Aneurism of the Femoral Artery 
AND 
A Knife-Wound of the Intestines. 
BY 
AV. O. ROBERTS, M. D., 
Professor of Surgical Pathology and Operative Surgery in the University of Louisville. 
\Reprints from American Practitioner, Ocfr, 1883, andJarfy, 1884.] 
LOUISVILLE, KY: 
PRINTED BY JOHN P. MORTON AND COMPANY, WEST MAIN STREET. 
1884 Aneurism of the Femoral Artery 
AND 
A Knife-Wound of the Intestines. 
BY 
W. O. ROBERTS, M. D., 
Professor of Surgical Pathology and Operative Surgery in the University of Louisville. 
[Reprints frotn American Practitioner, Oct'r, 1883, andJan'y, 1884.] 
LOUISVILLE, KY: 
PRINTED BY JOHN P. MORTON AND COMPANY, WEST MAIN STREET. 
1884 ANEURISM OF THE FEMORAL ARTERY- 
LIGATION OF THE EXTERNAL 
ILIAC-CURE* 
A negro man, thirty-seven years of age, presented himself 
at the University clinic on the nth day of last May, giving the 
following history: He had been a heavy drinker, and occasion- 
ally indulged in a protracted spree. Ten years ago he had been 
treated for syphilis, and having had no manifestations of the dis- 
ease since, considered himself cured. He was an uncommonly 
muscular man, and while turning somersaults in a strolling play 
company he fell in the act and struck his right thigh against the 
top of a chair. He was confined to his bed for some days after, 
and the thigh swelled greatly. This was in the summer of 1882. 
He has been lame since that time, and has scarcely been free 
from pain in the hip, thigh and knee. Several months after the 
accident, while rubbing his limb, he discovered a small, hard 
lump in the upper and inner part of the thigh, at the point which 
had been struck in the fall. This gradually increased in size. In 
February last he had become so lame as to be unfit for any kind 
of business, the tumor being about the size of the fist. He 
now for the first time consulted a physician, who recognized the 
tumor as an aneurism, and applied Martin’s bandage. This 
treatment was kept up for a week, the bandage being applied 
directly over the tumor, remaining on several hours of each day, 
when it had to be abandoned on account of the pain it produced. 
The tumor now increased in size more rapidly, and the entire 
limb began to swell from the foot up, and the lameness to grow 
worse. He came to the University clinic on the nth of May 
last, walking with extreme difficulty and in great pain. I found 
an immense tumor occupying the inner and anterior part of the 
thigh, extending for an inch and a half below Poupart’s ligament 
*Read before the Louisville Medical Society, July, 1883. 4 
Aneurism of the Femoral Artery. 
to the lower third of the thigh. The vertical measurement over 
the surface of the tumor was twelve inches, and the transverse 
thirteen inches. The pulsation and bruit were very distinct over 
the entire swelling ; the former could be seen even at some dis- 
tance. The bruit was likened, by a companion who came with 
the patient, to the noise made by the breathing of a wind-broken 
horse, and the comparison was strikingly good. The limb below 
the tumor was edematous; there was marked hyperesthesia of 
the anterior surface of the leg and foot. The slightest touch on 
the latter gave him great pain. There was some tenderness over 
the tumor itself, so much indeed that the patient could not stand 
sufficient pressure upon the artery above to cut off its pulsation. 
The situation and character of the tumor at once suggested liga- 
tion of the external iliac artery as the proper treatment. The 
patient was therefore prepared for the operation by a purgation 
and by elevating the limb. On the morning of the 12th, assisted 
by Prof. D. W. Yandell and Dr. McMurtry, in the presence of 
the post-graduate class of the University, I operated as follows: 
The patient being thoroughly anesthetized, a slightly curved 
incision, beginning about half an inch above Poupart’s ligament 
and to the inner side of the center and passing upward and out- 
ward for about three inches toward the ant. sup. spine of the 
ilium, was made down to the tendon aponeurosis of the external 
oblique. This was then divided the entire length of the former 
incision, and afterward the fibers of the internal oblique and trans- 
versalis muscles were very carefully cut through and the trans- 
versalis fascia brought into view. This was torn through with 
the fingers from Poupart’s ligament and the peritoneum pushed 
upward, when the sheath of the vessel was exposed, the vein 
lying to the inner side and the genito-crural nerve on top of the 
artery, this vessel being in a healthy condition. 
The aneurism needle was passed far within and outward, so as 
to avoid the vein, the nerve pulled aside, and the artery tied some 
distance above the region of the epigastric with a carbolized silk 
ligature. Both ends of the ligature were cut short, with the hope 
that it would become encysted. The incision in the aponeu- Aneurism of the Femoral Artery. 
