SPASTIC PARAPLEGIA in MIDDLE AGE by COLIN EDWARDS, M.R.C.P

172 Postgrad Med J: first published as 10.1136/pgmj.26.293.172 on 1 March 1950. Downloaded from

SPASTIC PARAPLEGIA IN MIDDLE AGE By COLIN EDWARDS, M.R.C.P. West End Hospitalfor Nervous Diseases

Before launching into this discussion one must of early onset surviving into middle age will cer- pause to define middle age. Obviously it is not tainly have had a remission and there may well the age period which would have been indicated have been subsequent exacerbations and re- 50 years ago, nor is it the actual middle of the missions. Transient visual disturbances-dim- average span of life. Its limits are set by con- ness due to a retrobulbar neuritis or diplopia due vention and they are not clear-cut, but it does not to external ocular palsies-are common in the begin before 40 years of age and nowadays one initial attack and less so in exacerbations. And can hardly say that it ends before 65. some patients are aware of their nystagmus which Paraplegia, with its serious restriction on may often be transient also. Bladder disturbances mobility, is more dramatic and striking than -precipitancy or frequency-are also common paralysis of the arms, and is apt to give its name to early symptoms. Later comes retention and diseases which are more than paraplegic in their usually, last of all, incontinence. effects. Hence a number of the conditions men- The motor symptoms of disseminated sclerosis, tioned will be essentially quadriplegic and more. however, are the commonest, and particularlyProtected by copyright. Spasticity, too, although a term which connotes those involving the lower limbs. Heaviness or essentially pyramidal involvement, with its clasp- weakness of the legs after exertion is the most knife type of muscular hypertonia, can occasionally usual and it is nearly always more marked on one bear superficial resemblances to extra pyramidal side. Where there is associated cerebellar dis- rigidity and so some extra pyrarpidal diseases will turbance and the disease has not begun until the have to be noted. fifth, sixth or early part of the seventh decade, one So much for the terms of reference. has to consider the possibility of one of the cere- Consideration of a clinico-pathological state can bellar degenerations of middle life-notably de- be approached with one's own idea of disease layed cortical cerebellar atrophy, and olivo-ponto- classification as a background pattern. This will cerebellar atrophy, both of which show bilateral ensure that one is comprehensive and is the safest pyramidal involvement. In them, however, the method to follow if under pressure for time in an curve of development of the disease is continuous

examination. Viewing one's middle-aged spastic and progressive, nor are ocular manifestations http://pmj.bmj.com/ patient as a problem in diagnosis, however, one common-except nystagmus. would inevitably tend to consider the diagnosis to Rarely Friedrich's ataxia may show a pre- some extent in terms of probability, and the com- dominance of lateral column degeneration over the moner causes would come first to mind. That is posterior, and the legs may be spastic despite how I propose to discuss paraplegia now. absence of tendon reflexes. The familial incidence, As a final prefatory remark one must stress the the foot and spinal deformities, and the lengthy primary importance in neurology of history taking. history without remissions in spite of a varying The clinical signs of neurological disease are so rate of deterioration should differentiate these on September 26, 2021 by guest. spectacular that one can understand why students occasional cases from disseminated sclerosis. are unduly impressed by them-but in no branch Their early onset will serve to distinguish them of medicine is history taking more important, and from the cerebellar atrophies mentioned above. it is certainly the major part of the task of diagnosis No laboratory confirmation of the diagnosis of in our middle-aged paraplegic. disseminated sclerosis is possible, but about half Disseminated sclerosis must rank as one of the of the cases on whose cerebrospinal fluid a sen- commonest causes of spastic paraplegia and sitive Lange test is done show a curve of ' paretic ' although four-fifths of the cases begin before shape or tending towards it. This is combined in middle age, it is some of these four-fifths, as well about one-quarter to one-third of all cases with a as the cases beginning in the fifth and sixth de- slight increase in globulin in the fluid and a cades, that make up many of the ranks of the raised cell count. This combination goes a long middle-aged spastics. The history will usually way towards establishing the diagnosis. point fairly definitely to the diagnosis. Any case Of other paraplegias of inflammatory origin at March 1950 EDWARDS: Spastic Paraplegia in Middle Age Postgrad Med J: first published as 10.1136/pgmj.26.293.172 on 1 March 1950. Downloaded from this time of life those due to syphilis have per- It produces upgoing toes and increased tendon re- haps been the commonest, although they are flexes but spasticity and paralysis do not become already ceasing