of removal of a part of the sternum,
and a second ligature placed above the sac. Here a ligature above and
below the communication would have been comparatively easy.

As a general rule proximal ligature is to be reserved for those cases
alone in which double ligature is either impracticable or inadvisable,
and it can only be expected to convert a varicose aneurism into the less
dangerous condition of aneurismal varix.

In the case of arterio-venous aneurisms in the limbs the possibilities
of treatment are enlarged, and here the alternatives of (_a_) local
interference with the sac and direct ligature of the wounded point,
(_b_) simple ligature above and below the sac, (_c_) proximal ligature
(Hunterian operation), come into consideration.

Direct incision of the sac is suitable, and the best method of treatment
for aneurisms in the calf, forearm, and probably arm. Several cases in
the two former situations were successfully treated by this method. On
the other hand, the only case I saw in which a proximal ligature had
been applied for an arterio-venous aneurism of the leg resulted most
unsatisfactorily. The sac in the calf suppurated at a later date, and
for many weeks the escape of small quantities of blood from the
remaining sinus kept up the fear of a severe attack of secondary
haemorrhage until the sinus closed.

In the case of femoral and popliteal aneurisms the method of Antyllus is
often unsuitable. A case of arterio-venous aneurism of the femoral
artery quoted in the _Lancet_[17] will illustrate the difficulty which
may be met with in determining the actual bleeding point in the
irregular cavity laid open. In any case the necessary ligature of both
artery and vein is a serious objection to the direct method either in
the thigh or ham, and more particularly if adopted before the damage
dependent on the dissection of the limb by extravasated blood has been
repaired.

Proximal ligature (Hunterian) even, offers dangers under these
circumstances. In one case with which I became acquainted, it was
followed by gangrene, necessitating amputation. The lesion in this
instance was a perforating one of the femoral artery and vein.

For either femoral or popliteal arterio-venous aneurisms ligature of the
artery above and below the aneurism is the best and safest treatment. In
view of the healthy state of the vascular wall in most of these cases,
the advantage of placing the ligatures as near to the wounded spot as
ca