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ABDOMINAL ANEURYSMS MEDICBALJORNAL 1543showed nothing abnormal, and those of the pelvis were unsatisfactory owing to flexion of the hip causing technical difficulties.Symptomatic treatment was given, and on July 20 his condition was unaltered. On July 21 the pain in his left hip became much more severe and spread to the left side of his abdomen. He was found to be pale, cold, and sweating, with a subnormal temperature and raised pulse rate. There was marked guarding in the left iliac fossa, and a large tender non-pulsatile swelling was felt. The signs in the left leg, apart from increased flexion of the hip, were as before. A diagnosis of retroperitoneal haemorrhage was made.After blood replacement, operation was carried out by one of us (C. R. S.) the same day (July 21). This confirmed the presence of a large retroperitoneal haematoma on the left side with a small quantity of blood in the peritoneal cavity. Both recent and old blood-clot were present and there was gross disruption of the psoas muscle and retroperitoneal tissues. The aorta and iliac arteries appeared normal and bleeding had ceased. The left kidney was also normal. Despite a careful search the source of bleeding was not discovered and the wound was closed, with drainage. Five hours after operation renewed bleeding occurred through the drain site: this was controlled by blood replacement. The next day, however, a further massive haemorrhage took place, and, despite blood transfusion, he died later the same day. Necropsy revealed a ruptured aneurysm about 1 cm. in diameter arising from behind the bifurcation of the left common iliac artery. It was thought to be of congenital origin, as there was no evidence of arteriosclerosis. DiscussionBonney (1956) and Filtzer and Bahnson (1959) have drawn attention to the occurrence of pain in the back and lower limb in occlusive disease of the aorto-iliac arteries and have stressed the importance in diagnosis of a history of its relation to exercise and the necessity for routine palpation of the femoral arteries. That pain may be referred to the lower limb from leaking aortoiliac aneurysms is less well known, and the diagnosis of such cases may be extremely difficult. A history of claudication is likely to be absent and the femoral pulses will probably be normal. Early recognition is of great importance, and may be assisted by attention to the following points. The distribution of referred pain in leaking aneurysm is likely to differ from that of the usual sciatic-nerve-root-pressure syndromes, and it is unlikely to be relieved by the standard conservative measures used in the treatment of these conditions. Careful abdominal palpation should be added to the routine examination of cases of backache and lower-limb pain and may reveal an abdominal swelling which may be pulsatile. The presence of obesity can, however, result in even large swellings in the retroperitoneum being overlooked. Radiography of the abdomen will show calcification in the wall of aneurysms in a small proportion of cases, but erosion of the...

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