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Fig. 146
 Thoracic (aortic) aneurysm. Death from external rupture.

Aneurysms may be minute and multiple, or single and large. The

former are seen in the brain in connection with syphilis, and in the
mesentery (Fig. 147). No artery in the body is necessarily exempt,
though obviously the larger arterial trunks are the more frequent
sufferers.
Spontaneous cure by natural methods is brought about in one of
the following ways: (a) By consolidation of laminated clots. (b) A
portion of the clot may become detached and plug the vessel on the
distal side, effecting the same occlusion there that is produced with a
ligature; in some cases the vessel may be occluded above the sac by
a clot from the heart. (c) That which occurs naturally may be caused
by accident as the result of some trifling injury. (d) The clot contained
within the sac may have become infected, so that suppuration with
necrosis of the sac contents is produced. In connection with this
there is sufficient acute arteritis to occlude the vessel, and the
resulting abscess within the sac may be opened and its contents
cleared out. This method is extremely rare and can only terminate
happily when the surgeon intervenes promptly.
In an aneurysm in which spontaneous cure has occurred there
may be progressive condensation of its contents, obliteration and
partial reduction in size, and a slow process of absorption.
The importance of collateral circulation, in recovery from
aneurysm, cannot be overestimated, as only by taking advantage of it
is it possible to furnish blood for the needs of the part affected. There
is no vessel with which the surgeon can interfere where natural
provisions in this direction appear insufficient (Fig. 148).
Certain conditions predispose to aneurysm of the idiopathic type,
such as age, with its accompaniment of arteriosclerosis; syphilis, with
its well-known tendency to chronic endarteritis; occupation and sex,
in that it is most frequent in those who are liable to violent exertion
and dissipation, because of the well-known tendency to arterial
structural changes after excesses of all kinds. Again, aneurysm may
be the secondary result of embolism when an embolus leads to a
local arteritis with disorganization.

Fig. 147 Fig. 148

Multiple aneurysms of the mesenteric arteries. (Eppinger.) Change in the trunk

after ligature; with
anastomosing
vessel. (Erichsen.)

Classification.—For surgical purposes there is no better

classification than the one used by Eve:
1. Sacculated aneurysm.
(a) Hernial;
(b) Diffuse, being a form of false aneurysm.
2. Fusiform, cylindrical, or tubular aneurysm.
3. Dissecting aneurysm, which may become
 (a) Sacculated;
(b) Diffuse and false; or
(c) Circumscribed.
4. Traumatic aneurysm.
(a) Circumscribed;
(b) Diffuse;
(c) Arteriovenous.
5. Arterial varix, cirsoid or racemose aneurysm.
6. Angioma or aneurysm by anastomosis.
1. Sacculated Aneurysms.—The sacculated are the most common.
They assume various shapes and dimensions, and may be seen
anywhere in the body. The opening between the sac and the main
vessel may vary in size. These sacs are usually strengthened by
plastic exudate in and around them, and condensation of surrounding
tissue. In thickness they vary from 1 Cm. to the thinnest which will
sustain blood pressure. In old scars may be found a stratiform or
layer-like arrangement, especially where the blood stream is less
active. Should spontaneous cure take place the sac may be
obliterated, while later calcific or other changes in the old scar may
occur. When the outer portion of such a sac has disappeared and the
inner coat is pushed out so as to assume, apparently, a secondary
aneurysmal arrangement, the condition is referred to as a hernial
aneurysm. When the ordinary sacculation gives way as the result of
necrosis, of pressure from within, or loss of support from without, the
opening first made is usually small and the extravasation outside the
true sac will depend upon the nature and resistance of the
surrounding tissues. In this way a diffuse aneurysm is formed, which
is one of the varieties of false aneurysm.
2. Fusiform Aneurysms.—Fusiform aneurysms are more or less
tubular and spindle-like dilatations of arterial trunks, in whose walls
may occur the changes common to all these lesions, the dilatation
rarely being sufficiently large to permit of laminated coagula unless a
sacculation occurs later at some particular portion (Fig. 149).
Fig. 149
 Fusiform aneurysm of popliteal artery, due to arterial disease (man
aged 59), requiring amputation of thigh on account of gangrene.
(Lexer.)

