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SURGERY 
4 MONTHLY UVISW OP «U ROICAL SCISHCS AND PAACT1C* 
EDITED *Y 
L S. PILCHER. A M, M O, 
FREDERICK TREVES. F R.CS, 
J„WILLIAMI H P,) 
WILLIAM MACEWBM. M.D, 
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TABLE OF CONTENTS* 
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UNIVERSITY OF PENNSYLVANIA PRESS 
PHILADELPHIA. PA 
Oreat Britain: Cassell and Company. London. 
JANUARY, 1804 
THE EXTIRPATION OF ANEURISMS. 
By JOSEPH RANSOHOFF, M.D., 
OF CINCINNATI, 
PROFESSOR OF ANATOMY IN THE MEDICAL COLLEGE OF OHIO; SURGEON 
TO THE CINCINNATI AND TO THE GOOD SAMARITAN HOSPITALS. THE EXTIRPATION OF ANEURISMS.1 
By JOSEPH RANSOHOFF,M.D., 
OF CINCINNATI, 
PROFESSOR OF ANATOMY IN THE MEDICAL COLLEGE OF OHIO; SURGEON 
TO THE CINCINNATI AND TO THE GOOD SAMARITAN HOSPITALS. 
THERE are a few morbid conditions affecting the human frame 
which appear to possess an abiding charm for medical men 
from generation to generation, and from century to cen- 
tury. Among them may be mentioned stone in the bladder, 
hernia and aneurism. The greater rarity of aneriusms, and its 
always impending tragic termination by rupture, have given it 
an interest peculiarly its own. Hence is it that the pathology, 
relative liability of different arteries, symptomatology and diag- 
nosis are all but completed chapters. With the proximal deli- 
gation of Anel and the apparently more rational procedure of 
Hunter, the operative therapy of aneurisms of the extremities 
seemed perfected. Less heroic, though by no means harmless 
methods, have been devised; some, like the injection of wax or 
of blood-coagulating chemicals, only to be remembered in the 
repleteness of history ; others to be followed by success often 
enough to warrant a trial, yet not often enough to make it other 
than a surprise. Among these may be mentioned galvano- 
puncture, flexion, direct elastic and digital compression. 
Certain is it that in the great majority of peripheral aneur- 
isms the question of operative interference must be solved by 
selecting one of three methods. They are: (i) Proximal liga- 
tion at a point immediately above or some distance removed 
from the aneurism. (2) Splitting and emptying the sac with 
peripheral and proximal deligation. (3) The total extirpation of 
the aneurism. 
1 Read before the Surgical Section of the American Medical Association, June, 
1893. 2 
JOSEPH RANSOHOFk. 
The first and second of these methods are sufficiently well 
known. The third, although described by Purmann 200 years 
ago, had fallen entirely into oblivion until five years ago. The 
most recent of our text-books but mentions it. It is for this 
reason that I beg to direct the attention of my colleagues to this 
ideal method, and to use for my text the following cases, one 
from my own, the other from the practice of my friend, Dr. L. 
F reteman. 
Case I.—Merman S., aged twenty-two. Seven months before 
admission to the Avondale Hospital fell on the left hand and fractured 
his thumb. States that shortly after the accident he’observed a pul- 
sating tumor over the wrist. Has been treated in dispensary and in 
hospital by elastic bandage and compression. 
Present Condition.—On the left forearm, two inches above the 
wrist-joint, is a pulsating tumor as large as a hickory-nut. It has 
deep attachments, pulsates uniformly, and is clearly aneurismal; 
compression of the radial arrests its pulsation. Forced flexion of the 
forearm also accomplishes it. 
April 19, 1893. Forearm flexed on arm, and maintained in this 
position by bandage for two hours. Pain necessitated removal for 
one-half hour. Bandage replaced and flexion maintained for three 
hours. Then, finally, removed. Pulsations returned within a few 
minutes. 
April 2i, 1893. Pad placed on radial artery above aneurism 
and by means of continuous pressure by nurses, all pulsation was 
checked for three hours. Aneurism had decreased in size about two- 
thirds, but within an hour was of original size. 
April 25, 1893. Operation.—Incision three inches long over 
tumor. Surface of tumor readily exposed, and radial artery traced 
upwards and ligated with silk twice at each end of the sac. Artery 
then divided. To remove the sac in its entirety a portion of the 
tendon of the radial flexor of the wrist was sacrificed. Pulsations 
did not cease after the ligatures above the sac were brought home. 
The operation was a dry one. No drainage ; catgut suture. 
Result.—Union by first intention, and under one dressing. 
Function unimpaired. 
Remarks.—The aneurismal sac presents a smooth intima. The 
sac wall has the thickness of a normal artery. Microscopic examina- EXTIRPATION OF ANEURISMS. 
3 
tion reveals all the arterial coats in the section. It is to be remarked 
that whereas compression of the radial at first checked pulsations, the 
anastomotic circulation was so established thereby that at the time 
of operation such compression no longer affected the tumor. 