5 
rosis of the external oblique and the muscles beneath was then 
closed with the continued suture of whale tendon, and afterward 
the superficial wound brought together, except at its dependent 
point, which was left open for drainage. The two sets of sutures 
were thought necessary because of the great thickness of ab- 
dominal walls due to the immense amount of adipose tissue. 
The entire limb was then enveloped in cotton batting, which 
was confined with a roller bandage, and carbolized dressings 
applied to the wound. Pulsation ceased in the tumor as soon 
as the ligature was applied, and has never since returned. The 
hyperesthesia of the limb disappeared entirely. No peritonitis 
occurred, and the patient recovered from the operation without 
an untoward symptom, his temperature never rising above 100.5°. 
The temperature of the foot on the affected side, to the touch, 
seemed somewhat higher than that of the opposite one. The 
cotton and bandage were kept on for ten days, and when re- 
moved the edema had nearly entirely disappeared. The patient 
was kept in bed five weeks, and then allowed to get up and walk 
about. He has felt but little inconvenience in walking, and the 
neuralgic pains, from which he suffered so much prior to the 
operation, have not troubled him since. The wound healed, 
except at its most dependent portion, by first intention. 
Ligation of the external iliac artery for the cure of aneurism 
of the femoral was first practiced by Abernethy in 1796; but it 
was not until 1806 that he met with success, the three opera- 
tions prior to that time having terminated fatally. Dr. Dorsey, 
of Philadelphia, in 1811, was the first to perform it in this coun- 
try. The tables of Drs. Norris and Cutter (American Journal 
of Med. Sciences) show that the vessel has been ligated, for all 
cases, 153 times, with 47 deaths: 17 died of gangrene; 9 of 
hemorrhage ; 5 of peritonitis; 3 of sloughing of sac; 3 of ex- 
haustion; 2 of tetanus ; 2 of causes unconnected with the opera- 
tion ; 1 of pleurisy; 1 of delirium tremens; 1 not stated, and 
1 doubtful. There have been three successful cases recorded in 
which both external iliacs have been ligated in the same patient; 
one by Arendt, in which the interval between the operations was 6 
Aneurism of the Femoral Artery. 
only eight days; one by Tait, the interval being eleven months ; 
and one by Watson, with an interval of nine months. 
Ligation of the external iliac artery is considered a much 
safer operation than that of the common femoral, for several 
reasons, viz., that the latter vessel, being so near the aneurism, 
its coats are more apt to be diseased ; inflammation is more liable 
to attack the sac as a result of the close proximity of the liga- 
ture ; the vessel being so short, and the origin of its large branches 
so near together, render it difficult for a solid coagulum to form 
above the ligature, and the liability of occlusion of the two great 
nutrient vessels of the limb with gangrene below as a conse- 
quence. 
It goes without the saying that, in ligating the external iliac 
artery, care must be taken not to wound the deep epigastric 
artery, the spermatic cord, the peritoneum, external iliac, or 
circumflex vein, or genito-crural nerve, or to injure the sub-peri- 
toneal cellular tissue. If the deep epigastric artery be divided, of 
course it can be ligated, but its occlusion would increase the dan- 
ger of gangrene, as an important anastomosis would be stopped. 
Wounding of the spermatic cord is not apt to occur, as it can 
be easily detected and avoided. Wounding of the peritoneum is 
much less apt to occur when the abdominal wall is opened one 
half inch above Poupart’s ligament, as recommended by Sir 
Astley Cooper, and when the transversalis is torn through than 
when it is cut through. Sometimes it is impossible to avoid 
injuring this membrane, especially when adhesions exist. The 
vein is not likely to be punctured if proper care is taken in pass- 
ing the aneurism needle from it. The genito-crural nerve can 
generally be seen and readily pulled aside ; even were it divided, 
no special harm would be done. Should the external iliac be 
found diseased, or secondary hemorrhage follow its ligation, 
then by an extension of the incision the common iliac may be 
secured. Of thirty-two cases of this operation, tabulated by 
Stephen Smith, of New York, only seven recovered. To this 
table Mr. Erichsen adds eight cases, and gives thirty deaths and 
ten recoveries. A KNIFE-WOUND OF THE INTESTINES— 
ABDOMINAL CUT ENLARGED-THE 
GUT SUTURED-RECOVERY. 