3. Dissecting Aneurysms.—The dissecting aneurysms are nearly

always expressions of previous atheromatous changes, by which
blood is forced between the arterial coats, separating them and
causing them to bulge at one or more points into sacculations or
distortions. In a false aneurysm there is no true arterial coat; the sac
is made up of surrounding tissue.
 Fig. 150

Traumatic aneurysm of axillary artery. (Park.)

4. Traumatic Aneurysms.—Traumatic aneurysms are generally

sacculated by the time they come under the surgeon’s observation.
They are circumscribed and diffuse. According to their age and other
circumstances they may contain old and dense laminated clots as
well as those which are fresh and stratified. Much will depend upon
whether the artery has been extensively injured or only slightly
punctured, and also upon the location and distensibility of the
surrounding tissue. Such a case seen in a fresh state will show
infiltration of blood and ecchymosis (Fig. 150). Arteriovenous
aneurysms are now seldom seen. When venesection was more
frequently performed the artery and one of the veins at the bend of
the elbow were often thrown into communication, as the result of the
indifferent performance of this operation and the use of the old-
fashioned lancet. When the communication is direct such a condition
is known as an aneurysmal varix; when indirect and through the sac
it is called a varicose aneurysm (Figs. 151, 152 and 153.)
 Fig. 151 Fig. 153

Aneurysmal varix. (Bryant.)

Fig. 152

Varicose aneurysm removed from its connections. Arteriovenous

(Erichsen.) aneurysm at bend of
elbow: a, brachial
artery; b, radial artery;
c, basilic vein; d,
median basilic vein; e,
aneurysmal sac; f,
dilated vein. (Lenoir.)
 Fig. 154

Cirsoid aneurysm. (Bruns.)