•Case II.—I am indebted to Dr. L. Freeman for the report of 
this case. A. B., aged twelve, was injured just over the ankle by an 
ice-pick. • The wound healed without untoward symptoms. Several 
months later a pulsating tumor developed. Globular in shape and 
large as the end of the finger it presented a slight cicatrix on its 
dome. Under pressure the tumor disappeared, and compression of 
the femoral checked pulsation. Diagnosis. Traumatic aneurism. 
Operation.-1— Incision over tumor, three inches long. A well- 
developed sac was found, and by tedious dissection severed from its 
connections. Ligature above and below. Suture without drainage. 
Recovery uninterrupted. 
Though the aneurism in each of the cases was small and 
involved a part where a parallel vessel assured the nutrition of 
the parts beyond, the results achieved justify the use of the word 
ideal to designate the method of treatment by total extirpation. 
When resorted to for the relief of aneurisms of larger trunks like 
the axillary, brachial, femoral and politeal, the adjective is none 
the less appropriate. By briefly comparing the advantages and 
the disadvantages of the three operative methods of operation, 
the reasons for my greater faith in one will be best elucidated. 
The acknowledged advantage of the Hunterian operation is 
its simplicity. It is performed in parts undisturbed in their 
anatomical relations. It is formal and quickly accomplished. 
The wound is easily kept aseptic, and the recovery is rapid. 
That the operation is made in a more healthy part of the artery 
is largely assumption. In traumatic aneurisms, and in those of 
arterio-venous character, this view is clearly untenable. In the 
idiopathic variety the danger of meeting the dreaded atheroma, 
the supposed source of secondary haemorrhage ought certainly 
to increase as the heart is approached. Bowlby and C. O. Weber 
failed to find it oftener just above the aneurism than at a distance 
above it. Furthermore, the danger of gangrene increases with 
the stretch of artery cut off from the circulation between the 4 
JOSEPH RANSOHOFF. 
aneurism and the point of ligation. For these reasons the 
beneficent influences of modern wound-treatment have failed to 
decrease the mortality of aneurisms treated by proximal ligation 
according to Hunter as much as was expected. 
While it is true that in 1881 Stimson was enabled to collect 
in New York twenty-nine cases of ligaturing of the principal 
arteries with catgut without secondary haemorrhage and with but 
one case of gangrene, statistics drawn from wider sources are 
not nearly so favorable. In 1885 Scriba tabulated ninety-six 
cases treated antiseptically; twenty-four of these terminated 
fatally; seven through sepsis ; seven through secondary haemor- 
rhage; in four through haemorrhage from rupture of the sac ; in 
two through gangrene ; in one through embolism of the middle 
cerebral artery ; and in three from unknown causes. In eight 
additional cases amputation had to be resorted to for gangrene of 
the extremity. Delbet places the mortality of proximal ligation 
at 18 per cent. 
The presence of the sac after the Hunterian operation is a 
menace to the limb. By a too rapid establishment of the collat- 
eral circulation soft clots may be washed into distal branches, 
thereby producing localized patches of gangrene. Bardeleben 
detected this blocked condition of the vessels after the ligation 
of a healthy femoral artery for popliteal aneurism. Months 
after ligation trophic changes from implication of nerves in the 
sac wall may necessitate amputation. 
Proximal ligation for aneurism always entails uncertainty 
concerning the finality of the cure. In not a few cases recurrence 
ensues after a few months or many years. Davies-Colley, 
Annandale and Hutchinson have reported cases in which the 
aneurism returned three, four and seven years after a supposed 
cure had been effected. In forty cases of total extirpation col- 
lected by Kubler the Hunterian operation had been done in five. 
It is particularly in traumatic aneurisms of arteries with gener- 
ous anastomoses that there is danger of recurrence or of secondary 
haemorrhage after proximal ligation. The glories of the Hun- 
terian operation probably belong to the immediate past. 
In recent years attention has, therefore, centred in the old EXTIRPATION OF ANEURISMS. 
5 
■operation of Antyllus as revived by Syme. It comprises the 
splitting of the sac, the removing of clots and the ligation of the 
artery above and below. By the use of the tourniquet the 
chief danger, that from haemorrhage during the operation, has 
been almost removed. The sources of failure are in the sac 
itself. It is virtually a foreign body, remaining in a large and 
irregular wound. Deprived of its nutrition, suppuration and 
sloughing are often unavoidable. In the course thereof second- 
ary haemorrhages may be expected. A further source of this 
bleeding is in the many vessels which are within the walls of and 
open into the sac itself. They are the vasa vasorum enlarged 
by the development of an anastomotic circulation in consequence 
of operative measures like digital compression or ligation, or 
from the unaided efforts of nature to overcome the disastrous 
effects of the diseased vessel on the nutrition of the parts below. 
