d bullet wounds healed. Considerable
extravasation of blood in the posterior triangle. Beneath the
sterno-mastoid in the course of the bullet track, swelling,
thrill and pulsation over an area 1-1/2 inch wide in diameter.
Loud machinery murmur audible to the patient when the left side
of the head is placed on the pillow, and widely distributed on
auscultation. The left eye appears prominent, but the pupils
are normal and equal in size. Voice weak and husky, and there
is cough. Laryngoscopic examination showed the cords to be
untouched, but some swelling still persisted. No headache, but
giddiness is troublesome at times. Pulse 100, regular but
somewhat irritable.

The patient was kept quiet in the supine position for a month,
and during this time the condition in many ways improved. The
voice improved in strength, the pulse steadied, falling to 80,
the prominence of the left eye disappeared, and all the blood
effusion in the posterior triangle became absorbed. Meanwhile
the aneurism contracted at first, until it became oval in
outline, with a long axis of 2 inches by 1-1/2 broad extending
in the line of the wound track, but mainly situated in the exit
half. During the last fortnight, however, it remained quite
stationary in size, and as it showed no further signs of
diminution in spite of the favourable conditions under which
the patient had been placed, it was considered best to try to
ensure its consolidation by a proximal ligature. Thrill had
become slightly less pronounced, and was less evident to the
patient himself, but was otherwise unchanged. The probabilities
in this case seemed rather in favour of wound of the internal
carotid artery, and it was decided to bare the upper part of
the common carotid, follow up the main trunk, and if possible
apply the ligature to the internal branch. On April 12, 61 days
after the injury, the classical incision for securing the
common carotid was made, and the sterno-mastoid slightly
retracted. It was found that the sac of the aneurism extended
over the bifurcation of the artery, reaching to the wall of the
larynx. The omo-hyoid muscle was therefore divided, and the
artery ligatured beneath, in order to ensure against any
interference with the sac. Some difficulty was met with, for on
openi