UNITED STATES FLEET 
UNITED STAATES NAVAL FORCES, GERMANY 
TECHNICAL SECTION (MEDICAL) 
ROOM 124, EUCOM HDQTRS. 
APO 757 
File: P3-1 
Serial: 242-Med, 
22 April 1948 
From; Assistant Technical Officer (Medical), U.S. Naval Forces, 
Germany 
To: Chief of Bureau of Medicine and Surgery, 
(Attn: Chief, Publications Division). 
Via: (1) Technical Officer, U.S. Naval Forces, Germany, 
(2) Chief of Naval Operations (0p-32-F2) • 
Subject: Experiences in 221 Aneurysms - by Dr, raed. H, RUSSELT - 
Forwarding of a translation. 
Enclosure: (A) Subject translation. 
1, Because of its bulk enclosure A will be forwarded directly 
under separate cover to each recipient of this letter listed below, 
2, This report prepared by Dr. Russelt of the Surgical Clinic 
of the University of Giessen is a straight forward excellently prepared dis- 
cussion of the experience with 221 aneurysms. This is surely one of the 
largest collections of this sort compiled from the experience of a single 
clinic. It covers the early and late results observed in this series, in- 
cluding several cases of unusually long history and the operative results 
of 172 cases operated by Prof, Dr. Bernhard, the Chief of the clinic, 
3* At the present time the University of Giessen is closed. An 
attempt is being made to reorganize the Medical Faculty and open an Academy 
of Medicine in the remaining buildings of the University Clinics. This is 
as yet only in the "hopeful" stage, 
4* This manuscript is as yet unpublished and if publication in 
the U.S. is desired this officer has been promised that a release can be ob- 
tained. 
5* The reserve supply of this folio is limited. It will be for- 
warded on a government bill of lading to the Publications Division, Bureau 
of Medicine and Surgery, Navy Department. Requests for further distribution 
should be directed to that division, / 
X# 
HARRY J. ALVIS, 
Commander, Medical Corps, 
U.S, Navy, 
cc: 
CNFG, Technical Sect, 
CNO (Op-32-F2) 
BUMLD (Publications Div) 
BuMLD (Professional Div) 
BUMED (Research Div.) 
Nat, Nav,Med,Center, 
Navy Medical School 
NMRI 
Army Medical Library 
Department of the Army, 
Office of the Surg,Gen, 
Department of the Air Force, 
Office of the Surg.Gen. 
U.S.Public Health Service, 
Office of the Surg.Gen, 
U.S, Veterans Administration 
Office Chief Med,Director Surgical Clinic if the University ofGIESSEN 
Director; Prof, Dr, Fr* B F R N H A R D 
EXPERIENCES IN 221 ANEURYSMS 
by 
Dr, med. habil, H, NUSSELT 
With ’ Illustrations 
Translation prepared by: 
U. S, Naval Technical Unit, Furope, (Medical Section) 
Office of Naval Advisor 
.Office of Military Government (U, S,)  SYMPTOMATOLOGY A ND D Z AG NOS TS 
While the number of cases of damage to the 
vessels with subsequent clinical problems following 
such injuries does not play too big a part in peace 
time, an accumulation of such clinical pictures will 
always be observed in war times, Fven in prehistoric 
wars the surgeons were dealing with the problems arising 
from injuries of vessels. The term "ancur.ysm" 
(aneurynein - to extend, one of the most important 
effects following injuries of big vessels) was first 
formed by HIPPOCRATES, In comparison with the last 
two world wars aneurysms occurred very seldom in 
earlier wars. Thus only 44 cases of aneurysms were 
counted in the war of 1870/71, It is certain that 
thousands of cases were observed in the first world 
war (1914/18)* This makes it understandable that 
at that time extensive experiences could be collected 
in this special field, A further incre-.se of this 
clinical picture was observed during the last war on 
account of the increased use of small calibre infantry 
bullets and shell and bomb splinters, but most 
important of all, however, on account of the increased 
flat trajactory of modern arms. Further problems 
arose in this connection and further experience con- 
cerning the early and late results and the operation 
technique could be collected, especially by new methods 
of examination, such as arteriography, oscillometry, 
measuring of the blood pressure in the veins and 
others. It seems indicated, therefore, to report about 
our experiences in more than 221 cases of aneurysms. 
In the beginning, however, we want to .win some re- 
marks, which seem to be important for the further under- 
standing. 
One can no longer believe in the former point 
of view that the vessels could parry a gunshot on 
account of their elasticity.. In spite of the fact 
that some of the so called "fortunate gunshots" can 
only be explained in this way, gunshot experiments and 
more than that the experiences on men have proven 
that the above mentioned point of view is erroneous. 
While injuries of the big artery in the chest and 
stomach cavity regularly have a fatal outcome, this 
does not need to be true in cases of damage to the 
big peripheral vessels. A blood staunching might 
occur, especially in cases of gunshot wounds with 
narrow canals, on account of the piling-up of the 2 
soft parts or on account of the counter pressure 
from the soft parts on account of the hematoma arising, 
or even on account of coagulation in the surrounding 
area* Besides these mechanic?.! processes the decrease 
of the force of the heart and the blood pressure, the 
reduction of the speed of the blood stream and the 
centrally directed vessel contraction caused by the 
anemia all play an important part. Further ore the 
active participation of the wall of the vessel is of 
importance as well as the formation of a thrombus 
which closes the vessel. While STICK regards the 
last mentioned circumstances as of subordinated, even 
of secondary importance and places the segmental 
contractionand retraction of vessels before, NILDEGAFS 
regards the separation and coagulation thrombus as of 
the highest importance. Everybody who has seen numercu: 
injuries of the vessels in the field will have to support 
the last mentioned point of view. Under special 
circumstances the ends of big vessels, separated 
by gunshots, are lying completely free in a big and 
gaping wound and are on both sides closed by a thrombus 
At the time of a removal of this thrombus an arterial 
bleeding arises immediately. WILDEGANS did in numer- 
ous histological examinations of arteries injured by 
gunshots not find the "leaf-like rolling-in of the in- 
tima" as taught years ago. On the other hand tears of 
the intima were observed, running transverse or in the 
direction of the longer axis with widely separated inner 
layers and a development of fibres and more cr less 
severe destruction. The knowledge of these processes 
in cases of injury to big arteries seems to me to be 
important for understanding the clinical development of 
the most freauent clinical problem following such in- 
juries? The__ aneurysm-arterial^. 
According to how much such a blood staunching 
process develops, a more or less extensive hematoma 
occurs. The pulsation waves of the arterial blood 
stream are communicated to this hematoma especially 
in cases where a defect on the side of an artery 
exists. Thus we have the picture of a "pulsating 
hematoma". In contrast to the "cuiov hematoma", where 
this com:' unication is insignificant-, the extravasated 
blood is absorbed only to a small extent. More- 
over, a capsule of compact sclerotic connective tissue 
forms and limits the pulsating hematoma.. This 
"formation of the sack" requires different periods of 
time and therefore no exact time limit is possible 
betvfeen the fresh injury of the vessel and the formed 
aneurysm. Regularly this takes several weeks. VOF 
HABERER has seen it in 2 cases of axillary aneurysms 
as early as 8 and 12 days. VON BONIN has seen all 
symptoms of a completely formed aneurysm after 10 
days. Therefore no free collection of blood can 
be found in the tissue in the case of this "fully 
developed aneurysm", but all the blood runs in 
closed spaces. A resorption and therefore a self- 
healing are then only possible by a thrombosis of the 
sack, a very rare occurrence. This we have seen, how- 
ever, and wr shall reft to it in the discussion of 
the spontaneous healing of aneurysms. 3 
As we could confirm by numerous exam?nations, 
no endothelial lining of the sack is found histological- 
ly in the final state of the pulsating hematoma. 
At the most a participation of the layers of the 
vessel walls can be recognized in the neck of the 
sack, while the rest of the limitation consists of 
a more or less delicate fibrinous membrane corres- 
ponding to the age of the sack, which contains con- 
nective tissue like components. In only one case have 
we found an arrangement of connective tissue cells 
with an epithilial character as the lining of an 
aneurysm, and this aneurysm was 25 years old. Al- 
though the inner lining is sometimes smooth and 
shining, it is not formed of endothelium, The 
wall can furthermore be reinforced by the develop- 
ment of elastic fibres. Sometimes we see a piling up 
of calcium (see 111, 10 and ll) and sometimes 
we can even see placques of bone, espec.tally in such 
cases, where the bone is also injured. However, 
we have once observed bone cells in the wall of the 
sack of an aneurysm without any injury of the bone. 
The si7e of the hematoma as well as ".he sire and 
shape of the sack are multiform,differont and changeable. 
This does not in all cases, depend on the size and 
the position of the vessel alone, but it depends on 
the kind of wound, on the surrounding coating of the 
soft parts, transport and so on- The pictures of 
the different regions of the body -ive an idea about 
the different sizes of aneurysms and their many varieties. 
In some cases the damaged artery extends for some 
distance right through the middle of the sack 
(according to STICK), The knowledge of this event 
is of some importance for the operative treatment. 
The effect of the modern arms of our days ¥/her’cby 
several splinfers may strike one vessel, makes it 
understandable that several aneurysms might develop 
in fine, vessel , On the other hand, one gunshot can 
as v/ell be the cause of multiple aneurysms, B1SR 
has observed a case where one gunshot has c y-.sed 
3 aneurysms? two arterial, one each of the art , anonyma 
and subclavia. and one aneurysm of the artery sub- 
clavia. In one of our own observations we have seen 
ho?>r the carotis, the vcrtebralis and the v„ subclavia 
were involved in an anourysmc 
As already mentioned above, an aneurysm can develop 
clinically in another method as well, A hemerr'iu ge 
and an aneurysm might arise as a result of the soparat:- 
of a thrombus which had closed a defeat in the vessel 
for days and weeks. In e?.l oases of quickly healing 
non-infected gunshot wounds of the sett parts, uno-s 
attention should be directed to this fact, especially;, 
however, in cases of gunshots which pass through the 
effected part. 
The greatest number of aneurysms arises on 
account of gunshot injuries, also by stab injuries. 
It has to be pointed out, however, that other causes 
might be considered as v/ell, such as fractures, luxations 4 
strains and continuous rubbing or pressing of the 
vessel, (for instance the development of an aneurysm 
of the prof, fern, between the shell of a prosthesis and 
an osteophytic roughness of the stump of the femur. 
The effect of blunt force occurring but once also might 
cause an aneurysm. One should furthermore think of 
developing aneurysm subsequent to emboli as well as of 
lues and of arteriosclerosis. 
f _t he_Aneury sma_Ar t or iale 
Direct and indirect symptoms help us to establish 
the diagnosis of an arterial aneurysm. The following 
procedures belong to the category of the direct symptoms 
1. The_formation_of_a_tumpr, which is caused by 
one or several more or less organized blood 
sacs attached to the artery, 
2. The synchronous pulsation in this sac with 
the arterial pulse wave, 
3. The thrill, synchronous with the systole 
which can be recognized by palpation as well 
as by auscultation. 
The following procedures are regarded as belonging 
to the category of the indirect symptoms: 
4. Interruptions of the circulation, where the 
pulse cannot be detected or with a weak 
pulse, 
5* Irritation effects arising from the nerves, 
6, Contracture position of the surrounding- 
joints. 
It will be easy to establish the diagnosis in cases 
where all or a large number of these symptoms, especially 
the direct ones, are found. Frequently, however, several 
of them and under special circumstances all of them are 
missing, so that disastrous mistakes may happen, as 
in one case of BRAUSCH, where the right leg was 
amputated in the hip joint because of a tumor (sarcoma) 
which really was a luetic aneurysm of the hollow of the 
knee. Furthermore a perilous situation might arise, 
if the diagnosis "Abscess” is made because of a tight 
elastic or even board-like tension which is accompanied 
by fever and other clinical symptoms suggesting an 
inflammation, A dramatic bleeding follows the in- 
cision, which can only be controlled by a very active 
intervention to avoid the danger of bleeding to death. 
Especially in cases of aneurysms of the throat vessels, 
symptoms occur occasionally which simulate a retropharyn- 
geal abscess and their incision means death in almost 
any case. 5 
On the other hand, swellings with a liouid content 
such as abscesses or cysts or soft tumors might be 
mistaken for an aneurysm, if they are lying over a 
large vessel in such a way that the pulsation waves 
of the vessel are transmitted to these swellings. 
In some cases even a pulse synchronous thrill can 
be recognized by means of the stethoscope, If pressure 
is put on the artery lying underneath. However, wd 
are not dealing with an expansion pulse (lit? expansive 
pulse) as would be characteristic for an aneurysm, but 
with a transmitted pulsation. In such cases arterio- 
graphy, to which we shall refer later, will be useful, 
although even it may fail in rare cases for the differ 
ential diagnosis between swelling and aneurysms. Thus 
DYES reports 2 cases, one where the filling of a 
”traumatically developed bl«od sac with contrast liouid 
failed to occur and may regularly fail, while in 
the other a solid swelling was dyed in toto by a 
contrast medium and was thus demonstrated in the X-ray'! , 
By knowledge of the medical history of the patient 
and by clinical observations, one usually succeeds in 
differentiating pulsating swellings, sarcomae with 
many vessels, angiomae pulsans cavernosum and similar 
clinical pictures from an aneurysm. The trial 
aspiration serves as an important auxiliary means 
for the recognition of an aneurysm. This trial 
aspiration is performed according to the directions 
applicable for a cold abscess. It extracts blood 
in case of a pulsating hematoma and a chocolate colored 
liquid in the later stage. Also from other signs one 
might detect the existence of an aneurysm, such as 
for instance from the kind of nerve interruptions. 
If a complete or far reaching loss of the nerves 
occurs in the moment of the damage, this is not con- 
sidered in the aneurysm diagnosis. However, it can be 
used in cases where the same interruptions of sen- 
sation occur in course slowly, which can increase from 
a mild drawing pain to the point of intolerableness. 
Slowly arising paralysis as well as the formation 
of trophoneurotic interruptions should be evaluated 
in a similar method, In case of an enlarging aneurysm 
the patient often places the limbs in a relaxing 
position. Therefore, one should think of an aneurysm 
even in cases where no other signs are present but 
contractures of the joints. 
All these clinical pictures, which are important 
for the recognition and for the differential diagnosis, 
were well known to the surgeons of the first World 
War 1914-/1918, Recently additional methods of 
examination have been used, which are not only of 
diagnostic importance but wh:ch have also led to 
further criterias for the entire clinical process of 
an aneurysm. Such are: 
Arteriography 
Oscillometry 
Measurement of the skin temperature 
Measurement of the venous pressure 6 
As these are of import nee for the arterial aneurysm 
as well as for the arteriovenous aneurysm, they will 
be discussed later on. 
.TJ2 1 i 9. a i i ons 
The patient suffering from a large injury of a 
big artery, which, however, did not lead directly 
to death from bleeding, is still exposed to the danger 
of death from bleeding* The spectre of postoperative 
bleeding is well known to every war surgeon. This 
postoperative bleeding sometimes occurs as a slight 
trickling of blood. Thus it must lead to the sus- 
picion of an aneurysm and should furthermore be bhe 
reason for a careful revision (examination, renewed 
treatment) of the gunshot wound. The degree of danger 
of these postoperative bleedings can be recognized by 
the fact that LANG ascribes to it a mortality rate of 
57%, Furthermore an internal hemorrhage may lead to a 
perilous condition. The following clinical pictures 
should direct #ur attention to this point: increasing 
pain in the extremities, paraesthesiae, swellings, 
edemas arising peripherally to the wound and a rising 
temperature. On the other hand, the opposite of a 
hemorrhage might arise as-well, namely a thrombosis. 
The artery or the uninjured vein can be effected by 
this and a fatal lung embolism might be the outcome 
Arterial embolisms are also not too rare, although 
only in the brain do they lead to severe clinical 
pictures. Local necroses might by caused by the 
pressure of the aneurysm especially in the muscles but 
also even in the bones. We shall refer to all these 
complications later on because of some of our own ob- 
servations, By the fact that our hospital reports 
came from clinics in the home territory, it can be ex- 
plained that we did not see another very serious compli- 
cation; gangrene of a limb, which might be caused by a 
thrombosis or by a compression of the main bl*od 
vessels by pressure from the hemat»ma. These clinical 
pictures were observed only in hospitals very near 
the front lines. Changes of the heart and of the 
blood circulation due to arterial aneurysm will be 
discussed later. 
li2®_Al2®^XiZsma-Arterio-Venosum 
If the artery and the vein are opened during an 
injury and an open connection is thereby caused, the 
possibility of the formation of an aneurysm-arterio- 
venosum exists (VIRCHOW), The different forms of 
the mechanical process can be seen in Illustration 1, 
If the formation of the sac is missing we speak of an 
arterio-venous fistula. HUNTER who is regarded as the 
discoverer of this clinical picture, called this 
condition "aneurysma peranastomosim:l, The terms 6a 
Ul- uterUle; c A ;*n -Ten 
art 
.-Vt. 
Illustration 1 
a) Aneurysm art, ven, directum 
b) Aneurysm art, ven, directum with aneurysm arteriale 
c) Aneurysm art, ven, directum with the formation of varix 
d) Aneurysm art. ven, directum with aneurysm afteriale and 
the formation of varix 
e) Aneurysm art, ven. indirectum 
f) Aneurysm art, ven, indirectum with aneurysm arteriale 
g) Aneurysm art, ven. indirectum with the formation of varix 
h) Aneurysm art. ven, indirectum with aneurysm arteriale and 
the formation of varix 
(according to STICK) 7 
"varix aneurysmaticus" and "aneurysma varicosum" 
were originated by SCARPA while SUBBOTITISCH has 
called the varix aneurysmaticus as "aneurysma arterio- 
venosum direct". We find this kind of aneurysm 
especially often as a result of rough small calibre 
missiles. According to our own observations the 
aneurysm arterio-venosum is far more freouent than 
the aneurysm arteriale. 
With regard to the operative technioue which 
will be discussed later on, it seems to be important 
to point out that in addition to the communication 
injury of the artery or of the vein or of both of 
them, a second place of damage may mxist, out of which 
further traumatic aneurysms or varicosities may arise. 
On account of the increased arterial pressure which 
effects the vein we often find it considerably 
thickened in the peripheral as well as in the central 
direction, the vein thereby being 11 arterialized", 
The distension of the vein can therefore be explained 
on a purely hydrodynamic basis by the arterial blood 
stream entering the vein. According to WACHSkUTH it 
depends on the kind of aneurysm whether or not the 
widening effects the peripheral section of the vein 
or whether it effects principally the central part of 
the vein leading to the heart as we shall explain 
later on. 
The clinical pictures are in many respects 
similar to those of the arterial aneurysm. It can be 
understood that in this case the danger of a bursting of 
the sac is relatively slight. Besides the formation 
of a tumor there is frequently in the background the 
presence of a continuous thrill which is transmitted 
towards both sides and which increases in systole and 
decreases in diastole. The same fact can as well be 
proven by palpation. In this case the hand li'htly 
laid on feels a pronounced vibration. 
We shall later on refer to changes of the skin 
temperature, the conditions of the blood pressure and 
so on. However, we want to point out right in the 
beginning, that a positive pulsation of the veins is 
the best indication of an arterio-venous connection. 
On account of the interrupted conditions of the 
blood circulation we find edema, elephantiasis, trophic 
complications all of which are frequently far more 
developed than with the arterial aneurysm, Although 
the process of an arterio-venous aneurysm hardly 
ever develops, or with few symptoms, subjective com- 
plaints occur in almost every case. These subjective 
complaints, however, may be entirely different in each 
case and freouently are relatively slight. Thus it is 
understandable that arterio-venous aneurysms often 
remain without treatment for several years. In spite 
of the possibility that the clinical picture of the 
patient remains constant, there is always the danger 
of a sudden rapid growth, possibly even of a sudden 8 
bursting. Furthermore the patient suffering from 
an arterio-venous aneurysm can be endangered by 
changes of the heart or of the blood circulation 
as will be shown later on. 
Since the time when the demonstration of the 
vessels by contrast medium was introduced by I.iONITZ 
and SANTOS this method has won numerous supporters. 
The main indications for arterio raphy are diseases of 
the brain and changes in the circulation with chronic 
interruptions and acute obstructions. On the other 
hand, injuries of the vessels with their subsequent 
clinical problems (aneurysms) constitute a large 
field where arteriography is indicated. 
Techni^ue_pf_Arteriography 
In former days arteriography was used only 
on the exposed vacoalo. Later on the nothod 
of the percutaneous demonstration of vessels was used 
more and more and in our numerous arteriographies of 
recent years this percutaneous method was used ex- 
clusively, With some skill it will in almost any case 
be successful. It would be advisable, therefore, 
that one physician acquaints himself with this 
technioue, and thus his skill and experience increases 
steadily. The largest number of the arteriographies 
of this clinic were performed by the assistants of the 
clinic, Dr, STOTZ and Dr, GLOCX, The instruments 
necessary for these purposes can be seen in Illustration 
2. 
It seems to me to be especially important to 
point out that needles of very small calibre should 
not be used. 
Compared with the exposure method the percutaneous 
puncture of the artery has the advantage of causing 
only a small puncture wound and to reduce the danger 
of infection thereby, A rep eatod arteriography as is 
sometimes necessary, is much easier possible. 
Furthermore, it is easier to obtain an agreement with 
the patient for this procedure. 
In order to prepare the patient Yte give a morp-hinc 
injection or an injection with S,E,E. (weak) (Scoyal*- 
amine H61 0,00f5, Eucodal 0,01, Ephetonin 0,02$), 
With these injections puncture of the large vessels 
of the neck can also be made easier and the patient does 
not fool that it is so disagreeable, daptcially in those 
cases whv.ro the area around the canal of the uuncture 8a 
Illustration 2 
The instruments necessary for the percutaneous arterio- 
graphy* (Gloves, local anaesthesia, table salt for rinsing 
the syringe and the injection needles before use, contrans 
medium, Rotantaor Record syringe, rubber tube with a glass 
insert in the middle, up to which the suction might go, 
short bevel injection needles of at least 1 millimeter up 
to 1,2 millimeter thickness, according to the size of the 
vessels, is rendered insensible previously by a local anaesthesia. 
The best method is to bring the needle right up 
to the artery after a careful palpation of the puls act- 
ing artery. This is indicated by a motion of the 
needle synchronous with the pulse. Then the syringe, 
which is partly filled with a solution of saline, is 
attached and the injection needle is suddenly pushed 
through the wall of the artery, A transfixion of 
the artery must be avoided. The flow of blood will then 
take place rhytmically and in a strong stream. If the 
patient does n»t suffer any pain the contrast medium 
may now be injected. If the of the vessels for 
the arteriography cannot be avoided or, if an arterio- 
graphy is to be performed during an operation, one 
should desist from holding the arteria carotis communis 
in a loop of tape as in this case the back wall of 
the artery may be pierced too easily. In any case 
holding the artery by a loop according to FHILLIPIDES 
is unnecessary. I am of the opinion that raising the 
front wall of the artery with a fine tweezer is much 
more useful. When puncturing the communis it will be 
best to insert the needle percutaneously after an ex- 
posure, as thus the needle is held more firmly. The 
piston of the syringe is pressed out by the blood 
pressure. This indicates clearly that the injection 
needle is in the proper position. In cases where an 
internal puncture of the carotid is intended during 
the exposure of the vessels, it will be useful to 
introduce the injection needle into the communis beneath 
the place «f bifurcation and to insert the needle on 
into the interna. For the interna, about 8cc, and 
for the communis about 10 to 12 cc, of Thorotrast 
will be a sufficient quantity of contrast medium. The 
injection must take place as rapidly as possible, 
(therefore, a small calibre needle should not be used.) 
In cases wh re 2 pictures arc wanted, a quick change of 
the plates must take place as well as a rapid turn 
of the head, DIFS has therefore worked with 2 crossed 
X-rays from 2 tubes and PHILLIPIDES has used an in- 
jection and film changing device for the arteriography 
of the arm and of the leg, Fven without these auxiliary 
means good pictures can be obtained, v/hen the injections 
are made with a steady moderate pressure if the film 
changes are made quickly and if the physician and the 
medical personnel arc accustomed to working together. 
For the demonstration of the aorta abdominalis 
PHILLIPIDES gives the following descriptions: The patient 
has to be on the belly, A needle L4 centimeters in 
length and 1 millimeter thick is introduced along the 
left side of the second lumbar vertebra L centimeters 
lateral of the mid line at an angle of 60°, At a 
depth of 11 to 12 centimeters the aorta will be reached, 
he have not had proper experiences of our own in this 
field. 
In order to obtain a better demonstration of the 
post traumatic aneurysms one may impede the inflow 
of blood by an injection into the sack of the aneurysm 
with a tourniquet applied proximally from the aneurysm. 
By this method even a retrograde filling of the feeding vessels may be •btained. In order to demonstrate an 
arterio-venous fistula the contrast medium has to be 
brought into the feeding artery. By a slight com- 
pression of t&e veins one can then obtain better pic- 
tures. The demonstration of arterio-venous aneurysms 
in the throat is relatively difficult as the contrast 
medium is very ouickly dilut d by the blood stream and 
carried away. In the case of sufficient skill and 
technioue, however, one may even in such cases succeed 
in getting very descriptive pictures as shown in 
Illustrations 26 and 32. 
Some authors have proposed the use of arterio- 
graphy of the vertebral artery in va'uc cas~s of 
aneurysms in the throat. In this case a direct in- 
jection of the contrast medium into the aneurysm sack 
may be performed,. If considerable pressure is used, 
the feeding art ry will fill as well* Under special 
circumstances an exposure of the vertebral artery 
according to the classical method of KOCHER must be.- 
performed. We have been able to demonstrate an 
aneurysm »f* the vertebral artery by arteriography 
(111. 28). 
The puncture #f* the subclavia takes place in the 
cavity of MOHREMHFIM, In this case the arm has t£ 
be brought into abduction and downwards traction applied. 
In order to obtain a better palpation of the artery, 
it might be useful to increase the pulsation by in- 
creasing the blood pressure by means of some drug, 
perhaps t,5cc, Veritol injected intravenously,- When 
the proper arteriographic technique is used the in- 
jection of 20 to 25 cc, Thorotrast will bring about a 
picture rich in contrast of the entire vascular tree. 
For the vascular tree of the femoralis, which we in- 
jected in the femoral canal, we need about 4-0 cc. 
Obviously we must try first of all to perform 
arteriography with a minimum of pain and hazard* On 
the other hand we roust also get pictures rich in con- 
trast, We have used Uroselektan, Thorotrast, Pera- 
brodil and Vasoselcktan as contrast media. None 
of these contrast media can be said to be ideal for 
they do not meet the rcauirements, which we consider 
necessary. The iodine solutions which wo formerly 
used for brain arteriography led to such severe and 
in some cases even fatal complications that their use 
had to be discontinued for demonstrations of the 
vessels of the brain. Thorotrast is undoubtedly the 
contrast medium which is best tolerated and has the 
least subjective iucon?onlencos . However, we must 
not overlook the considerations expressed against 
Thorotrast, VON HABERFR, first and later SCHUMANN 
and BAUER have expressed their opinion against it, 
Thorotrast is a radioactive substancc which is not 
elminated and separated like other contrast media 
but is stored in the human body, principally in the 
reticuloendothelial system. In case of paraarterial 
injections it can be demonstrated in the tissue by 
X-rays for many months (Illustration 3) Htwever, 
artifical radio-activity of tissuescarries with it 
the danger of ulcer formation. The reason ?;hy v»re 10a 
Illustration 3 
Contrast medium after paraarterial 
injection. have not yet been informed about such clinical 
problems may be that wo have to reckon with a latent 
period of 10 to 25 years, ECXSTROEM and LINGREN 
have demonstrated that the contrast medium persists 
in the shape of small drops or spicules in the 
very fine vessels of the brain in 60% of the fatal 
cases where an arteriogram was performed prior to 
death. These authors believe that the danger of 
damage to the brain increases parallel to the 
amount of Thorotrast used. In cases of careful 
consideration one will, therefore, desist from 
Thorotrast more and more and use another contrast 
medium, especially in such cases where repeated 
arteriographies are required. 50% Perabrodil, for 
instance is more suitable for the arteriography of the 
extremities than Thorotrast. In cases of sound kid- 
neys it may be used repeatedly without danger. In 
this case, however, the sensitiveness of the patient 
to iodine has to be determined previously by potassium 
iodine solution. 