to be so. They most commonly marked. Sensory disturbance is slight but the make their appearance late in the first half of life, bladder may sometimes be involved, and there are and if they do appear for the first time in middle occasionally lightning pains. Argyll Robertson life they will be seen in its early part and not pupils are occasionally found. towards its end. Syphilis causes paraplegia most It is difficult clinically to separate Erb's syphilitic commonly by spinal meningo-vascular inflamma- spinal paralysis from syphilitic lateral sclerosis, tion, but also occasionally by setting up a par- and indeed they may well be the same condition, enchymatous degeneration. The lesion in but at times signs of lateral sclerosis with its spastic meningo-vascilar cases is usually a meningo- paresis are associated with those of posterior mvelitis. The meningitis gives rise to pain of root column involvement (loss of some, at least, of the origin. It occurs most commonly in the dorsal tendon reflexes, ataxia, and loss of deep sensation). region and it may occasionally irritate the anterior The condition is then named syphilitic combined roots too, causing muscular cramps or spasm. or postero-lateral sclerosis and is essentially a The meningitis spreads along the pial septa into parenchymatous degeneration. With it may some- the cord and its progress and resolution produce times be associated muscular atrophy due to tract involvement. This process may take from a anterior horn cell degeneration. few days up to many months. Bladder dis- Gumma of the cord is not common. It belongs turbance is frequent and early. Spastic paralysis to the meningo-vascular group of spinal syphilitic is often the result but quite frequently is not disorders and is often associated with some actual markedly bilateral. A bedside indication of the meningitis (both lepto and pachymeningitis), and syphilitic nature of the spinal lesion is the tendency with arteritis. It produces signs and symptoms of to patchy, cutaneous, sensory impairment, par- an intramedullary tumour but the spasticity re- Protected by copyright. ticularly of pain sensation as shown by pin prick. ported has been most usually unilateral with So it is that the victim of syphilitic meningo- contralateral sensory disturbance-the Brown- myelitis will sometimes show bedsores of sur- Sequard syndrome. prising size in an area where tactile sensation is Finally, and rarely, the lower limbs may share almost normal. Where a severe transverse lesion in the general rigidity of a Parkinsonian picture of of the cord supervenes suddenly in a case with syphilitic origin, due to a parenchymatous de- other neurosyphilitic features (e.g., root pains, im- generation in the striatal area, the subthalamic and paired deep and pain sensibility and possibly tegmental mesencephalic region. These rare cases pupillary changes and diminished tendon re- usually show associated tabes dorsalis, general flexes) the cause is usually the thrombosing of a paresis, or tabo-paresis. spinal artery due to endarteritis. More rare types Whenever neurosyphilis is suspected as a cause of syphilitic spastic paraplegia are those resulting of spastic paraplegia cerebrospinal fluid analysis

from hypertrophic pachymeningitis, Erb's syphilitic with Wassermann tests, and also a blood Wasser- http://pmj.bmj.com/ spinal paralysis, gumma of the cord and syphilitic mann reaction, must always be done. lateral and combined sclerosis. In meningo-vascular cases the fluid most often Syphilitic hypertrophic pachymeningitis is com- shows a high cell count, usually of 30 to 200, monest in the lower cervical region. The great principally lymphocytic, although in gumma it may dural thickening causes initially signs and symp- be low, and in pachymeningitis it may be almost toms due to root compression-namely pain, normal. paraesthesiae, muscular atrophy and impaired The cell count in spinal parenchymatous neuro- cutaneous sensation of nerve root origin. As syphilis is usually only slightly raised. The on September 26, 2021 by guest. hypertrophy goes on the cord becomes compressed Wassermann reaction may be negative in the fluid with the production first of signs of pyramidal in meningo-vascular cases but is positive in the compression (extensor plantar response and in- majority. It is more frequently positive still in creased tendon reflexes) and later of actual slowly parenchymatous cases. It should be remembered increasing spastic paraplegia and increasing sen- that a negative blood Wassermann reaction in sory loss up to the level of the lesion. association with a positive Wassermann Reaction Erb's syphilitic spinal paralysis has never re- in the cerebrospinal fluid has been estimated to ceived widespread acceptance, at least as a patho- occur in as many as 30 per cent. of cases of neurological entity. Clinically it shows a very slowly syphilis, and the test may be negative in both increasing spastic type of paraplegia with an onset blood and fluid in a small number (about io per ten to twelve years after the initial infection (i.e., cent.) of undoubted cases. The protein is usually the period of parenchymatous degenerative neuro- slightly increased