5. Cirsoid or Racemose Aneurysms.—Cirsoid or racemose aneurysms

constitute vascular tumors of irregular shape and outline, according
to the extent of the arterial system involved.
—The difference between angiomas and cirsoid aneurysms is more
artificial than natural. When a single vessel is involved with all its
branches it constitutes an Fig. 155
elongated tumor and partakes of
the nature of a varix. When the
growth is a collection of small
arteries the condition is then
known as an angioma. Between
these there may be all varieties of
vascular changes. Fig. 154
illustrates a case of this kind in
the scalp, while Fig. 155,
contributed by Parker, illustrates
a congenital involvement of the
vessels of an entire limb, with
overgrowth of the same from
increase of blood supply.
—All aneurysm so constituted as
to be easily palpated can scarcely
be mistaken for a tumor of any
other kind. It can be recognized
by its circumscribed nature; its
pulsation, which is always of the
expansile type; its bruit, which is
synchronous with systole. It can
be emptied by pressure, fills
somewhat slowly if pressure is
made above it, but more rapidly if
pressure is made below it, being
in this respect the counterpart of
a venous angioma. Its size and
rapidity of pulsation are
influenced by position, and its
location is usually that of one of
the large arterial trunks. The
murmur, heard through the
stethoscope, is sometimes more
than a mere bruit, and may be of
a tumultuous, almost roaring
character, the sounds being Cirsoid aneurysm of femoral artery
modified by the smoothness or and telangiectasis, with lengthening
of affected limb from hypernutrition.
roughness of the interior blood
(Parker.)
channel as well as by the
6. Angioma or Aneurysm by Anastomosis. Diagnosis.thickness of the
parts outside.
Naturally the sounds can be altered by pressure. The overlying
integument is at first unchanged, but if an aneurysm is working its
way toward the surface and threatening rupture the skin will be
stretched and discolored and may finally ulcerate. Blood pressure as
measured by the sphygmomanometer is not altered in a limb which is
affected by aneurysm.
Signs and symptoms which are not local are also produced in most
cases, their variety being great and depending upon the location of
the primary disturbing cause; for example, there is generally edema
with venous congestion of parts situated distally, these features being
so extreme in some cases as not only to threaten but even to
occasion gangrene. By pressure upon nerves both pain and paralysis
are produced and important functions impaired.
The tendency in all aneurysms is to increase in size and cause
atrophy or disappearance of the tissues upon which they exercise
their present influence.
—Innominate aneurysms usually appear behind the right
sternoclavicular joint. As they increase in size they cause pain and
edema of the right arm and the right side of the face, cough,
dyspnea, and dysphagia. As the swelling increases it rises above the
rib and sternum, pushing forward the sternomastoid and the clavicle.
After being displaced the bones and cartilages in front begin to
disappear by erosion, and the growth makes its way to the surface,
where pulsation can be easily seen as well as felt and heard. In
proportion to their increase other significant pressure symptoms, with
venous turgescence, will occur. Innominate aneurysms can
sometimes be differentiated from aortic by the sign, described by
Porter, of tracheal tugging. This is elicited by causing the patient to sit
up and bend the head forward, after which the cricoid is grasped and
drawn forcibly upward, thus stretching the trachea. If with each
cardiac impulse a well-marked tugging sensation be felt it may be
 Fig. 156 Regional Indications.attribute
Innominate Aneurysms. d to the
pulsation of an aortic aneurysm.
Subclavian Aneurysms.—
Subclavian aneurysms of the first
part of the vessel present similar
features, only that the bruit is
propagated down the axillary
artery rather than up the carotid,
and is not influenced by carotid
pressure, while the pressure
symptoms are limited mostly to
the arm. In axillary aneurysm the
radial pulse is more delayed.
Carotid Aneurysms.—Carotid
aneurysms are not always easy
of early diagnosis, as at the root
of the neck solid tumors often
transmit a deceiving pulsation
and convey an exaggerated
vascular sound. They may also
give rise to the same pressure
symptoms as do subclavian
aneurysms. Non-vascular tumors
do not have an expansile
pulsation, nor is the arterial sound
conveyed upward along the
carotid as in true aneurysm. In
aneurysms of the external carotid
there may be paralysis of the
tongue as well as difficulties in
speech and deglutition.
Varices of saphenous and branches Aneurysms of the internal carotid
(phlebectasis). (Lexer.) Compare tend to extend inward rather than
with Fig. 153.
outward. Intracranial aneurysms
are difficult of diagnosis, but they
usually give the symptoms of brain tumor, with possibly a bruit that
may be heard and described by the patient himself, especially in
certain positions of the head.
Wardrop used to formulate the diagnostic features of certain
aneurysms at the base of the neck, as follows: Innominate
aneurysms generally monopolize the episternal notch or rather its
right side, taking up this whole space, even though not rising high.
They first present to the inner side of the right sternomastoid, while
carotid aneurysms appear in the interval between the sternal and
clavicular heads, and subclavian aneurysm to the outer side of this
muscle.
In the abdomen the aorta is most frequently involved, and
sometimes its larger branches. An aneurysm of the renal or
mesenteric arteries can easily be mistaken for an aortic aneurysm.
The aorta proper terminates at the level of the umbilicus. A pulsating
tumor below this level should belong to one of the iliacs. Recognition
will depend largely upon the thinness of the abdominal wall and the
absence of fat. In many cases expansile pulsation can be detected
even here, while the pain is radiated along the well-known branches
of the sympathetic, and the location to which it is referred may be of
aid in deciding the part of the aorta most involved. Aortic pulsation is
communicated by growths overlying it, and the surgeon is liable to be
deceived by a certain abnormality of the natural pulsation through
this trunk, as it is often exaggerated and appears pathological when it
is not. Abnormal pulsation of the abdominal aorta was first described
by Cooper, and has served as a topic for surgical essays ever since.
Schede’s test may be applied here to advantage: if firm pressure be
made simultaneously upon both femoral trunks the extra blood
pressure thus caused inside the tumor will give rise to pain, whereas
in the absence of aneurysm it produces no such effect.
Iliac and femoral aneurysms may be made difficult of recognition
by obesity, but the bruit can almost always be heard, and this, with
such extra aid as the rectal or vaginal examination may afford,
coupled with pressure symptoms confined to one limb, will usually
facilitate diagnosis. Fig. 157 illustrates what features a tumor of this
kind may present when located in the upper part of the thigh.
 Fig. 157

Sacculated aneurysm of femoral artery. (Parmenter.)

