I believe all these factors were of importance, since it appeared to me that gangrene occurred more often than I should have expected. In one case which I have heard of, gangrene followed a very slight injury to the foot in a patient who had apparently made an excellent recovery after ligature of the femoral artery.
The nervous factor seems another element in favour of reasonable delay in active interference with traumatic aneurisms of the above varieties in the absence of threatening symptoms.
It is worthy of remark that no case of gangrene due to aneurism came under my notice, except subsequently to operation.
Since the above chapter was written, my friend, Mr. J. E. Ker, has sent me his experience in the treatment of four aneurisms, which is of such interest that I insert it as an addendum.
Arterial hæmatomata.—(1) Popliteal, treated by local incision. Both artery and vein completely divided. Ligature of the four ends. Cure. (2) Traumatic aneurism of upper third of forearm. Treated by rest and pressure by bandage. On the eighth day pulsation and bruit ceased spontaneously, and the remains of the sac steadily consolidated until the man's discharge on the twenty-sixth day.
Arterio-venous aneurisms.—(1) At junction of brachial and axillary arteries. Proximal ligature. Cure. (2) Arterio-venous aneurism at the bend of the elbow. Ligature of the brachial at the junction of the middle and lower thirds of the arm. Cure.
FOOTNOTES:
[14] The murmur is still present at the expiration of one year, but no other change.
[15] Lieut.-Colonel Lewtas, I.M.S. See Lancet, 1900, vol. ii. p. 1073.
[16] Lancet, 1900, vol. ii. p. 1074.