in parenchymatous cases, more syphilis). It may show remissions or even arrest. so in meningovascular cases, whilst hypertrophic 174 POSTGRADUATE MEDICAL JOURNAL March 1950 Postgrad Med J: first published as 10.1136/pgmj.26.293.172 on 1 March 1950. Downloaded from pachymeningitis gives rise to a steadily rising pro- an otherwise normal fluid is virtually pathogno- tein culminating in a Froin's syndrome when monic of a space-filling spinal lesion. Usual but spinal block is established. A relative excess of less constant features are motor weakness in the globulin is commcon. In the occasional case of lower limbs which becomes spastic in type when rapid transverse myelomalacia due to spinal artery the mass is above the conus medullaris, and sensory thrombosis, the cerebrospinal fluid may be impairment which ends abruptly at a line trans- entirely normal. verse to the body axis. This sensory impairment Subacute combined degeneration is a condition is frequently dissociated in type in intramedullary which is still overlooked with surprising frequency growths. Root pains at the level of the lesion are in its early stages. Its maximum incidence is frequent in extramedullary tumours, particularly if round about the age of 50, but it may begin even they appear posterior to the cord, and bladder dis- as early as the late twenties or as late as 70. The turbance comes relatively early in many intra- principal early symptom is paraesthesiae in the medullary growths but late in the extramedullary feet and legs and, to a lesser extent, in the hands. ones. Muscle atrophy at the segmental level of an Sensations as of constricting bands round the intramedullary growth is not uncommon. knees or of girdles round the body are also These are some of the salient points to be re- common. Weakness of the legs and general membered when one considers spinal cord com- fatiguability appear next and there may be ataxia pression, but it must be emphasized that there are at an early stage. The signs and symptoms are very many non-neoplastic causes of this. The symmetrical and the onset insidious. Unlike dis- role of trauma is not likely to be overlooked where seminated sclerosis ocular and bladder symptoms spinal fracture or dislocation has occurred. Dis- are usually absent and it begins much later as a location is sometimes only momentary and spon- rule than that disease. Early signs are limited to taneouslv rectifies itself. This occurs principally slight peripheral blunting of sensation which in the cervical region, and X-rays in such casesProtected by copyright. spreads slowly up the limbs. There may be slight may show no abnormality unless the spine be ataxia and intention tremor, and there may be acutely flexed or extended for the purpose of the signs of pyramidal involvement. The blood count film-a procedure not without danger and so is seldom entirely normal, but very often it does hardly justifiable. The cord compression in trau- not show a typical pernicious anaemia picture. matic cases is usually a momentary affair and re- Smoothness of the tongue is a common sign but is sults in laceration which shows no recovery. often so slight as to be of less diagnostic value than Laminectomy is useless in such cases. There are is commonly alleged. Achlorhydria is very nearly at least two types of acute traumatic compressions constant although some undoubted cases do show which do call for surgery, however. The first is a slight response to histamine. Spastic paralysis where only laminae are broken and the second is a late development in a majority of the cases, where evidence of a severe cord lesion (extensive in and nowadays there can be no excuse for its de- the transverse sense) arises soon (i.e. within a few velopment. In the remainder, peripheral nerve days), but not immediately, after a spinal injury. http://pmj.bmj.com/ and posterior column degeneration predominate The reasons for removing fragmented laminae are over that in the lateral columns and a flaccid obvious. The second group of cases includes a paralysis is the result. The plantar reflexes, how- number in which an intramedullary haemorrhage ever, are extensor. Tabes may be simulated in occurs (haematomyelia) and some in which cord this second type, but serological tests and cerebro- compression is due to extradural haemorrhage spinal fluid analysis can exclude it. (haematorrhachis). The cerebrospinal fluid may A subacute combined degeneration producing contain blood if there be associated meningeal on September 26, 2021 by guest. spastic paraplegia occurs in pellagra, and usually haemorrhage, but there is often a completely in the advanced stages, although the neurological normal fluid. It is worth remembering, too, that picture is more commonly one of hypotonia and there may be no hint of a subarachnoid block even ataxia. The typical skin lesions on exposed areas though a fairly extensive haemorrhage is present. and the prominence of the accompanying mental Haemorrhage into the cord can occur following symptoms and stomatitis should suffice to settle very slight trauma indeed such as sudden, rapid the diagnosis. It is most likely to be missed in neck flexion, or it may be apparently spontaneous. cases of Fellagra sine pellagra and in countries It is more common before middle life, however. where the disease is not prevalent. It occurs principally in males and usually where Tumours of the spinal cord and canal are all spinal vascular abnormalitv is already present. In characterized by a steadily progressive history such cases of cord compression laminectomy and, with the occasional exception of a meningioma, should be done. 