The contrast medium "Uroselektan1* has the dis- 
advantages of causing pain during the injection and 
that the patient is therefore restless during the 
X-ray, Pictures with insufficient contrast might be 
a result of this restlessness of the patient* We 
have tried to avoid this by doses of S.E.E* (S.E.E* - 
Scopolamin, Eucodal, Ephetonin), 30 minutes before the 
arteriography• These attempts were not always success- 
ful, however* luring the demonstration of the vessels 
of the neck of one patient we have had a very alarming 
incident with Uroselektan* 
On account of injuries on the right side of the 
neck with interruptions of the circulation in the 
right hand we have first made an arteriography of the 
right subclavia with Perabrodil, which the patient 
tolerated without complications, During a further 
arteriography three weeks later with injection of 
15 cc* Uroselektan into the percutaneously punctured 
carotid with a squeezing off the carotis at the upper 
part, a clear contrast shadow of the jugularis in- 
terna was seen in addition to an arterio-venous fistula* 
A few seconds after the injection life endangering 
complications arose with a tonic state of spasm, 
unconsciousness and respiratory arrest. The spasms 
started in the right side of the face and extended 
quickly to the upper and lower extremities* This 
condition lasted about 2 minutes. After the use of 
Lobelin, Calcium and Euvaperin, the threatening effects 
decreased. During the night the spasm recurred at an 
interval of three to four hours* Neurologically a con- 
siderable irritation of the brain was observed without 
any special localization. No abnormal clinical findings 
of the retina of the eye were observed. During the 
following days the spasms were less freouent and not so 
severe. However, only a slowly decreasing somnolence 
could be observed. For the period of three and a half 
days there was a retrograde amnesia from the moment of 
the arteriography on* Vasoselektan gives pictures rich in contrast* 
The injection of this contrast medium takes place with 
practically no pain and only in cases of para-arterial 
injections do pains arise. The effects following 
the injections are in the form of a feeling of heat 
in the corrsponding limb or, more freouently, in the 
entire body* In some cases a clear dilatation of 
the capillaries with a pink skin was observed as well 
as a state of condition similar to- a collapse. 
In the case of carotid arteriograms PHILLIPIDES 
reported about irritation effects of the brain such as 
unconsciousness, aphasia, hemiplegia and spasms, in 
about one third of the cases. Therefore, if we want 
to express an opinion concerning the different con- 
trast media at the end of these considerations based on 
our experiences, we would say that Thorotrast is the 
preferable contrast medium compared with all others, 
in spite of its radio activity, for arteriography of the 
brain. For all the other regions of the body, however, 
Vasoselektan or Perabrodil could be justified for 
first choice* 
In cases »f an aneurysm arteriography has proven 
to be extraordinarily useful for clarifying the cir- 
cumstances, No matter that an expert vascular surgeon 
like VON HABEHER has a rather critical attitude towards 
arteriography or at least believes that he can re- 
frain from its use, the opinion of numerous other ex- 
perts in this field indicates clearly that the 
arteriography is one of the most: important methods 
of examination of aneurysms available today. Negative 
statements of LOEHR and CHRIST concerning an imperfect 
filling of an aneurysm should therefore be considered 
as outdated. By means of the above described skill- 
ful technique using a tourniquet which can be in- 
flated applied above the vessels in question, the 
flow of blood can be reduced or interrupted as one 
chooses and the contrast medium can therefore be kept 
at the desired place. In this way arteriography 
gives us the necessary information concerning the kind, 
condition and localization of an aneurysm. The know- 
ledge of these facts can be important for the pre- 
liminary planning of the operative technique. We 
can also draw conclusions concerning the formation of 
collateral circulation by means of arteriography. On 
the other hand the demonstration of the vessels may 
protect the physician from a false diagnosis and the 
patient from an unnecessary operation. Also the 
demonstration »f the vessels during... the operation 
may sometimes bring about important conclusions. 
Principally, howrver, it is the postoperative arterio- 
graphy which permits us a far reaching judgement con- 
cerning the success of the tperation, which gives us 
information concerning the patency of the sutured vessel 
and which, therefore, permits important conclusions 
concerning the advantages or disadvantages of the 
different methods of operation. Especially in co- 
op- ration with clinical examinations we can obtain a 
reliable picture. From a completely patent vessel we may properly expect full capacity and there will probably 
b© no limitations necessary during the cold of 
winter, while with a blood supply maintained only by 
collateral branches a different opinion has to be made. 
In spite of all these advantages a too high 
estimation of this procedure must be avoided. As in 
the cases of organic diseases of the vessels we have 
to ask the Question, when dealing with the aneurysm, 
whether ©r not the arteriogram corresponds to the 
real anatomical circumstances or if filling defects 
have to be considered. In the cases of an exposure of 
big vessels we see repeatedly a state of contraction which 
may even become a complete blocking. Also, in cases 
of operations of an aneurysm we find such segment spasms 
and we shall refer to that again later. On account 
of the examinations of MAGNUS, we know that not only 
mechanical irritations, such as for instance a prick, 
but also chemical irritations, as for instance blood1s 
carbonic acid, adrenalin or histamin, Pituglandol may 
cause local contraction of the vessels, while in 
the larger surrounding area a contraction or dilatation 
takes place according to the strength and degree of 
the stimulus. The war surgeons of old times profited 
by this fact. They staunched the hemorrhage of large 
blood vessels in amputations by pressing on hot sponges 
which were soaked in vinegar-water. All these possi- 
bilities have to be considered when judging an arterio- 
gram, The demonstration of vessels is, as a matter of 
fact, dependent on several components, furthermore, 
on the intruisic reactivity of the vessels to chemical 
or mechanical irritations, from the contrast medium 
(Uroselektan for instance might cause spasms, while 
Thorotrast does not cause any vascular spasm), on the 
differences in the concentration of the contrast- 
medium in the blood, on the different speed of the 
blood stream and finally on the technique of arterio- 
graphy and X-ray, In spite of all these facts, arterio- 
raphy is today an important and useful means for the 
judgement of the circumstances of the blood circulation 
with an aneurysm before, during and after the operation. 
With our patients, arteriography was used as well as 
measurement of the skin temperature, oscillometry and 
measurement of the venous pressure. In a dissertation 
SEDLACZEK has reported about measuring the skin temperature 
and oscillometry in case of aneurysms. 
As mentioned before, the symptoms of severe con- 
gestion occur freauently with arterial as well as 
with arterio-venous aneurysms. In the case of arterial 
aneurysms, this congestion depends on a mechanical dis- 
pla cement of the channels of drainage, on the limitation 
of the arterial blood supply because of the hematoma 
which was formed or by the thrombosis. In case of an 
artcrio venous aneurysm, however, the congestion is the 
result of a fl#w of arterial blood into the periphery of 
the venous system. The pressure in the veins which is 
f'us increased is ©pposed to the normal venous drainage,On 
account of these different causes, different values had 
to be expected in the different cases of aneurysms when 14 
measuring the skin temperature. The purely arterial 
aneurysms regularly showed a decrease of the temperature 
on the affected extremity or at least an approximately 
equal temperature in comparison to the sound side. 
With the arterio-venous aneurysms, however, we have re- 
gularly found a clearly increased skin temperature on 
the affected extremity in comparison to the sound 
limb. In some cases, this difference of the temperature 
amounted to several degrees Celsius, This increase 
of temperature was not only observed in the immediate 
area about the aneurysm but it could also be recognized 
further peripherally from the aneurysms. These differ- 
ences in the temperature cannot be understood only in 
connection with the congestion. Today we know, as 
FRANZ pointed out before, that other additional regu- 
latory means of the human body exist for the pre- 
servation of the body temperature in a certain section 
of the limb, which are of central origin as well as of 
sympathicotonic origin. With the sympathicotonic 
influence, the increase of temperature which remains 
or even increases postoperatively can as well be 
explained, similar to the rise of temperature following 
the periarterial sympathicotony, FRANZ has repeatedly 
recognized this postoperative rise of the skin 
temperature. At the same time he observed a lengthen- 
ing of the leg amounting to 3 centimeters, IB months 
after the traumatic development of an arterio-venous 
aneurysm on the thigh of a boy 12 years of age, HERLYN 
has recognized the same increase of the growth in 
length with a man 21 years of age as a result of dis- 
orders of the circulation because of an arterio- 
venous fistula of the popliteal artery, from which 
the patient had been suffering for 8 years. One 
can therefore take an increased arterial blood supply 
in the case of an arterio Venous aneurysm for granted. 
This is also proven by artoriographic observations. 
In numerous cases of arterio-venous aneurysms which 
have been demonstrated arteri©graphically, we have 
found a clear dilatation of the artery proximal to 
the communication, while peripherally a clear stenosis of 
the lumen could frequently be demonstrated. As V, 
BRAMAN has explained, the peripheral change of the 
artery is effected by the constant incomplete filling 
and the imperfect tension of its walls. We explain 
the dilatation by the fact that, on account of the 
communication with the vein, a new and larger area for 
the drainage of blood is open for the arterial blood. 
This circumstance must lead to a decrease of the 
pressure in the main artery. If we had to deal with an 
inflexible vessel system, a rapid decrease of the 
pressure in the main vessel, as well as in the side 
vessels extending from it, should develop according 
to purely physical laws because of this drainage of the 
circulating arterial blood, 
A decrease of the tension ¥/ould be closely connected 
herewith, which should result in a narrowing of the 
lumen of the supplying artery. The human body now tries to accomodate to these circumstances. In order 
to equalize the difference of pressure in the main 
artery and the branches arising from it, an increased 
blood sup: ly takes place, -whereby a dilatation of the 
artery r suits. Thereby other arteries which form the 
collateral circulation and which soon branch out as 
far as the skin area, get essentially more arterial 
blood than before the existence of the aneurysm. This 
increased blood sun-ly of the surface of the body ex- 
plains the increase of the temperature. In other cases, 
we observed a clear rise of the temperature, especially 
in the area of the tightly filled veins. Undoubtedly 
a reflux of arterial blood is the cause of this event, 
which congests the veins backwards, starting at the 
fistula. On account of these observations, it is not 
quite understandable why BRAMAKN could recognize a 
decrease of the temperature peripherally to the commun- 
ication, lie explains this by the fact that an increased 
loss of heat takes place on account of the slower 
blood circulation and on account of the marked distension 
of the blood vessels of the skin. For this process., 
however, considerable congestion might be necessary. 
Our numerous observations also did not confirm an explana- 
tion of BRmhFF concerning the dilatation of the artery. 
It is the assumption that a vein obliteration near the 
place of communication would influence the dilatation of 
the arteries, especially in the peripheral section, but 
not so frequently in the central section. By the con- 
gestion of the venous blood in the peripheral section, 
which depends on the above mentioned circumstances, the 
passage of arterial blood from the peripheral arteries 
into the capillaries and veins is considerably more 
difficult. This would lead to an increcse of the 
pressure in the artery and to a dilatation. Apart from 
the fact that, according to our experience, we have no 
reason to assume a more difficult blood exchange in the 
periphery in the case of obstruction of a larger vein, 
we heve found an obliteration of the vein in only one 
case, a carotid aneurysm, among our numerous aneurysm 
Operations, Accorcing to our opinion, no purely mechanical 
and hydrodynamic circumstances cause the change of the 
artery, but principally physiological causes and above 
all the ;‘blood hunger11 which is caused by the arterio- 
venous fistula. 
Besides these clinical symptoms in the artery (di- 
latation in the proximal section and narrowing in the 
distal section), the often enormous dilatations of the 
vein which were observed with the arterio-venous aneurysm 
can be easily explained. By the passage of the arterial 
blood, an increase of the pressure in the vein takes place 
purely hydrodynamically, which leads to a dilatation. 
According to FACES. UTH, it depends first of all on the kind 
of the aneurysm whether or not only the part of the vein 
through which the blood drains off centrally takes any 
part in this process or if in addition the peripheral 
sections ere more or less affected by this -dilatation. 
This depends on whether we are dealing with only a small 
arterio-venous fistula or whether we are dealing with 
a fully developed aneurysm with the formation of a sac. . In the latter esse, n diversion of the blood stream is easy 
•n account of the "wind tunnel", so that the arterial blood is 
immediately led In the central direction and therefore venous 
congestions in the periphery fail to occur. In cases of small 
arterio-venous fistulae, however, the blood runs into the 
peripheral veins and there often leads to a high degree of con- 
gestion. 
These conditions of the vessels can also be proven arterio- 
graphically. In Illustrations 4, 8, 9, 56 and 58 they can be 
clearly recognized. 
The results which we have obtained by measuring the blood 
pressure of the affected extremities are in close cooperation 
with the above mentioned clinical effects. One can, therefore, 
not always work with the hemodynamometer of RECKLINGHAUSEN as 
in the case of fistulae located more proximally; the placing of 
the cuffs proximal to the fistulae causes difficulties. On the 
other hand, the ausculatory or palpatory observation of the 
pulse wave, which can just be recognized, is not always practical 
cn account of the reduced blood stream peripheral to the aneurysm. 
In case of disorders of the blood circulation, we have used the 
oscillometer for years, an instrument which seemed suitable to 
us for obtaining an impression of the circumstances of the blood 
pressure without using the assistance of ausculation or pal- 
pation. We do not wish to describe details of this instrument, 
but it should be pointed out that by the use of this instrument, 
we possess the possibility for drawing conclusions concerning 
the nature of the wall of the vessel and the cross section of the 
vessel besides the fact that we can use this means for the ob- 
servation of the blood pressure. 
In both kinds of aneurysms, namely the arterial and the 
arterio-venous, we always find peripherally a decrease of the 
blood pressure. la cases of arterial aneurysms, this depends on 
their circumference and their location, in cases of arterio-venous 
anemrysms, it depends on the size of the arterio-venous ccimrunicatiejn. 
In any case, the decrease of the blood pressure is regul rly more ob-* 
vious with the arterio-venous aneurysm than with the arterial aneurysm. 
According to the above statements, a strong increase of the oscillo- 
metric index had to be expected with the arterio-venous aneurysn 
proximal to the arterio-venous communication. In fact, this is the 
case as the cross section of the vessel is not decisive for the 
oscillations. The cross section of the vessel, however, has to be 
considered as considerably enlarged, on the one hand because of the 
above mentioned dilatation of the artery itself and on the other 
hand indirectly because of the veins which contain back-flowing 
arterial blood and which, therefore, contribute to an increase of 
the pressure. The abnormally high oscillatory vibrations proximal 
to the arterio-venous connection are, therefore, even characteristic for 
the rrterio—venous aneurysm. Peripheral to the communication, we can 
always see a marked flattening of the curve compared with the 
sound side. This means that the blood supply in this area is worse. 
In case of arterial aneurysms, we have recognized normal 
vibrations proximal to the place of injury. Only in such cases where 
the lumen of the artery is narrowed by the pressure of the hematoma, by 
the formation of scars or of thrombi could we find decreased values. 
Also PHILLIPIDES obtained similar results with posttraumatic aneurysms. By the measuring of the pressure in the veins, we have a 
possibility to support the above statements concerning the in- 
creased arterial blood supply with the arterio-venous aneurysms 
by the recognition of a positive venous pressure. In addition 
to that, we can exclude an arterio-venous aneurysm with certainty 
when these symptoms are missing. This is a procedure which we 
have used in uncertain cases (pseudo-aneurysms) for the forecast of 
the diagnosis. 
Besides these more local peripheral effects of an aneurysm, 
we sometimes find very considerable changes of central nature in the 
heart and circulatory system. WIGDOROWITSCH was one of the first 
to point this out. During the first World War, GUNDERMANN collected 
basic knowledge in this field, together with WEBER, In a work 
performed during the recent war in our clinic, STOTZ has reported 
about "Changes of the Heart and Circulatory System in cases of 
Traumatic Aneurysms" and we shall copy his statements. This work, 
which was fully prepared in 1944, not be published on account 
of the general circumstances of that time and especial]y as the 
author is still a prisoner of war in Russia (1946)). 
GUNDERMANN and PAULY have observed several cases where a 
definite slowing of the pulse rate occurred when pressure was 
applied on the arterio-venous aneurysm. Thereupon further examinations 
were made in cooperation with Prof, 1EBER, Bad Nauheim. GUNDER- 
MANN (1915) and WEBER (191?) have later on reported about the 
results of these experiments, I do not want to discuss now the de- 
tails of the explanatory descriptions of the findings, they are 
written down in the above mentioned medical reports. It was ob- 
served that with a decrease of the pulse rate of 20 to 36 pulse 
beats per minute associated with compression on the arterio- 
venous aneurysm, the duration of the diastole was increased three 
times its previous extent within a period of 3 cardiac cycles. 
Together with the decrease of the pulse rate, an increase of the 
blood pressure amounting to 15 to 25 millimeters, occurred and a 
distinct reduction in the size of the heart was observed during the 
pressure on the aneurysm. WEBER has explained this clinical event 
as follows: Because of the direct connection between a large 
artery and the vein, the average blood pressure can be kept at a 
moderate height only by considerable additional work of the heart 
muscles or the vessel muscles. Hypertrophy of the muscle elements 
which effect the compensation is to be expected. Now, if the aneu- 
rysm is compressed, the loss of pressure ceases suddenly and an in- 
crease of the pressure must occur because the compensatory activity 
of the hypertrophic muscles of the heart vessel system continues. 
This increase of the blood pressure causes a decrease of the pulse 
rate because of irritation of the depressor nerve. While normally a 
decrease of the pulse rate because of more complete diastolic fillings 
usually leads to an enlargement of the heart, the circumstances are 
different in cases of an arterio-venous aneurysm because a congestion 
exists in the right heart. This congestion is created by the fact 
that too much blood is brought into the central vein under high 
pressure and because of a broad arterio-venous connection which is 
relatively near to the heart. This surplus of blood is kept away by the 
compression of the aneurysm. As the system of the veins as well as 
the heart get only their normal quantity of blood, the diminutio* of 
the right heart can be understood. It 
Later, these symptoms have been confirmed by numerous other 
authors. During the treatment of more than 150 patients suffering 
from aneurysms during this war, we could observe that these symptoms, . 
which were created by the pressure, can frequently be seen with arterio-'j 
venous aneurysms and, when this is the case, particularly on the 
large vessels next to the heart as well as in those cases with a 
broad arterio-venous connection. Vvhen dealing with aneurysms which 
are situated well in the periphery, even in cases of a broad arterio- 
venous connection, as well as in cases of aneurysms next to the 
heart with or without a small arterio-venous fistula (for instance 
in case of a small arterio-venous aneurysm of the art. carot. comm.) 
these symptoms are completely missing. Therefore, they are undoubtedly 
of a certain value for the evaluation of the seriousness of the 
vascular injury or for the changes of the heart and of the cir- 
culatory system, which in this connection also gives some clue to 
the prognosis and our indication for cp< ration. Furthermore, T 
believe that they are an indication concerning the good adaptability 
of the organism; for in case of a mere dilatation of the heart and 
vessel system because of a flaccid insufficiency of the corresponding 
muscles against the enormously increased pressure created by the 
aneurysm, the above mentioned symptoms cannot be expected. For 
this, the permanent elasticity in the entire circulatory system is 
necessary, which the human body preserves by the hypertrophy of the 
muscular elements and by the possibility of an increase cf the 
tonus which might perhaps be required as a measure of defense. 
During the treatment and our examinations of several of our 
patients suffering from aneurysms since the first World War, we 
could observe kow great the adaptability of the human organism is 
to the consequences of patients with a broad arterio-venous fistula 
which might even have been existing for a long time. In some 
of these cases, the aneurysm was successfully removed by an oper- 
ation, even after such a long time. The results of these extensive 
examinations will be published later. In the following lines, 
we only want to take into consideration some observations of changes 
of the heart and of the circulatory system. In this connection.,, 
the result of a late examination of a patient seems to be especial- 
ly interesting, of whose disease first of all GUNDEWANN (1915) and 
later WEBER (191?) have reported. On account of our request. Prof. 
WEBER, Bad Nauheim, was so kind as to make one more late examination 
of the same patient, whom I could present to him 28 years after his 
first examination. At this point, I want to express my very par- 
ticular thanks to Prof, WEBER for the evaluation of this case and 
making the result of his late examinations available to me* 
At the time of the late examination of the 54 years oik 
patient (F.SCH., hospital report # 2832-42/43), an orthodiagram 
with and without compression of the aneurysm was made (ill, 4) 
after an arteriographic demonstration cf the aneurysm which had 
existed for 28 years. If we compare this illustration of the 
heart with the illustration of 1914 (ill. 5), we find it remarkable 
that the diminution of the right side was essentially more pronounced 
in 1915 than in 1942 while, on the other hand, the diminution of the 
left side of the heart was far more pronounced in 1942 than 28 
years ago. The increase, of. the blood pressure and the decrease, of 
the pulse rate in the case .of pressure on the aneurysm existed now, 
although they jvero not present to such an .extent as in the former 
times, The difference of the pulse rate .amounted .only from 6 to 10 
pulse beats per minute and 10 millimeters hemoglobin. The pressure 
of the vein in the percutaneously punctured vena femoralis amounted 
to 156 millimeters hemoglobin, at a point a few centimeters above.the Illustration 4- 
Arteriography of a 28 years 
old broad arterio-venous 
fistula. An extended di- 
latation of umorous veins as 
an indication of a consider- 
able venous congestion and 
surplus blood in the periphery 
can be seen. The artery is 
demonstrated as widened out for 
the breadth of a thumb above 
the fistula. 
Illustration 5 
accord, to GUNDERMANN) 
12A2 
-border of the heart in 
ease of an uninfluenced 
aneurysm 
border of the heart in 
ease of pressure on the 
aneurysm for 5 seconds. 
border of the heart in 
ease of compression of 
the aneurysm 
border of the heart 
after a pressure of 
20 seconds on the aneu- 
rysm. 
(To the ease F.Sch. Nr. 2032-4-2/42) 
The orthoditgrans of a heart which is dilated on both sides in 
the ease of a broad arterio-venous fistula of the art, fcmoralis, 
which existed since the gunshot injury in 1914), 19 
arterio-venous fistula, and it to 5 millimeters hemoglobin 
•n the sound right side. If we now use the electrocardiogram for 
the completion of the entire clinical evaluation (111. 6), we 
shall see that there are no pathological changes recognizable with 
or without compression of the aneurysm. The patient himself 
declared that with his wounding in 19H, his pains increased slowly 
but steadily, especially in the left leg. (War disability was fixed 
at 8i$). However, he could not make up his mind, for an operation as 
he had an easy job as a tax inspector, which he could perform quite 
well. The difficulties of two other patients suffering from large 
arterio-venous aneurysms due to an injury of the first World War, 
finally increased so considerably and the changes became so important 
that they came for an operation* One of them, W.M., was a lock- 
smith in the age of UU years. Since he had received an injury by 
a shell splinter in 1918 he was suffering from an arterio-venous 
aneurysm of the right thigh with a sac of the aneurysm as big as a 
cherry at the beginning (War disability 60$), Because of the 
rupture of the sac , this aneurysm sac grew in several stages to 
the size of a child's head and thus led to severe peripheral disturb- 
ances of the circulatory system with pain. In the course of the 
years, the patient was, furthermore-, suffering from increasing heart 
trouble. The examination showed a dilatation of the heart, especial- 
ly to the left side (111, 12), In the electrocardiogram (ill, 7)> no 
definite sign is seen of myocardial damage. 
On account of the abnormal size of the aneurysm sac and be- 
cause of the intense filling with blood, there were extensive peri- 
pheral changes of the circulatory system. The continuous buzzing 
noise of the vessel with the pulse synchronous amplification could 
be heard from the aneurysm down to the calf and up to the lower 
abdomen, The pressure in the vena femoralis, which was percutaneously 
punctured closely below POUPART1s ligament, amounted to 15§ millimeters 
After the compr ssion of the aneurysm, it amounted to 95 milli- 
meters > a^cr the compression of the clearly recognizable vena 
saphena, the pressure in the vein rose to 280 millimeters H2®* In 
contrast to all this, the pressure on the sound side of the vena 
femoralis amounted to only 60 to 45 millimeters during rest. 
The arteria femoralis could be clearly palpated and could be well seen 
beneath the skin as a thick pulsating and slightly serpentine 
vessel. Besides the expected marked dilatation of the vein, a con- 
siderable broadening of the Slightly serpentine shadow of the artery 
could be recognized above the aneurysm (illustration 8, a and b). 
During the operation (Prof. BERNHARD), the large sac of the 
aneorysm was removed in toto, the arterio-venous connection was 
removed and the artery as well as the vein were supplied with a 
suture. Because of its size, the extirpated sac of the aneurysm 
was very impressive, even as a macroscopic preparation (ill. If), 
In the structure of the aneurysm wall, it could be clearly recognized 
which part of the sac had to be considered as the older one and 
which part had to be regarded as having developed only recently 
the last rupture (ill, 11), 
The success of the operation was excellent with regard to the 
looal as wdl as to the general findings. The artery which was 
treated by a circular end-tb end suture has remained quite patent* 
(111, 9j a and b), 19a 
a 
b 
Illustration 6 
EKG with photographic reproduction of the sound of the 
aneurysm of the patient F.Sch, (Prof, WEBER). In tracing a , 
we have the sound curve of the aneurysm with the degree of carol-: 
fication exactly as we are used to seeing for the heart tones. 
One can see extraordinarily large amplitudes of a high 
freouency, constant noise, which is considerably amplified 
during systole. In tracing b, the sound of the aneurysm is 
drawn with a considerably dampened amplification, so that the 
systolic noise contrasts especially well. The electrocardio- 
gram is absolutely normal, the picture of the sound of the 
heart shows an insignificant systolic noise. 
Illustration 7a 
The electrocardiogram of W, 
M, (Pr*f, WEBER) showst sinus 
tachycardia, indifferent type cf 
the ventricular complex, no defi- 
nite sign of myocardial damage. 
Heart sound with low and high 
definition of the amplifier com- 
pletely normal. Venous pulse: 
very large presystolic wave and 
a small systolic wave, The sys- 
tolic collapse enis in time. 
According to the tachycardia and 
the short diastole due to it, the 
diastolic wave is only slightly 
developed. The large presystolic 
wave speaks for an increased 
activity of the right auricle. The small systolic wave 
speaks for a small pulse volume. 19b 
The sound curve #f an 
arterio-venous aneurysm, 
taken near the place of 
exit of the bullet, shows 
a continuous series of high 
frequencies which indicate 
a strong crescendo and then 
again a descrescendo begin ■ 
ning from the last third 
of systole until well into 
diastole, 
Illustration 7b 
Illustration 8 
( a and b;c«uld not be re- 
produced with the facilities 
available,) 
(Case W.M.) The arteriogram in two planes shows a 
large arterio-venous aneurysm with two broad shadows 
of the highly dilated arteria femoral!s and correspond- 
ing vein. In the soft parts, several shell splinter 
shadows can be seen. Above an aneurysm sac the size of 
a fist with a calcium infiltration in the wall, another 
bigger sac without a calcium shadow can be recognized. 
Illustration 9 
(a and b,c»uld not be re- 
produced with the facilities 
available,) 
(Case W,M.) The arteriogram shows the condition follow-* 
ing the operative removal of a 24- year old arterio-venous 
aneurysm with a circular suture of the artery. The 
abnormal difference of the size is particularly marked 
at the place of the suture, which is quite patent be<- 
tween the highly dilated and tortuous upper section and 
the lower part of the arteria femoralis, which is only 
normally wide. 19c 
Illustration 10 
(Case W#M|) The patholegico-anatomical preparation of the 
sac of the aneurysm of the femoralis which was removed 
and which had grown as big as a head within 24- 
hour s, 19d 
Illustration 11 
In the soft X-ray of the aneurysm-sac demonstrated in Illustration 
10, it can be seen that then arc numerous irregular shadows in 
the sections marked by the arrow (4)> corresponding to calcium 
infiltrations in the sac wall of that part which has existed for 
a long time. In the rest of the area tf this preparation, no or 
only a very few calcium particles can be recognized. This 
corresponds to the total size of the aneurysm, which has developed 
only because tf ruptures of the sac wall during the last few 
years, 
Illustration 12 
could not bo reproduced with 
the facilities available. 
Illustration 12 
Case W.M, In the X-ray, a dilatation of the heart, partictilarly 
towards the left side, can be soon with a 2U year old large arterio- 
venous aneurysm of the artcria fcmoralis in the lower part of 
the thigh* In the illustration, the contours of the heart of the 
control X-ray arc marked, on account of which a diminution tan be 
recognized, especially on the left side. The periph ral disorders of the circulation as well as the 
other troubles have decreased considerablym, even the heart trouble 
has improved according to the statements of the patient. The 
heart itself decreased slightly aft,r the operation, as can be 
se.n in the X-ray controls in comparison to older photos (ill, 13). 
Also in the case of the other arterio-venous aneurysm which was re- 
moved by an operation 28 years after the wounding, the changes and 
inconveniences of the circulatory system and of the heart were 
within tolerable limits for many years. The patient, who is- 
now 50 years old, (F,St,, Nr,•.), was not particularly disabled 
af the time the disability was evaluated at 1+B% so that he decided 
to ask for an operation only now, since increased trouble has arisen. 
The heart of the patient was only slightly dilated on the right 
with an otherwise normal finding and an unchanged electrocardiogram, 
although the patient was sufiering from considerable disturbances 
of the circulation in the injured leg. Besides a dilatation of 
the vein in the form of a sac , the arteriogram of the aneurysm 
with a broad arterio-venous connection in the middle of the lower 
leg shows an essentail dilatati-n and a slight winding of the 
artery femoralis above the aneurysm. 
The observations of several aneurysms which were all older 
than 20 years demonstrate that th-j human body disposes of a far- 
reaching adaptability to the giv.n pathological circumstances. 
On the other hand, they also prove that in case of the existence 
of an aneurysm sac , the danger of a rupture with the corresponding 
results will always remain and that this danger is not completely 
removed by the protecting calcium deposits in the wall of the 
sac . Furthermore, the increase of the disorders of the circulation 
can be explained by the fact that with the increase of the size of 
the lumen of the artery and of the vein in the area next to the 
aneurysm, the connection between the artery and the vein becomes 
wider as well, and that, therefore, a circulus vitiosas develops • 
In cases of arterial, as well as of arterio-venous aneurysms, the 
size and looaliaaticn are of decisive importance with regard to the 
late results as w.;ll as with regard to the changes whic.h develop 
soon after the injury, while in cases of large arterial aneurysms, 
the menace of dangerous complications (such as rupture or gangrene) 
exists most often only in the periphery, one has to reckon with early 
severe changes of the heabt and of the peripheral circulatory system in 
cases of broad -rterio-vencus connecti ns with and without sac 
formation. 
