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Five cases in which operation revealed aneurysm of the posterior communicating artery of the circle of Willis were reported. In 4 of the cases cure was effected by clipping the arteries running into the aneurysms. The largest aneurysm was approximately 2.5 cm. and the smallest 1 cm., in diameter.In 4 cases there were the classic symptoms of spontaneous subarachnoid hemor¬ rhage with sudden generalized headache, later localizing to the eye and supraorbital region, with stiffness and pain in the legs and neck, and nausea. In each of the 4 cases, at the onset of headache or soon after, paralysis of the third cranial nerve developed. In 1 case there was no headache, but paralysis of the third nerve was present. In all cases evidence of hemorrhage from rupture of the aneurysm was disclosed by discoloration of the cerebral cortex or by blood in the spinal fluid.In 2 cases the aneurysm was disclosed by arteriography ; in 2 cases the contrast medium failed to show the lesion, and in 1 case no angiogram was made.Since the ultimate mortality from untreated intracranial aneurysm must be close to 100 per cent, it is necessary to attempt surgical cure of this lesion. Sudden headache, generalized or localized to the eye or the supraorbital region, accompanied with a paralysis of the third nerve, localizes the lesion to the intracranial position of the third nerve, back of the carotid artery. In this location, an aneurysm of the carotid or the posterior communicating artery must be suspected, and such symptoms are sufficiently localizing and diagnostic to warrant surgical exploration.The procedure of arteriography is not accurate enough to be dependable as a positive diagnostic test. Clinical examination alone should determine the diagnosis.As shown by these 5 cases, craniotomy, exploration and ligation of the supplying arteries are both feasible and life saving, since there was only 1 death in the 5 cases. discussion Dr. Walter Freeman, Washington, D. C. : Dr. Jaeger sent me a copy of this paper, and I was delighted beyond measure to know that something could be done in these cases. Neurologists have been rather helpless before the neurosurgeons showed a way of handling them. Of course, we are familiar with Dandy's pioneer exploits in the treatment of aneurysms, but in the case of the little thinwalled aneurysms, I have heretofore felt pretty hopeless.I wonder whether the cerebral circulation will stand either a clip or a temporary ligature on the carotid artery during the operation to prevent flooding of the wound at the time of operation? I believe that Dr. Jaeger mentioned the desirDownloaded From: http://archneurpsyc.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/31/2015

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Dr. William H. Everts: In reply to Dr. Riley's question about improve¬ ment of the central nervous system: First, the time element during which we had to observe these patients was too short, but I may say there was pronounced im¬ provement in strength and in the numbness of the feet and legs, as well as in the vision of some of them. The acuity of vision which they had remained, but there was practically no improvement in the central scotomas. The period of observa¬ tion, during which the diets were better, was about seven weeks. For the first four weeks we did not see them. They had food dropped by airplane, and the diet was thus improved; but, according to many, it was not adequate. In the hospital the regimen was adequate, but neither the scotomas nor the symptoms referable to the cord improved during the time of observation. As I was observing them, I felt that the improvement recorded on many of the charts was purely that of general strength, of the peripheral nervous system, and not that of the central nervous system at all. In the course of a few weeks these men were ready to get up and be on their way, and they hiked off to the ships of the British army and to our ships without too much trouble. That was not so with the men who were serevely ill, and I think they will be permanently crippled. The literature relating to the value of pneumoencephalography in the differ¬ ential diagonsis of the presenile dementias was reviewed. The report of Flügel indi¬ cating that the extracortical air is distributed as large, confluent masses over the frontal lobes in cases of Pick's disease and as broad stripes over the convexity in cases of Alzheimer's disease was shown to be based on rather tenuous evidence.Nine cases were reported, in all of which pneumoencephalograms had been made and in 8 of which autopsy had been performed. The pathologic observations were compared with the pneumoencephalographic findings, and it was pointed out that the lack of clearcut pathologic distinction between Pick's and Alzheimer's disease vitiates the value of air studies in the differential diagnosis. Uniform or asym¬ metric ventricular dilatation without displacement was found in all the 9 cases reported. In these cases the appearance of the extracortical air was of little or no value in differentiating the two conditions. It was concluded that the pneumoencephalogram is a valuable diagnostic aid in distinguishing the presenile de¬ mentias from other conditions, but that it is of little or no value in differentiating the various members of the presenile group. discussion Dr. Walter Freeman, Washington, D. O: Dr. Chodoff might do well to bring out in his final discussion that pneumoencephalographic examination in these cases is not always without risk. I recall a patient, not in this series, who after pneumoencephalographic examination went into profound shock and was saved only by heroic efforts, including a blood transfusion and oxygen inhalations. Another patient, who probably had unrecognized septicemia at the time the pro¬ cedure w...