al vessels. In
the leg the tibials may readily and safely be attacked, but it may be
mentioned that the widespread and diffused nature of the thrill may in
some cases give rise to considerable difficulty in sharp localisation of
the varix to either of the vessels, or to any particular spot in their
course. In one case in my experience the posterior tibial was cut down
upon, when the varix was probably peroneal in situation.

The operation most in favour consists in ligation of the artery above
and below the varix, the vein remaining untouched. Even this operation,
however, in two cases of femoral varix failed to effect more than a
temporary cessation of the symptoms, although the ligatures were placed
but a short distance from the communication. Failure is due to the
presence of collateral branches, which are not easy of detection. Even
when the vessels lie exposed, the even distribution of the thrill
renders determination of the exact point of communication difficult, and
the difficulty is augmented by the temporary arrest of the thrill
following the application of a proximal ligature to the artery. A
successful case is reported by Deputy Inspector-General H. T. Cox, R.N.,
in which the ligatures were placed 1/2 an inch from the point of
communication.[16] Single ligation, or proximal ligature, is useless.

If the vein cannot be spared, excision of a limited part of both vessels
may be preferable, particularly in those of the upper extremity.

Proximal ligation of the artery combined with double ligature of the
vein, as adopted in case 15 by Colonel Lewtas for a varicose aneurism,
might offer advantages in some situations.

Given suitable surroundings and certain diagnosis, the ideal treatment
of this condition, as of the next, is preventive--_i.e._ primary
ligation of the wounded artery. Many difficulties, however, lie in the
way of this beyond mere unsatisfactory surroundings. It suffices to
mention the two chief: uncertainty as to the vessel wounded, and the
necessity of always ligaturing the vein as well as the artery in a limb
often more or less dissected up by extravasated blood, to show that this
will never be resorted to as routine treatment.

_Arterio-venous aneurism._--Many of the remarks in the last section find
equal application here, but in the presence of an aneurismal sac
non-intervention is rarely possible or advisable. In the early stages
the proper treatment in any case consists in placing the pati