In the case of several of cur aneurysm patients whom we have 
treated during this warj, we could observe how intense these dis- 
orders of the circulation may be even within a relatively short 
time after the injury. Thus, we have treated a soldier 2® 
years of age (W, FR,, case Nr, Cl) who was suffering from the 
following considerable periph> ral and central of the 
circulation because of a broad arterio-venous fistula on the left 
side of the iliaca communis, closely below the aorta; There were 
marked signs of congestion ip the left leg with a swelling of the 
thigh of up to 11,5 centimeters in contrast to the sound side, a 
dilatation of a high degree of the subcutaneous veins of the left 
leg and of the lower abdomen, pronounced ascites and a swelling 
of the liver as well as of the spleen, bronchial congestion and a 
considerable dilatation of the heart in all directions (ill, 13). 
Over all ostia, a systolic noise could be heard, which was the loudest 
in the second intercostal area (ICR) on the left and beside the 
sternum at the bottom, left. Electrocardiogram: Sinus tachycardia 
of 1®0, PQ #,13, QRS widened to ®,12, high T-waves, high P2 and P3, 20a 
Illustration 13 
(Case W. F,) Considerable 
dilatation of the heart in all 
directions in the case of a broad 
arteriovenous fistula in the left 
common iliac, closely below the 
aorta, B months after the injury. 
The contours of the heart marked 
in the control X-ray picture a 
fortnight after the operation of 
the aneurysm show the essential 
diminution of the heart. no evidence of a myocardial damage reflected by a disturbance of the 
conduction system. Dr. KORNMANN, a specialist for int rnal diseases, 
regard_ed the considerable decompensation of the circulatory 
system as due to the tonogenic dilatation of the heart, especially 
towards the right side with tricuspid and probably also with mitral 
insufficiency* As a result of the operation of the aneurysm made toy 
Prof, BERNHARD, 8 months after the injury, all disturbances of the 
circulation have decreased surprisingly early. The diminution of 
the heart after the operation , which can be recognized in 
Illustration 13, is especially impressive. We have furth rmore treated 
a 28 year old patient who, on account of a war injury, suffered 
from an enormous dilatation of the heart with the formation of a broad 
arterio-venous fistula of the femoralis closely below POUPART’s liga- 
ment, which in the same way has decreased rapidly as a result of 
th operative removal of the arterio-venous connection 5 months after 
the injury (ill, 14). In this case, the peripheral disturbances 
of the circulation were considerable even before the operation, 
whereas the electrocardiogram was practically normal. 
The extensive ability of the heart for recovery from this 
marked degree of dilatation is considerable. The hearts of the 
patients who were wounded only a short time ago have decreased more 
after the operative removal of the arterio-venous aneurysm than 
those of the patients with aneurysms as old as 20 years and more. 
This can be probably explained by the fact that the dilatation is 
later joined by hypertrophy. The long-lasting pathological state 
will later have definitely unfavorable effects on the elasticity of 
the her rt. 
This is true also with regard to tho often considerable di- 
latation of the arteries an arterio-venous aneurysm, as can 
be seen in Illustration 8, The dilatation has only slightly decreased 
after the operative removal of the 24 year eld aneurysm. Further- 
more, the observation, obtained from arteriographs seems to be 
of importance, that the section of the artery lying above the broad 
arterio-venous connection increases its size in all directions. 
Not only a broadening, but also an increase of thm length can be 
observed, which can be recognized by the tortuosity of the artery 
and turning to the side as an angle at the level of the quite patent 
location of the suture (ill, 9, a and b). 
We have observed such dilatation of the artery not only 
with the aneurysms of the first World War tout also with aneurysms 
following injuries of this war. In every case, several months seemed 
to be necessary for the developm nt of such changes of the 
artery. Thus we have seen a clear widening of the arteries in the 
case of a 2 year old arterio-venous fistula of the popliteal 
artery (ill, 15). Also 0n a smaller vessel of the peroneal artery, 
an essential increase of the size of the artery above the arterio- 
venous connection could be observed with an arterio-venous fistulg 
of 21 months duration (ill, 16), which has promptly recovered after 
the operative removal of the aneurysm. The vessel of this 2} 
year old patient had not lost any of its elasticity at that time. 
These were the statements of STOTZ. In additio*, it should be 
pointed out, that as a result of their exam'1*' WACHSFUTK tcog'ther 
with KLEINS CPT IDT an ' RIDER all c mo to the canclusi n that the 
phenomena observe in th. heart, caused by tho rtorl -venous aneu- 
rysm re, above all, ■ f ochnnical nature, GER1 CH an'. HE MCE 
h~vo observe- ecr.asGS f the , ulsc after a, s inal n'-sthosia an 
After r rlcrtorial sympathy my. It w s ; .entienod that -‘urlng the 
narcosis 1 the experiments, the ecrease ef the pulse frequency was 
not so very pronounced. 21a 
Illustration 14- 
could not be reproduced with 
the facilities available. 
Illustration 11 
(Case J,F,) Dilatation of the heart 
in all dirretions with a broad 
arterio venous fistula of the 
femoralis closely belo.w Poupart’s 
ligament, 5 months after the in- 
jury, The heart size, which Is 
marked, is noticeably smaller and corresponds to the contours of 
the heart of the control X-ray four weeks after the operative re 
moval of the arterio-venous connection. 
Illustration 15 
(Case G,N,) The arteriogram shews an 
arterio venous fistula at the level 
of the large shell splinter at the 
bend of the knee, 2 years after the 
injury. The point of the needle 
lies in the popliteal artery, which 
is percutaneously punctured for the 
contrast medium injection. The 
popliteal artery can be clearly 
seen as a widened vessel band above 
the fistula, which is of only 
normal size beneath it. Behind the 
artery, one can see the broad vein. 
111. 15 
Illustration 16 
Illustration 16 
could not be reproduced with 
the facilities available 
(Case 0,B,) The arteriogram 
shows a widened vein besides the 
arterio peronea demonstrated 
as evidence »f an arterio-venous 
fistula at this place, 21 months 
after the injury. The arteria 
peronea is clearly widened above 
the fistula in comparison to the 
other arteries of the lower leg. 22 
As the local influence can be eliminated at tho place 
of the pressure by disconnecting the paths of conduction, it 
can be presumed that the decrease of the pulse rate is caused by 
the variation of the pressure in the itself* This happens 
in a reflex manner through a very sensitive nerve arising at the mouth 
of the large veins (BAINBRIDGE), WACHSMUTH has also made examinations 
concerning the reaction of the minute and pulse volume and has found 
an increase of 100%, especially in those cases whore an infection 
existed at tho same time. However, also aft-.r the disappearance of 
the general symptoms, a certain difference could still be clearly 
recognized, and that can be demonstrated by interrupting the circulation 
on tho sound side and the ill side by pressure. Only after the 
operation, an interruption of th~ aneurysm by pressing produced 
hardly any change of the pulse volume and minute volume. 
For the completion and the illustration of the values of the 
blood pressure, the change of the pulse rate and the oscillometric 
results, we are now going to describe another case of an arterio- 
venous and one case of an arteria] aneurysm: 
Case C 20 
Diagnosis: Arterio-venous aneurysm of the right 
femoral artery, The injury was caused Ipy a gunshot 
with an infantry bullet through the right thigh, No 
serious arterial hemorrhage arose. On the 5th lay 
after the injury, the aneurysm was recognized be- 
cause of a buzzing and the pulsation. For a longer 
period, an infected hematoma and an acute osteomye- 
litis existed. 
Measurements before the operation; 
Blood pressure (oscillemetric) 
right loft 
Thigh, above tho aneurysm 226 146/45 
Lower leg 95 135/55 
Upper arm, abovo the elbow, normal 10&/55 
upper arm, above the elbow, during 
compression of the aneurysm 1*2/45 
upper arm, during compression of the 
sound femoral artery 115/46 
Pulse: 
Normally 74 
during compression of the aneurysm 42 
during compression of the solind 
femoral artery 74 22a 
Illustration 
case C 20, Description see 
t here, 
Illustration 
to case B 30, Description see 
there, (Measure'before operation) 
Illustration 
•to case B 30. Description 
see there, (Measure after 
operation), Oscillometry; 
The curve for the affoctee thigh abov. the aneurysm is 
many times as high as the one of the sound thigh, 
because of the markedly increased blood supply 
by the "Arterial" vein blood* In contrast, the 
oscillometric variations of the affected side are 
considerably less than those of the sound side in 
the lower leg as a result of the poor blood supply 
with arterial blood. 
Case B 3®. 
Diagnosis; Arterial aneurysm of the right 
axillary artery. The patient was injured on 
5 September 1943 by a shell splinter with the 
splinter lodging in the affected part. The 
aneurysm w s recognized for the first time in Feb- 
ruary ljuu. 
Measurements before the operation: 
Blood pressure (Rira-Rocci) right left 
U per arm, below the aneurysm 1*5/55 IZ5/55 
Lower arm 80/55 125/65 
Upper arm, during compression 
of the aneurysm 129/55 
Pulse: 
Normally 64 
During compression of the 
aneurysm. 
Temperatures (thermo-electric); right left 
MOHRENHEIM cavity (infraclavicular fossa) 28,3° 2}° 
middle of the arm 26,3 27*2 
middle of the lower arm 25,2 27,2 
back of the hand 26,3 27,3 
Oscillometry; 
The carves on the upper arm show an increase 
of the oscillometric index to 45 on the sound upper 
arm in comparison to 20 on the affected upper arm. The curve on the sound lower arm is also twice as 
high as that of the affected side. This find- 
ing corresponds to the arteriogram, which shows an 
arterial sac of the aneurysm with a clearly 
recognizable stenosis and an insufficient 
blood supply. On the 16th of M rch 19Uk, an 
operation of an arterial aneurysm of the 
axil, ary artery was mad., with exposure of the 
sac , which was about the size of a hen’s egg. 
The ends of the arteries were removed and a 
circular suture was made. After this, a pulsa- 
tion could be palpated in the artery where it 
carried the blood away from the aneurysm site* 
Measurements after the operation; 
Blood pressure (Rira Rocci) right left 
Upper am ;— 1x2/50 
Lower arm 105/55 
The blood pressure could not be measured 
on the affected arm, as the pressure was tao 
low. 
Temperatures: right left 
MOHRENHEIM cavity (infraclavicular fossa) 31>8° 31.5"' 
middle of the upper arm 32,0 31.7 
lower arm 29.2 28,8 
back of the hand 29.9 29.2 
Oscillometry: 
The curves of the affected upper arm and* lower 
arm arc considerably flatter, which fact also 
emphasised the insufficient blood supply on 
the affected side after the operation* 
H. INDICATIONS FOR OPERATIONS. 
A, General Facts, 
The operatiom of an aneurysm can bo one of the most difficult 
operations of all surgery. The principal reason for this is that 
surprises occur again and again in spite of sufficient surgical 
skill and wide experience in this field. These surprises do nfct 
permit a "typical" method of treatment. In many cases, these sur- prises and incidents are dangerous to life and only a very active 
intervention combined with sufficient experience can prevent severe 
physical damage or oven death. As one of the first and absolutely 
necessary conditions wo regard the exact knowledge of anatomy, 
sufficient surgical experience as well as a knowledge of anatomical 
function, although one cannot speak of normal anatomical conditions 
in cases of very extended aneurysms. In spitu of those facts, the 
advice of LERICHE appears hazardous to us, which was to desifet from 
a clear anatomical exposure of the area of operation and to be 
"less anatomical, less desirous of knowledge of all details". 
Especially in thoses cases where the method of KATAS is supposed 
to be used, LERICHE recommends avoiding such an exposure. We 
can only agree in part with this recommendation not to be too 
exacting in the knowledge of all details under certain restrictions. 
As HEREIN has pointed out, too, some freedom should be shown in 
this case. By incisions which should be large enough and bv 
favorable exposures, the area of operation should be clear and in 
such condition that everything can be roll The sparing of 
one small nerve must not hinder clear vision or consume time. 
Large aneurysms often require much time in any case. This fact 
should be considered before the operation. Furthermore, 
those big operations require considerable physical and psychic 
achievements from the surgeon. Therefore, only a fully trained 
surgeon should dare to perform such an operation, especially as 
the outcome of the operation can never be predicted ■ ith certainty* 
Difficulties arising during the operation lead either to an 
inappropriate treatment which is harmful for the patient, or they 
leave no other choice than that of interrupting the operation, 
whereby a later operation, which has to be performed in any case, 
becomes more difficult. Therefor., the instruction in the former 
German Army to gather all cases of aneurysms in special hospitals 
seems to have been fully justified. It might be regarded as a 
proven fact that the success of the operation will increase if the 
patients are in the hands of some skilled surgeons, and that the 
experience of the surgeon in this field increases the more he is 
acquainted with it. Because of this reason, all cases of aneurysms 
were operated by the director of our clinic himself, Prof, BERNHARD. 
p; Indications .for- operations 
Particularly during World War I, but also until a couple 
of years before the outbreak of World War II, the points of view con- 
cerning the necessity of an operation in case of an aneurysm varied • 
widely, BIER, who first favored conservative therapy, later 
on advised surgical treatment more and more, SAUSRBRUCH 
-id not consider the operation of a fresh aneurysm as indicated, 
however, in cases where an operation was necessary after a lengthy 
period of time, perhaps after months or years, he did not express any 
concern against a ligature of the vessels. The above mentioned sub- 
sequent clinical problems and the complications which may follow 
an arterial as well as an arterio-venous aneurysm should leave no 
doubt, that the removal of an aneurysm is certainly the more 
desirable method. Even the existence of an aneurysm for weeks, 
months, or decades does not protect the patient from serious com- 
plications, as has been proved in our case W#M,, (see page and 
in a case published by RDTHMANN. In the course of 20 years following an aneurysm of the common 
carotid which had grown from the size of a pigeon’s egg to the size 
of a child’s head, centers of softening of the brain had arisen in 
the right parietal lobe and in the temporal lobe of the brain as 
a result of a compression of the common carotid. Sudden un- 
consciousness and hemiplegia have quickly led to death, 
WILDEGANS describes the case of a woman with a gunshot aneurysm, 
inflicted during "/orId War I, which had persisted through 25 years. 
Instead of a fistula, a considerable cicatrical stenosis occurred, 
which led to a sac like distension and an angulation of 
the afferent femoral artery, and to an enormous general congestion 
of the veins. In a case reported by PHILIIPIDES, the arteriogram 
of an arterio-venous aneurysm of a 50 year old man, which was in- 
flicted during World War I, showed a much distended vein at the 
level of a fistula of s false aneurysm. Even if it shows no 
inclination to grow at first, even if there are no or only in- 
significant complaints, even if an operation might lie dangerous 
owing to the unfavorable location of the aneurysm, it should be 
attempted to remove the aneurysm by operation. Though spontaneous 
healings do occur and have even been observed by us, they arc comparar 
tively rare. Among the 172 cases of aneurysms observed by us, 
spontaneous healing occurred bnt 6 times. 
Speaking of spontaneous healing, we must make a difference 
between the healing of fresh injuries of the vessels and pulsating 
hematomas on the one hand, and that of fully developed aneurysms 
on the oth>_r hand. The fact that the former are healed spontaneously 
more easily and more frequently has been confirmed at subsequent 
operation in numerous cases (e,g. at operation on the nerves). 
At times, the two ends of the vessels are connected only by a 
string of connective tissue. In case of penetrating or extensive 
gunshots, the healing process is obviously more easy than in case 
of smaller lateral hoi. s. The spontaneous healing of fully 
developed aneurysms is very rare and is possible only through 
thrombotic filling up of the cavity. The discrepant data with 
regard to spontaneous healing result from the fact that these 
differences have probably not always been made. Thus, GUNDERMANN 
has observed 25 cases of spontaneous healing among 42 men with 
gunshots through vessels, V, H.ABERER 4 among 1?2, FROMIffiL 1 among 
50, and FRANZ at least 30 cases of spontaneous healing. . In each 
of our cases, the healing was confirmed arteriographically. We 
mention two cases: 
Case B29, 
Wounded on July, 17, 1942. At first a large aneu- 
rysm in the left armpit, which even suggested the 
possibility of a perforation. On further ob- 
servation' , however, the aneurysm underweit in- 
volution, and, during an operation on the nerves 
(neurolysis) performed 34 months later, a globular tumor 
the size of a plum was found, the puncture of which 
yielded no blood. Arteriography showed the failure 
of the axillary artery where it joined the 4rachialis, 
wit It an adequate collateral circulation. 26a 
Illustration 17 
Failure of the arteria 
brachialis as a consequence 
of the spontaneous healing 
of an arterial aneurysm, 
found at operation and 
arteriographically demon- 
strated during a neurolysis 
made 3'? months after the in 
Jury. 
111. 17 
Illustration 18 
Arterial aneurysm of the 
cubitalis healed spontan- 
eously during a period of 
several weeks of observation. 
Arterial defect, 5 centi- 
meters long, with good formation 
of a collateral circulation. 
111. 18 Case B 49 
A fist-sized aneurysm of the arteria cubitalis slowly 
underwent spontaneous involution to the size of a 
plum. Neither thrill nor pulsation could lie ascer- 
tained thereafter. After seven weeks of hospital 
treatment, arteriography showed a 5 centimeters 
long defect of the arteria cubitalis, which was 
bridged by collateral circulation. No sac 
was formed, an operation was not necessary. 
In contrast to these observations, spontaneous healing of an 
arterio-venous aeurysm cannot be expected. 
We consider it a lucky incident that we once have seen 
disappear, after arteriography, an arterio-venous aneurysm of the 
neck with all typical symptoms (distinct continuous thrill, 
ringing in the head, shortness of breath). In this case, the 
vein probably thrombosed, or the fistula opened, or the hematoma 
caused by the puncture, to which a compressive bandage was applied 
obliterared the communication or the vein. 
Medicinal and dietic measures are no longer considered important 
and a treatment aiming at making the aneurysm sac disappear 
through chemical drugs is eliminated because of the dangers con- 
nected with it. Of the conservative measures, only compression 
treatment persisted at the end of ' World War I. By means of 
compression of the sac , one endeavored to further agglutination, 
to diminish the sac • and to make it disappear finally. The com- 
pression of the artery was meant to stimulate and to form a collateral 
circulation. According to our opinion and experience, the inter- 
mittent compression method of treatment has more disadvantages than 
advantages, apart from some extension of the collateral circulation, 
which is even dubious in many cases. Though compression may effect 
a certain diminution of the sac ., the chronic inflammatory changes 
existing in most cases are intensified by it. The already frequent 
fragile condition of the vessel becomes even more pronounced, and 
thus renders operation more difficult in many respects. In the 
case of an aneurysm of the peplitea, we were quite convinced that the 
previous compression treatment had affected the vessel most unfavor- 
ably (see case D 60, page GH , 111. 55> a and b). 
For this reason, it is the surgical treatment only which has 
remained the most reliable method of treatment up to the present day. 
The danger of a constant dilatation with subsequent rupture and violent 
arterial hemorrhage, the deleterious effect which the growing aneurysm has 
upon the surrounding area, upon muscles, nerves and bones owing to 
the damage it causes by pressure, the occasional disorders 
of the circulation, all these facts leave no doubt of the absolute 
indication for operation of the arterail aneurysm. 
In case of arterio-venous aneurysm, it is the cardiovascular disorders 
which indicate operation. The excessive supply of arterial blood to 
the right heart, which received considerably more blood in the unit of 
time than normal, results in a dilatation and hypertrophy of the right 
heart with later participation of the left heart as While 
this state is at first compensated by corresponding extra labor of the 
heart, decompensation or insufficiency may occur eventually. Even in 2£ 
this state, the patient may be saved by an operation, but the 
grave injuries of the heart and of the circulation caused by 
arterio-venous short-circuiting and the local disorders of the cir- 
culation which may largely impede the functions, require an early 
operation in most cases of arterio-venous aneurysms. these 
circumstances, an operation is advisable even if the symptoms are 
still slight, paiticularly as its performance is then much easier. 
This le ds us to another point of the treatment of aneurysms, viz, the 
time of operation. 
IH. TIME OF OPERATION 
While the necessity of open- tion is generally agreed upon 
today, the problem of the most favorable time for operation has not 
been settled until now. Even on the strength of the experience of 
World War I, STICK warmly recommended early op ration of the pulsating 
hematoma, while he sees no urgency to operate the fully developed aneuryc;. 
particularly if there is no imminent danger. At all events, it is a 
fact that no time should be lost by using the compression treatment. 
As I mentioned before, even the formation of the collateral circu- 
lation is not much furthered by it, its damage is greater than its 
use in most cases, since during the lost time, symptoms may occur, 
which we are most anxious to prevent in case of arterial aneurysms, 
such as embolus, gangrene, and particularly the formation of 
callosities, which complicate the operation considerably. If you 
have seen the extensive formation of callosities of the fully developed 
aneurysm again and again and are aware of the difficulties they cause 
by involving the nerves and other surrounding areas, you will not 
wait till the sac has fully developed and will operate when the 
callosities are not y„t fer pronounced. Besides the formation of the 
collateral circulation, it is also the danger of infection which 
will decide the time of operation. We are of the opinion that a 
sufficient collateral circulation will develop within 3~4 weeks 
thereafter even the fresh granulation tissue and the soft scars are 
replaced bT callous and cicatricial tissue (HERLYN). For this reason, 
this moment has been regarded as thu most suitable time for operation 
so far. It was recommended also by LEXER. He made a difference between 
early and late operation. stipulating for early operation that in- 
fection had not yet set in and for late operation that it had dis- 
appeared again. If an operation was necessary between these two 
stages, he spoke of an emergency operation. Now 7.HABERLR has pointed 
out that, in contrast to his experience during Warld War I, he has 
changed his opinions as regards temporal indication for operation. 
He ascribed this to very intense inflammatory symptoms which set 
in very early after injuries of the vessels and require an extra- 
ordinarily long time for involution. Many months after the wound 
had been inflicted, ho hae observed, as he said, fresh inflammation 
chiefly in the lymph nodes in addition to the old inflammation foci. 
In the case of an arterio-venous aneurysm between the carotis communis 
and vena jugularis, which he operated 4 weeks after the injury, the 
operation had to be stopped because of serious chronic and acute 
inflammatory processes* 
These inflammatory symptoms, which have evidently become more 
serious since the last war, can be explain' d only by the changed 
type of arms, particularly by the explosive missiles by the 
Russians, but also the above mentioned increased flat trajectory of rough missiles, which may cause great damage to the tissue and form 
large cavities in spite of the smallest entrance hole of the bullet. 
The geographical character of the theater of war may afford some 
explanation. Choosing the time for operation, one has to decide 
either to operate soon and to risk the danger of an infection owing 
to the still existing acute inflammation, or to wait and then find 
the operation complicated by cailo-sities, which are difficult to deal 
with:, and injured nerves. But as regards the danger of a late 
septic hemorrhage, even a serious infection of the aneurysm cavity 
does not contraindicate an immediate operative intervention. Only 
the method of operation (ligature, suture, transplantation) depends 
on the circumstances. In case of the rapid growth of an aneurysm, 
particularly if there is the danger of rupture, the conditions of the 
wound are not taken into consideration. As our observations have been 
made with the patients of a hospital in the honeland, early 
operation had to be considered but rarely. It must be regarded 
as absolutely indicated, however, for the pulsating hematoma or the 
state of primary formation of the sac 9 if no serious infection need 
be reckoned with {STICK, REHN, V.HABERER, WILDEGANS, KILLIAN), 
If possible, we performed late operations only 2-3 months 
after the wound had healed. After this period, the danger of in- 
fection is largely eliminated (in case of war—injuries, latent in- 
fection may always occur) and there is a fair prospect that the suture 
will be durable, which is always the objective. If suture is not 
possible or even not necessary., ligature in the callous tissue is 
not too difficult. On the strength of the experience of the 
last war, one will accordingly double the period of delay for the 
late operation of arterial aneurysm and wait 2-3 months instead of 4*”6 
weeks, as was iBual until now. In case of arterio-venous aneurysms, 
the time of operation is not so important as with the arterial 
particularly if there are no dangerous symptoms. For 
this reason one will wait for the most favorable ase!ptic conditions, 
which promise a healing p-r primaaa. 
IV. OPERATIVE TECHNIQUE * GENERAL CONSIDERATIONS 
Though I mentioned above that, in the operation of aneurysms, 
surprises must always be reckoned with and any typica 1 method 
is therefore often impossible, there are certain rules which must 
be observed during the operation. As in all other interventions, it 
is aimed at preserving or restoring first, life; second, the limb; 
third the functional efficiency. This means that, if possible, 
methods of operation should be used which comply with these require- 
ments. The objective of aneurysm operations accordingly is the 
restoration of normal circulation. For this purpose, two methods 
are available: vascular suture and transplantation of veins ( 
special oases, the transplantation of an artery may be considered, 
too). Where these methods are inapplicable or unnecessary, there is 
ligature as another method. Certain arteries for instance can be 
ligated without any concern, such as the arteria hypogastrica, 
artcria glutaea, arteria carotis externa and maxillaris, arteria 
meningea media, the small arteries in the lower arm, radialis and 
ulnaris, arteria. profunda brachii and interossea. But even 
in the leg below the knee, disorders after ligature have been ob- 
served in vessels, the ligature of which has been thought safe. Though vascular suture and transplantation of veins must not be 
considered too lightly, one ought to consider in dubious cases 
whether a ligatur- can be risked or whether a better method might 
be used. Various circumstances must be taken into account, such as 
the age of the patient, the condition of the vessels, arteriosclerosis, 
and even the time. Early ligature certainly yields less good results 
than late ligature, on the other hand, ligature of arterial aneu- 
rysms is, in most cases, more dangerous than that of arterio-venous 
fistulae. By means of arteriography and other examination signs, 
wo are in a position to ascertain in some cases a sufficiently developed 
collateral circulation even before the operation, and during the 
operation there is available the LEXER—KENLE-OOENEN symptom which 
allows us to draw conclusions concerning the collateral circulation. 
This test permits us to assume an adequate collateral circulation, 
if a jet of arterial blood still flows out of the peripheral end 
after the afferent artery has been pinched off. Also the 
MOSCOWICZ symptom and the KOROTKQFF symptom are useful for testing 
the collateral circulation. HOTZ recommended deep incisions into 
the toes or fingers as the only safe method as a test of the amount 
of the hemorrhage after the ends of the vessels been pinched 
off. We think the LEXER-HENIE-COENEN test is most reliable, while 
the other tests to be less reliable. For instance, the skin 
can be adequately supplied with blood, while there are ischemic 
zones in the interior of the limb, particularly in the muscles. It 
is a well-known fact that the muscles are particularly susceptible 
to damage by a deficient blood supply. So if there is reason to 
suspect that ligature will cause any damage, one of the ideal methods 
for the treatment of gunshot aneurysms , vascalar suture or trans- 
plantation of veins, must be used. It was occasionally doubted 
whether suture should be preferred to ligature (SCHOERCHER). But even 
World War I has shown that more necroses appear after ligature than 
after suture (FRANZ). In addition to the technical problems, which 
are not simple, the opponents of vascular suture hold that a 
thrombosis often appeared at the place of suture, which obliterates 
the free passage of the blood through the vessels, as in the case 
of ligature. In addition to that, a recurrent aneurysm might 
possibly occur at the place of suture. This is possible, but extra- 
ordinarily rare, V. HABERER has observed it once among 182 vascular 
sutures, and we, too, have observed but one recurrence among our 
patients, but in that case the vascular wall had been seriously 
injured before due to the considerable strain, which the aneurysm 
had exerted on the vessel during 25 years (Case D 39)* The ad- 
vantage of suture, even if a thrombosis develops sooner or later, lies 
in the fact that the gradually developing thrombus allows time and 
opportunity for the development of the collateral circulation. 
The ischemic symptoms accordingly are considerably fewer than in 
case of ligature, where the circulation is interrupted all at once. 
After compiling several statistical tables, FRANZ arrived at the 
result that suture is throe times better than ligature, and most of 
the other authors also conclude that vascular suture, in the long run, 
yields better results than ligature. As for the methods of suture, 
the lateral suture and the circular one are to be considered. As 
already mentioned by STICK, no special instruments are required. 
We used, however, special needles for vessels with particularly 
fine paraffin silk, as otherwise, there will be easily a late 
hemorrhage out of the puncture canals, as shown by experience. For 
this reason,also REHN had a special needle made for the vessels. 
