A dense process of cervical fascia (just becoming thoracic) now covers the vessel, binding it on the right side to the right innominate vein, and on the left maintaining the relation of the innominate artery to the trachea. The inferior thyroid veins lie on this fascia, and must be drawn aside, not cut. The fascia is then to be scraped through very cautiously, exposing the root of the right carotid, which, being traced downwards, will lead to the innominate. The following parts lie in close relation to the vessel at the point of ligature, and must be avoided:--1. The left innominate vein crosses the artery in front from left to right, and must be drawn down. 2. The right innominate vein and right pneumogastric are in close contact with the artery on the right side; to avoid them the aneurism-needle must be entered on the outside (right of the vessel). 3. The apex of the right pleura and the trachea are in close contact behind, requiring the point of the needle to be kept close to the artery in bringing the thread round. It might have been expected that the sudden arrest of so large a proportion of the vascular supply of the body, so very near the heart, would cause serious, or even fatal symptoms; this, however, is not the case, no serious inconvenience of this sort being experienced; yet hitherto every case has proved fatal, either from secondary hæmorrhage or inflammation of lungs and pleura. In fifteen well-authenticated, and in three more doubtful cases, the ligature has been applied; all of these died at periods varying from twelve hours (as in Hutin's case), to forty-two days as in Thomson's, and sixty-seven days (Graefe's).[11] A successful case of ligature of the innominate along with the right carotid and (after secondary hæmorrhage) the right vertebral, in a mulatto aged thirty-two, for a subclavian aneurism, has been put on record by Dr. Smyth of New Orleans, in the _American Journal of Medical Science_ for July 1866. And here we may also note that Mr. Heath has lately treated a case of innominate aneurism by simultaneous ligature of the third part of the subclavian and the carotid. Both ligatures separated on the eighteenth day, and the tumour was much smaller some months afterwards.[12] Mr. R. Barwell has reported several most interesting cases in which simultaneous ligature of carotid and subclavian have proved of marked benefit in aortic as well as in innominate aneurisms.[13] In four cases the operation was attempted, but the operators had to desist before the application of the ligature, in consequence of the diseased state of the arterial coats. Of these, three died, and one (Professor Porter's of Dublin) case recovered, the patient leaving the hospital with the aneurism nearly consolidated.