Mr. —, a stout man, aged fifty-four years, while in an 
altercation, August 28, 1883, was cut in the abdomen with a 
pocket-knife. The wound was on the left side and was three 
inches long—extending obliquely from a point three inches to 
the left of and two inches above the umbilicus. It had opened 
the cavity and penetrated the small intestine. A considerable 
knuckle of the gut at once protruded and there was much hem- 
orrhage. The wound was dressed soon after by a physician who 
was near by. Dr. Turner Anderson, Mr. —’s family physician, 
now saw the patient, and had him removed to St. Joseph’s 
Infirmary, where Dr. Palmer saw him with Dr. A. Considerable 
bleeding having occurred on the way and there being some 
bulging about the wound, I was sent for. It was quickly agreed 
among us that the sutures should be removed, the wound opened 
and the bleeding vessel sought for. Dr. D. W. Yandell was then 
added to the consultation, and concurring in our views, the opera- 
tion was proceeded with. It was now midnight. The patient 
took chloroform. The sutures,, which were found to embrace 
but the skin and superficial fascia, were removed, and the 
wound extended at its two ends so as to admit the hand freely. 
A large coagulum of blood was seen lying just underneath 
the abdominal walls. This was removed and the intestines 
carefully drawn out until the cut portion was brought into 
view, when it was found that, in addition to slitting the gut, 
the knife had penetrated the great mesentery in two places, 
each an inch in length. One of these was occupied by a 
clot and was not bleeding. In the other bleeding was going 
on rapidly from three small vessels. Catgut ligatures were 
immediately thrown around these, and the hemorrhage ceased. 8 
Knife- Wound of the Intestines. 
The wounded bowel proved to be the jejunum, and, fortu- 
nately, was empty. The physician who first saw the patient 
had put interrupted sutures in the cut bowel, two in the larger 
and one in the smaller cut, but in neither was the opening closed. 
On removing the sutures one slit was found to be the size of a 
common lead pencil, the other that of a pea. Both extended 
into the gut. The knife had stripped off the serous coat of 
the tube over the space of an inch by one quarter of an 
inch, and this had retracted toward one of the lips and lay 
there.* In this denuded area, from which blood oozed freely, 
were the two bowel cuts. I secured the lips of both these cuts 
and the wound of the serous coat with continued sutures of 
catgut. When completed it was found that the stitches had 
considerably diminished the caliber of the tube, but not, it 
was believed, to an extent which would interfere with its 
functions. The peritoneal cavity was now well exposed to 
view by the aid of a mirror and thoroughly cleansed with 
sponges made hot in carbolized water; the intestine was returned; 
the external wound was closed by deep sutures of silk carried 
through the parietal peritoneum and the more superficial sur- 
faces approximated by sutures of horse-hair. A drainage-tube 
of gutta-percha was left in the lower angle of the wound, and 
the entire abdomen was covered by a thick layer of absorbent 
cotton which was secured in place by a broad flannel bandage. 
A quarter grain of morphia was given hypodermically, the 
patient placed in bed and surrounded by bottles of hot water. 
It was now one o’clock in the morning. The patient’s pulse 
was 108 and temperature in axilla 97.50 Fah. He slept well 
for six hours. On waking his pulse was 102, temperature 
99.6°, respiration 28 ; no pain, no nausea. Some bloody fluid had 
come through the drainage-tube, soiling the cotton over a space 
*1 am aware that in all wounds of the kind I am describing, there is always 
considerable retraction of the peritoneal coat of the tube, giving the appearance 
to the underlying tunic of having been peeled ; but the surface exposed in this 
case was so much larger than is usual, that I must believe the peritoneal coat had 
been more than simply cut, and that a portion of it had been actually dissected up 
by the knife. The medical gentlemen present concurred with me in this opinion. Knife-Wound of the Intestines. 
9 
as large as the hand. The soiled portion only was removed and 
replaced by fresh cotton, and the bandage reapplied. For five 
days the progress of the case was altogether satisfactory—the 
pulse falling to eighty, the temperature remaining under ioo°, 
and a quarter grain of hypodermic morphia every four or six 
hours securing comfort and sleep. No fluid came any longer 
through the drainage-tube, and it was removed. 
During this time no food whatever had been given. Water 
was allowed in small quantities, iced champagne when asked 
for, and crushed ice, of which he took a good quantity, ad 
libitum. 
On the evening of this day—the 5th—the patient complained 
of nausea, and during the night vomited several times. The 
ejecta had a suspicious though not a positive fecal odor, but 
during the sixth day they became distinctly stercoraceous. 