A r peated suture of the puncture canals narrows the lumen. When 
not operating in bloodless field, we use, if necessary, the 
HOEPFNER clips to pinch off the ends of the vessels, but secure the 31 
vessels previously by twisting a moistened band around them which 
is technically not difficult. Illustration 19 shows an instrument 
developed by REHN for this purpose and other clips and hooks ised by 
him during vascular suture. The disadvantage of the HOEPFNER clips 
consists in their being somewhat unwieldy and their slipping off 
easily, so that it is often necessary to see to it that they 
are properly fixed. Through their own weight, the clips 
have a considerable pulling effect on the vessel. For this reason, 
particularly the assistant must see to the cautious handling of these 
clips, especially if there are incidents, e.g. a hemorrhage, Une 
is apt to pull on the clips or on the loops around the vessels, 
which is an additional damage to the vessels. But any rough handling 
must b avoided during vessel operations. Even pathologico-anatomical 
observations enjoin the absolutely necessary careful handling of 
the HOEPFNER clips. Careless handling may even annul the success of 
a laborious operation, 
AMICH published two cases in which a post-mortem had been con- 
ducted and one linical case, in which after M a few seconds” appli- 
cation of the elastic artery clips provided with thick 
rubber coats, serious, chiefly shai*p edged injuries of the arterial 
intima and media occurred with subsequent thrombotic obstruction of 
vessel or perilous hemorrhage from vascular rupture. In both cases, 
which were operated by experienced surgeons, the success of the 
operation was frustrated, and the arterial damage would have been 
a fatal complication, if the original disease had not already reached 
a near fatal stage. 
As regards the mechanism of the injury, it was interesting 
in these cases, according to AMlCH, that a force acting on a large 
area had caused a sharp separation of the tissue (as if cut with a 
knife), in addition to extensive but less evident injuries by 
pressure. This process is explained by the extraodrinary elasticity 
of the arterial wall,, which springs wide apart at the moment of the 
trauma, but snaps together again after the clips have been removed 
and thus shows, in its state of rest, the picture of a fine, sharp 
separation of continuity. The outer layers of the wall apparently 
have a greater powex of resistance than the inner ones, though they 
are directly exposed to the pressure of the clips. Illustrations 
20,21 and 22 show the circumstances of a case, in which the 
artery clip had been applied to the carotid artery for one minute 
only (illustrations according to AMICH) 
These detailed arguments show sufficiently that the HOEPFNER 
clips must be handled with caution. As they, yielding to their own 
gravity, easily slide off the vessel, the operating surgeon is 
tempted to apply them with heavy pressure. This must be avoided. 
The pressure of the clips need be only strong enough that the 
circulation is just interrupted. An adequate immobilization or 
the assistant’s holding them will prevent the clips from slipping off. 
After the application of 2 or 3 supporting threads, we make the 
circular vascular suture with single sutures, in contrast to most 
of the other descriptions, according to which there is a continuous 
suture between the supporting threads. All layers are pierced, and 
intima is laid on intima. If tke suturing is made at rather 
narrow intervals, about 1-2 millimeters, a blood proof suture will 
result; if there is, in spite of that, a late hemorrhage from the 
ope or tfte other puncture canal, this hemorrhage may be staunched 
ip almost every case within a few minutes by the application of 31a 
Illustration 19 cbuld not 
be reproduced with the 
facilities available. 
Illustration 19 
Instruments for blood vessel 
operations as used by KEEN, De- 
schamps with branches and hooks 
for arterloversion (of the in- 
tima). 
Illustration 20 
Arteria carotis communis slightly 
enlarged a. secretion thrombus 
b, red stagnation thrombus point- 
ing towards the heart, c, distinct 
sharp separation of the inner wall. 
Abb. I. \. carotin commun. in natilrilchor GrdBo. Hoi a 
Abaohoidungstbroinbus, bel b dor herwAi t ■> - utihIo rote 
Stagnatiunathrmnbus, bel c dio deutlleho ~o!mrfo Innon- 
wanddurohtrennung 
Illustration 20 
Abb. 2. Sechsfaoho Vo rgrb Boning. Elastica-van Gicson. Schnltt durch die in Abb. 1 crkenubare 
Thvonibusha f tstelle. Die durchtrenntc und durch dio Blutstromung abgchobeue Int ima- und 
obcr.ste Mcdiaachiohtc im Thrombus festgohalton 
Illustration 21 
Six times enlarged, Flastica van Gieson. Transverse 
section *f the place where the thrombus recognizable in 
111, 20 is attached. The intima and uppermost media- 
layer separated and detached by the hemorrhage are de- 
tained in the thrombus. 31b 
Al.b.3- ™fache Vt-rgrrilflerung. Elastiea-van Gieson. Sohnitt durch die in Abb. 1 m b,-.. 
•.'fi.Bi " 1 lirombus iiomnde acharfc Vcrletiunitszone. Bci a klaffendc stufonformiKo. v.m 
blhrin- und HWtohinmassen orfullte Verlctznnsr. Waiter peripher bei b. bier imr mideutlioh 
siohtbar, Eintritt von roten BlutkOrperchen In die traumatisch erweiterten intriMitbn 
1209 
Illustration 22 
70 times enlarged. Elastica van Gieson, Transverse section 
through the zone of sharp edged injury next to the large 
thrombus represented in Illustration 20, a, gashing gradual 
injury filled with fresh masses of fibrin and platelets, b, 
more to the periphery, only indistinctly visible here, pene- 
tration of red blood corpuscles into the interstices which are 
traumatically enlarged. 
Illustration 23 
Right arteria carotis communis 
in natural size, a, b, and c, 
distinctly indicate the sharp 
edged injuries caused by the 
clip s, 
Al»b.4. UechteA. carotis commun. in natilrlich vr Grofio. 
Hei a, b mid c sind deutlich die scharfon KlemmeuA J 
verlctzungen erkennbar Y 
111. 23 slight pressure on the suture. If it is not necessary to rseaat large 
damaged pieces of the artery at the ends, the suture can lie made in 
most cas'-s without any considerable tension. If a larger defect arises, 
however, the vascular tubes must be widely exposed to both sides. 
Lateral branches spared if possible, and BIER believes that their 
dissection is never necessary. In this way> a defect of several centi- 
met' rs can be bridged over and the suture can be mado without any con- 
siderable tension, which is assisted by a corresponding flexion of 
the joints* Thus, the suture can be well made with a certain tension, 
and t.HABERER has applied extension without any damage immediately 
after vascular suture ih three cases of aneurysms of the femoralis 
with attendant fracture of the femur, though KILLIAN advises favor- 
ing the ligature in case of fractures caused iy gunshots. This cannot 
be absolutely approved, for if a good reduction is possible and an 
exact immobilization may be attained, which is quitu possible, even 
in certain cas-s of fractures caused by gunshots, by use of the 
marrow nail according to KUENTSCHER, suture can be risked without 
any concern. In another case, V.HABERER, after resection of 5 centi- 
meters and circular suture, observed that the femor lis had been 
torn off, not at the place of suture, but above it in the area where 
a HOEPFNER clip hae been applied. This is one more warning against 
careless handling of this instrument during the operation. The ad- 
vantages of the' circular suture, even when made with tension, have 
doubtless been overestimated on the strength of the experience of 
World War I. Though clear patency could be often attained immediately 
after the operation, arteriography showed to an increasing degree that 
the suture became obstructed after a certain period. This is doubt- 
less connected with the fact that -a thrombus forms at the place of 
suture, which obstructs the vessel. But even if patency is preserved, 
blood supply in the periphery is reduced in the artery under tension, 
which, in this case, behaves as an india-rubber tube and is narrowed 
in its diameter. According to rFHN, the POISEUIILE rule can be 
applied to such an artery according to which the volume of discharge 
decreases as the square of the reduced diameter. In considering a 
circular suture, another point of view seems important to me. This 
is the condition of the artery itself. Some vascular surgeons intimate 
again and again that the vessels, after injuries caused by gunshots in 
this war, are sometimes remarkably fragile and that to such a degree 
as V. HABERER had not observed in World War I, Since such brittle 
vascultr walls with soft, flaccid spots are quite liable to burst, 
they are less suitable for suture than an arteriosclerotic vessels. 
We too, have often observed, chiefly in case of arterial aneurysms, 
remarkably damaged arterial walls. For these reasons, it is advised 
to be careful in performing the suture and to judge the outcome with 
a critical attitude, for in spite of the indisputable advantages of 
the circular suture as contrasted to the ligature, obstruction at bhc 
place of suture will sometimes arise. If the circular suture is too 
narrow, another circumstance may be responsible for the obstruction 
of an artery. Thus, DRSSGHER describes a case, in which, after 
suture of the arteria femoralis, no blood came out of the peripheral 
section, even after puncture incision. After a powerful probe had been 
centrally introduced without meeting any resistance suggesting a thrombus, 
an intense jet of blood gushed forth upon the withdrawal of the probe. 
After the suture performed in a bloodless field, the peripheral section 
again remained without any pulse and the test with puncture incision and 
probe was repeated with the same result. The subsequent suture of the 
puncture incision was not performed in a bloodless field, and patency was 
retained. The only convincing explanation of this process is that an 
eddy formed at the much narrowed place of suture, which caused a re- 
versal of the current, a phenomenon which is sometimes observed even 
in the natural bed of a river. The danger of such a narrowing with formation of a bend and narrowing is even greater in case of an 
nalmost circular suture" than in case of a truly circular one. In 
case of aneurysms attached to the wall, you will often observe that 
you have a gaping slash before you, after the sac has been removed, 
while the back wall of the vessel is intact. If you try to obtain an 
'1lm;st junction by suture and leave the back wall untouched, 
patency and arterial pressure will result, it is true, but a poor 
transmission of the pulse wave results on accout of the bend and 
narrowing. For this reason, the wholly circular suture is to be 
preferred in such cases. 
Because of the difficulties which sometimes arise when suture is 
performed, above all because suture is Impracticable in some cases, 
another method of restoring normal circulation conditions must be 
mentioned :transplantation of veins. As already described by STICK, 
an - rterial defect of 5 centimeters can be eliminated by suture 
by appropriate mobilization of the vascular ends by appropriate po- 
sition of the joints (extreme flexion). For this reason, he as well 
as other authors (BIER, V. HABERER, ORTH) hardly ever used trans- 
plantation of veins in numerous vascular operations. Since trans- 
plantation is, in addition, dependent on many other conditions 
(aseptic conditions), it was not used in our operations, though we 
took it into due consideration in individual cases. But then, 
either ligature could be performed safely or there was no security 
for an aseptic healing. At all events, our results listed below 
show that we have renounced transplantation of veins without any 
considerable loss. We by no means intend to undervalue the trans- 
plantation of veins, It is doubtless one of the ideal methods of 
operating an aneurysm. 
During World War I, about 50 transplantations of vessels were 
made after the preliminary work of CARREL, STICK, LEXER etc. During 
this war, the method has been used more frequently, and HERLYN 
performed 30 transplantations among 3®0 operations of aneurysms, 
HERLYN chooses the place from where the transplant is taken 
according to the tasks it has to fulfill: 1, The vein must be 
able to stand the arterial pressure, A vena jugularis transplanted 
into an arteria iliaca burst 21 days later and caused a new aneurysm; 
2, The vein must have the appropriate diameter, so it is better to 
transplant the vena femoralis than the vena saphena magna; 3* The 
transplant must completely bridge over the defect. Since it has the 
tendency to contract, it must be taken somewhat longer; some winding 
does not matter; 4, In order ot obtain satisfactory circulation - 
conditions, it is best to implant it in the sense of the stream, 
so that the valves do not obstruct, though even implantation in the 
reverse does no harm. 
On the whole, technique and postoperative treatment are the 
same as in case of vascular suture. REHN also points out that, in 
order to prevent the troublesome sticking together of the venous 
walls and to adjust the lumen to the arterial calibre, it is suitable 
to fill the transplant with paraffinum liquidum to somewhat more 
than arterial thickness, i,e, tightly, immediately after the re- 
moval under application of two elastic clips. Some minutes afterwards, 
the limp venous walls will tighten and thus, they can be better handled 
and sutured, Frequent rinsing of artery and voin with paraffin goes 
without saying. In this way, REHN was able to cover a 15 centimeters 
long defect of the high femoralis and external iliaca by trans- 
plantation of veins, For the sake of completeness, another ideal method of oper- 
ation is mentioned by ■which normal circulation can be restored. 
This is the transposition of one end of an arterial branch at a 
place of division, an idea put into practice at the arteria pop- 
litea by A, HOFMANN, at the arteria carotis by REHN, and at the 
arteria cubitalis by HERLYN. 
Besides these methods which remove the arleurysm and restore, 
or at least try to restore, normal circulation, there are methods 
removing the aneurysms but renouncing the restoration of normal 
circulation. In this case, the danger of a disorder of blood- 
supply is, of course, considerably greater, since a central and a 
peripheral ligature is always made after the extirpation of the sac.. 
Whilst these methods almost always prevent the danger of a 
recurrence, the danger of a recurrence is greater with the methods 
of aneurysm treatment as briefly described below. For this reason, 
they are used only in exceptional cases and are, therefore, emergency 
methods. 
The more palliative method of trying to control the aneurysm 
by artificial strengthening of the wall, e.g, using a pedunculated 
lobe of the fascia lata, is practically of no importance today. On 
the other hand, we must have recourse in some cases to one of the 
following methods which try to heal the aneurysm by reduction 
of blood supply, by contraction of the wall, or by introduction 
of foreign bodies into the sac, 
1. Gradual constriction of the afferent artery 
above the aneurysm by autoplastic material, 
2. Ligature of the aneurysm*, 
3. Ligature below the aneurysm-sac, viz, be- 
tween tumor and capillaries, and ligature 
above the aneurysm, viz. between tumor and 
heart, without touching the sac itself. 
This applies to those very serious cases, 
where one cannot approach the afferent 
vessels (intrathorscic subclavia aneurysms, 
anonyms aneurysms) or where one cannot 
approach the efferent vessels (aneurysms of 
the carotis interna, located high, near the 
base of skull), 
4. The method of MATAS, who used 3 kinds of aneu- 
rysm repair: 
a) the obliterating method, in which the 
sac is opened and both the two main arteries and 
all joining secondary branches are sutured from 
the inside, 
b) the restoring method* incision of the sac, 
suture of the arterial hole, turning in of the 
sac by gathering suture; 
c) reconstructive method? opening of the sac, 
the hole of the artery is closed by plastic from 
the adjoining pert of the aneurysm sac, the aneu- 
rysm sac is again turned in by gathering sutures. 35 
No reliable facts are known of results obtained by introduct!-r 
of silver-wire or gilded wire into an inoperable aneurysm in 
connection with electrolysis. These non-radical methods of oper- 
ation i ay be justified in desperate cases as a final attempt 
for healing, particularly in case of purely arterial aneurysms; 
in case of arterio-venous aneurysms, no positive result can be 
expected. 
During the operation of arterio-venous aneurysms, the most 
important thing is the absolute separation of artery and vein* if 
a recurrence is to be prevented. To this purpose, ope approaches 
the afferent and efferent vessels if possible through sound tisjsuc 
and places a small ribbon loop around them. If there is only one 
fistula, it is prepared in an exposed, position as far as 
possible and only then incised. The holes of the vessels are 
closed by suture. We wish to emphasize particularly the exact 
often toilsome and wearisome preparation of the fistula in an 
exposed position. In doing so, one will often succeed in Pre- 
serving the artery and vein to a large extent, and defects in 
the vascular walls actually occur only in the area of the slit 
of the fistula. We believe that by this exact preparation we, in 
•ontrast to other authors (HERLYN), were so successful in using v 
suture and could renounce the transplantation of veins since wo 
avoided greater defects by the preparation. If th.re is-a sac 
which is not rare, it is also suitable to prepare the sac in an 
exposed position as far as possible without incising it, after 
placing a ribbon loop around the vessels. One is astonished 
again and again at the considerable hemorrhage which occurs if 
the sac is prematurely incised; voluntarily or involuntarily, 
though loops have been placed ''■round, the afferent and efferent 
vessels* This hemorrhage inmost cases arises from congested vc ins 
or unexpectedly large arteries flowing into inapproachable 
secondary sacs, or into the principal sac at a place where it is 
not yet exposed. After preparation of the sac, it is important 
to emphasize this once more, to arrive at a perfect separation 
between artery -and vein at their juncture. Simple ligature of 
the afferent and efferent main vessels, which seems to. be suffi- 
cient, at first sight, actually is not sufficient to prevent a 
recurrence, since, at the juncture, the vein sucks the blood/cut 
of the artery and thus - having the same effect as narrowing 
of the artery - has particularly fostered the formation of a 
collateral circulation prior to the operation. 
When the connection between rtery and vein is severed, one 
can, if no difficulties °risc, extirpate the sac or proceed accord- 
ing to the methods of MATAS described above, FRANZ writes that he 
never extirpated the sas. As for ourselves, we have almost 
always extirpated it. This has the advantage that in case of 
possible suppurations, which must always be reckoned with in war 
injuries,;secretion wild stop more rapidly. 
In addition to that, the question of a bloodless field appears 
important. It doubtless facilitates the intervention considerably 
in many cases and prevents a large loss of blood, which must not be 
considered lightly, since the op ration of an arterio-venous aneurys. 
often lasts several hours. On the other hand, the bloodless field 
also has its disadvantages. In spite of adequate exposure of th~ 
leg, in which one had bettor not include the aneurysm'itself be- 
cause of the danger of carrying thrombi, one often does not succeed 
in operating in a bloodless field because of venous stasis, and this complicates orientation. Sometimes one is even temporarily com- 
pelled to give up operating in a bloodless field. Another dis- 
advantage is the fact that one cannot palpate the thrill any longer. 
If the aneurysm is located on one of the smaller branches with- 
out any distinct sac, it is very difficult to discover it, some- 
times even impossible, particularly if the arterio-venous fistula 
has not been positively proven previously. In some case, and they 
are the most difficult ones, such as aneurysms of the large cer- 
vical vessels and intrathoracic aneurysms, no bloodless field 
can be obtained. Also within the SCARPA1 s triangle and in case 
aneurisms of the iliaca externa and interna, it is impossible tc 
obtain a bloodless field. Whoever, therefore, is not practiced i: 
operating an aneurysm without a bloodless field, will meet with 
particular difficulties in these cases. 
V. TREATMENT BEFORE AND AFTER OPERATION 
As mentioned before, we consider it suitable to collect 
cases for aneurysm operation together at special clinics, since 
it has been proved that expert vascular surgeons obtain the best 
results. Thereby it is inevitable that the patients are in 
most cases informed of the dangers threatening in an aneurysm 
operation. For this reason, it is the surgeon*s task to Inf r 
of a certain risk of the operation, but, on the other han , t. 
talk them out of fear of an operation and to point out the dan rs 
of a non-operation. Since the patients are chiefly young, robust 
people, and, as experience has shown, the operation may occasionally 
last several hours, we have administered, as a preparation for 
the operation, 2 tablets of Bellergal and Luminalettes, 3 times a 
day, for about 8 days. This considerably reduces the sensitivity 
of the vegetative nervous system, so that we could manage with 
a comparatively small dose of nacotics (ether). 
As mentioned before, the majority of our aneurysm patients 
were examined an internist for possible cardiac disorders. If 
there were symptoms of a morbid involvement of the heart, par- 
ticularly symptoms of insufficiency of decompensation, the heart was 
treated for about 8 days before operation with strophanthin—redcxcn, 
though we were well aware of the fact that only the removal of 
the aneurysm could stop these symptoms. The area of operation 
was prepared in the usual way; if possible, we let infections 
subside. In case of arterial aneurysms not yet ready for oper- 
ation, which progress without considerable complaint, the patientTs 
request to be discharged until ready for operation is understandable , 
All the same, we advise hospitalization, for sometimes there is a 
rapid growth with danger of nerforation or perforation itself, - 
which we have observed several times - with the dangers described 
above, whieh demand prompt intervention. In all events, such 
patients should be conscientiously instructed before they are dis- 
charged. 
During every operation of aneurysms, but particularly of the 
large vessels, a serious hemorrhage may occur. For this reason, one 
or two blood donors must always be available, and it is suitable to 
keep everything ready to perform a transfusion of blood quickly. In case of lengthy operations, even with slight loss of blood, 
transfusion has proved excellent to overcome the postoperative 
shock* 
To relieve pain, we have chosen, in most cases, general parcosis 
with ether* In order to manage with smaller quantities of ether 
during lengthy operations, we have also used avert in as a basic 
narcotic in some cases, though the involved reduction of blood 
pressure may have a disagreeable effect in that t)|o thrill may be- 
come considerably lower or even disappear during the operation. 
We occasionally have also used local anaesthesia, especially 
in case of operations on the throat, but in most cases additional 
ether narcosis had to be applied. With elderly patients, we have 
operated aneurysms of the lower extremities with spinal anaesthesia* 
As regards postoperative treatment, the individual authors 
again and again emphasise the necessity of immobilizing the oper- 
ative area. This is easily done with the extremities by means of 
plaster or splint bandages. On the lower extremities, the VOLK- 
MANN T-splint is to be preferred to BRAUN’s splint* This causes 
a relaxation in the large joints, which facilitates the blood supply 
on by-paths. For this reason, the limb must be placed in. a re- 
laxed position also after the ligature of a vessel, KINGREEN thinks 
that the lower extremities are better supplied with blood when the 
patient is lying on his belly, so he orders his patients to lie 
on their bellies after vascular operations on the legs. Since, 
particularly after vascular operations on the extremities, a 
considerable ischemia because of spasms may occur, we recommend, 
in addition to appliance of heat, repeated high doses of spasmo- 
lytics (eupaverin). In order to control the spastic condition, it 
is often necessary to eliminate the sympathicus through anaesthesia 
of the lumbar (possibly spinal anaesthesia) or dorsal sympathetics. 
We have used the injection of the sympathetics in numerous cases 
of postoperative disorders of blood supply and havu always observed the 
best results, subjectively as well as objectively, authors 
even recommend immediate postoperative resection of the sympathetics 
in desperate cases; cth rs perform it even before the operation, 
e.g, in case of ligature of thr poplitea. SCHOENBAUER, for instance 
has observed danger of gangrene after spasm in two cases (arteria 
femoralis and arteria carotis). For this reason, even a resection 
of sympathetics on both sides was performed in the latter case. 
Even in case of cervical aneurysms removed by suture or trans- 
plantation some authors (REHN, HERLYN) demand a fixation of the head 
by means of plaster bandage. As for ourselves, we hrve been content 
in most cases with an ordinary bandage of the head and have observed 
no late hemorrhage nor any recmrrence. All the same, it is ad- 
visable to immobilize the operative area. 
Since in case of war aneurysms, we must always be prepared to 
operate within the area of a latent infection, the wounds were 
primarily sutured, with the use of plenty of Marfanil-Prontalbin 
powder, but a drain was put in for 4S hours. The surgeon must 
see to it that the drain is not placed at the level of the vascular 
suture. In order to prevent any lengthy suppurations of cavities, one 
should endeavor to close the cavities in so far as possible; if their 
walls are rigid, possibly with mobilization and adaptation of the 
muscles. If a splinter is removed at the same time or if there is 
the danger of its mobilization, tetanus scrum must be administered 
previously. After primary healing, active and passive exercise may 
be started in a fortnight. SPECIAL TREATMENT OF ANEURYSMS OF THE SINGLE REGIONS CF THE 
BODY WITH CONSIDERATION OF PARTICULAR INDIVIDUAL CASES 
AND 
RESULTS OF TREATMENT 
't ■■■■'■ i" v vsstsv 1 ■■-j- iuuaa 
I. CERVICAL AND CEPHALIC ANEURISMS 
In most cases of aneurysms of the cervical and cephalic 
region, operation is inevitable. Since there are no masses of 
muscles in this region, the aneurysm sac can grow without any 
considerable resistance and then exert a destructive influence on 
the surrounding area, particularly on the nerves. Chiefly the 
plexus brachialis, vagus and sympathicus, but also trachea, 
larynx, and thyroid gland are involved. Through inflammatory pro- 
cesses and formation of callosities, such difficulties may arise 
for the operation, that, in one case, even such an eminent vascular 
surgeon as is V. HABERER had to stop the operation, and among our 
own operations, there are two in which the aneurysm was operatively 
attacked from the outside and which persisted without any success 
whatsoever. 
One more indication for operation is the usually harassing 
thrill and whizzing which the injured man nearly always feels and which 
is often so tormenting, that the patient gets hardly any sleep. 
Then the patients will urgently demand operation, 
Cases in which the vessels of the thyroid gland are involved 
and which thereby lead to a general disease in the nature of a thyreo- 
toxicosis, are particularly interesting and indicated for oper- 
ation. SYNOPSIS OF THE CERVICAL AND CEPHALIC ANEURISMS. 
jVessel 
Number 
i 
j Arterio-venous 
» 
Arterial 
jcarotis communis 
IB 
14 
4 
(carotis interna 
4 
3 
1 
externa 
1 
3 
2 
1 
arteria vertebralis 
1 
1 
- 
truncus thyreo* 
cervicalis 
• *3 
3 
- 
iarteria temporalis 
1 
1 
- 
Total: 
30 
24 
6 
RESULTS OF OPERATIONS OF ANEURYSMS OF THE CAROTTS 
COMMUNIS AND INTERNA. 
The aneurisms of the common carotid were operated 14 times, 
these of the internal carotid artery 4 times; the methods of 
operation and their results are illustrated in the following table; 
Common Carotid Artery 
Method of operation 
number 
complete patency 
narrow healed 
ing ! 
j 
died I 
Lateral suture 
13 
10 
1 
12 
1 
' 
Circular suture 
i 
- 
- 
1 
Internal Carotid Artery 
Lateral suture 
3 
3 
- 
3 
i 
* 
Ligature 
1 
- 
- Caae A 4 
Arterial aneurysm of the arteria caretis com- 
munis, Despite considerable formation of callo- 
sities (previous compression-treatment), the aneu- 
rysm sac could be satisfactorily prepared in an ex- 
posed position and the lateral slit, which was about 
lj centimeters long, could be closed by lateral su- 
ture without narrowing the vessel. Completepatency 
was ascertained. The operation was performed with- 
out any considerable loss of blood. Five hours 
after the operation, a hemiplegia was observed. The 
following day, a sudden respiratory arrest occur- 
red, which caused death. The post-mortem showed 
extensive embolic involvement of the left arteria 
carotis interna from its entrance into the cranial 
cavity and of the left arteria cerebri media. 
Case A 7 
A 30 year old soldier, shot through the neck 
in June 1942. An aneurysm the size of a fist 
formed in the left side of the neck with slight da- 
mage to the plexus on the left and a distinct 
HORNER's syndrome (miosis, enophthalmus, ptosis). 
In the neck, there was, besides a completely healed 
scar where the bullet entered, an old non-irritant 
scar 'originating from a goitre—operation; the left 
side of the throat was distinctly protruded by a 
tumor about the size of an apple, which showed a 
discontinuous thrill. The operation was performed 
under ether narcoeio* Since a thyroid operation 
had been made a few years before, a cross inci- 
sion was made through the old scar just above the 
collar bone. The incision was widely extended to 
the sides and to the back and the sternocleidomastoid 
muscle severed at its insertion. After a diffi- 
cult preparation, it was finally possible to expose 
the aneurysm sac from all sides. It had nearly the 
size of two fists. First the vena jugularis interna 
was doubly ligated above and below the aneurysm sac 
and then severed* Thereupon, the 'thrill ceased at 
once, though it was very distinct before. Only 
arterial pulsation was still felt in the aneurysm 
sac. Above and below the aneurym sac, which rested 
with its bulk on the carotid, the carotis com- 
munis was prepared by exposure, and a small ribbon 
was pushed under it, in order to staunch the hemcr - 
rhage better# It was then attempted to detach the 
aneurysm sac from the carotis communis, particularly 
from behind. During this process, the aneurysm burst 
wide open and an extraordinarily violent hemorrhage 
of an artery occurred, though the carotid was tied 
off above and below the aneurysm. The source of that 
hemorrhage could not be clearly detected. The hole 
in the artery was very hard to find. Eventually, it 
was possible to suture a slit in the vena subclavia 
and to staunch the hemorrhage, after two thirds of a 
circular suture of the arteria carotis communis had 
been performed. Thereafter, the arteria carotis communis pulsated again; the place of suture was 
patent according to palpation. Somewhat higher 
and at the back, beside the vertebral column, 
there was another arterial hemorrhage, though not 
a considerable one. This must have come from the 
arteria vertebralis. The hemorrhage was staunched 
by ligating that vessel. The hemorrhage being 
staunched, a respiratory arrest occurred, while the 
heart continued to beat distinctly. Artificial 
respiration was immediately applied but it was no 
longer able to reestablish respiration. A trans- 
fusion of blood had been made before. Despite 
adequate cardiac stimulants, arrest of the heart 
and death occurred-, 
This case is instructive in many respects. First, the question 
of how to make the incision. In order to expose the large cervical 
vessels, we made, as is usual, a longitudinal incision into the 
front edge of the sternocleidomastoid muscle and thus gained a good 
general view of the whole area. It is often inevitable to trans- 
sect the sternocleidomastoid muscle at its sternal end. In this 
case.- the old goiter operation scar suggested where to make the 
incision, and some authors (KULENKAMPFF) always use the straight cer- 
vical incision in case of carotid aneurysms. As regards these 
aneurysms, KUIFNKAMPFF raises the question whether to expose the 
fistula by separation of the two vessels in case of arterio-venous 
aneurysms or to choose the "safer way"; to ligate the vein above and 
below the aneurysm, so that only a small sac remains which closes 
the hole, as it were, through the short remaining piece of vein, 
KULENKAMPFF recommends this way os the safe one. This 
proposal seems to be convincing at first, if one sees from our 
case what difficulties the staunching of the hemorrhage and the 
closing of the slit may cause. But our case also shows, and 
other cases prove, that this is no safe method for definitive re- 
moval of the aneurysm and for prevention of recurrences. We know 
that this remaining "small sac" may contain the mouths of arteries 
and veins which are originally completely unimportant but may lead, 
later on, to extensive formation of aneurysms. Only the absolute 
separation of artery and vein is a safe protection, and all other 
methods are to be used only as emergency measures. Also in our 
case, the thrill disappeared all at once after ligature and dis- 
section of the jugular vein above and below the aneurysm sac. 
