cerebral arteriovenous aneurysms

21

vertebral discs. As regards the diagnosis of functionalpain, on the other hand, there is room for more differenceof opinion. Palmer’s observations on the distributionof pain in such disorders are interesting, but he wouldprobably agree that the diagnosis of psychogenic paindepends on a good deal more than its distribution andcharacter, and indeed on more than the apparentexclusion of an organic cause. The personality of thepatient, his adjustment to complex situations, the familyhistory relating to nervous instability, and the circum-stances in which the disorder originated are all highlyrelevant.

CEREBRAL ARTERIOVENOUS ANEURYSMS

4RERZOVErrous aneurysms of the brain may manifestthemselves by causing epilepsy or an intracerebralor subarachnoid haemorrhage. Until recently, however,the preoperative diagnosis was uncertain and manycases were never suspected. The injection of non-

irritant easily excreted radio-opaque substances into thecarotids by percutaneous puncture has converted cerebralangiography into a routine diagnostic procedure. Asa result our knowledge of the vascular anomolies of thebrain is being steadily extended. In his postgraduatelecture at the Institute of Neurology in London on

May 30, Prof. H. Olivecrona of Stockholm said that byusing the newer X-ray technique he had detected anarteriovenous aneurysm in 83 out of 3500 verified casesof cerebral tumour, whereas among the 1500 cerebralneoplasms which made up Cushing and Bailey’s series

only 9 were diagnosed. Usually the condition can onlybe suspected on clinical examination; for the patho-gnomonic feature, a systolic intracranial bruit, can befound in only 15% of cases even when the site of the

aneurysm is known. However, the combination of

epileptic seizures, particularly of jacksonian type,with one or several" episodes of intracranial haemorrhagemakes the diagnosis almost certain. In the remainingcases the differential diagnosis lies between a slowlygrowing neoplasm and a cerebral arterial aneurysm.Occasionally an X-ray film of the skull may showclassical calcification in the vessel walls, but the vastmajority of cases will require arteriography before thediagnosis is finally established.The treatment has until recently been disappointing.

Simple decompression increases the tendency to hoemor-rhage, which may be fatal. Ligation of the superficialcortical vessels is useless, for the deep vessels are farmore numerous and often larger. Carotid ligation inOlivecrona’s hands has either had no effect or left the

patient with a permanent hemiplegia, owing to suddencessation of the cerebral blood-flow, most of which isshunted through the aneurysm. Carotid angiographyusually shows that the normal cerebral arteries are thinpale shadows, compared with the dense shadows cast bythe abnormal vessels. This poverty of blood-supplyto the brain itself is said to account for the slowly pro-gressive dementia in these patients. Deep X-ray therapyseems to have very little effect on the abnormal vesselsand the only treatment left is removal. Though thecondition was even quite lately regarded as completelyinoperable, advances in neurosurgical technique and

particularly in continuous blood-transfusion have com-pletely changed the outlook. Olivecrona has operatedon 49 of his 83 cases with only 4 deaths-a truly remark-able achievement. Of the survivors, 50% are well andworking; 30% show some defect, usually a hemi-paresis, but are able to do some work ; 20% are

not improved or made worse and are unable to work.The inability to do some work is usually due to dementiapreventing the patient from making an adequate adjust-ment to the motor defect, and in most cases the dementiawas present before operation. Half the patients lost theirfits as the result of the operation and the remainder

had them less frequently. Postoperative arteriographyshowed a great improvement in the filling of the normalvascular tree and this is regarded as very important inpreventing progressive dementia.The indications for operation must be more than an

occasional fit. Frequent fits, a haemorrhage with or

without motor defect, or progressive dementia must bepresent before a patient should be submitted to an

operation which in the best hands still carries an 8%mortality. The patients who are not operated on mustbe reviewed periodically, for these arteriovenous

aneurysms continue to extend and may reach a sizeor invade a region which completely precludes totalextirpation.

VOX POPULIAN unexpected complication has arisen in 1:Seauly,

Inverness -shire, during the process of filling a death vacancyin general practice. After advertisement, and the usualselection and interview of a short leet of candidates,a successor was appointed who was regarded alike by thelocal medical committee, the executive council, and theScottish Medical Practices Committee as the mostsuitable doctor for the vacant post. One of theunsuccessful claimants was a doctor who had beenassistant to the deceased practitioner for some eighteenmonths, and so was known by very many of the patients.This doctor chose to exercise his statutory right ofappealing to the Secretary of State for Scotland againstthe decision. not to award the practice to him. TheSecretary of State upheld the decision of the executivecouncil. Meanwhile a petition, which over 3000 people =signed, had been organised in the district, asking thatthis assistant to the deceased doctor should be namedhis successor. When the decision of the Secretary ofState became known, indignation meetings were heldin the district ; and means are apparently being soughtfor legal action to have the decision of the Secretary ofState set aside, on the ground that the expressed wishesof so large a number of the local population have beenignored.To us this is a matter of great importance. At first

sight it may seem that injustice is being done, and thatthe desired choice of doctor of the community is beingheedlessly and bureaucratically frustrated. Certainlynewspaper readers are likely to form this impression.Yet it is known that, both north and south of the Border,local medical committees and executive councils are

taking considerable care in making these appointments :if they arrive at a unanimous decision, and this decisionis confirmed by the Medical Practices Committee andupheld on appeal, the probability is that they havechosen wisely from among the men available, and theirdecision should be accepted. Organised petitions for oragainst a doctor should not become part of the proceduredetermining succession to a practice. Almost anydoctor, well known and not disliked in a district, couldsecure the signatures of more people than he ever knew,but few of these signatories would be really aware of therelative merits of the rival contestants for the practice.They would certainly not be in a position to weigh thewhole evidence of qualifications, experience, personality,and compatibility that had led the local medical com-mittee and the executive council, after interview anddeliberation, to reach their decision.The choice of doctor for a district cannot be wisely

made on the hustings. It is in the executive councilchamber, and through the representatives from the localauthority assembled there, that the voice of the peopleshould be raised in support of any locally favouredcandidate. When the council has decided and itsdecision has been upheld further local agitation canbut undermine confidence, delay effective replacement,and jeopardise the establishment of harmonious relationsbetween the incoming doctor and his future patients.