'I he results of clot removal are they are accompanied by a rise in the cerebrospinal sometimes most gratifying. fluid protein. Indeed a marked rise in protein in Late effects of trauma which may produce cord .March 1950 EDWARDS: Spastic Paraplegia int Middle Age Postgrad Med J: first published as 10.1136/pgmj.26.293.172 on 1 March 1950. Downloaded from compression are thecal scarring, herniation of an tumours need offer no difficulty in diagnosis be- intervertebral disc and arachnoiditis with cyst cause of signs of these diseases elsewhere. Both formation (meningitis serosa circumscripta). All conditions are much commoner before middle three conditions, if diagnosed early enough, can be age and they will be very rare causes of spastic helped considerably by surgery. The traumatic paraplegia in the middle aged. history should put one on the alert although the However it is neoplastic disease proper which is remainder of the story is not usually distinguish- by far the commonest cause of extradural cord able from that of any slowly increasing space- compression, and this is usually secondary car- occupying lesion. Thecal scarring virtually never cinoma invading bone. Primary growths are occurs in the absence of easily recognizable pre- usually sarcomata. ceding bony injury. Because of their position In every case of spinal cord disease where a near the intervertebral foramina, where they im- diagnostic lumbar puncture is done a manometric pinge on nerve roots, disc herniations are seldom test for the freedom of subarachnoid fluid flow painless, but when they cause cord lesions this is must be made, using jugular vein compression to due principally to interference with the cord blood raise the fluid pressure in the head. The absence supply, sometimes associated with arachnoiditis, of. a block does not exclude a space-filling lesion, and not to direct structural deformation of the cord but if present it goes a long way towards estab- itself by the hernia. Cyst-forming arachnoiditis lishing such a diagnosis. Bedside examination is seldom painful. It may be very slow in de- alone is often insufficient to localize the lesion velopment and spastic spinal symptoms are more within limits sufficiently narrow for a surgical prominent than the sensory ones. ft is a condition, approach. Myelography must then be used and a of course, which may arise from many causes other tilting table with facilities for screening the re- than trauma-notably local spinal infections, cumbent patient are desirable. It is only by general infections such as the specific fevers, screening that many partial blocks can be de- Protected by copyright. syphilis, any acute meningitis, and secondary to tected. The radio-opaque medium used can be spinal cord disease such as syringomyelia or dis- introduced by the lumbar route and allowed to seminated sclerosis. The bulk of cases of spinal run upwards or by the cisternal route and allowed arachnoiditis, of course, are not characterized by to gravitate downwards. If the lumbar route is cord compression, and many of the post-meningitic used care must be taken that substances such as spastic states are due to a meningo-myelitis rather lipiodol do not get up into the cranial cavity as the than to cord compression. In syphilis, hyper- iodine may separate out and set up arachnoiditis by trophic pachymeningitis, as already mentioned, irritation. No more than 2 CC. of lipiodol is may give rise to cord compression. necessary, and the stability of the preparation is Other inflammatory causes of cord compression very important. Indeed it is desirable, as a rule, with spastic paraplegia are spinal caries and extra- to try to avoid putting lipiodol into the theca unless dural abscess. This is most commonly tubercu- there is a reasonable prospect of its subsequent

lous, but it may be due to one of the common removal at operation. http://pmj.bmj.com/ pyogenic organisms. In the latter group the Another group of spastic paraplegics is that due patient is usually acutely ill with septicaemia and to acute myelitis other than syphilitic. These are the diagnosis will probably prove obvious, but in almost all sudden in onset. Those which are due the tuberculous cases bony disease may not be to direct extension from a vertebral abscess present apparent at a stage when cord symptoms are quite little difficulty in diagnosis. Many cases of acute definite. The area of the spine near the cord transverse myelitis, however, show no obvious lesion must be watched assiduously for signs of cause. Their onset is rapid, even sometimes with the inflammation which the patient's temperature, the speed of a stroke, and although they may on September 26, 2021 by guest. erythrocyte sedimentation rate and general