n be managed without interference with the sac is afforded. A number
of popliteal cases treated in this way did perfectly. In the femoral
cases a considerable period of rest to allow of consolidation of the
sac, and readjustment of the circulation, should always be allowed to
elapse.

In the case of popliteal arterio-venous aneurisms a number were
successfully treated by proximal (Hunterian) ligature, and by single
ligature immediately above the sac. In a considerable proportion of the
latter both artery and vein were tied. This was apparently the result of
the difficulty of isolating the vessels in the tangled mass of clot and
cicatricial tissue surrounding them, and is a strong argument against
too early interference. The late Sir William Stokes expressed himself as
in favour of ligature of the artery in Hunter's canal, combined with
that of the great anastomotic branch, and quoted some successful cases
to me. I have grave doubts, however, whether the varix can often be
permanently cured by this operation.

I can give no useful statistics on this subject, but with regard to the
popliteal aneurisms I may state that in three instances gangrene of the
leg followed early operative interference in the popliteal space.

My own opinion on this subject is strong, and to the effect that none of
these operations should be undertaken before a period of from two to
three months after the injury, unless there is evidence of progressive
enlargement. In every case which came under my own observation
progressive contraction and consolidation took place up to a certain
point under the influence of rest. When this process has become
stationary, and the surrounding tissues have regained to a great extent
their normal condition, the operations are far easier, and beyond this
more likely to be followed by success.

It appears to me that one argument only can be raised against the above
opinion, viz. the possibility of healing of the recent wound in the
vessels when the force of the circulation is lowered by proximal
ligature. Such experience as that quoted from Sir W. Stokes and two of
Mr. Ker's cases, mentioned below, support this possibility, but in all
the reported results were recent. Against them I can only advance my
knowledge of several mishaps following early operation.

In concluding these observations on injuries to the arteries and
aneurisms, a few general remarks as to the occurrence of gangrene after
operation must be ad