained in bed for about three weeks, at the expiration of which time, the wound being primarily united and the patient free from pain, he was allowed to sit up for an hour each day.

It is now three months since his last operation, and he is able to do a full day's work.

leg, patient, tumor, external, left and days