As: further preparation showed, also the vena subclavia and the 
arteris vertebralis were affected by the aneurysm, so that li- 
gature of the vena jugularis alone certainly would not have resulted 
in a permanent healing. For this reason, curs is a particularly com- 
plicated case, for it hardly ever occurs that two important arteries 
of the body are involved in an arterio-venous aneurysm. Thus, 
HERIYN, describes a case with an arterio-venous aneurysm of the 
carotis communis rnd subclavia, in which he ligated the subclavia 
and applied a circular suture to the communis, BAETZNER also 
describes the case of an arterial aneurysm with involvement of the 
carotis communis and the vertebralis, which was operated by REHN. 
This was a case of operating a recurrence, since only the 
carotis communis had been ligated centrally to the aneurysm before. 
So a recurrence was inevitable and was even liable to occur very 
soon, since, in consequence of the carotid being ligated, more 
blood was supplied to the vertebralis. 41a 
Abb. 1. a Schilddriise, b Vagus (medial vorschobpn). r, Durch- 
tronntor Kopfnicker. d Kestsack des doppclt unterbundenen und 
durchtrennten Bulbus jugularis, fest mit dcr Carotis vcrldtet. 
Illustration 24 
a) thyroid gland 
c) severed sterno- 
cleidomastoid 
muscle, 
b) vagus(medially shifted) 
d) remaining sac of the 
doubly ligated and severed 
bulbus jugularis, firmly 
agglutinated to the carotid As the post mortem showed in our case, there rs, besides the 
operated aneurysm, '-.ncth.r arterial aneurysm of the left arteria 
vertebralis apart from the operative area. This aneurysm had the size 
of a cherry. Death must have been caused not only by anemia 
through loss of blood but also by the shock effect and a 
damage to the respiratory center. 
Case A 22 was another fatal case. 
Arterial aneurysm of the left internal carotid 
of a 19 year old man, who had, shortly after his in- 
jury, a 1: rge retropharyngeal hematoma. Some oto- 
logist proposed "incision”. After involution of the 
hematoma, an aneurysm of the left side of the neck 
was ascertained, after previous "punctures of glands" have 
had no success. Subjectively, there was ringing in 
the ears, difficulty of hearing and weakness of the voice, 
objectively paralysis of the left recurrent nerve 
and injury of the plexus (C3~ C5)« 
On the ascending ramus of the lower jaw there 
was a healed operation wound. There had been a 
previous attempt to operate the aneurysm. The hole 
where the bullet entered was th- size of a penny and 
fairly well healed, It was just beneath the lobe 
of the e~r, Arteriography showed: arterial aneurysm, 
probably of the internal carotid, about 3i centi- 
meters above the place of division with plum sized 
transverse aneurysm sac extending almost to the 
base of the skull. Medially close by the sac, there 
was a shell splinter of pbout 4*5 millimeters. 
The operation started under local anaesthesia 
and later continued under ether, turned out to be a 
very difficult one. After holding the communis in 
a loop, the submacillary ramus was severed at the angle 
of the jaw and the proximal end was drawn upwards. 
Despite satisfactory general view created thereby, 
the aneurysm could not be adequately exposed, nor 
could the place of division, which was adherent to 
the sac and to the callous tissue. During further 
preparation, a serious hemorrhage occurred which 
could not be staunched even by ligature of the com- 
mon carotid just below the place of division. 
Thereupon, the carotis interna was ligated once more 
high above, near the base of skull, the thrombotic 
masses wore removed from the aneurysm sac and the 
latter extirpated down to the artery. The ends 
of the aneurysm sac were sutured against each other. 
Thereupon the hemorrhage w-s controlled. Because 
of the seriously injured wall of the interna, the 
radical operation or extirpation of the with 
vascular suture impossible. After the oper- 
ation, a hemiplegia occurred. When the patient awoke 
from the anaesthetic, he suffered from a motor aphasia. 
In the course of the following day, the patientTs 
state became aggravated and in the night, death occurred 
with the symptoms of an aspiration pneumonia. 42a 
Illustration 25 
Arterial aneurysm of the internal carotid close by the base of 
skull above the place of division of the communis. Splinter 
beside the sac. 43 
Because of some peculiarities, one more 
case of an arterio-venous aneurysm of the earotis 
externa and vena jugularis externa is briefly 
mentioned (Case A 23), 
The arteriogram (see Illustration 26) showed 
the following picture; after injection of 15 cc, 
uroselectan into the percutaneously punctured left 
arte»ia earotis communis, the carotid could be de- 
monstrated only as a feeble shadow stripe extending from 
the needle. Lateral to it, there are 2 contrast 
ska dow bands the widfrh of a finger, which correspond 
to the progress of the jugularis interna and externa. 
The arterio-venous fistula cannot te certainly located, 
’ In contrast to the clinical and roentgenological 
findings, accor ing to which an arterio-venous connection 
of the c.arotis interna and vena jugularis interna 
was expected, after separation of the jaw, and 
arterio-venous aneurysm of the earotis externa with 
considerable formation of callus was found, which 
did not permit any exact separation of the vessels, 
After ligature and incision of the markedly congested 
veins and the arteria oarotis externa one finger above 
and below the arteria lingualis, the thrill dis- 
appe red. Some weeks later a slight thrill recurred, 
but without any symptoms of a tumor or congestion 
and without any considerable subjective complaints. 
These cases are our failures in the area of the arteria earotis, 
'll other cases ended with healing as regards the vessel; once 
a circular suture, 16 lateral sutures were performed. Adequate 
patency was obtained 13 times, while in 3 cases, there are no records 
concerning patency, There is one fatal case each after lateral 
suture, circular suture and ligature. 
Gunshot aneurysms of the arteria earotis communis and earotis 
interna are a specialty because the course after their ligature 
is so varied. Many reasons are mentioned to explain this varied 
course, above all, the patient’s age or a particular hypersensi- 
tivity of certain parts of the brain against the interruption of 
the blood supply. According to us, the structure of the ductus ar- 
teriosus Willisii is usually the principal influence on the 
further course after the failure of the large cervical vessels, 
REHN, too, points out these irregularities am peculiarities in 
the structure of the ductus arteriosus WiHisii. Particularly 
the French literature has paid increased attention to the anomalies 
of this region of the circulatory system and, according to POIRIER: 
anomalies of WillisiJs hexagon (lthexagone) are very frequent. 
For instance, an arteria communicans posterior of the carotid 
may not exist, which form both arteriae fossae sylvii or even froth 
arteriae cerebri anterior!* Such irregularities involve serious 
dangers for the patient, if the carotid is ligated. Also a 
failure of REHN’s warns us to give careful consideration to these 
anomalies. In that case, a lateral suture of the earotis interna 
had been performed, and the circulation had been interrupted only for 
6 minutes. From this case, REHN deduces the clinical rule to reduce 
the period of absolute obstruction as far as possible, if the re- 
constructive methods 're applied in the region of the earotis communis 
and interna, Illustration 26 
Arterio-venous aneurysm of the carctis externa 
and the vena jugularis externa. The needle lies 
within the artery; laterally two broad vessel 
shadows, (Vena jugularis and interna). 44 
At the same time, one more aspect must lee considered with 
arterio-venous aneurysms, viz. the postoperative change of 
circulation conditions, particularly the reaction of the vein. 
Even in case of ligatures of the carotid made for other reasons 
such as after fresh injuries, some authors ask that the vein lie 
ligated, too, since thereby the blood will flow more slowly 
out of the respective half of the brain and the blood supply 
of the brain will thus be improved. Similar reflections have been 
made also in case of arterio-venous aneurysms. Thus, it has 
been ascertained several times, that the suction towards the 
heart of the vena jugularis interna in an arterio-venous con- 
nection with the carotis communis may be so strong, that this 
alone may lead to a cerebral anemia with its consequences. Ana- 
tomical findings do not confirm this assumption, as is emphasized 
also by JUNGHANNS, He did not find any corroboration of 
SUBBOTITSCHTs rule(that the enlargement of the vein in the 
arterio-venous aneurysm is located toward the heart) the thickening 
of the vein, if there was any difference at all, always lay 
distal from the aneurysm. Here, arterial blood directed away from 
the heart, and venous blood, flowing towards the heart, meet in a 
whi.il, producing thereby a congestion in the part of the vena jugu- 
laris interna away from the heart, that is to say towards the 
heart from the arterio-venous connection. JUNGHANNS always 
ligated the vena jugularis interna. As regards our cases, we 
always suture the vein at the same time if possible, in order to 
restore normal conditions, Also REHN supports venous suture, if 
possible, for the reason that in case of some arterio-venous fistulae, 
the venous system is particularly enlarged and overfilled. Sudden 
ligature of the jugularis interna, however, means a p rhaps injurious 
change of pressure in the blood supply of the brain despite a favor- 
able preparation of the way for the arterial blood. 
The kind of blood supply to the brain is singular in com- 
parison with other regions of the body. Ehile, for instance, 
the hollow of the hand is supplied with blood from two directions, 
radially and ulnarly, by the formation of the arcus volaris super- 
ficialis or profundis, we find in the circulus arteriosus Willisii 
a ring of vessels, closed by anastomoses, which emerge from branches 
of the arteria carotis interna and the arteria basilaris, that is, 
we have not only a bilateral, but also a ventro-dorsal blood supply. 
The question of what effect ligature of a large cervical 
vessel of the arteria carotis communis or the arteria carotis in- 
terna has upon this ring of vessels and therewith upon the blood 
supply of the brain, is not yet settled, though it is quite fre- 
quently necessary to ligate these vessels. ligature is enforced 
chiefly by injuries of these vessels with perilous hemorrhages 
which cannot be staunched otherwise, particularly if vascular 
suture, which should be always attempted first, or transplantation 
of veins are impractical. Besides, aneurysms of that area as sequelae 
of the»e injuries, claim the interest of surgery in wartime. Be- 
cause of intracranial aneurysms, these vessels have been ligated 
occasionally and frequently an inoperable tumor in the cervical 
region, such as a carcinoma of the thyroid gland, of the pharynx, 
or of the submaxillary gland, requires ligature because of marked 
adherence to the vessels. Statistics of successes of failures after ligature of 
the large cervical vessels are limited and cannot be safely evalu- 
ated for this reason. Thus, RIESE has observed 2 cases with fatal 
termination after 8 ligatures of the arteria carotis interna, 
8 fatal cases among 25 ligatures of the arteria carotis communis, 
HOTZ observed 5 cases of disorder of the brain among 6 cases of 
ligature of the arteria carotis communis, FRANZ none among U eases, 
TORRACA describes 6 cases of ligature of the carotid because of 
hemorrhage; in 5 of them death occurred. According to KOCHER, the 
danger of ligature of the carotis interna is great with people 
older than 30 years, with people older than 35 years, it is to be 
called almost a fatal mistake, except there is an indicatio vitalis. 
Thus, it cannot be denied that through ligature of the large 
cervical vessels, such damage can be done to the brain that death may 
occur rapidly or within a short time, 
A preliminary condition for extensive elimination of the 
above mentioned damage is a well developed collateral circulation. 
The adjustment of blood supply in the brain is, therefore, 
of great practical importance, and the problem of blood supply 
to the brain was the subject matter of a great many treatises 
during the last decade. Though the physiology of this region is 
by no means definitely settled, a good deal of important knowledge 
has been gained during the last few years. 
While BIER was still of the opinion that, as far as the brain 
is concerned, there are other rules valid for collateral circulation 
than those established by himself for the extremities, KRIEG was 
in a position to prove that these are largely valid even for the 
brain. The high sensitivity of the tissue causes the brain’s 
standing somewhat apart, it is true, since "blood attraction" and 
’’feeling for blood" of the brain is no longer efficient if the 
tissue is seriously damaged. 
Besides this "feeling for blood" there is a series of other 
physiological facts which are important for knowledge of the blood- 
supply of the brain. As long as 10 years ago it was the common 
belief that the cerebral vessels were passive towards blood- 
pressure (BERING, HEYMANN), It was assumed that a greater or 
lesser blood supply was caused by an increase or decrease of the 
general pressure at the expense of other organs. The systematic 
anatomical recognition of the paths of the cerebral vascular 
nerves (research work of WOLFF, LOB, GOLLWITZER-MEYER and EOKARD 
(1935 W,and D, SCHNEIDER)) shewed vasomotion of the cerebral 
vascular system. Of particular importance is the statement of 
GOUWITZER-MEYER, ECKARB, that an irritation of the sympathicus 
causes a dilatation of the cerebral vessels and that,sjmjeatbA*aI]y ca well as 
iparasym; ethically both halves of the brain are simultaneously inner-, 
vated from one side. 
In addition, cerebral mechanisms of compensation are im- 
portant, particularly the meningeal reflex discovered by D. SCHNEIDER, 
which will be discussed later. 
As mentioned above, opinions concerning the consequences of 
ligature of one of the large cervical vessels still vary, nor is there 
any agreement as regards the direction of the blood stream after 
ligature of the arteria carotis communis. According to former opinions, 
maintained even today, in case of ligature of the arteria carotis 
communis, the interna is supplied by a retrograde blood stream from 
the externa, which is connected with thr. other side by a fair number of anastomoses (PLCEGER, MORTON) JUNGH/'NNS). On the other 
hand, SIMONETTA thinks he is justified in assuming the opposite di- 
rection of the stream after ligature of the arteria carotis communis. 
In order to clarify the complicated situation and the 
various contradictions, we have made several experiments. First, the 
problem was examined in some dogs*. 
Order of Experiments: 
In a dog, the arteria carotis communis was seyered and a manometer 
introduced into both ends towards the heart and towards the head. 
Then, all vessels, except the arteria carotis interna and carotis 
externa, wore ligated at the place of division of the carotid. 
Pressure in the manometer amounted to about 120 millimeters towards 
the heart, to 40 millimeters towards the brain, the latter 
pressure approximately corresponding to pressure in the circulus 
arteriosus. Furth r research showed that the arteria carotis 
externa plays a special part with regard to pressure and circulation 
conditions, for, if the arteria carotis externa was ligated a 
distinct increase of pressure immediately arose in the manometer 
inserted towards the head, while, if the ligature was removed, the 
pressure dropped to the original value (see. 111. 27 a and b). 
This shows that, after ligature of the arteria carotis externa, 
pressure in the circulus arteriosus Willisii, which is of decisive 
importance for the blood supply to the brain, increases to almost 
double the usual amount, but if the ligature is removed, the 
arteria carotis externa forms, as it were, a leakage for the cir- 
culus arteriosus, into which the blood is drained from the brain. 
Besides, one can safely deduce from the experiment that, in a dog, 
the blood streams from the interna to the externa after ligatur: of 
the arteria carotis communis. 
We also can prove quantitatively the existence of this 
leakage caused by the considerably less resistance to pressure in 
the externa as contrasted to the interna. If, in our experiments 
(that is with the communis ligated), we let blood run out of the large 
cervical vessels, we observed that, in the unit of tine, 1© - 20 
times more blood streamed out of the externa than out of the interna. 
Thus, in one experiment, 6 cc. blood per minute streamed out of the 
interna* 114 cc. out of the externa; in another experiment 14 cc. 
out of the interna, 156 cc. out of the externa. 
These results, however, can by no means be indiscriminately 
transferred to man. We have examined conditions here as well. Con- 
sidering the fact that the human artorll carotis interna is consider- 
ably stronger developed in proportion than that of the dog* which is 
only of a few millimeters caliber, the above mentioned results ob- 
tained from a dog are to be expected in an increased degree> viz. 
* The experiments were performed in the Physiologic In- 
stitute Giessen. I wish to express, also on this occasion, my 
gratitude to Director Prof. E. KOCH for his advice and support 
in this work. 46a 
Illustration 27 
a b 
a) After ligature of the arteria 
carotis communis, the blood 
flows in the direction of the 
arrow from the interna to the 
externa« 
b) After ligature of the arteria 
carotis externa with closed 
communis, there is an increase 
of pressure to almost double 
values in a manometer inserted 
towards the head (from 10 mm Hg, 
to 75 mm Hg*) 
HI. 27a 
111* 27b 
Illustration 27c 
With ligated communis, an in- 
jection of contrast medium is 
made into the arteria carotis 
interna. Demonstration of the 
area of the externa through re- 
flux from the interna to the 
externa, 
111. 27c the outflow into the area of the externa takes place to an 
increased extent. At all ©vents, the reflux from the interna 
to the externa could be roentgenologically confirmed. 
If one injects contrast medium into the arteria carotis 
communis, it flows into the arteria. carotis interna and externa 
and the supply areas of both arteries arc demonstrated. But if one 
ligates the arteria. carotis communis and then injects contrast 
medium, one will detect the principal part of the contrast medium 
in the area of the externa. This demonstration succeeded par- 
ticularly well in Illustration 27c. In this case, an injection was 
made into the arteria carotis interna under slight pressure after 
ligation of the arteria carotis communis. The picture shows how 
the contrast medium is dilated, caught by the current and transported 
to the area of the externa. 
This reversal of the blood stream direction has probably 
nothing to do with the "reflux” into the arteria carotis communis 
after aspiration of the arteria carotis interna, observed by 
MONITZ and KRISG, since the injection was made there with great 
pressure with a patent communis, in our case only with slight pressure 
and with a ligated communis. 
Our own experience with a corpse showed after injection of 
colored solution into the arteria carotis communis, which had 
been ligated before, that the fluid str- amed to an increased degree 
into the area of the ext rna, it is true, but"partly also into the 
area of the interna. So is no previously determined draining- 
into the area of the externa exclusively. 
This knowledge gained from man end animals suggests, there- 
fore, the following theoretical conclusion: In order to avoid a 
reflux into the area of the externa after ligature of the arteria 
carotis communis and to stop the leakage opening in this area, 
it is necessary to ligate the arteria carotis externa as well. 
This inference based on mere hydrodynamic considerations is 
furthermore confirmed by the sequelae of the meningeal reflex dis- 
covered by Dr. SCHNEIDER. It is caused by ligature of the arteria 
carotis communis or of the arteria carotis externa or of the 
meningea media, viz. whenever the meningea media is obstructed, 
too. On the contralateral side, the blood supply of the interna 
is increased by 79-80% also the vertebral arteries supply more 
blood. The consequence is a considerable increase of the amount 
of blood in the brain, which furthers the reversal of direction of the 
stream in the ligated arteria carotis communis and thus'intensifies 
the leakage in the area of the externa. For this reason, also the 
reflex process, named meningea reflex by D. SCHNEIDER, urges the 
suitability of simultaneous ligature of the externa during ligature 
of the arteria carotis communis. 
On the strength of our experiments with dogs and the'Ob- 
servation in man, we think wo are justified in summing up as a 
most important result: 
The opinlm first expressed by MORTON (1914)* then by 
according to which the blood flows from the arteria carotis externa 
into the arteria carotis interna after ligature of the arteria carotis 
communis, is untenable. On the contrary, a reversal of direction 
of the blood stream arises and the blood flows from the interna' to 
the externa, the latter being a leakage into which the blood is 
drained from the brain. For this reason, it is suitable to ligate, in case of ligature of the arteria carotis communis, the 
arteria carotis externa, as well, 
Although we have not yet been in a position to collect 
much experience in this field, in the interest of the importance 
and considering the contradictions still existing in this field, 
communication of the results obtained by us appears to be justified. 
B. VERTEBRAL ARTERY ANEURYSMS 
The aneurysm of the vertebial artery is one of the rarest 
gunshot aneurysms, since death occurs in most cases in which 
the vertebral artery is involved. Among 2235 gunshot injuries of the 
American War of Secession, only 2 cases of injuries of the ver- 
tebral artery re reported (OTIS, according to KRUEGER). BTER 
mentions only one case, V. HABERER, in his former treatises, did 
not mention any an- urysm of the vertebralis and only 2 in his 
latest list of 549 vessel operations. HERLYN reports A cases 
among 150 and BAETZNER 3 cases among 240. We have observed an 
aneurysm of the vertebralis only once, though in another case 
the carotid was involved in the aneurysm, and the post mortem 
shewed another aneurysm of the vertebralis apart from the one of 
the carotid. 
Different methods have been described for exposing or 
ligating the vertebral artery. Its ligation is one of the most 
difficult because of the vessel's lying so deep and its peculiar course; 
and KLEINSCHMIDT writes in KIRSCHNER's science of operation: 
Since in its whole second section, the vessel can hardly be 
exposed, the vessel can be ligated only in either the first or 
the third section. Thus, the vessel is divided into three 
sections. Section 1, extends from the origin to the entry into 
the transverse process of the sixth cervical vertebra, the 
second section runs through the canalis transversarius and the 
third in the regie suboccipitalis. Even in the vertebralis, 
anomalies are not altogethu r rare, e.g. arising elsewhere than 
from the subclavia, directly from the aorta, under the truncus 
thyreocervicalis or from the anonyms or carotis communis. For this 
re son, an operation in the first section may be rendered most 
difficult. The artery also may enter into the foramen trans- 
verse rium VII instead of VI or into any other up to II. 
As for the first section, the sternocleidomastoid muscle and 
the carotid artery are pulled outwards and downwards, the thyroid 
gland and the medial cervical muscles towards the center and 
downwards. Then, one f..els for the tuberculum caroticum (transverse 
process of the sixth cervical vertebra), the vertebral artery 
is right under it. In contrast to KLEINSCHMIDT, HERLYN thinks that 
access to the second section is possible and reliable.He put it 
into practice in 2 cases in tne tract where the artery runs in the 
second to the sixth transverse process. The sternoclaidomastoid 
muscle is moved outwards with the cervical vessels. By blunt pre- 
paration and by moving the thyroid gland with its adnexae inward, 
one penetrates into the loose tissue surrounding the esophagus 
and the larynx. Then, one easily arrives at the vertebrae and 
transverse processes. Those are pinched off and the artery is exposed in its bone canal. As regards the third section, the 
posterior arch of the atlas must be found. The artery runs arched 
along the upper sharp edge of the posterior curve of the atlas. 
The artery can be palpated there. 
These aneurysms may cause great difficulties diagnostically 
and therapeutically. In most cases, one assumes an aneurysm of the 
subolavia or carotid. By pressing the latter aside, one can eliminate 
an injury of the carotid. Even arteriography fails us here in most 
cases, though BAETZNER was in a position to confirm the diagnosis of 
a vertebralis aneurysm by elimination of an injury of the carotid 
through*' arteriography. He reports also concerning an aneurysm in 
the first section, whore aneurysms are observed most rarely. The 
second and third sections are affected more frequently. Also in 
our case (Case A 30), the aneurysm was placed in the suboccipital 
part. 
It was a case of multiple injuries of the head, chest, and 
arm, sustained on August 15, 1942. Even 8 days after the injury 
a rustling was perceived in the left side of the hoad, which, 
in the course of months, increased to an intolerable degree and 
considerably disturbed sleeping. The left ear was almost com- 
pletely deaf. Behind the mastoid process, there was a protuberance 
the size of a thumb-tip over which a distinct thrill was palpable 
and audible. Arteriography showed (ill. 28) an aneurysm sac the 
size of a walnut near the base of the skull, which is projected 
right on the atlas in the lateral picture. 
During the operation under general anaesthesia performed on 
July 22, 1944j the aneurysm sac was exposed by indentation of the 
sternocleidomastoid muscle and partial severing of the splenius 
capitis and the semispinalis capitis, which was very difficult, 
since numerous small veins join it. The aneurysm sac had partially 
destroyed the periosteum of the tabular part of the occipital bone. 
For this reason, when thu periosteum was moved, considerable hemor- 
rhages from small apertures in the bones occurred, which were 
staunched by compression. The aneurysm sac was as thin as paper in 
some areas, particularly where it was attached to the bone. The 
transverse process of the atlas was exposed, and it was observed 
that the pedicle of the aneurysm was about one finger's width above 
it and ran in a direction toward the front of the cervical vertebral 
column. The aneurysm was doubtless supplied from the vertebralis, the 
latter was ligated above the posterior eta Is arch. Since it was 
impossible to work one’s way farther on, ligatures were made on the 
aneurysm sac itself and distally to it, and the sac was extirpated. 
Thus, no recurrence occurred. It would have been a mistake to be 
satisfied with a central ligature of the vessel supplying the 
aneurysm, since the vertebralis is supplied with blood also from 
the periphery, which causes continued blood-supply or a recurrence. 
In the further course of the case, there was a serous secretion 
moderately mixed with blood, but the wound healed well. Even after 
weeks, no more thrill occurred, there was only a slight feeling of giddi- 
ness after exertion, sometimes headaches. The patient was dis- 
charged as fit for service under certain conditions. 49a 
a 
b 
Illustration 28 
Aneurysm of the vertebral nrtcry near 
the base of the skull with aneurysm- 
sac the size of- a walnut C. ANEURYSMS IN THE REGION OF THE TRUNCUS THYREQCERTTCALIS. 
We have observed this kind of aneurysm times. If 
those are distinctly developed and arteriography does not help to 
locate them, one will always think first of an aneurysm of the large 
cervical vessels, and then one will b© astonished at finding the 
large cervical vessels unchanged during the operation. Then, one 
should not be satisfied with the diagnosis of ,,pscudo~aneurysmM, but 
look for an aneurysm of the vessels of the thyroid gland. 
Also in one of our cases (A 29), the operation was begun under 
bhe suspicion of an arterio-venous aneurysm of the carotid, 
but no arterio-venous connection could be found in the area of the 
carotis communis. On the other hand, a capsular vein of the 
thyroid gland was enlarged to nearly the thickness of the small 
finger and showed an intense thrill. After ligature, the vein 
was severed. The arteria thyr. inf, was as thick as a pencil. 
After its ligature, the thrill at the thyroid gland ceased at 
once. It was therefore ligated and severed. Marfanil-Prontalbin, 
subcutaneous suture. Suture of the skin. 
But this case was interesting even in another respect. 
Before the open' tion, the injured man had distinct symptoms of 
BASEDOW1s disease, which were manifest by an enlargement of the 
thyroid gland, particularly on the right side, excitement, inner 
restlessness, trembling of the hands, and increased appetite. All 
those symptoms disappeared after the operation. Thus, this is one 
of the cases where a thyrotoxic state developed as a sequel of 
an arterio-venous aneurysm in the region of the thyroid gland. 
SAUERBRUCH observed two similar cases with exophthalmus, tremb- 
ling of the hands, nervous restlessness, symptoms which gradually 
developed as a sequel of an rterio-venous aneurysm, once between 
the carotis communis and the vena jugularis interna, and once be- 
tween the jugularis interna and the carotis externa. We can ex- 
plain these symptoms only by the fact that the increased arterial 
blood supply to the thyroid gland caused an enlargement of 
the struma with BASEDOW* s syndrome. For this reason, these com- 
plications are one more absolute indication for operation. 
II. ANEURYSMS OF THE CHEST AND UPPER EXTREMITIES,,. 
Even today,the introthoracic aneurysms have not yet lost 
their terror, since a hemorrhage out of the large arterial 
trunks may be fatal within a few seconds. For this reason, one 
endeavors, in case of an intrathoracic aneurysm, to find the best 
possibility of preventive blood control by suitable ways of access, 
if location and extent of the aneurysm permit. To this purpose, 
several approaches to these vessels have been mentioned which 
afford a better oneral view than the rest of the methods of li- gature, Even if we had no aneurysm of the anonyma among our oases, 
we repeatedly had to expose the area of the thorax in aase of 
aneurysms of the subclavia with large sacs, e.g. in a case where 
several ribs had been partially destroyed by the pulsating aneu- 
rysm sac. 
Illustration 29 shows the extrapleural exposure of the anonyma 
and of the arcus aortae according to KUEITNER, 
One begins with a longitudinal incision just below the jugular 
with a 5-6 centimeters long cross-section and lays back a triangular 
flap together with the peotoralis major. After subperiosteal re- 
section of the cartilage of the left second rib and severing of the 
back periosteum of that rib, one carefully puts one’s finger 
medially under the sternum and c refully detaches the pleura. 
The left sternal margin is pried off up to the middle of the sternum 
from the insertion of the third rib to that of the first. The 
cartilage of the first rib is also resected. 
The arcus aortae is now only covered by thin layers of tissue, 
which rre severed by blunt dissection. The places of origin of the 
anonyma of the carotid artery and of the subclavian artery are now 
exposed. Special heed is to be paid to the vena anonyma sinistra and 
to the left vagus, which run downwards above the origin of the left 
subclavia. While exposing the arteria subclavia, one must consider, 
on the one hand the difference between right and left, on the other 
hand, the question whether the artery should be exposed above or 
below the clavicle. We do not wish to enter into particulars of the 
different methods, but it is emphasized that a good general view must 
be demanded especially for the subclavia during the operation of 
aneurysms. V.HABERER thinks operations of the subclavia the most 
difficult of all vascular operations, and w know th t failure of the 
subcl-via will frequently cause gangrene or grave ischemic disorders. 
