ent in as
complete a condition of rest as possible, and affording local support to
the limb by a splint, preferably a removable plaster-of-Paris case.
Should no further extension, or, what is more likely, should contraction
and diminution occur, it will be well to continue this treatment for
some weeks at least.

When the aneurism has reached a quiescent stage the question of further
treatment arises, and whether this should consist in local interference
or proximal ligature. The answer to this mainly depends on the size and
situation of the vessels concerned. To take of the cases above described
the five instances in which the cervical vessels were the seat of the
aneurism. In No. 13 the symptoms appeared fairly conclusive of the
injury being to the innominate artery and vein, or possibly innominate
artery and jugular vein. Fortunately the aneurismal sac in this case was
small and showed a tendency to decrease, but in any case no interference
would have been justifiable. I think a similar opinion was unavoidable
in No. 14, probably affecting the root of the right carotid. Here under
any circumstances interference would have been most hazardous. The
position of large aneurism made the route of approach to the wounded
spot necessarily through the sac, exposing the patient to the double
danger of immediate haemorrhage and of entrance of air into the great
veins. Nos. 10, 11, and 12 fall into the same category, except that in
No. 11 the immediate indication for interference was extension. In each,
ligature of the artery above and below the point of communication would
have necessitated so near an approach to the sac which must remain in
communication with the vein as to have entailed injury to the latter,
when both artery and vein must have been ligatured, probably risking
serious cerebral trouble. In No. 11 I believe both the external and
internal carotids were implicated; in No. 10 I believe the internal
alone, close to its origin. The operation of proximal ligature ensured
primary consolidation of the sac in both cases 10 and 11, but left the
thrill unaltered, except in so far as it was temporarily weakened. It,
in fact, converted these cases from arterio-venous aneurisms into pure
aneurismal varices. In No. 10 a sac subsequently redeveloped. No. 12
stood on a different basis. No operation was done for him in South
Africa, but the first portion of the carotid might have been ligatured
in the episternal notch, or by aid