con- complicate infectious illness such as smallpox or dition will probably suggest. Tenderness of the measles, and although some follow hard upon the spine is likely to be the first sign. giving of a spinal anaesthetic, the aetiology of many Frank Pott's disease of the spine need give rise is remarkably obscure. The cell count in the fluid to no difficulty, and although it is commonest in tends to be abnormally high and lymphocytic in the young it is also found in middle age and even type, and although virus infection has been blamed late in life. for many of these cases this is an unproven sus- Rarely a hydatid cyst may form within the picion as yet. spinal canal and compress the cord, but this is Most of these cases of acute myelitis occur almost a curiosity even in countries where the early in adult life but they are not rare in the disease is common. middle aged. Cord compression by acute meningeal ex- Sometimes the acute cord lesion is part of a tensions of Hodgkin's disease or acute leukaemic disseminated encephalomyelitis which may com- G 176 POSTGRADUATE MEDICAL JOURNAL March [1950 Postgrad Med J: first published as 10.1136/pgmj.26.293.172 on 1 March 1950. Downloaded from plicate one of the exanthemata, may follow occur in young, middle aged and elderly subjects vaccination, or may arise quite independently. in the absence of any hint of muscular atrophy or Spastic paralysis is rare from such a cause, how- of lateral sclerosis. They are provoked in some by ever, most patients showing flaccidity during the fatigue and in others by smoking, but in many acute state and, if they survive, recovery tends to subject no cause is apparent. The label ' myo- be well nigh complete. kymia ' has been given to certain varieties of these. These acute myelitides may be simulated by One should never rush into a diagnosis of amyo- sudden cord compression due to vascular mishaps trophic lateral sclerosis merely because of the such as haemorrhage into a vascular tumour, or a presence of such twitchings. In doubtful cases syringomyelic cavity, or by spontaneous haemato- the electromyogram can give useful help in the myelia. Cerebrospinal fluid analysis will usually differential diagnosis. Pure primary lateral sclerosis serve to distinguish these from the inflammatory without atrophy of muscles (except ultimately cases where the cell count is almost always raised from disuse) is an entity whose separate existence and where subarachnoid block is uncommon. is denied by many neurologists. It is contended The preceding history, of course, often supplies that these are cases of amyotrophic lateral sclerosis the answer. beginning in the pyramidal sphere and that if Syringomyelia perhaps merits a little special watched long enough amyotrophy will usually consideration. The disease will almost always appear, or, if examined with sufficient care post- have declared itself, although sometimes very un- rnortem, typical anterior horn cell changes will be obtrusively, before middle age, usually first in the revealed. The surprising frequency, however, sensory field with dissociated loss over a hand or with which one sees such cases in the absence of arm and extending on to the neck and thorax. any vascular or syphilitic basis has raised my own Although most cases show signs of pyramidal tract suspicion that there does exist a primary abio- involvement on one or both sides, only a few trophic lateral sclerosis, and one recent personalProtected by copyright. develop spastic paraplegia, but this development case in a man of 6o with spastic paraplegia, no has occurred after the age of 40, either due to the accompaniments and a normal fluid, blood, gastric steady enlargement of the cavity in the cord or to secretion and vascular system, appears to have its very occasional rapid distension by haemor- become statir after nearly three years. rhage. A spinal block may be set up and even a There is, of course, a progressive bilateral transverse cord softening. Syringomyelic cases pyramidal involvement without muscular atrophy, showing extensive cord tract involvement with a which is due largely to cerebral atheroma. The -complete or material degree of spinal block merit a degree of paraplegia in these cases is usually mild laminectomy. Incision of the cavity wall in the and a pseudo-bulbar type of spastic dysarthria mid-posterior line with consequent relief of commonly accompanies it. This speech impair- pressure may lessen the upper motor neurone ment is due to bilateral pyramidal tract impairment paralysis considerably. above the level of the speech nerve nuclei. Cerebro-

