If the p a t i c n t dicd, t h e dlzto, cause and autopsy firCiin.gs ere recorded i n iteix 11. Red blood c e l l counts, hemoglobin, hematocri.t, white blood c e l l counts and other laboratory da.ta a m ~:ntmwl i n i t e m 12. o f the case was made by t h e examining physician (item 13) A diagnosis and rcvieved-by the Bmericm physici.an l a chnrg.2, Additional observatims and comp l i c a t i o n s a r e rccorded i n item I.

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carotid artery, so that now, in the last few cases, in addition to fractional ligation I divide the artery. Six of the 8 cases were the result of fractured skull. One was a spontaneous pulsating exophthalmos in a woman of 73 and 1 case was due to gunshot wound from birdshot in which the other eye had been destroyed. Secondarily, ligation or division was carried out on an average of sixteen days after the first partial ligation.Dr. Alton Ochsner, New Orleans: There are two points that I should like to emphasize. Occasionally one will find persons whom ligation of either the internal carotid or the com¬ mon carotid will not help. In such instances it is necessary to combine ligation of the carotid with the intracranial clip, as suggested by Dandy. Recently Dr. DeBakey has shown that the gradual occlusion of the artery by cellophane does not work. In an extensive experimentation he was unable to verify Pierce's work concerning this. He has had 2 patients on whom, in an attempt to increase the intracranial vascularity, he has done a sympathectomy. One of these persons was greatly improved following the sympathectomy. This is based on the observations of Gage that in patients with peripheral arteriovenous aneu¬ rysms, by .decreasing the peripheral resistance and by increasing the vascularity, the aneurysm can be attacked with impunity. One of these patients was definitely improved following the sympathectomy, so that the ligation could be done safely. The other patient was cured by sympathectomy, simply indicating that by slowing the blood stream through the arteriovenous anastomosis, clotting was made possible, so that I think in the older person in whom hemiplegia is likely to occur, the use of cervicodorsal sympathectomy is of value and should be tried.Dr. James Rudolph Jaeger, Denver : It is obvious if we remember the anatomy concerned in the carotid-cavernous arteriovenous communications that a good many of these cases will not be cured by ligating the carotid in the neck or intra¬ cranially because the internal carotid has branches inside and near the cavernous sinus which connect up with the external carotid branches, and these branches enlarge to a tremendous extent in an attempt to feed this communication. Recently I had a case which had been treated conservatively without bene¬ fit, and there is no reason why these cases should not be treated first by the conservative ligations as mentioned by the speaker. This little 11 year old fellow had had the common carotid ligated in the neck. After three months I ligated the carotid proximal to the ophthalmic artery intracranially, and there remained a tremendous bruit and a pronounced exophthalmos. At a third operation I opened the internal carotid artery in the neck and placed a muscle strip with a silver clip on the end of it, as an embolus, and then ligated the external carotid. It progressed upward to the fistula, and x-ray examinations showed the silver clip in the cavernous sinus. Before the external carotid was ligated, and before I had inserted the muscle em...