The performance of the incisions and the technique are partly shown 
in Illustration 29 and 30. Resection of the medial two thirds of 
the clavicle or temporary exarticulation with sawing in the middle 
arc the methods used most often, LERICHE recommends, instead of this 
method of exposure, the median splitting of the sternum, because the 
vessels lie more medially than laterally, . ore behind the sternum 
than behind the clavicle. In his 50 removals of the thymus, he has 
found out that it is easy to get into the anterior mediastinum a ad 
to pross the thymus forwards, as well as to expose safely the first 
portion of the left carotid and of the subclavia. LERICHE advises the 
use of local anaesthesia, lest the veins are much dilated. Illustration 29 
Extrapleural exposure of the 
anonyma and the arcus aortae 
(KUETTNER) 
VMt. • Kn-ikvuiitf <Ur proton Art«TM iwtHiiiim- mi At*rt«-nhoprn (nx-b Kflitner). 
Ill* 29 
Illustration 30 a and b 
Performance of incisions and 
echnique of exposing the sub- 
Pavian artery with partial re- 
jection of the clavicle and of 
upper ribs. 
Hild 25 
Bild 25. A. O. Subklaviaancurysma. Hautschnitt zur Freilegung 
l<lM -t;- A ° Subklaviaancurysma. Abklappen der inncrcn Halite des Schlusselbeines 
Bild 2G 
Bild 27 
Bild 28 
HiJd 27. A. O. Freilegung tit's Subklaviaancurysmas. 
Bild 28. A. O. F'reilegung tier Subklavia Fntt-rbindung. 
111. 30b SYNOPSIS OF THE ANEURYSMS OF THORAX AND ARM 
1 
,Vessel 
Numbers 
art. 
yen- 
art. 
operated 
spontaneous 
healing 
recurrence 
t 
i 
jsubclavia 
1 
18 
id 
S 
14 
1 
.4 
iaxi1laris 
14 
4 
8 
12 
- 
1 
ibrachialis 
11 
,8 
3 
9 
1 
1 profunda brachii 
1 
1 
- 
1 
- 
- 
cubitalis 
6 
3 
3 
5 
1 
1 
|ulnaris 
2 
_ 
2 
2 
- 
- 
i 
tadialis 
2 
1 
1 
2 
- 
- 
Total 
54 
29 
25 
45 
3 
1 
The methods of vessel operation and the results of the 14 
operations of the subclavia are shown in the following table: 
Method of operation 
Totsl 
disch 
Healed 
arged as 
with disorders of 
the circulation 
{ 
Death j 
i Lateral suture 
If) 
3 
h 
1 
i 
11 - 
i 
Circular suture 
! 
2 
1 
1 
i 
S 
i 
... i 
i 
Ligature 
L 
2 
- 
1 
i I 
i 
This shows that we have performed vascular suture in the 
majority of the cases, since ligature involves the great danger of 
gangrene, as mentioned before. 
Illustration 31 affords a synopsis of the possibilities of 
ligature and the dangers connected with it in the arm according to 
ANDREE (On injuries of crteries and their subsequent treatment. 
Dissertation, Goettingen, 191©). 53 
SYNOPSIS OF THY POSSIBILITIES OF LIGATURE ON THE ARM 
Ligature of the arteria anonyms causes violent disorders of 
blood supply, The arteria subclavia on the left side may get 
sufficient collaterals from the cervical and thoracic vessels* 
Between truncus thyreocervicalis and arteria circumflexa 
scapulae; in case of ligature, preservation of the arm is endangered. 
Between arteria circumflexa scapulae and arteria circumflexa 
humeri; supply of tho arm is guaranteed, though disorders of blood 
supply and functional disorders are to be expected. 
Between arteria circumflexa humeri and arteria profunda 
brachii: ligature becomes more critical. It must be endeavored 
to preserve the vessel. 
From the arteria profundadownwardst ligature is without 
dangers as regards preservation of the arm, though functional dis- 
orders may be expected; there is no danger as for ligature of the 
single branches of the arteries of the arm below the elbow. 
Among our cases, we have observed no gangrene and only one 
case with fatal termination. Among 30 operations on the subclavia, 
V. HABERER had 4 cases with fatal terminations, that is 11,1$ 
while during World War I, mortality amounted to 23,4$ with the 
French, to 20$ with the English. Worth mentioning is the 
comparatively high percentage of disorders of the circulation 
( 6 times). This is perhaps caused by the fact that in case of 
aneurysms of the subclavia, as well as those of the brachialis, the 
nerves are either directly injured themselves or seriously affected 
by the aneurysm. In case of these aneurysms, larger nerves, some- 
times nearly the whole plexus, are involved in the aneurysm sac and 
sometimes form part of the sac wall. One is then compelled to make 
a cautious neurolysis. Twice we had to perform a regular nerve 
suture. These severe injuries of the nerves will easily cause 
neurotrophic disorders, which will be influenced particularly un- 
favorably by a deficient blood supply. In one case with a post- 
operative median paresis, an additional, rather serious causalgia set 
in. 
In such a case, both with neurotrophic disorders and disorders 
of blood supply, novocain block of the cervical sympathetica has an 
excellent effect, which we could observe again and again. In very 
grave cases, we even recommend to sever the preganglion dorsal 
sympathetic, which we did in numerous cases also because of 
other disorders of the blood supply. 
Case B 1® 
Injury of the left shoulder with formation 
of an aneurysm on 30 August 1943* Ligature 
of the subclavia in a field hospital, which 
led to grave disorders of the blood supply. On 
March 2, 1944, the cervical sympathetic was 53a 
( bersicht liter die Unterbindungsmoglichkeiten 
am Arm. 
Unterbindung dcr Arteria anonyma hat schwerstc 
Frnahrungsstdrungen zur Folge. I »ie linksseitige Arteria 
subclavia kann ausreichende Kollateralen iiber die 
Hals- und BrustgefaBe erhalten. 
Zwischen Truncus thyreocervicalis und Arteria 
circumflexa scapulae: Die Krhaltung des Armi*s ist bei 
Interbindung gefahrdet. 
Zwischen Arteria circumflexa scapulae und Arteria 
circumflexa humeri ist Versorgung des Amies gewahr- 
leistet. Allerdings sind Durchblutungs- und 1'unktions- 
stdrungen zu erwarten. 
Zwischen Arteria circumflexa humeri und Arteria 
profunda brachii wird die I nterbindung bedenklicher. 
Die Krhaltung des GefaBes ist anzustreben. 
\ on der Arteria profunda abwarts ist die Unterbin- 
dung beziiglich der Krhaltung des Amies meist gefahr- 
los, jcdoch sind Funktionsstdrungen zu erwarten. Die 
I nterbindung der einzelnen I nterarmaste kann un- 
bcdcnklich crfolgen. 
Illustration 31 
(Description see begin- 
ning of article on page 
53). severed, which caused a distinct improvement 
of the blood supply and of mobility. The 
increase of heat of the hand and the fingers 
was distinctly perceptible both objectively 
and subjectively. 
Case B 15 was the only fatal case after 
operations in this region: 
The arterio-venous aneurysm of the 29 
old injured man led to marked symptoms of 
congestion with distinct delineation of the 
veins in the area of the back, of the thorax, 
and of the arm, then, violent additional nerve- 
pains occurred. Even before the aneurysm was 
exposed to any considerable extent, an intense- 
hemorrhage set in, the slit at the place of the 
anastomoses was the longest one ever observed, 
about 8-10 centimeters long. Though subsequent 
ligature of the subclavia was a success, and 
the slit in the vein could be sutured, death 
occurred despite two transfusions of blood. 
Continued hemorrhage with status thymicus 
lymphaticus was assumed to be the cause of 
death. 
In case B we once observed a postoper- 
ative pleural empyema as a further complication: 
Injuries by shell splinters on March 1913 
had led to an arterial aneurysm of the subclavia. 
The formation of the tumor and its growth may be 
seen from illustration 32 a and b. In addition 
to the dang r of perforation because of late 
hemorrhage, the complaints on swallowing and the 
painful pressure on the plexus brachialis 
made an operation necessary. Arteriography, per- 
formed 3 weeks before the operation, showed an 
aneurysm sac the size of 2 fists in the area of 
the subclavia (ill. 32c). The operation showed 
that the aneurysm spread to the place of origin 
on the arcus aortae, so we had to perform an ex- 
tensive exposure with removal of the uppermost ribs. 
During the attempt to expose the arteria anonyma, the 
carotis communis, and the subclavia by blunt dis- 
section, the pleura burst on its left side. Be- 
cause of the enormous formation of sac and callo- 
sities, the anatomical conditions were very in- 
tricate, The pleura was sutured again, and it was 
managed to extirpate the sac and to suture the ar- 
terial slit of 1 centimeters length. The pulse 
wave passed well and the pulse of the radialis was 
satisfactorily palpable. The wound healed secondarily 
following pleural empyema, which required a resection 
of the ribs. 
No functional disorders of the arm or the hand 
occurred. 54a 
Illustration 32b could 
not be reproduced with 
the facilities available. 
Ill, 32a 
111. 32b 
Arterial aneurysm of the sub- 
clavia. 
The s&ma ease after rupture of 
the sac, danger of perforation. 
Illustration 32c 
Arteriogram of the same 
ease 
111, 32c 54b 
Illustration 32d 
The seine ease 6 months r.ftor the 
opere.t 1 on 55 
We have postoperatively observed decubital tumors or marked 
injuries of blood supply three times after lateral suture and once 
each after ligature and circular suture, while, in another case 
of circular suture, good permeability and complete healing was 
attained. 
The following table shows the results of the aneurysm cases 
of the upper extremities, of which 3 cases have been operated. 
[ 
1 
| Vessel 
L 
Total 
lateral 
suture 
circular 
suture 
ligature 
turn.in 
of sac 
heal. 
HealT~ 
with 
circ* 
disord. 
recur 
fence 
: axillaris 
12 
2 
7 
2 
1 
7 
4 
- 
Ibrachialis 
9 
3 
4 
2 
- 
rj 
i 
2 
- 
i 
prof, brach. 
1 
- 
- 
1 
- 
- 
1 
- 
j cubitalis 
i 
5 
Ji 
1 
1 
- 
2 
2 
1 
I 
ulnaris 
2 
- 
- 
2 
- 
2 
- 
- 
; radialis 
1 
2 
1 
- 
1 
- 
2 
- 
- 
Total 
31 
9 
12 
9 
1 
20 
9 
1 
It is remarkable in this table, that there arc the same 
numbers of ligatures and lateral sutures, and that the circular 
suture is predominant. Circular suture is the kind of vessel 
operation that has yielded next after ligature, the most unfavor- 
able results, we think thc.t can be explained by the fact that the 
arteria axillaris in 7 cases, the brachialis in 1 cases and the 
cubitalis in one case, were either completely shot off or destroyed 
to such an extent that only circular suture or ligature were 
still possible. All the same, the results are satisfactory. 
9 cases of circular suture showed no disorders of the circulation 
at all, in 2 cases slight disordeis of the circulation are re- 
ported, in one case, there are no d'-‘ta. In 4 cases, in which 
a postoperative arteriography was mad a, failure of the vessel was 
observed, it is true, but a good collateral circulation had been 
formed. 
While ligature of the arteries of the forearm passed with- 
out any disorders, there w. re grave disorders of nutrition with 
restriction of mobility and temporary occurrence of decubital 
tumors in one case each after ligature of the larg- vessels 
(twice axillaris, twice brachialis and once cubitalis). 
Furth r arter": ographies of aneurysms of this area show con- 
ditions before and after the operation. 55a 
Illurtration 33 
Case Bl, Aneurysm sac of the 
size of two fists in the area 
of the subclavia at its juncture 
with the brachialis, 2 broad 
vessel shadows (veins) are to 
be seen in the lateral lower 
section. 
Condition 10 weeks after 
the operation, ITormal 
picture of the vessels. 
The fistula is removed, no 
narrowing of the vessels 
after lateral suture. 55b 
Illustration 34a 
Case B 39« a, Artcrio venous aneurysm of the 
brachialis on the level of a healed gunshot 
fracture with distinct cnlargmcnt of the 
vessel. 
Illustration 34b 
After lateral suture good 
permeability. In the area 
of the subclavia para-* 
arterial contrast medium. 
Ill, 34-b 55c 
Illustration 35 could not 
be reproduced with the 
facilities available, 
(a and b) 
Illustration 35 
Case B 31* a. Artcrio-*fcnous aneurysm of the 
brachialis with formation of a small sac of 
the artery and .considerably enlarged vein , 
b* Control arteriography 24. days. after the 
operation, in the area of the fistula a 
slight sac with free.permeability persists, 
no delineation of veins, fistula removed. 
Illustration 36 
Case B 43% 
a. Arterial aneurysm of the 
art, brachialis with sa.c 
the size of a walnut. 
b. Control arteriography si 
months after the operation 
(circular suture). Failure 
of the brachialis (9cn) 
with good *>oll*it®rai cir- 
culation. 
a 
b 
111* 36 Illustration 37 
Case B 21 
Arterial aneurysm of the 
brachialis with formation of 
a sac of the form of a heart 
( as on playing cards ) 
111* 37 
Illustration 38 
Case B 45 
a* Arterio-venous fistula 
of the cubitalis 
b* Condition after lateral 
suture of artery and 
vein, fistula removed, 
tiny eversion at the 
place of suture* 
a 
b 
111* 38 Illustration 39 
a# Arterial aneurysm of the 
cubitalis with 2 sacs* 
b. Condition after lateral 
suture and extirpation of 
the sac with failure of the 
artery at the place of suture 
In the soft parts, longi- 
tudinal shadow-streak (old 
contrast shadow). 
a 
b 
111, 39 
Illustration 40 
a. Arterial aneurysm of the 
ert, ulnaris with gunshot 
fr acturc of the ulna. 
b, Condition after removal of 
the aneurysm by extirpation of 
the sac and ligature. 
a 
b 
111, 40 Q 
b 
Illustration 41 
Case B 54 
a. Denonstration of the fore am vessels 
beginning with the cubitalis, with ar- 
terial aneurysm of the radialis. 
b, The same ease with arterial aneurysm 
of the common carotid with onion-pcel-likc 
stratification. 55g 
a 
b 
c 
Illustration L2 
Case B 52 
Arterial aneurysm in the area of the 
arcus volaris caused by iron splinters . 
a, Mycotic-cnbolis arterio-venous aneurysm in the area of the 
forearm (art. radialis), Arteriography shows the different 
phases of blood circulation* 
first stage; arteriography performed from the cubitalis. 
While ulnaris and intcrossea arc demonstrated well, the ra- 
dialis is filled only up to the arterio-venous connection, 
where a sac ie distinctly force.d0 
b, second stage; Radialis represented distally from the arterio 
venous junction by collaterals; only now is the formation of 
the arcus volaris complete. There is no blood supply to the 
fingers, thus atrophy of the bones* 
c, third stage; A later picture shows very slight representa- 
tion of the finger-vessels, also the heavily filled venous 
convolutions* Operation with extirpation of the blocked veins 
and removal of the arterio-venous union by ligature of art, 
and vena radialis. 55h 
Illustration 43a 
a. Arterio-venous aneurysm 
of the subclavian v/ith 
formation of a sac and en- 
largement of the vein. 
Ill, 43a 
Illustration 43b 
Venography of the same case 
shows enormous enlargement of 
the vein in the area of the 
basilica and cephalica with 
distinct representation of the 
Valves, Gunshot fracture of 
the 4th rib. 
Sven without arteriography, an 
aneurysm may sometimes be as- 
certained reontgenologically, if 
there are calcifications, as in 
our Case B 17, 111, 44 a and b. 
Illi 43b Illustration UU a and b 
could not bo reproduced 
with the facilities 
available* 
Illustration 4-4- 
Calcification of an aneurysm sac with 
an arterio-venous aneurysm of the sub- 
clavia. Because of calcification, the 
sac can be recognized without contrast 
medium* III. ANEURYSMS OF THE ABDOMINAL VESSELS 
Since the aneurysms of the retroperitoneally situated art. 
iliaca ext* must often be approached transperitoneally, they 
wore included in the discussion of the abdominal aneurysms, 
particularly since there are in most cases simultaneous intra- 
peritoneal injuries. While, during both World Wars, aneurysms have 
been olserved of all major and intermediate arteries of the outer 
parts of the body down to the art, temporalis, maxillaris, mammaria, 
radialis and ulnaris, aneurysms located intraabdominally were ob- 
served very rarely. This is easy to understand with the big vessels 
(aorta, iliaca comm, and ext,), since a fatal hemorrhage will at 
once result. Though the danger of bleeding to death is not so great 
if smaller or medium abdominal vessels are injured, it is much more 
serious than in case of an artery of the same calibre in the ex- 
tremities, for the abdominal artery discharges its blood into the 
free abdominal cavity, and there is practically no resistance of 
the surrounding soft parts. Thus, a fatal hemorrhage may occur 
even in these cases, or an early operation is required, because 
of the danger of the artery’s bleeding empty or because of concomitant 
injuries. These may be the reasons why traumatic aneurysms are 
seldom developed. Intrahepatic aneurysms, or aneurysms of the 
hepatic vessels, are still observed most frequently. 
Synopsis of the Abdominal Aneurysms 
Vessel 
Numbers 
—~ 
arterio 
venous 
arterial 
Method of 
Operation 
Result 
Iliaca comm, 
i 
i 
“ 
extirpation of fistula 
recurrence 
Hiaca ext. 
• 
i - 
► 
3 times airc, suture 
3 times later, suture 
1 amputation 
mesent, sup. 
i 
- 
lalarftl nature 
healing 
_ 
We have observed two cases of pure abdominal aneurysms, 
one of the iliaca communica and the other of the arteria mesenterica 
superior. 
The aneurysm of the art. iliaca comm, has been described in 
detail in Case C 1, During a later examination in April 1946, a 
recurrence was observed. There was an extraordinary intense con- 
tinuous rustling in the abdomen with a distinct systolic tumult 
like the sound of a drum. The noise could be noticed from the 
arch of the ribs down to the tip-toes. Besides, there was a 
considerable congestion of the veins in the area of the left leg, 
of the left buttock and in the inguinal area (ill, 45 a and b). 56a 
Illustration 45a 
Ill, U5 a and b. Congestive and trophic disorders in the 
left leg, considerable varices in the area of the left 
buttock with arterio-venius 
aneurysm of the abdominal 
aorta just below the level of 
division. 
111, 45b In the leg below the knee, there were the beginnings of 
trophic disorders of the skin, and a considerable swelling of the whole 
leg. Subjectively, mainly complaints of impairment of gait. 
There were no complaints of pain in the abdomen itself or of the 
intestinal organs (heart, lungs). 
Since these symptoms evidently kept increasing and endangered 
life, one more operative intervention was planned despite the 
great danger connected with it, MATAS and LERICHE have undertaken 
the problem of the aortic aneurysmsand the latter has indicated a 
way to expose the aorta behind the peritoneum which ensures previous 
staunching of the blood. He proceeds as in case of lumbar sympa- 
thectomy and thus approaches both iliacae and the bifurcation of the 
aorta from behind through the peritoneum without any considerably loss 
of blood. 
In 1%0, MATAS reported the first successful ligature of the 
abdominal aorta as treatment of an aneurysm syphiliticum. By 
means of gauze trips, he performed a double ligature proximally 
from the aneurysm. 17 months later, death occurred by "galloping" 
consumption, The aorta had recanalized itself in a narrow lumen. 
Before the operation a collateral circulation had developed above 
and behind the aneurysm. But since ligature of the aorta is nearly 
always fatal, one even tried ligating the aorta, for instance with 
fascial strips. Even ensheating the artery with cellophane was 
attempted in an experiment, which caused an enormous irritation of 
the tissue and puts a constricting ring of scars round the vessels 
(PEASE), Since this process cannot be checked, obliteration will 
occur, as a rule. Whilst at the arcus aortae, considerable improve- 
ment of the aneurysm was attained by palliative methods, e,g. oper- 
ation according to BRASDOW-WARDROP, conditions are more unfavorable 
in case of aneurysms of the abdominal aorta, since only a radical 
operation promises healing. 
The second case (C 8) concerned a 2? year old man who had 
been wounded three times. The second wounding on 19 August 19A3 
by khell splinter in the area of the right loin led to a rupture of 
the liver, therefore laparotomy. The wound healed without any 
serious consequences. Almost 2 years afterwards, a distinct thrill 
appeared in the middle of the belly above the Havel, There were 
no remarkable complaints except a slight feeling of pressure, Ob- 
a well healed longitudinal scar of the laparotomy was found 
in the upper belly of the lean patient. In the linea alba right 
above the navel, a distinct thrill was to fee felt, which did not 
increase in intensity after pressing nor spread to a larger 
area. The continuous rustling was imperceptible both at the 
iliaca vessels and in the back. 
Heart and lungs showed virtually no finding of disease. The 
same applied to the graph of the cardiac sound and the record 
of the sound of the aneurysm, (These examinations were made fey 
Prof, WEBER, Bad Nauheim, whom we sincerely thank here also. ) 
A radioscopy of the stomach showed a splinter the size of a small 
bean in the area of the gastrohepatic omentum. The urine was 
normal. A test of the liver function conducted with sugar showed 
no abnormal values. 
Though these examinations had settled that the arterio-venous 
aneurysm did not affect the aorta, and probably no gastric artery, only 
an operation could clarify the situation. The operation was per- 
formed under general anaesthesia. Approach was made through the old scar. One felt an intense thrill everywhere over the back 
wall of the abdominal cavity, most distinctly at one place, 
where also a splinter could be felt, and that was in the area 
of the duodenal arch and behind the mesocolic attachment. The 
descending duodenum was examined. The gall bladder was imbedded 
in scars, but was intact. The portal voin was enlarged almost 
to the width of a childI8 arm, After turning up the transverse 
colon, the upper jejunal and the lower duodenal sections were 
exposed. Thus, it was possible to expose an arterio-venous fistula 
about centimeters wide between the arteria mesenterica superior and 
the vena mesenterica superior. The art, mesent. sup, was tied above 
and below, then the fistula was carefully exposed and severed. 
Lateral suture of the art. mesenterica sup, was possible without 
narrowing the lumen. In the wall of the vein, there was a bean-sized 
splinter, which was renoved, Lateral suture of the vein was 
accomplished without any .hemorrhage worth mentioning. Marfanil- 
Prontaibin powder. Peritonealization of the area of operation. 
Suture of the abdominal wall in three layers. 
The postoperative course occasioned concern on several 
points. First, a postoperative penumonia occurred, which sub- 
sided rapidly: by sulfonamide.. treatment. The sixth day, an 
icterus set in with distinct yellow coloring of the skin and the 
s-clerae. The urobilinogen in the urine was distinctly increased, 
the TAKATA—ARA reaction wa.s positive, the test of the liver 
function made with grape sugar yielded almost normal values. 
At the same time, there were rather violent at times colic-like 
pains in the belly, the leukocyte count was much increased (1700 0,), 
A pleural and an abdominal puncture yielded negative results. 
The wound of operation healed primarily. The icterus subsided a 
few days later, but since the pain in the belly aggravated a 
reoperation vjas decided upon. At the place where the splinter had 
been an abscess was found which discharged thick matter. Thereupon 
the fever subsided, the patient felt well and the further coarse of 
healing was normal. 
The icterus which appeared as a sequel of the operation, 
doubtless indicated an injury of the liver. Its origin cannot be 
certainly explained. As the pneumonia subsided comp ratively 
rapidly, it should not be held responsible. It is much more 
probable that the icterus set in because of the changed circulation 
conditions caused by the operation of the aneurysm. It is a well- 
known fact that the liver, being abundant in vessels, is of the 
utmost importance for the circulation. Situated immediately 
before the right heart, it can absorb immense quantities of blood as 
a reservoir-like sponge and retain them if necessary (by tfen- 
traction of the hepatic veins). Thereby, it prevents the 
heart’s being overcharged with blood and thus .regulates the cir- 
culation. Probably for this reason, the changes of the heart we 
are accustomed to finding in cases of arterio-venous aneurysms near 
the heart, did not occur in our case. The liver is supplied 
through the art. hepatica, while the principle supply of bhe blood 
it has to work up according to its function, enters through the portal 
veim. Before the aneurysm was removed, conditions were changed in 
so far, as the liver certainly received more arterialized blood 
than usual through channel of the portal vein. This was 
evidently compensated less in an enlargement of the liver, than 
rather in a portal vein enlarged nearly to the width of a child’s 
arm and relatively of a lighter red color than usual, The removal of the aneurysm now restored the normal con- 
ditions of the circulation. This caused a sudden change of blood 
supply to the livr. If one considers that the liver had already 
been damaged in its functional efficiency by the previous rupture 
and was perhaps at the limit of its normal efficiency, one may 
assume that a temporary dysfunction of the organ occurred after 
the operation because of the necessary adaptation (increase of uro- 
bilinogen, positive TAKATA-ARA) and that also the icterus 
may thus be explained. 
T,rhen the injury was inflicted, the arterio-venous union 
evidently did not cause any considerable bleeding or the rupture 
of the liver was predominant so that the injury of the vessels 
was not noticed during the first laoaratomy, Only in the course 
of months did the objective and subjective symptoms, because 
of the changed conditions of the circulation develop. 
So ours was a case of a genuine traumatic aneurysm of a large 
intestinal artery. These cases are decidedly rare. LANG describes 
a traumatic aneurysm of an rtery of the wall of the large intestine 
in consequence of the affect of blunt force,. In the seventh week 
after the accident, the arterial aneurysm burst into the intestine 
and caused a fatal hemorrhage, V• SCHRCETTER found only 220 
aneurysms within 10 years among 19330 autopsies of the Vienna 
Pathologico-anatomical Institute, without differentiating 
their origin, among them only 3 of the abdominal aorta, 4 of 
the splenic artery, 1 each of the art, coeliaca, renalis, and 
mfsenterica superior. There are no data as regards the frequency 
of traumatic origin. GILMOUR and McDOMALD describe a case of 
gunshot aneurysm of the aorta loc ted between the art. mesent, sup, 
and the right side of the diaphragm, in which the lumen of the 
mesent. sup, was closed by a thrombus, but in which there was mo 
communication with a vein nor any aneurysmatic change of the wail 
of the mesent. sup. Our case obviously seems to be the first and 
only arterio-venous gunshot aneurysm of the art, mesent. sup. 
known until now, probably the first arterio-venous aneurysm of this 
kind altogether. IT. ANEURYSMS OF THE BUTTOCKS AND OF THE LOWER EXTREMITIES. 
This category of aneurysms is the most frequent, among them, 
the aneurysms of the arteria femoralis are predominant, as shown 
in the following table: 
Synopsis of Aneurysms of the Legs and Buttocks 
1 
Vessel 
Numbers 
arterio-venous 
arterial 
j arteria femurails 
4X 
36 
5 
arteria prof, femoralis 
5 
4 
1 
arteria poplitea 
17 
13 
4 
arteria tib. anb. 
7 
7 
- 
arteria tib. post. 
5 
/ 
3 
2 
arteria peronea 
2 
2 
- 
arteria glutaea 
— 
2 
1 
1 
Total 
79 
66 
13 
The predominance here of the arterio-venous aneurysms as con- 
tractod to other regions of the body is remarkable, which 
permits the conclusion, at least as far as the art, fern, is con- 
cerned, that a high percentage of the pure injuries of the femo- 
ralis bleed to death, while in case of arterio-venous aneurysms, 
the blood pressure at the injured place decreases by partial 
diversion of the arterial blood into the vein and the shell 
of soft parts can effect the isolation of the injured place. 
Even if an arterio-venous aneurym may lead to no considerable 
functional disorders for years and decades (see cases 39 and 29); 
just these very cases show that operation is indicated, as has 
been mentioned before. The 35 operations of the art, fern, per- 
formed by us had the following results: Method 
of Operation 
Numbers 
Freely 
permeable 
Narrowed 
Healed 
Circulation 
disorders 
lateral suture 
25 
23 
2 
13 
12 
circular suture 
4 
3 
- 
4 
- 
ligature 
6 
- 
— 
2 
4 
i 
1 
In 15 of these cases, a postoperative arteriography was 
made, which yielded the following results; 
Postoperative Arteriography 
Method 
of Operation 
Failure 
Narrowing 
1 
Permeability 
lateral suture 
1 
2 
6 
- — ■ 1 ' ■ 'TT 
circular suture 
1 
- 
2 
ligature 
3 
— 
— 
Among our 25 of lateral suture, 1/+ times complete 
healing and efficiency of the leg were obtained, Among the 11 
disorders of circulation, there was only one r colly serious Involve men 
while all the rest caused only slight impairment of the efficiency 
of the leg and they mostly improved in the course of time. The 
2 cases of failure of the artery after lateral suture, as ascer- 
tained by postoperative arteriography, are surprizing, since in' fcoth 
cases no considerable narrowing was caused by the suture immediately 
and the blood passed smoothly. But the failure led to no unfavor- 
able sequelae. In one case ( Case D 28), where there was a 1? 
centimeters long failure.of the femoralis with the development of 
a good collateral circulation, trophic tumors healed and the damage 
to the nerves improved. 
*mong the U cases of circular suture, one failure was as- 
certained in a postoperative arteriography, three times there was 
smooth permeability directly after the operation. All k cases re- 
mained clinically without vascular disorder. 
We performed 5 of the 6 ligatures, one case was ligated else- 
where, Among these cases, there is also case D 39 (Aneurysm of the 
first World War, see page 18)* 61a 
Cbersicht iiber die 
am Hein 
\or clem Abgang cler Artcria iliaca int. hat die 
I’ntcrbindung schwerste Krnahrungsstbnmgcn des 
Beines zur I'olgo Die Unterbindung der Vene bis zur 
\ ena saphena magna ist ebenfalls nicht ohne schwer- 
wicgende lolgen. 