Treatment.—The general purpose of the treatment of aneurysms

is to favor coagulation and to effect a cure in this way.
In the pre-antiseptic era it is not strange that men resorted to the
method of starvation, by which the coagulability of the blood was
much increased, or to the rest treatment, with the use of cardiac
sedatives, by which the heart’s activity and power were greatly
reduced. Nor was it strange that non-operative, yet mechanical,
methods were used, in order to minimize the danger attending
operative procedures. With the confidence, however, which Lister
and his followers have given, it is generally conceded that with an
aneurysm which can be made accessible by an operation radical
methods are more satisfactory. To the surgeon belong all aneurysms
except, perhaps, those of the aorta and the innominate, and even
these have not been exempt from surgical methods. The following
operative measures are worthy of discussion in these cases: (1)
Ligature. (2) Open operation. (3) Extirpation. (4) Opening and suture.
(5) Introduction of wire, with or without electrolysis.
1. Ligation includes the application of a ligature in one of the
following situations: (a) Proximal ligation (Anel’s) at a convenient
point shortly above the sac; (b) proximal ligation (Hunter’s) at a
distance from the sac; (c) distal ligation, either of the main trunk just
below the sac (Brasdor’s) or of the highest main branch given off
below the sac (Wardrop’s). Thus proximal ligation could be practised
in case of aneurysm, either of the external or internal carotid, by tying
the main trunk, or in the case of popliteal aneurysm (Hunter’s
suggestion), by tying the femoral in Hunter’s so-called canal.
Brasdor’s distal ligation may be illustrated by ligature, in Hunter’s
canal, of the femoral for aneurysm in the groin, while Wardrop’s
modification would consist in tying one of the tibials for popliteal
aneurysm, or one of the lesser carotids for aneurysm of the common
trunk. Should ligation be determined upon, circumstances will dictate
where the ligature should be applied, and the surgeon will decide the
character of the suture material. The methods of attack upon the
large vascular trunks will be considered later. Inasmuch as it takes
time to establish collateral circulation, attention should be given to
physiological rest, as well as to all other general measures calculated
to make any operation successful.
 Fig. 158

Anel’s operation. Hunter’s operation. Distal operation.

(Erichsen.)
 Fig. 159

Brachiocephalic aneurysm; Brachiocephalic aneurysm; Brachiocephalic aneurysm;

ligature of the subclavian ligature of the carotid only. ligature of the subclavian
only. and carotid.

Different schemes for application of the ligature according to the necessities of the
case. (Erichsen.)

2. Open division was first suggested in the fourth century by

Antyllus. It soon fell into disuse and was taken up during the middle
of the past century by Syme, to whom the operation has been
frequently credited, although it was really the revival of an antique
method; but Syme gave it so much of his anatomical exactness and
brilliancy of operative skill that he almost made it his own. The
method was essentially one by long and free incision, through which
the interior of the sac was fully exposed, its contained clots turned
out, its vascular openings plugged, while a ligature was applied
above and below in order to prevent further arterial communication.
Performed before the days of anesthesia or of antisepsis it was an
exceedingly bold procedure, yet in Syme’s hands it gave brilliant
results.
3. The open division has been replaced by the more perfect
procedure of extirpation of the sac, based upon the general principle
that an aneurysm is a tumor and should be extirpated, the parts
being sutured and expected to heal promptly. It constitutes in many
cases the ideal method of treatment. There could be but one
improvement on it, namely, that suggested by Matas, of
arteriorrhaphy, as one of the radical methods which is often
applicable to aneurysms of the extremities, or to those where rupture
has occurred or is imminent. The part should be made bloodless, as
in this way perfect control can be secured; should this be
impracticable, the vessel should be ligated above the aneurysm
before proceeding to its excision. This done, and the vessels secured
above and below, the wound may be closed as after any other
operation, and in this way radical cure achieved within a few days.
Fig. 160 illustrates a recent case of this kind in the author’s hands,
where an aneurysm of the common carotid, of about the size of a
lemon, was treated in this way, the patient leaving the hospital in
eight days, and having no unpleasant complications.
 Fig. 160

Aneurysm of the common carotid successfully treated by complete extirpation.

(Park.)

4. Open division with arteriorrhaphy has been proposed by Matas

and Murphy and in their hands has been successful. Its greatest
usefulness is found in traumatic aneurysms of long standing where
the arterial opening is usually small and the vessel wall healthy, so