193 that the eyeay on the cheek, perfect sight was restored. In the present case I think that lateral pressure must be the cause, as, although the media are not quite clear, the eye being glaucomatous, the disc can be made out as a round, white patch with a faint red streak up and down it. About a month after ligature I could see some of the vessels resembling red hairs. Of treatment other than by ligature of the carotid artery I gather these facts from Mr. Rivington's paper. Local

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... hat is, pressure on the eye itself-in ten cases cured none. Instrumental compression (of the common carotid artery) was employed in four cases : one died, and three received no benefit. Digital compression was resorted to in sixteen cases : three were cured. Galvano-puncture was employed in two cases : one died, the other received no benefit. Injection of ergotine was performed in one case, making the disease worse. Injection of coagulating fluids was carried out in four cases : two were cured by perchloride of iron, one was made worse, and one was cured by lactate of iron after ligature had failed. When we come to ligature of the carotid artery a very different tale is told. Forty-six cases are mentioned, but as one was malignant it must be excluded. Two died, aged sixty-five and sixty-three. Of eighteen idiopathic cases fifteen recovered and three obtained partial benefit. Of twenty-six traumatic cases twenty-three recovered and three died. In two cases both carotids were tied. Another fatal case has been mentioned above. To these Liverpool can add four, all of which were cured. Another case would have been cured had not Jigature been forbidden. Three of these I have treated of in this paper, and a fourth, under the care of Mr. Richard Williams and Mr. Robert Jones,5 has been already published. The opinion that these cases should be let alone or temporised with, which is so fashionable in London, is based on the idea that they are not aneurysm but varix. Now I do not deny that if an aneurysm is left alone an opening is likely to be made into the cavernous sinus, as this is in the line of least resistance. An aneurysm let alone long enough will always burst. Of course, in young subjects, as in the boy aged fifteen, the resilience of the tissues is such that it takes a long time to produce rupture of the sac. But those who object to ligature are scarcely logical. If the disease is not aneurysm, but varix, why do they employ those remedial agents, such as digital pressure, iodide of potassium, hellebore, &c., which are supposed to influence aneurysm, but not, as far as I am aware, varix, whilst they discountenance the only treatment which, with any approach to certainty, cures aneurysmnamely, ligature ? I believe that the very rare cases in which digital pressure has appeared to succeed in curing this disease have been cured accidentally-very likely by displacement of clot in the excitement consequent on the torture necessarily involved in the carrying out of the treatment, and not by the direct action of the pressure. In order to cure directly by pressure one must block the artery for the many hours required to produce a sufficient collateral circulation and at the same time give such an amount of rest to the aneurysm as will allow the clot to coagulate sufficiently firmly to prevent it being disturbed when the full force of the heart is brought to bear on it. Were I asked to pick out a typical example, displaying at once the beneficial effect of ligature and the inutility of other treatment, I should choose the very one on which, as far as I know, the temporisers rest their case-namely, Mr. Rivington's. For in this case, surely, it is indisputable, firstly, that there was a communication between the artery and the sinus, seeing that red blood poured out of the orbital vein when it was punctured, and therefore, according to the opponents of ligature, it was an unsuitable case for ligature. It is, secondly, equally indisputable that every conceivable treatment other than ligature was tried without doing any good, and that when ligature was at last resorted to the disease was cured at once. That the perchloride of iron did anything but harm surely no one will maintain in the light of all the other cases cured by ligature. For the diagnosis between intra-cranial aneurysm and varix there is suggested what I believe is called Nélaton's sign. Nelaton is said to have laid it down as an axiom that if the murmur is continuous the disease is varix, and if interrupted it is aneurysm. One would wonder how many cases he had verified post mortem before he ventured on such an assertion. Failing such evidence, I believe that the dis-5 Transactions of the Ophthalmological Society, 1891. tinction is worthless. Whether a murmur is continuous or not depends, I think, almost altogether on the acuteness of the listener's ear. Of the many surgeons who listened to the boy's head at the meeting of the Ophthalmological Society about half of their number said that it was continuous, and the other half that it was interrupted. But, surely, all such murmurs are continuous ; if the heart is not in systole the contraction of the large arteries keeps up the murmur, though, of course, less audibly. The murmur heard in the first patient mentioned was continuous; she had almost always a full, vigorous pulse. To sum up, I venture with some confidence to submit that, except when brought about by direct violence-such as a stab by a pointed weapon or a splinter of bone-these cases, in youth and middle age at any rate, begin as aneurysms : arteries, like teacups, are oftener cracked than broken, and can be cured by being treated as aneurysms, whether they have burst into the cavernous sinus or not; and surely, in these days of aseptic surgery, the best treatment of aneurysm is the Hunterian operation of ligature of the artery leading to it, and in these particular aneurysms, where the possibilities are so grave, where not only sight but even life may be lost, our duty is not only to tie, but, without wasting time in futile experiments, to do as we did in this case-tie at once.