Zwischen Arteria iliaca int. und Abgang der Arteria 
circumflexa femoris: Vorbedingungen zu gutem Kolla- 
teralkreislaul Bei Jugendlichen kann die Unterbindung 
- was die Krhaltung des Beines betrifft gefahrlos 
vorgenommen werden. Die Durchblutung wind jedoch in 
jedem 1'aIIe verschlechtert, 1'unktionsstorungen sind zn 
erwarten. Die Krhaltung der Arterie ist anzustreben. 
Zwischen Abgang der Arteria circumflexa femoris 
und den Kniegelenksarterien ; Die Unterbindung ist aus 
Mangel an Kollateralen bedenklich. Die Krhaltung des 
Blutkreislaufs ist gegebenenfalls (lurch i berpflanzung 
anzustreben. 
Bis zur Aufteilung der Arteria poplitea: Unterbin- 
dung vermeiden. Kollateralen meist ungiinstig. Die 
Krhaltung des (iefalies ist gegebenenfalls mittels Ver- 
langerung (lurch Umschlag einer Unterschenkelarterie 
• oder (lurch I ransplantat anzustreben. I >ie I 'nterbindung 
einzelner Venen kann unbedenklich erfolgen. 
Die Unterbindung der einzelnen Aste nach der Auf- 
teilung ist vollkommen unbedenklich. 
Bild :!1 
Illustration 4-6 
a^I]i2ESis_of_the_Eossibili- 
s_of_ligature_in_the 
leg* 
Before the division of the arteria iliaca 
int#> ligature will cause the most serious dis- 
orders of blood supply to the leg* Up to the vena 
saphena magna, ligature of the vein too, will lead 
to grave sequelae, 
Betvfeen the arteria iliaca int*, and the parting 
of the arteria circumflexa femoris, preliminary con- 
dition to a good collateral circulation. As regards 
juveniles, ligature can be performed without danger as 
far as the preservation of the leg is concerned. Blood 
supply, however, will be impaired at all events, function- 
al disorders must be expected. Preservation of the 
artery must be attempted. 
Between the branching off of the arteria cir- 
cumflexa femoris and the arteries of the knee-joint; 
ligature is precarious for want of collaterals. If 
necessary, maintenance of the circulation is to be 
endeavored by transplantation. Up to the bifurcation 
of the arteria poplitea: avoid ligature. Collaterals 
are unfavorable in most cases. Preservation of the 
vessel must be attempted if necessary by means of pro- 
longation by turning of an artery of the leg below the 
knee or by means of transplantation. Ligature of single 
veins can be safely performed. 
Ligature of the single branches after the division 
is absolutely safe. Synopsis of the possibilities of 
ligature in the leg with the different degrees of danger 
(according to ANDREE), After the operation (in 1943)* the patient felt well at first, 
2 years afterwards, again had drawing pain in the right thigh, pain- 
ful knocking and swelling from the middle of the thigh to below the 
knee. The arteriogram showed a considerable enlargement of the vein 
with arch-like medial displacement (see 111, 47). Another operation 
on January 29, 1946. Masses of blood coagula were removed. The 
proximal stump (it was a case of a burst arterial aneurysm) was li- 
gated. The peripheral stump did not bleed any longer. Secondary 
healing with tendency of the leg to swell. 
In another case (D 17), we were forced to ligate, because a 
late bleeding occurred with the development of a pulsating hematoma 
in consequence of getting out of bed too early following a lateral 
suture of the femoralis, which had been done for an arterio-venous 
aneurysm. Even here, no grave consequences remained* 
One ligature was made because the artery was destroyed to such 
a degree that a suture was impossible, and once, the peripheral 
end of the vessel did not bleed at all, though a sufficient collateral 
circulation was to bo supposed. 
An explanation for the fact that these cases led to no radical 
symptoms of failure is that the ligatures were performed below the 
profunda femoralis, i.e, in the second and third fourths of the 
thigh, A ligature above the profunda, within Scarpafs triangle, 
will take, as a rule, a much more unfavorable course. According to 
HEIDRICH’s statistics, gangrene occurred in 21,8$ of the cases, 
whereas gangrene set in only in 10.7$ of the cases ligated frelow 
the profunda. Also V, HABERER found this rule confirmed and obtained 
the best results during operations on the femoralis in the adductor 
canal. On the other hand, ligature of the femoralis is again more 
dangerous in its lowest section, after its egress out of the adductor 
canal. Some surgeons think this section as already belonging to 
the poplitea, which explains that these operators then had better 
results with ligature of the poplitea and that different opinions 
as to the dangers of ligature of the poplitea could arise. 
The following illustrations ©how some of our cases before and 
after the operation. 
Case D 4 
On 15. VIU. 1944* removal of an arterio-venous 
aneurysm in the area of the femorails by cutting of 
the fistula and lateral suture of the artery and 
vein which had a 5 centimeter long slit. 
Several weeks afterwards, thrill occurred 
again. Another operation on October 9, 1944; A 
communication between a secondary branch of the 
prof, fern, and the vena femoralis. No more 
thrill after ligature of the secondary branch. 
Control arteriography after 8 weeks : fistula removed. 
Slight narrowing at the old suture site ( 49b), 
There had obviously been a double fistula, one be- 
tw.en the art, and vena femoralis, the other be- 
tween a secondary branch of the profunda and the 
vein. Illustration 47 could not 
b« reprodnoed with the fa- 
cilitiea available. 
Illustration 47 
Aneurysm recurrence of Case D 39, 
see also page and Ills* 8 and 
9. Swelling of the soft parts by 
hematoma with displacement of the 
dilated vein 2 years after the 
operation of the aneurysm, 27 years 
after the injury was inflicted. The 
artery is thrombosed proximally to 
the place of ligature and palpable 
in a length of about 25 centimeters 
as a hard cord of the thickness of 
a finger. 
Illustration 48a 
a. Threefold aneurysm sac 
of the femoralis. 
111. Z.8a 62 b 
Illustration 48b 
Good permeability after lateral 
suture. As arteriography 
apparently hit a secondary 
branch, the fenoralis and the 
profunda are represented only 
faintly. 
Illustration 
49 b, could 
not be reprc 
duced with 
the facili- 
ties avail- 
able. 
111, 48b 
Illustration 49 
a. Arterio-venous fistula be- 
tween art, and vena femoralis, 
about 20 cm , above the knee- 
joint* 
b# Fistula reroved« Slight 
narrowing at the place of suture* 
a 
b 
111# 49 62c 
Illustration 50 a and b 
eould not be reproduced 
with the facilities 
available. 
Illustration 50 
Case D 27 
a. Arterio-venous fistula with 
big aneurysm sac and splinter, 
b. After removal of the fistula 
and after lateral suture, dis- 
tinct narrowing at the place of 
suture but good permeability. 
Illustration 5* a and b 
could not bo reproduced 
with the facilities 
available, 
Illustration 51 
Case D 4-3 
a. Arterial aneurysm at the 
transition of the art, fcnorali 
into the poplitca, 
b, Failure of about 10cm of the 
main artery after circular 
suture with good development of 
a collateral circulation. 
Illustration 52 
Case D 32 
Failure of the main artery 
after ligature of the ar- 
tery and vein (operated 
elsewhere) bridged by col- 
lateral circulation. 
111# 52 62d 
"illustration 53 b 
could not be re- 
produced with the 
facilities avail- 
able. 
a 
h 
Illustration 53 
Case D 30 
Arterio-venous aneurysm of the 
fcmoralis with formation of a 
sac and badly healing ulcera 
cruris. Rapid healing after 
operation. 
Shows the sac in situ during 
the operation. 63 
7. ANEURYSMS OF THE ARTERIA PROFUNDA RETORTS 
Hemorrhage or aneurysms of the prof, fern, in most cases 
make a clinical impression like those of the femoralis, and 
only by aid of arteriography can the true conditions be ascertained 
preoperatively. Since the profunda may be very variable in 
its course and origin, it is often difficult to locate it. Its 
origin may be from the femoralis right under the lig. Pouparti, 
or even 11 centimeters lower. Its origin is usually 4-6 centi* 
meters lower. It may originste from both the medial and the 
lateral periphery. By the fact that also the two circurnflexae 
femoris often arise from it, it virtually -supplies all muscles 
of the thigh with blood (FRANZ), So we have endeavored in our cases 
to avoid ligature, which we performed only on a secondary branch. 
The disorders of the circulation after this injury (3 times lateral 
suture, once circular suture) were negligible, V. HABERER, who 
otherwise enthusiastically recommends suture, thinks that aneu- 
rysms of this artery should be ligated and that suture should be 
used only in exceptional cases. He did not observe any gangrene. 
Case D 63 shows that injuries of the profunda may become danger- 
ous and even lead in rare cases to a f-tal hemorrhage in the muscles 
of the thigh, 
A few days after the injury by shell splinters, gradual swelling 
of the thigh developed in the area of the injury accompanied by 
violent pain. A swelling of the size of a man’s head results with 
a dimple scar where the bullet entered (ill, 54a). At first, 
rustling and thrill in the rhythm of the pulse is audible and palp- 
able which gradually disappears, so that a vascular noise and puls- 
ating can no longer be ascertained. In this state arteriography 
(ill. 54b). The art. fern, is pressed medially in a large arc, by 
the existing tumor of the soft p rts (quiet hematoma). With its 
origin in the prof, fern., there is a filled aneurysm sac the 
size of a walnut, right beside a shell splinter. 111. 54c shows the 
condition after excision of the hematoma, with preservation of the 
secondary branch of the profunda by lateral suture, normal circulation 
conditions• 
Thus, first a pulsating, then a quiet hematoma arose at a 
place of predilection, viz, where the artery is surrounded by strong 
muscles. This state will be caused whenever the internal pressure 
of the hematoma and the resistance of the displaced tissue counter- 
balance each other. The thrombotic tumor presses against the afferent 
artery, and the vein may be compressed, too. Congestion and pain re- 
sult. The fact that in our cases the pulse of the dorsalis pedis was 
still distinctly palpable though more feeble than on the opposite 
side, led to the clinical conclusion that there was some injury of the 
profunda, a fact, which is mentioned because in most of these cases, 
a participation of the femoralis is considered first. This was con- 
firmed also by raphy, which refuted even one more opinion 
supported until then. In literature, the opinion is supported that, 
in case of a quiet hematoma,a throaboblc blocking plugs the place of 
injury of the vessel, thus causing a complete separation of the Illustration 54a 
Arterial aneurysm (quiet hematoma) 
of t he profunda fenoris with dimple 
at site of entry of the bullot; dis- 
tinct swelling. 
Illustration 54b 
A»t, fenoralis pressed me- 
dially in a wide *rc by the 
dissecting tuner of the soft 
parts (quiet hematoma). 
With its origin in a main 
branch of the prof, fen, 
there is a filled aneury&n 
sac the size of a walnut, 
right beside a shell-splinter< 
111. 54b 63b 
Illustration 54c 
Condition after excision of the hcnatona 
with preservation of the secondary branch 
of the profunda by lateral suture. Normal 
circulation conditions* hematoma from the artery, which renders the hematoma quiet. As 
also SCHROEDER was able to show in some pictures, the vessel 
always retains some, even if slight, communication with the 
hematoma, some blood always flows from the artery into the 
blood-cavity, and that in most cases into a small section of the 
hematoma directly adjoining the arterial injury. 
YI. ANEURYSMS OF THE ARTERIA POPLITEA 
Even if statements concerning the occurrence of gangrene after 
ligature of the pcplitea still vary very much (15-80$ according 
to FRANZ)> it is agreed upon, that ligature of this vessel is very 
dangerous and therefore should be avoided if possible. Besides, 
practice shows that the statements of anatomists concerning a 
favorable development of collaterals from the artry of the knee 
are not borne out. One assumes that in the tight tissue of 
the knee joint, the development of collaterals is more difficult 
than in the muscles. an injury of the vena popl. alone may 
lead to gangreno*(FRANZ). According to HEIDRICHTs statistics, 
gangrene occurred in 37*2$ of the cases after ligature. Even if 
matters stand somewhat more favorable in case of aneurysms because 
cf the possibilities of better development of collaterals, we 
can rely on this in only very few cases, for instance, if arterio- 
graphy shows a good collateral circulation even before ligature. 
But since good blood supply and functional efficiency of the leg 
below the knee and cf the foot after ligature are more or less a 
lucky incident, one should always use one of the ideal methods 
during operation of an aneurysm of the poplitea. For this reason, 
we intentionally never applied ligature in our 14 cases , but 11 
times lateral suture, 3 times circular suture. Twice, an ampu- 
tation had to be performed but in one case, ligature could not be 
made responsible for it. This was 
Case D 60, 
Injury inflicted on July 26, 1942 by shell 
splinter, which rengined in the body. An arterial 
aneurysm developed with pronounced paralysis of the 
peronous and extensive trophic disorders in the 
foot and the toes. ■rteriogr phy, made on January 
27, 1943 (ill. 55a) showed an arterial aneurysm of the 
poplitea the size of a chicken's egg, with compression 
of the artery and good development of a collateral cir- 
culation. During the operation on February 2 , 1943, 
the aneurysm sac, which was at least as large as a chicken's 
egg was exposed freely and the afferent and efferent artery 
visualized. The ischial nerve cleng to the sac and 
had to be isolated. It turned out that the artery was 
largely destroyed and that a lateral suture was impos- 
sible. About 3~4 centimeters of the artery had to be 
resected, and a circular suture was performed with the 64a 
a 
b 
Illustration 55 
Case D 60* 
a. Arterial aneurysm of the poplitcaj there 
are distinct collaterals making a circuit 
around the aneurysm beside the main artery 
above and below the aneurysm sac* 
b* * Failure of the poplitca, after circular 
suture with sufficient development of a 
collateral circulation, so that the vessels 
of the leg below the knee arc well filled* knee-joint bent. Thereafter, a distinct pulsation 
was ascertainable in the peripheral arterial stump* 
The preparation showed a large aneurysm sac which 
was crossed by a Still patent vessel (vein). The 
Vessel was severed outside the aneurysm sac with 
the use of cords of connective tissue for ligature* 
The extensive destruction of the artery beyond the 
aneurysm sac was remarkable and required a resection* 
Besides the before mentioned reasons (infection etc.) 
which we hold responsible for the fragile condition 
of the artery, it is certain that the compression * 
treatment made for months elsewhere had some part; 
that treatment had not only hot. been*useful but had 
rather been injurious. Control arteriography made 
three weeks afterwards (111. 55b) showed a filling 
defect of the poplitea of 6 centimeters.up to close 
above the division of the tibialis ant, and post. 
The defect was bridged over by well developed col- 
laterals, hence good filling of the vessels of the leg 
below the knee. 
The arteriogram conesponded to the clinical course* 
Immediately after the operation, the foot 
t;as cold and cyanotic and there were no pulses of the 
foot, caused evidently by vascular spasms, but then a good 
blood supply to the foot was obtained by injection 
of the sympathetics and doses of eupaverin. The dor- 
salis pedis was easily palpable* The trophic tu- 
mors improved in a. remarkable way. Since the neu- 
rologist held that the nerve disorders were caused 
by the formation of a scar in the hollow of the knee, a 
neurolysis of the ischiadicus and a tenotomy of the 
Achilles tendon because of pes equinus were per- 
formed on October 6, viz. S months after the aneu- 
rism operation. Subsequently, an empyema of the 
ankle joint developed which led to amputation of 
the leg below the knee. This amputation, therefore, 
cannot properly be considered as a sequel of the 
aneurysm operation* 
A .lac the second case which led to amputation 
took an unfortunate course in so f-r as an rterial 
aneurysm of the poplitea had to be operated because 
of the danger of a perforation. The sac, the size 
of 2 fists was excised, the slit closed by lateral 
suture. Good patency. On the 12th day, the wound 
had to be revised because of a late hemorrhage* 
The suture hi opened at the foul, putrescent in- 
jury, Despite this, vascular suture of the fragile 
artery was attempted once more, and the pulse of the 
foot was again readily palpable, rt last amputation 
in the thigh, because of gangrene of the foot. Patho- 
logico—anatomically, there was observed a circum- 
scribed phlegmonous pubescent invasion of the muscles 
in the surroundings of the place of suture. In the 
poplitea itself, thu-re was a small thrombus at the 
place of suture above the place of division, which 
led to an absolute closing of the vessel. Illustration 56 could not 
be reproduced with the fa- 
cilities available. 
Illustration 56 a and b 
(Case D 50), 
a) Arterio-venous aneurysm of the poplitea 
with intense aneurysmatical enlargement of 
the artery and distinct enlargement of the 
vein, 
b) State after removal of the aneurysm by 
circular suture of the poplitea U months 
after the operation. Moderate narrowing at 
the place of suture. The former considerable 
arterial enlargment by the aneurysm still 
exists proximal to the fistula, but there is 
smooth permeability. So the infection, to which the suture became a victim, 
was the cause of the unfortunate termination. Deducting 
the first case amputated because of an ampyema of the ankle 
joint, we have only one amputation among our 14 cases, or 
7% In all other cases, the leg below the knee and the 
foot were preserved with good eficiency. 
VII. THE ANEURYSMS OF THE LEG BELOW THE KNEE 
AND OF 
THE GLUTEAL REGION 
Ligature cf the vessels of the leg below the knee (art. 
tib.,post,, ant., and perenea) has been considered rs safe until 
now and thus performed as chosen treatment of that place, I 
have mentioned above the damages as seen by BAETZNER after 
ligature of the art, tib, post,, and we failed once too after li- 
gature .of the art. tib. ant. 
Case D 48 
This esse was a secondary operation* OriBLy a 
small aneurysm sac was removed, during a 
previous aneurysm operation performed abroad 
in which no fistula had been found. There were 
intense disorders of the circulation, besides 
causalgic pain, so that a second operation be- 
came necessary, Artery and vein w.:re ligated above 
and below the thrill, which ceased thereupon* 'In 
the next few days gas gangrene developed, which 
probably was furthered by a throttling circular strap 
of adhesive plaster. It was necessary to am- 
putate in the thigh, th reafter rapid healing. 
Once we have observed a recurrence, once a temporary postoper- 
ative damage to the peroneus. In the rest of the cases, th re were 
temporary disorders of the dirculation, which, however, could be 
improved so much by adecuate bandaging , that the patients 
became fit for service, if no other serious injuries of the bones 
or nerves made this impossible from the first. 
IHiist rat ions 57 and 58 (Case D 74), and Illustration 5^ 
(Case D 72) show aneurysms of the different vessels of the leg be- 
low the knee. Illustrations 51 a and b> 58 a and b, and 
Illustration 59> could not bo reproduced 
with the facilities available. 
Illustration 57 
Case D 74- 
a* Arterial aneurysm of the art, tibialis 
post* with development of a sac, 
b* Failure At- the place of suture after 
removal of the sac and lateral suture. 
Illustration 58 
a, Artorlo-vcnous aneurysm of the art* peronca 
with distinct enlargnont of the artery above 
the fistula* The peronea has alnost the sane 
calibre as the poplitea, 
hi Control arteriography after operative removal 
of the fistula shows the art, peronca consider- 
ably thinner than before the operation, as com- 
pared other arteries of the leg below the 
knee, Af the level of the splinter, the peronea 
is interrupted (ligature during the operation) 
at an angle, an enlarged secondary branch goes 
down from the place of ligature. 
Illustration 59 
Case B 72 
Arterio-venous aneurysm of the tibialis ant, 
with the formation of a double sac and dis- 
tinct enlargment of artery and vein proximal 
to the fistula. VIII* ANEURYSMS IN THE GLUTEAL AREA 
Both the aneurysms of the gluteal arteries and the hemor- 
rhages cut of the large vessels of the gluteal area (arti glutaoa 
sup, and inf.) are judged quite differently in the literature. Though 
ISRAEL proposed, even in 1905* to ligate the place of ofigin of 
these vessels, viz, the art, hypogastrica* because of the difficulties 
of staunching the blood in the injured every now and then 
(KRISCHE and FRISCHBERG) the aneurysm of the gluteal area are oper- 
ated at the injured place. Even if the glutaeus maximus is opened 
widely, ligature of the vessels is difficulty even impossible some- 
times, particularly in case of aneurysms, for it is often hardly 
possible to approach the vascular stalk of the art, glut* sup, or 
inf. centrally from the aneumnir. sac, GimJUlar cotdHiofca vdil 
arise in case of bleedings when the blood spurts i'crlh out cf the 
pelvis from under the bone. Then, one must first mate ligature 
practicable if necessary removal of the bone. These diffi- 
culties make one understand why most of the authors choose the 
simpler method of ligature of the for Cfee treatment 
of the gluteal an£Urysms, particularly since it will be successful 
in many cases* But if one wishes to take no chances, one must 
approach the aneurysm also at the place of injury alter ligature 
of the hypogastrica, which must therefore be called the method of 
selection. The operation may be performed in one or two sessions. 
Very frequently, the symptoms of the aneurysm, particularly the 
thrill, disappear after ligature of the hypogastrica, but they 
may again set in afterwards, which happe'hed also in our case. 
Case D 1 and la 
Injury inflicted on November 23, 1942; v 
laying bare the art. glut?* at its place of 
egress because of an arterio-venous aneu- 
rysm. Intense interlacing prevents free ex- 
posure of the aneurysm sac. The afferent and 
efferent vessels are ligated. Ligature ex- 
tends even into the pelvis, but thrill and 
pulsation reappeared a few days afterwards. 
For this reason, ligature of the art. hypog. on May 31* 1943 
after which pulsation and thril disappear, 
one week later on, however, a thrill is ascertain- 
able again. This case thus proves ligature 
of the hypogastrica with removal of the aneu- 
rysm to lie the only safe method, -which was no 
longer possible, since the patient had to be 
transferred to another hospital. 
In the case of an arterial aneurysm of the 
art. glut, (Case D 2), ligature with extirpation 
of the sac led to rapid healing. As fre- 
quently with aneurysms of this region, a 
serious damage to the ischiadicus had arisen, 
which rendered a nerve suture necessary. IX. PSFUDOAF'FURYSMS 
At times, one observes symptoms, particularly noises 
of the vessels, which may feign an aneurysm where there 
is actually no injury of the vessel. Then we are justi- 
fied to speak of a so-called pseud®-aneurysm, Accord- 
ing to the experimental research work of FRANZ, the 
causes of the vascular noises of arterio-venous aneurysms, 
arc a change of speed of the blood stream (speed noises) 
or a narroY/ing of the track (noise of stenosis). Such 
noises arc, however, occasionally observed in the human 
ody even if there is no aneurysm or tumor, and diffi- 
culties may arise in the explanation of that noise, if, 
on the other hand, there is the possibility of a vas- 
cular injury bccauoe of a gunshot wound of this area, 
rvcn in World War I, such cases wore described, and we 
have met some cases of pseudo-aneurysms, too: 
A 33 year old soldier was wounded by 
shell splinter in the left thigh. Pene- 
tration and issue of the bullet in the area 
of the left flexure of the groin or the left 
hip. Wounds healed without complications. 
The leg was shortened by 3 centimeters. 
Distinct pulsation in the left flexure of 
the groin with distinctly audible noise, 
which increased during systole, on the 
right side normal conditions. The roentgeno- 
gram showed a medial fracture of the neck 
of the femur. For suspicion of an aneurysm 
arteriography which shoY/ed normal conditions 
of the vessels without any symptom of an 
aneurysm (ill, 60), Evidently the medial 
fracture of the neck of the femur with 
twisting of the head of the femur had 
caused a displacement of the art, fern, 
to the front, the thus formed narrowing 
led to the noise of pulsation and sus- 
picion of an aneurysm. 
In another case, a 20 year old soldier 
had been wounded by a shell splinter in the 
rirht shoulder. Immediate paralysis of the 
arm and. hemathorax had followed. Some 
months afterwards, an aneurysm was diagnosed 
for the first time. Under the lateral part of 
the clavicle, a well healed scar of the size 
of a penny with pulse synchronal thrill was 
observed. Arteriography of the subclavia 
shov/ed a normal arteriogram, so did arterio- 
graphy of the art, vertebralis; but on both 
sides there was a pronounced development of 
cervical ribs; the venous pressure had nor- 
mal values. In th:s case the aneurysm was 
feigned by the anormally (cervical ribs) 
and by scar bands or callosities in the area 
of the old wound* 68a 
Illustration 60 
Psoudoancurysm as sequel of a displace- 
ment of the femoralis after fracture of 
the neck of femur. 
A.bb.1 
Pseudo-ineuryana in: o.l e Vascular noises of such an intensity that they 
make one think of an aneurysm do not rarely lead to 
operati n in order to confirm the diagnosis. Operation 
then will reveal the cause of the vascular noise, for 
instance cicatricial changes of the gunshot canal 
with constriction of the artery, callosities of the 
vessels, pressure by masses of callus etc. If, during 
the operation, one finds no cause at all of the 
origin of the noise and if the noise persists during 
the operation, it is highly probably that there is a 
genuine aneurysm after all, the thrill of wh:ch is 
conducted very far and which is heard more distinctly 
at a remote place for anatomical reasons. One can be 
easily deceived in such cases, and in one of our cases, 
(Case D 70), only a second operation led to final 
healing, the first operation with ligature of the 
art. tib, ant, having made the thrill disappear tempo- 
rarily, In these cases, one must think of a communication 
between an arterial and a venous secondary_branch, and 
one should endeavor to. find it. The methods of examin- 
ation described above, particularly arteriography, 
oscillometry, and measuring of the venous pressure, may 
be of decisive importance for the differential diagnosis 
between genuine and pseudo aneurysm. AND 
cartel 
SECOND T70RLD WARS 
msaratra^t^^sgarasasrvtmsacarainaggi C IRST 
AND 
SECOND WORLD WARS 
A comparison of the aneurysms of the first and the 
second World Wars has been made in only a few points 
by some authors. Thus HFRLYN reports that he made 
general innuiries among operated patients of world War 
I and received J+ 3 answers, which showed that ligature 
loaves behind greater complaints than the more conser- 
vative methods. WILDECANS and PHILLIPIDFS have recently 
found, in individual cases of the last war, similar 
changes as we have observed in the case described 
on pave 18, WILDEGANS described a gunshot aneurysm of 
/orId War I in a woman which had persisted through 25 
years. In place of the fistula, a considerable cicatri- 
cial stenosis developed which led to a sac-like dilatation 
and sinuosity of the afferent artery femoralis and to 
an extraordinary general congestion of the veins. In 
the case mentioned by PHILLIPIDFS, the arteriogram 
of an arterio-venous aneurysm of a 50 year old pat its nt 
of World War I showed a greatly enlarged vein and a 
false aneurysm at the level of the fistula. By 
inouiry and later examinations of aneurysm patients of 
the first World War, we have tried to make a comparison 
of the aneurysms of both World Wars possible (NUDING), 
17 cases of aneurysms of World War I have already been 
described by GUNDERLANN in the "Report of War Surgery 
of the Giessen Clinics concerning the first 5 Worths of 
the Present War", A comparison »f the aneurysm cases 
of the first World War treated at our clinics with those 
we have observed now yieldedv interesting results as re- 
gards distribution, cause of origin etc. The following 
table is a synopsis of the vessel-injuries from 191A to 
1918 and of their location, numbers, kind of aneurysm 
and cause: Ple.ce of 
the 
aneurysm 
Tota 
1 art* 
art 
ven 
, shell 
, splint 
inf, 
* gun- 
shot 
spontaneous or 
other injury 
art, 
carotis comm. 
1 
1 
- 
- 
- 
art. 
interna 
1 
- 
1 
1 
- 
- 
art, 
subclavia 
3 
2 
1 
- 
- 
1 
art, 
axillaris 
$ 
3 
2 
- 
1 
- 
art, 
brachialis 
9 
7 
2 
3 
1 
- 
art, 
cubital!s 
3 
3 
- 
1 
1 
- 
art, 
ulnari s 
5 
5 
- 
- 
2 
- 
art, 
femoral!s 
11 
7 
4 
2 
7 
1 
art, 
poplitea 
2 
- 
2 
- 
- 
- 
art, 
prof, fern. 
1 
1 
- 
- 
1 
- 
art, 
cir. fern. 
1 
1 
- 
- 
- 
- 
art, 
tibialis 
5 
5 
- 
- 
2 
- 
art . 
p g r o n c a 
1 
- 
1 
- 
- 
- 
art, 
interossealors, 
1 
1 
- 
- 
- 
Total: 
49 
35 
71,4-356 
u 
23, 
6 
57$ 21, 
15 
73$ 65, 
2 
22% 
A comparison table of the war 1939-45 shows the following 
figures: Seat of the 
aneurysm 
Numbers 
art, 
art,vcn, 
shell- 
splint , 
inf, 
gun- 
shot 
spontaneous 
or other 
injury 
art. 
car, comm. 
IB 
4 
14 
13 
4 
- 
art, 
car, int. 
4 
1 
3 
3 
1 
- 
art, 
car, ext. 