Notwithstanding these defects of the method under considera- 
tion, its mortality is decidedly less than that of proximal liga- 
tion. Delbet places it at ti per cent. Scriba has collected 
thirty cases, of which only three terminated fatally. One of the 
unsuccessful cases should be excluded, since the operation was 
limited to the splitting of the sac and tamponing with perchloride 
of iron. In two of the cases only did gangrene occur. The 
danger from gangrene is placed by Delbet at a little less than 
3 per cent., whereas for proximal ligation it is nearly 8 per cent. 
Favorable as are the results from the Antyllus operation, 
they do not equal those obtained from the total extirpation of 
the sac, an operation to which attention has recently been 
directed by Scriba, Delbet, Trelat and Kubler, to whose experi- 
ences I am largely indebted for the views herein expressed. 
Practised by Philagrius of Macedon in the fourth century, it was 
forgotten until the end of the seventeenth, when it was resorted 
to with success in a brachial aneurism by Purmann. It is gen- 
erally designated as the operation of Purmann. A method 
might certainly be called ideal which in forty cases was followed 
by but one death, and after which gangrene and secondary 
haemorrhage were not at all observed. The one death resulted 
from acute anaemia several hours after an operation made by 
Socin for aneurism of the scalp. In twenty-four of the cases 6 
JOSEPH RANSOHOFF. 
large arterial trunks like the axillary, brachial, femoral and pop- 
liteal were involved. In the very latest literature I have been 
enabled to find four more cases of popliteal aneurisms similarly 
treated, thus making twenty-eight extirpations of major aneur- 
isms of the extremities without a death. 
Of the forty-six cases, including those of Kubler, the four 
just refened to and the cases above reported, thirty-one were 
traumatic and fifteen spontaneous. Twelve were arterio-venous, 
the remainder arterial. The presence of a sac in recent trau- 
matic aneurisms has been questioned. Nevertheless Trendelen- 
burg found one in an injured femoral artery as early as the sixth 
day. While in such cases of recent traumatic aneurism the 
mere incision and double ligation may answer, it certainly seems 
better surgery to insure that retraction of the arterial stumps 
into the sheath above and below which is so essential to safe 
occlusion of their lumina. This applies particularly to the distal 
end from which secondary haemorrhage, if it occurs at all, is 
more likely to ensue. 
The disadvantages of total extirpation are the difficulty of 
its execution and the danger of wounding important parts to 
which the sac has formed adhesions. The first of these is not 
greater than that which attends the removal of tumors of the 
same size with adhesions. Under the artificial ischaemia obtained 
by the rubber tourniquet, a careful dissection of the sac wall is 
made through an ample incision. The smaller vessels are ligated 
as encountered before they are divided. The afferent and effer- 
ent vessels are sought, ligated and divided above and below the 
sac. To accomplish this it may be necessary to divide the sac 
in its long axis. It is in the dissection of the deeper portion of 
the sac that the attending vein may be injured. The danger 
from this accident has certainly been overrated. From the table 
of Kubler it appears that the femoral vein was injured in three 
cases, the popliteal in five, the axillary in one and the brachial 
in three. In all but one of these the vein was ligated or resected, 
but gangrene did not ensue. The supposed disadvantage of 
ligating an unhealthy part of the vessel has already been seen to 
be largely assumption. Fifteen of the cases were spontaneous 
aneurisms. EXTIRPATION OF ANEURISMS. 
7 
The advantages which make extirpation, in the words of 
M. Trelat, uttered in the French Surgical Congress of 1889, 
the operation of the future, are manifold. It is radical. It per- 
mits of the ligation of all vessels which could give rise to second- 
ary bleeding. The danger from cicatricial contraction of the 
sac and the consequent involvement of nerve-trunks is averted. 
The wound, being a clean one, is, like that after the removal of a 
neoplasm, likely to unite by first intention. 
Based on the foregoing, I beg to submit for your considera- 
tion the following propositions regarding the operative treatment 
of aneurisms of the extremities: 
(1) Extirpation is the ideal method. It should be resorted 
to unless there are weighty reasons against it. 
(2) In aneurisms of the fore-arm and of the leg no other 
method should be adopted. 
(3) Aneurisms which have suddenly grown large from sub- 
cutaneous rupture of the sac, and those in which rupture is 
impending, should be subjected to extirpation. 
(4) In recent traumatic aneurisms the injured vessel should 
be divided between two ligatures; when a sac has formed it 
should be excised. 
(5) When other methods have failed, extirpation should be 
tried before resort is taken to amputation. 
(6) In arterio-venous aneurisms extirpation should be prac- 
tised, if any operation is indicated. 
(7) Proximal ligation is to be reserved for cases of idio- 
pathic or spontaneous aneurisms in which the age of the patient 
or an enfeebled condition from other causes would make a pro- 
longed operation hazardous, and for cases in which the positiou 
of the tumor precludes the possibility of extirpation.