The temperature, which had fallen to normal, and pulse were 
unchanged. On removing the dressing the abdomen below the 
wound was of normal fullness—above it was much distended 
and distinctly tympanitic. There was no tenderness except 
immediately about the wound, and there really only at the 
seat of the two upper deep sutures, at which several small 
abscesses had formed. The hypodermic morphia was changed 
to a suppository containing the same amount along with a 
quarter grain also of belladona, used every four or six hours. 
In the evening a quart of soap-suds was thrown into the 
rectum, but soon came away, bringing no feces and but a 
small quantity of gas. Abdominal features remain unchanged. 
Patient complains of the fullness of the stomach, has constant 
nausea, great thirst, and vomits after drinking water, the 
ejecta being of a deep yellow color and distinct fecal odor. 
The night was passed much as the day had been. On the 
morning of the seventh day castor oil was given by the mouth, 
in order to determine, if possible, whether the intestinal tube 
was closed or not. Two hours after the patient had a small 
action in which the oil globules were plainly visible. A hot 
water enema was now given, which was soon followed by a 10 
Knife-Wound of the Intestines. 
copious dejection along with much gas. The nausea and 
vomiting ceased at once—all abdominal distension subsided, 
and the patient said he “ felt like a new man.” The sutures 
were now removed, the wound having closed except at the 
seat of the drainage-tube. In the line of two of the sutures, 
as I have stated, some suppuration had occurred and the little 
points continued to discharge matter for several days. Food 
was now given—first as milk, then as soup, etc. The bowels 
gave no farther trouble, and convalescence was rapid. 
I think there can be little if any doubt that if the wound 
had been left as Dr. Anderson found it, the man would 
have died either from hemorrhage, peritonitis, or septicemia. 
The ligature saved him from the first danger, the sutures put 
in the gut averted the second, and the thorough cleansing of 
the cavity and the drainage-tube, prevented the third. 
The sutures put in the bowel by the physician who first saw 
the case had failed of their purpose, and either opening still 
remained large enough to allow the escape of fecal and other 
matter into the peritoneal cavity. And few rules in surgery can 
now be considered as better established than that which declares 
that no wound, however minute, which opens a gut should be 
left unclosed. Professor Gross relates, in his monograph* on 
Wounds of the Intestines, that in several of his experiments 
—on dogs—“death was produced, not from any undue injury 
inflicted on the bowel from stitching or any rough manipulation, 
but from the interval between the sutures being so great as to 
prevent the perfect closure of the wound; a fact,” he very per- 
tinently adds, “which should never be lost sight of in the 
management of a lesion of this kind.” “ I do not care, there- 
fore,” he continues, “ how small the wound may be, if it is 
only a line and a half, or two lines, in extent, it should by 
all means be sewed up.” In confirmation of this practice, 
♦Nature and Treatment of Wounds of the Intestines. By Samuel D. Gross, 
M. D., Professor of Surgery, University of Louisville, 1843. Knife-Wound of the Intestines. 
11 
Dr. Gross quotes the following from Mr. Benjamin Bell: 
“ However small a wound of the intestine may be, it ought 
always to be secured with a ligature; for although it is alleged 
by some that we should rather trust to nature for the cure of 
a small opening than to insert a ligature, to me it appears 
that the opinion is by no means well founded; insomuch that 
I would not leave even the smallest opening that could admit 
either feces or chyle to pass without stitching it up.” 
I have introduced the foregoing authorities in order that 
attention may be directed anew to the necessity for perfect 
closure of all wounds which penetrate the intestine—a fact which, 
as the case I have reported shows, is at least not always acted on; 
and that I may quote the following from the monograph of Dr. 
Gross referred to respecting the dilatation of the outer wound in 
order to facilitate the search for the injured bowel. Writing of 
wounds which penetrate or divide the gut and allow of the 
escape of feces, he says: “ Here the most prompt and decisive 
measures must be resorted to, or the person will perish from 
peritoneal inflammation. ... It will not do for the surgeon 
to fold his arms and look upon the scene as an idle and 
uninterested spectator. Far otherwise. He has a duty to 
perform, and that duty consists in dilating the external wound, 
if it be not already sufficiently large, in hooking up the injured 
bowel, and in closing the solution of continuity with the requisite 
number of stitches, at the same time that the effused matter is care- 
fully removed with tepid water and a soft sponge.” The italics 
are my own. What Dr. Gross suggested, now more than forty 
years ago, as applicable to extensive wounds of the gut has, as is 
well known, recently been widened so as to embrace all penetra- 
ting injuries of the bowel, but the honor belonging to the entire 
procedure is now claimed by others. 
I submit that it belongs to Dr. Gross. 
Louisville, Ky.