3 
1 
2 
3 
- 
- 
art, 
verte brails 
1 
- 
1 
1 
- 
- 
art, 
temporalis 
1 
1 
- 
1 
- 
- 
trunc 
,thyreoc erv, 
3 
- 
3 
2 
- 
- 
art, 
subclavla 
IB 
B 
10 
10 
6 
2 
art. 
axillaris 
U 
B 
6 
4 
7 
3 
1 art. 
brac hialis 
11 
3 
8 
6 
3 
2 
art, 
prof, brac h, 
1 
- 
3 
1 
- 
- 
art, 
cubit alls 
6 
3 
3 
2 
2 
2 
art. 
radialls 
2 
1 
1 
- 
- 
1 
art. 
ulnaris 
2 
2 
- 
2 
- 
- 
arcus 
volaris 
1 
1 
- 
- 
- 
1 
art. 
iliaca comm. 
1 
- 
1 
1 
- 
- 
art. 
mes, sup. 
1 
- 
1 
1 
- 
- 
art. 
iliaca ext. 
6 
- 
6 
1 
2 
- 
ar t, 
glutea 
2 
1 
1 
- 
2 
- 
**t. 
f emoralis 
41 
5 
36 
23 
13 
- 
, 
prof, fem. 
$ 
1 
4 
2 
1 
- 
-I't. 
poplitea 
17 
4 
13 
11 
2 
- 
tib, ant. 
7 
- 
7 
5 
1 
- 
tib. post 
$ 
2 
3 
3 
2 
- 
**t. 
peronea 
2 
- 
2 
2 
- 
- 
Total; 
172 
26, 
46 
7 U% 
126 
73,26% 
97 
56,7,0% 
u 
25,58% 
11 
6,40?i 73 
A comparison of these tables sho?/s that the pro- 
portion of arterial and arterio-venous aneurysms is con- 
siderably changed, 1914-18, 71,43% of the cases were 
arterial aneurysms (now 26,74/0; 28,57% arterio-venous 
aneurysms (73,26% in this war). Besides, there is a 
considerable change as regards the cause, :hile during 
the first World War, 65,22% of the cases were caused by 
infantry missiles and 25,58% by shell splinters; in 
this war, the percentage of shell-and bomb-splintcr 
cases amounted to 56,40%> as contrasted to 27,49% in- 
fantry missiles. Among the present arms, therefore shell-splinters 
cause an aneurysm most freouently, with the infantry- 
missiles following at a great distance, whilst the 
hand-weapons (swords, knives etc,) play practically no 
part any longer. The shell-splinters (rough missiles) 
are more liable to cause a simultaneous injury of artery 
and vein, which explains the increase and the predominance 
of arterio-venous aneurysms, 
8omparispn_pf_obseryations_of_thc_Giessen_clinics 
s_I„and_II *_wit]i_t]ie_statistic s_of 
other authors y/ith_c^r.sidora,tion_of_thc_singlc_yessel^^ 
s s el 
HER LIN 
82 cases 
1o 
v,HABERER 
318 cases 
at 
P 
GIESSEN 
49 cases 
% 
(1914-18) 
BERNHARD 
172 cases 
% 
(1939-45) 
"'•rt.car, comm. 
5,0 
7,86 
4,0 
10,47 
car. int. 
— 
0,63 
— 
2,33 
-I’t, car4 . ext, 
— 
0,63 
— 
1,74 
p*rt. vertebral is 
2,0 
0,63 
— 
0,58 
temporalis 
— 
0,31 
— 
0,58 
, max,int. 
2,0 
e,3i 
— 
— 
°^twthyr. inf. 
— 
0,31 
— 
— 
,j?Unc. thyreocerv. 
4,0 
— 
— 
1,74 
subclavia 
9,0 
14,46 
6,1 
10,74 
i3?t* axillaris 
5,0 
11,66 
10,2 
8,14 
■krt. brachialis 
17,0 
5,34 
18,4 
6,40 
'^t, prof, brochii 
— 
— 
— 
0,58 
cubitalis 
6,0 
1,57 
6,1 
3,49 
radial is 
— 
0,31 
— 
1,16 Vessel 
HEREIN 
82 cases 
% 
y*HABFRER 
318 cases 
cj 
p 
GIESSEN 
19 cases 
% 
(1911-18) 
BERNHARD 
172 cases 
% 
(1939-45) 
arcus 
! volaris 
— 
— 
— 
0,58 
art. 
ulnari s 
— 
— 
10,2 
1,16 
art * 
iliaca commj 
— 
0,31 
— 
4,58 
art* 
mcsent, sup* 
— 
— 
— 
0,58 
art, 
iliaca ext. 
— 
3 ,U 
— 
3,19 
art. 
hypogastr* 
— 
0,31 
— 
— 
art, 
glutea 
— 
1,26 
— 
1,16 
art, 
fenorails 
2,2 
26,10 
22,1 
23,84. 
art. 
prof, fern. 
l,o 
5,66 
2,0 
2,91 
art, 
poplit ea 
16,0 
10,69 
1,1 
9,88 
art, 
tibialis ant* 
5,0 
1) 88 
10,2 
1,07 
art. 
tibialis uost* 
5,0 
5,03 
1,* 
2,91 
art, 
tib,ant*and post 
. 5,0 
0,63 
— 
— 
art, 
peronea 
— 
0*31 
2,0 
1,16 
a n, r a 
.cemo sum 
— •• *" 
0,31 
Also surprising is the comparatively high percentage 
of aneurysms of the carotid from 1939 to 1916. In 
my opinion, this is no consequence of the kind of war- 
fare (war of position) as is held by NUDING, but of 
the fact that patients with cervical aneurysms, be- 
cause of their difficulties and dangers, are more 
likely taken to special hospitals than patients with 
the less dangerous aneurysms of the extremities. 
C OLPARI SO NaOF_ MORTAL IT Y^Fa 
WARS OBSERVED BY DIFFERENT AUTHORS 
HMHSsssaiaascsa&:assssas;3a7s:ssiBS{sa»aaa9aaai 
FRANZ computes in 1519 operations, 201 cases 
with fatal termination, that is 13,2%, though he 
includes fresh injuries of the vessels, STICK only 
reaches 7% in 1000 operations of aneurysms. Recently, 75 
HEELYN reports a mortality rate of 4-% among 82 oases, 
and V.HABFRER had only 18 cases with fatal termination 
among 34-9 vascular operations, (5%), The following 
table shows our results of the late war (1939-194-5) . 
Method of oper- 
ation , 
T o t a l's 
Healing 
Death 
Amputation 
Recidivation 
Lateral suture 
81 
75 
1 
2 
3 
Circular suture 
26 
23 
1 
1 
1 
Ligature 
39 
36 
2 
- 
1 i 
i 
Ligature round 
2 
-- 
- 
- 
2 
Suture round 
1 
-- 
- 
- 
i | 
Total 
U9 
134- 
4. 
3 
8 
Since 5 of our 8 recurrences could be brought 
to healing by a second operation, the numbers of our 
aneurysm operations increases to 156, the numbers of 
healings to 139, there remain 3 recurrences, 3 cares 
of postoperative amputation became necessary. Thus, 
BERNHARD succeeded in reducing mortality to 2,7% in 
a bno means small number of aneurysm operations; 
if we include our recurrent operations, we even arrive 
at only 2,5%. 
In this context, the successful operations of 
aneurysms treated at our clinics during World War I, 
appear remarkable. An inquiry sent to all A9 patients 
was ansfered by 3U, 2 patients could be reexamined at 
the clinics. These 3A patients had been treated as 
follows: 23 ligatures, 3 lateral sutures, in one case 
suture of the aneurysm sac with ligature of the art, 
prof* femj, 2 patients were treated conservatively. 
Among the 23 ligatures, a necrosis had set in 2 times 
(tibialis post, and circumfl. femoris), and an am- 
putation had to be made a few days after the operation, 
8 patients died within the last 25 years; 3 of 
these became fit for service during World War I, and 
were sent to the front a'ain, where they died in 
action 1917/13, Their families did not know about any 
complaints or sequelae of the vascular injury. One 
patient died in 1925 of the consequences of a gas- 
poisoning, These cases were ligatures of the art, fen., 
brach., tib, post and 1 lateral suture of the art, ul- 
naris. The other causes of death are with one patient 
"cerebral tumor, weakness after operation", one patient diod of the sequelae of a bladder disease; the cause 
of death of one patient is unknown, and one patient 
died in 1936 of "heart-failure1*. An epicritical 
judgement of the clinical record and the subsequent 
progress raised justified doubts concerning this 
diagnosis. Since the case is also interesting as a 
"late sequel of aneurysms", it is briefly mentioned* 
H,N,, born March 17, 1891, was v/ounded 
in France on August 23, 191K, on the right 
side of the throat. At that time, the find- 
ing reported a distinct pulsation thrill and 
a swelling at the right side of the throat. 
During the following operation performed on 
the strength of the diagnosis of "arterio- 
venous aneurysm of the art. carotis comm,", 
the aneurysm sac was opened in the attempt 
to free it, which caused such a violent 
hemorrhage, that the carotis communis had to 
be ligated, and a tampon was applied to the 
aneurysm sac. In the further course, no 
symptoms of paralysis or of irritation on 
the part of the brain was observed. The 
patient complained only at times of most 
violent headaches, which he localized in 
the right half of the skull. The dis- 
charge examination on October 17, 1914- 
records a slight thrill above the upper 
end of the jugularis interna right under the 
right ear as still noticed. 
The further course is described as 
follows by the deceased’s brother: The 
ctmplaints connected with the vascular injury 
subsided in the course of time, for all 
he know* Thus, the patient was able 
to engage in sports, such as tennis , 
swimming, skiing etc. Later sequelae 
which are to be explained by the vascular 
injury were: swelling of the throat, 
intensified reddening of the affected 
half of the face and visible pulsation, but 
the patient was no more treated because cf 
these symptoms. He drew a pension owing 
to his injury sustained in military srrvicc, 
but the amount of it is not known. On 
November 20, 1936, N,, suddenly fell dead with- 
out having previously felt ill. Cause of 
death stated as heart-failure. 
This finding and the sudden death suggest that 
a thrombus detached itself from the left aneurysm 
sac and that the cerebral embolism thus caused led 
to immediate death. It is highly probable, therefore, 
that there was an original causal connection between 
injury and death* 77 
The following table gives information of the 
cases still alive* 
L2jtfi_RQga_lt.g. Qf .2? g?f 'or Id .1. 
Seat of the 
operated 
aneurysm 
Number s 
big . 
treatm, 
suture 
free 
from 
c onscrv.compl, 
slight 
circ, 
scr, 
dis- 
order ; 
art. 
sublcavia 
2 
2 
- 
- 
1 
- 
1 
art, 
axillaris 
2 
2 
- 
- 
- 
2 
- 
art, 
brae hialis 
U 
3 
1 
- 
- 
K 
- 
art. 
ulnaris 
3 
3 
- 
- 
2 
1 
- 
art, 
cubitalis 
1 
1 
- 
. 
- 
- 
1 
art. 
femoralis 
7 
k 
1 
2 
2 
- 
5 
art. 
poplitca 
2 
1 
1 
- 
- 
1 
1 
art. 
tib, post. 
2 
2 
- 
- 
1 
1 
- 
Total: 
23 
18 
3 
2 
6 
26,l/o 
9 
39,1$ 
8 
Thus, 26,1% remained without any complaints, 
in 39,1%, there arc only negligible peripheral 
disorders of the circulation leaving the patient com- 
pletely fit for work, and there are more serious se- 
quelae in 3i+ , The pensions are fixed accordingly; 
8 patients get no pension 
11 patients are 30-4-0$, and 
4- patients 4-0-80% (injured during 
war-service) , 
As regards the latter group, it is worth mention- 
ing that in 2 eases, the respective extremity remained 
paralysed by a simultaneous nerve damage and a higher 
pension was awarded for this reason. 
The stated complaints are the same with hardly 
any exception: pain in the injured limb if the weather 
changes, greater feeling of exhaustion after exertion, 
greater sensitivity for cold in cool weather, swelling 78 
of the leg, chiefly after long standing, atrophy of 
the affected muscles and contractions appearing as a 
sequel of the injury* Only the two patients treated 
conservatively - both had arterio-venous aneurysms of 
the art. fem, - complained of graver sequelae, which 
got worse and worse in the course of time. Here is 
a clinical report as an example: 
On March 22, 1918, J*W* was wounded by a 
machine gun bullet. The bullet entered 
below the symphysis and came out somewhat 
lower on the outside of the right thigh. 
The right thigh was considerably swollen 
in its upper half. There was a distinct 
vascular thrill in the inguinal area, 
the right leg below the knee and the 
foot felt warm. On April 10, 1918, it 
was noted that the aneurysm has not grown 
and is now three times compressed for ten 
minutes every day above the Poupart's liga- 
ment, Since threrc were no subjective com- 
plaints any longer, no operation was made 
and the patient was discharged on April 22, 
W, now answered us as follows; In the first 
few years after the war, he had but few complaints and 
worked hard and much. Thereby, the aneurysm in- 
creased, and he developed pronounced varicose veins. 
On account of an examination by an official doctor, 
made in 1936, an impediment of his capability 
of earning his living of J+ 0% was ascertained and 
the corresponding pension granted to him. Recently 
the suffering has become so much worse, that he 
freouontly has to consult a doctor and his present state 
is almost intolerable, 
A comparison of the success of suture and ligature 
in these cases is hardly possible, since suture was 
made only twice and each time caused disorders of 
the circulation. 
Those observations of aneurysms of the first 
World War are meant to complete the discussion of 
the above mentioned late sequelae. S U M M ARY S U M MARY 
ssas ss ss ssss as can ssor 
221 aneurysms are reported, 172 of which have 
been observed during the late war, 4-9 during the 
first World War at the Surgical Clinics of the Uni- 
versity in Giessen, Hereby, manifold experience as 
regards early and late sequelae and their treatment 
was gathered. 
For the diagnosis and evaluation of the condition 
of the circulation before, during and after the 
operation, arteriography is highly important. The 
"percutaneous technique11 is described for the single 
vessels. As we have observed during several hundred 
> it is practically without danger and 
provides useful pictures. Advantages and disadvantages 
of the different contrast-media arc discussed. 
Measurements of the temperature of the skin, 
oscillometry and measurements of the venous pressure 
wore referred to for diagnosis and evaluation of the 
conditions of the disease and yielded important know- 
ledge. While in case of arterial aneurysms, there is 
a decrease in the temperature of the skin in the 
peripheral section as a conscoucnce of deficient blood- 
supply, there was found in case of arterio-venous 
aneurysms, a distinct increase of the temperature of 
the skin distally of the arterio venous communication. 
Those differences of temperature are not, as assumed 
formerly, only sequelae of a congestion, but they 
are caused by increased arterial blood supply evoked 
by the regulatory means of the body, partly central, 
partly sympathicotonic. This opinion is also confirmed 
b^r the enormous enlargement of the artery above the 
communication often observed in case of arterio-venous 
aneurysms, which is caused by the fact that the body 
tries to neutralize the fall of pressure occasioned by 
the draining of arterial bleed into the veins. Not 
more mechanical and hydrodynamic factors, but above 
all physiological factors cause these changes of the 
vessels in a reflex manner. Oscillometry, too, 
supports the same conclusions. In case of arterio- 
venous aneurysms, it always showed proximally of the 
arteriovenous junction, as a consequence of the in- 
creased arterial blood supply, a considerably rising 
oscilloraetrical index, which is characteristic of the 
arterio-venous aneurysm, while peripheral to the 
communication, the oscill«metrical curve always showed 
a flattening as a sign of worse arterial blood supply, 
ii^asuring_of_yenous_prcssure also confirms these 
results, and a positive venous pressure is a certain 
symptom of an arterio venous union, which is important 
for differential diagnosis, c.g. in case of pseudo- 
aneurysms. Beside these local peripheral effects illustrated 
by curves and pictares, serious central changes of 
the heart are freouently observed. Comparative 
examinations of art eric-venous aneurysm? of the art, 
femoralis over a period of almost thirty years have 
been particularly interesting. Slowing, down of 
the pulse, increase oJ blood pressure and diminution 
of the heart, when pressure is applied to the aneurysm, 
may be clearly seen from examinations and orthodiagrams 
of the years and 194.2, at the same time the adapt- 
ability of the organism to pathologic conditions. As 
could be reontgenologic ally proved in several cases, 
a dilatation of the heart will occur even after a few 
months in ease of arterio-venous aneurysms on account 
of over-exertion of the heart, which may even lead to 
decompensation and which will disappear within a few 
months after •perativc removal of the arterio-venous 
aneurysm. 
Concentration of the aneurysm cases accumulat«d 
in wartime at special hospitals and their operative 
treatment by a few .particularly experienced vessel- 
surgeons promises the best results and is therefore 
warmly recommended. 
Spontaneous healing of an arterial aneurysm has 
been observed six times ani proved by arteriography. 
In spite of that, absolute indication for operation 
remains because of the dangerous complications which 
will often set in even years afterwards. 
The most favorable time for the operation depends 
on different factors. Early operation, 3-4 weeks after 
the wound was inflicted, is recommended for the pulsating 
hematoma, if there is no grave infection and if the 
development of a collateral circulation is to be expected 
and if rupture or hemorrhage do not enforce an earlier 
operation. Waiting 2-3 months has proved advisable 
because of the often very , serious inflammatory symptoms 
observed in this war. Post operative infection has 
been rarely observed. In cases of arterio-venous 
aneurysms, one can wait nearly always for the most 
favorable aseptic conditions. 
The ideal nrthod__of_0£crati.on for the aneurysm 
is the vessel suture, which will restore normal circu- 
lation conditions. If this method is not possible or 
n»t necessary, ligature is considered, occasionally als# 
vein transplantation or displacement of an artery. The 
palliative methods arc emergency methods and not safe 
as regards healing and prevention of recurrences. 
Circular and lateral suture arc described in detail, 
as well as the circumstances that may lead to failures. 
Though impermeability will often occur after circular 
suture, it should be preferred tv ligature, since the 
gradual failure of the principal vessel will further 
the development of a collateral circulation. 8 abdominal aneurysms uere approached operative- 
ly, among them 1 aneurysm of the iliaca comm, 1 
arterio-venous gunshot aneurysm of the art, mosenterica 
sup,, evidently the first of its kind, ur.s brought 
to healing by operation. Interesting physiological 
particulars as to blood supply to the liver changed by 
the aneurysm before and after the operation uere ob- 
s erved, 
Aneurysms of the lower extremities, particularly 
of the art, femoralis, are most freruent in numbers, 
with five times as many arterio-venous aneurysms as 
arterial ones. 
As postoperative arteriographies show, lateral 
suture yields the best results as regards permeability 
of the vessels {75%) , but even in ca.se of failure of the 
principal vessel through ligature or thrombosis, a 
sufficient functional efficiency has been obtained by 
collaterals, as a rule. 
Among the formidable aneurysms of the poolitea (1A) 
in which an ideal method of operation should be always 
undertaken, a gangrene once set in, because the suture 
was destroyed by an infection. 
Ligature of the single vessels of the leg below 
the knee (art, tibialis ant,,post., and peronaea) is 
not always without dangers. 
The safest way of removing the aneurysms of the 
gluteal area is the treatment at the place of injury 
with ligature of the hypogastrica, 
Pseudoaneurysms and their differentiation against 
genuine aneurysms are discussed. Comparative statistics 
of the appearance of aneurysms in the different regions 
of the body shows a relatively high percentage in the 
area of the carotid among our patients as compared to 
the data of other authors, 
A comparison of A9 aneurysms of the first and 
172 aneurysms of the second World bars shows a con- 
siderable increase of arterio-venous aneurysms during 
the last war; the percentage of vessel injuries caused 
by shell- and bombsplinters in contrast to infantry 
missiles has considerably increased, too. 
Vicissitudes and late results of aneurysm patients 
of the first World War are described. 
Among 156 aneurysms of the late war (39-A5), which 
were operated by one_ operator, A cases with fatal 
terminations occurred. Mortality thus amounted to 
2,5%* The failures were practically inoperable cases 
or inevitable complications, so that operation appears 
to have been indicated in any case. 
Also the direct functional results have been out- 
standing with the technique applied, and postoperative 
amputation had to be made only very rarely because of 
Infection, LITERATURE 
■ainsssssasssssssssa 
AMICE On the dangers of serious injuries 
of the vessels in case of apply- 
ing the HOEPFNER-STICH artery clip* 
Zbli Chir, 19U, 37/38, 127 
BAUER, K, H, Arterio-venous aneurysm, of the 
carotis interna, 
Zbl. Chir. 1936, 29, 1730 
BATZNER Rare oorvical aneurysms and 
complications of carotid aneurysms 
Zbl. Chir. 194-4-, 37/38, 1201 
Concerning the question of treat- 
ment of hemorrhages and of 
of the gluteal area 
Zbl, Chir. 194-4-, 3/6, 58 
BERNHARD, Fr, Operatively healed arterio-venous 
aneurysm at the division of the 
aorta into the arteries iliacae 
Medizin, Welt 1944-, HI 
BIER, A. Manual of medical experience 
during World War I, 
Verl, Joh, Ambr, Barth, Leipzig 
v, BRAMANK The arterio-venous aneurysm 
Arch, klin, Chir, 33, 1 
DIMTZA, H, and JAEGER, W, Concerning technique of arterio- 
graphy of the loner extremities 
Zbl. Chir, 1938, 355 
DRESCHER Contribution to the operative 
technique of aneurysms 
Zbl, Chir, 1942, 1619 DYES Differential diagnosis; tumor and 
aneurysm 
Chir, 1939, 11, 4- 
EBHARDT Influence of thorotrast on healthy 
and diseased tissue in the animal 
test 
Brun’s Beitraege 171, 153, 194-1 
EWALD, C, Collective report of arteriography 
Brun’s Beitraege 171, 4-37, 194-1 
FERNANDES The vascular thrill in war surgery 
its occurrence with arterio-venous 
union 
Ref, Zbl, Chir, 194-2, 18, 768 
FRANZ Manual of war surgery 
Springer Verl,, Berlin 194-2 
GILMONS, J, and MCDONALD,St.jun, Aneurysna of abdominal aorta and 
thrombosis of superior mesenteric 
artery associated with bullet wound 
of the lung. 
Ref. Zbl, org, Chir, 61, 4.5 
GOLL'ilTZER-MEIER and FCXARD Naunyn-Schmiedebergs-Archiv 175, 68 
v, HABERER On the ouestion complex of vessel 
injuries and their treatment 
Dtsch. Z sc hr, Chir, 259, 139, 194-4. 
v, HARDENBERG Concerning symptomatology of the 
aneurysm dissecans of the abdominal 
aorta 
Zblf Chir, 38, 1766 
HEIDRICH, L, Concerning cause and frecmency of 
necrosis in ligatures of the large 
vessel trunks 
Brun1 s Beitr, 124-, 607, 1921 
HEYMANII, E, Cicatricial aneurysm of the art, 
carotis int, 
Zbl, Chir, 1933, U, 835 BERLIN On recognition and treatment of 
vessel injuries 
Beitr. z. klin. Chir, 173, 439 
Arterio-venous aneurysm of two 
large arterial trunks 
Zbl, Chir. 19-43, 36 
The transplantation of veins for 
restoration of arteries pierced 
by bullets 
Brun’s Beitr, 176, 2, 1944 
On the exposure of the arteria 
vertebralis 
Zbl. Chir. 1943, 713 
JUNGHANNS Lateral vascular suture of aneurysr• 
of the carotid after gunshot in- 
jury 
Arch, klin. Chir. 205, 149 1943 
KILLIAN Arteriography in case of aneurysms 
Brun’s Beitr, 172, 119, 1941 
On the indications for early 
operation in case of Injuries of 
the vessels and aneurysms 
Arch, klin, Chir, 204, 25$ 1943 
KRIFG, W, Development of collateral circula- 
tion during disorders of blood- 
supply to the brain in arterio- 
graphical pictures 
Zbl, Chir. 1939, 11, $6l and 12, 60. 
KULENXAKPFF Treatment of aneurysms, particular- 
ly of arterio-venous fistulas 
Dtsch, Lilitdr Arzt 1944, 4, 131 LANG On a traumatic aneurysm of an 
artery of the intestinal wall 
as a rare sequel of an abdominal 
injury by blunt force. Fatal 
hemorrhage from the aneurysm in 
the 7th week after the accident. 
Dtsch, Zschr, Chir, 111, 524, 1911 
LEMKE On the question of arterial suture 
Zbl. Chir,, 1938, 35, 1923 
LFRICHE Preoperative staunching of the 
blood during operations of arterio- 
venous aneurysms etc. 
Ref, Zschr. org, Chir, 107, 564 
Retroperitoneal exposure of the 
aorta for preparing control . 
against hemorrhage during oper- 
ations of aneurysms according to 
Matas, 
Ref, Zschr, org* Chir, 107, 661 
Some words on endo-aneurysmorraphy 
according to Matas in case of 
arterio-venous aneurysms. 
Ref. Zbl, Chir, 1942, 30 
LIEBICH Importance of arteriography In 
vascular suture for war-aneurysms 
Dtsch, MllitHr Arzt, 1943, 279 
LftHR, W, and JAKCBI, W, Vascular diseases of the brain as 
represented in arteriography 
Arch, klin, Chir, 177, 510, 1933 
LOHR, W, Diseases of the vessels of the 
brain as represented in arterio- 
graphy 
Arch, klin, Chir,, 186, 298, 1936 
KATAS Aneurysm of the abdominal aorta at 
the place of bifurcation. 
Ref. Zschr, org, Chir,, 101,712,194 NEUMEYER Traumatic aneurysms 
Arch, klin, Chir,, 200, 52, 194-0 
NIEDWER On ligature of the arteria carotis 
Brun1 s Beitr, 171, 574* 194-1 
NUDING Observations of traumatic aneu- 
rysms of the war 1914--18 and of 
the present war with special con- 
sideration of the late results of 
the methods of operation of the 
first World War* 
Dissertation Giessen 194-4- 
PEARSE, H.E, Experimental studies of the li*- 
gation of large arteries, 
Zschr. org, Chir,, 102, 30, 194-1 
PHILIPPIDES On arteriography with vasoselectan 
Zbl, Chir. 194-3, 19, 583 
The technique of arteriography 
Zbl. Chir.,194-2, 585 
Clinical methods of examining 
peripheral disorders of the vessel 
Zbl. Chir., 194-1, 5, 129 
PLOEGER, A, On traumatic aneurysms 
Eftnchhor- Mediz . Wsc hr, 1915,1, 64.5 
REHN, E, The aneurysm of the art, subclavia 
by gunshot -jound and its ideal 
operation with free transplantatioi 
of veins 
Zbl. Chir. 194-2, 31, 1262 
Fundamental remarks on reconstruct: 
surgery of gunshot aneurysms 
Zbl. Chir. 1943, 27 RIEDER Exceptional position of arterio- 
venous aneurysms of the renal 
vessels in the field of operative 
treatment of serious damage of the 
circulation in case of arterio- 
venous aneurysms 
Chir. 1942, 609 
SAUERBRUCH Development of Basedow*s disease 
as a sequel of arterio-venous 
aneurysms between carotis and 
vena jugularis, 
Dtsch* Zschr, Chir* 288, 125, 1943 
Discussion remark 
. Zbl* Chir., 1937, 4-6, 2630 
S-CHNEIDER, K.W, Aneurysm of the carotis int,, 
in the form of a sac in a 6 months 
old child with the picture of a 
retropharyngeal abscess 
Hals-Faseb-Ohrenatzt 1,32,60,194-1 
SCHNEIDER and B-ftTZNER Treatment of the aneurysms of the 
art. poplitea and its branches 
Zbl. Chir. 1943, 27 
SCHNEIDER, D. On the regulation of the blood- 
supply to the brain 
Arch, klin, Chir., 180, 46l, 1934 
Relations between blood-supply to' 
and pressure of the brain 
Arch, klin, Chir, 183, 448, 1935 
SCHMID Preliminary ligature of the art, 
hypogastrica in case of hemorrhages 
in its supply area 
Chir. 43, 10, 301 
SCHR0EDER On arteriography and treatment 
of the quiet hematoma 
Brun's Beitr, 175, 4, 612 SCHOENBAUER Discussion remark 
Arch, klin, Chir, 200, 54, 1940 
rr, SCHROTTER Diseases of the vessels. 
Special pathology and therapy of 
Mothnagel, vol, 15, 1901 
SEDLACZEK, G, Sequela of a false aneurysm. 
Dissertation Giessen 1944 
SIMONETTA On q retrograde blood stream from 
the carotis interna to the externa 
after ligature of the human carotis 
c omm, 
Ref. Zbl, Chir., 1939, 5, 259 
STICK and FROMME The injuries of the blood-vessels 
and their sequela 
Erg, Chir. 13, 14-4-, 1921 
STOTZ, W, Late sequela after injuries of the 
carotis communis and peripheral 
damage to the accessorius 
Mschr, Unfallheilkunde 45,315,1933 
VOGELER On the aneurysm and ligature of 
the art. vertebralis 
Zbl. Chir. 1941, 1, 309 
WACHSLUTH The arterio-venous aneurysm as a 
short circuit of the circulation 
Dtsch, Militaer Arzt 1943, 541 
WALKER, F, Some new ways for prognosis and 
possible complications after 
ligature of the art. carotis 
comm, (or interna). 
Arch,klin, Chir, 130, 736, 1924 
WEBER, A, Observations on traumatic arterio- 
venous aneurysms 
Mttnchner medizin, W sc hr,1917,409 
WILDEGANS • Process of spont aneous staunching 
of the blood in large arteries 
injured by war effect? 
Chir. 1943, 2, 33