5. For cases so situated as to make any of the above methods inexpedient there is still the more or less promising method of treatment by the introduction of wire, coupled perhaps with the use of the electric current, and the injection of gelatin solutions. While ligation of the abdominal aorta has been practised with temporary success it has not yet proved so encouraging as to justify its performance, save in exceptional cases, but into any intrathoracic or intra-abdominal aneurysm, which appears to be otherwise inoperable, a number of feet of fine steel wire may be introduced, in the attempt to coil it up irregularly within the sac and thus to afford a sort of skeleton framework, upon which coagula will more readily form and by which they may be retained. In some cases the end of this wire has been attached to the negative pole of a galvanic battery, the other pole being affixed to an external electrode, and a weak galvanic current has been passed for a period of say from five to thirty minutes, the time varying in accordance with the strength of the current. By this procedure coagulation is much encouraged. In cases of intra-abdominal aneurysm the abdomen may be opened and the sac more or less completely exposed, after which this insertion may be more minutely performed.
Occasionally surgeons have exposed an aortic aneurysm and endeavored to externalize or exclude it by producing adhesions around it, while some portion of the sac is exposed to the outer world. After adhesions have formed such methods of treatment can be repeated as may be desired. They may also be combined with the subcutaneous use of 2 per cent. sterile gelatin solution, or this may be thrown into the sac in small amounts. It is true, however, that cases of this character are desperate, and while life has been in perhaps half of the operated cases more or less prolonged, but few instances of final recovery have been recorded.
The after-treatment consists of physiological rest of the part operated upon, and rest and abstention from violent exertions of any kind. During this time elimination should not be neglected, emotional excitement should be avoided, and, in the presence of syphilitic disease or a well-founded suspicion of it, conventional antispecifics should be administered in sufficient amounts. When the aneurysm is of traumatic origin and there is no general vascular or cardiac disease, there will be a quick restoration of the integrity of parts as well as of their usefulness. Massage and an elastic bandage will be useful, in order to atone for the results of a disturbed circulation.
SUTURE OF BLOODVESSELS.
This is almost a new topic in surgery, especially suture of the arteries. Surgeons have learned that the walls of the arteries and of the veins, when not too much diseased, will tolerate sutures and unite easily. The larger the vessel the easier it is to apply a suture, as its walls are thicker and the method easier. The greater, too, will be the need of suture when the vessel is an important one. Small vessels are relatively so unimportant as not to demand so formal a procedure. The vessels to which the method is most applicable are the common carotid, the subclavian, axillary, brachial and femoral, with their accompanying veins, including the common jugular. It is applicable when it is an injury to the vessel which has necessitated an operation, or when, during its performance, some trunk has been torn out or torn open, as in separating adhesions. It is serviceable, also, when both artery and vein have been involved, as in the groin, where the danger of gangrene of the limb would be enhanced if both the outflow and the inflow of the blood were shut off.
Fig. 161
End-to-end suture of a divided artery, permitting a certain degree of invagination. (After Murphy.)
Lateral suture of injured bloodvessels may be regarded as a standard procedure, as it is nearly always possible to temporarily control the circulation on both sides of the field of operation, either by elastic constriction or temporary ligation or clamping. For this purpose fine silk makes the best suture material. It should be threaded into round needles and the sutures should include only the two outer coats. After completing the suture the distal provisional closure of the vessel should be first removed. As the blood backs up in the artery it will test the efficacy of the sutures. Should there be no leakage the proximal clamp may be removed, and then if the condition appear satisfactory the arterial sheath should be carefully closed, and over this the other tissues, with buried sutures.
End-to-end suture of bloodvessels is a recent measure, for which we are indebted to Murphy. It is applicable to vessels which have been divided circularly and completely or almost completely. In the event of the adoption of this method the ends should be divided squarely and then reunited by sutures threaded upon the needles, passing through all the coats, about 1 Mm. from the margin of division, as well as about the same distance apart. If the upper end can be drawn into the lower one, and gently held there by a series of U-shaped stitches, it may be considered the best method.[26] (See [Fig. 161].)