Perhaps next one should remember those de- spinal fluid protein in such vascular cases is often http://pmj.bmj.com/ generative cord diseases of quite unknown origin- slightly increased (e.g. to 6o to 8o mgm./Ioo cc.) the abiotrophies-which not infrequently cause in contradistinction to the two preceding types. spastic paraplegia in the middle aged. The most Another abiotrophic type is heredo-familial sinister is amyotrophic lateral sclerosis, painless, spastic paralysis which begins in the first half of insidious and lethal. It is essentially a disease of life (although often not until the third or even middle life. Muscular atrophy commonly be- fourth decade), but whose progress is usually re- ginning in the hand intrinsics is accompanied by markably slow, many of the victims living on to muscular fasciculation that is frequently wide- old age. It commences in the legs and it may be on September 26, 2021 by guest. spread, with increased tendon reflexes (in contrast as much as 20 years before the arms are involved. with the syphilitic kind) and pyramidal involve- There is no muscular atrophy and no sensorv ment that sometimes produces very spastic legs. change but the degree of spasticity is often very- As a general rule the more spastic the case the less severe. is the atrophy and the slower the disease. Objec- Another ' pure' spastic paraplegia often per- tive sensory changes are absent except for oc- sisting into middle and old age from infancy is casional blunting of cutaneous sensibility round that of cerebral diplegia (which includes Little's the periphery of limbs, due possibly to im- disease). Involvement of the upper limbs also poverished circulation there. As in all the abio- occurs and some of the cases are associated with trophies, cerebrospinal fluid analysis is normal. athetosis due to striatal damage. These cases show It is worth emphasizing, whilst talking of amyo- no deteriroration granted normal care, and con- trophic lateral sclerosis, that muscular twitchings siderable benefit from patient education is possible. sometimes of a fibrillary or fascicular kind, often The rigidity of striatal disease, whether of March I950 Book Reviews I77 Postgrad Med J: first published as 10.1136/pgmj.26.293.172 on 1 March 1950. Downloaded from Parkinsonian degeneration or encephalitis, can and leg. Yet quite commonly the hysterical para- hardly be said to cause paraplegia, and never true plegia which mimics a severe cord lesion will spasticity. show profound loss of pin-prick sensation in the Final consideration must be given to hysteria. legs with normal buttock sensation. A carefully Hysteria does not make its initial appearance in taken history alone, however, usually takes one middle-aged subjects with a hitherto stable psycho- nearly all the way to the diagnosis in hysterical somatic history, and only the rash will diagnose it paraplegics. at this time of life if there is no trace of a previous It has not been possible in this article to do more neurotic diathesis. It is nQt uncommon, however, than outline a few of the salient diagnostic points in to see hysterical paraplegia in middle life. The spastic paraplegia in middle life. To discuss diagnosis is only difficult at the bedside in very treatment has been impossible. I would like to occasional cases where plantar reflexes cannot be close, however, with an important therapeutic elicited and the characteristic non-anatomical generalization. Acute inflammation, haemorrhage sensory loss of hysteria is absent. These are few, or shock in the central nervous system as else- however, and the absence of an extensor plantar where in the body requires rest as the cornerstone response in a severe spastic paralysis nearly of treatment. Where C.N.S. function is impaired always clinches the diagnosis. On the sensory from any other cause, however, rest, except for the side it is always well to remember that the buttock purpose of recuperation from fatigue, is contra- and perianal skin areas are supplied through the indicated. This point is very important in lower sacral nerves from a cord level that is much paralysis in the young, but in middle life and after lower than that receiving sensation from the foot it is vital. Protected by copyright.

BOOK REVIEWS

TUMOURS OF BONE The style is heavy and at times not lucid; repetitions and summaries, however, do in most instances By CHARLES F. GESCHICKTER, M.D., and MURRAY clarify the authors' ideas. Certain sections should M. COPELAND, M.D. 3rd Edition. Pp. xviii + have been omitted from this edition, in particular 8io, with 642 illustrations. London: J. B. the two introductory chapters by Dean Lewis and Lippincott. 1949. 5 guineas. Bloodgood. Their unassailable dicta that physical http://pmj.bmj.com/ examination, roentgenographs, biopsies and blood This book is a unique work for reference in so Wassermann examinations are diagnostically helpful far as it tabulates the clinical, radiological, patho- are amply brought out in the later text and in any logical and prognostic findings in a truly enormous case have long been universally appreciated. The number of cases of bone tumours. It is beautifully chapter on endocrinopathies is too short to serve any produced and almost over lavishly illustrated. As useful purpose. Table 76, listing the sites of in the previous editions each type of tumour is primary carcinoma which have given rise to osseous dealt with in all its aspects, illustrated by a summary metastases, has not been altered since the first on September 26, 2021 by guest. of case records, many hundreds in number, a chart edition in I93I and in our view underestimates the of age incidence, a skeletal diagram of site in- role of bronchial carcinoma. The table cites a total cidence and numerous photographs of X-rays, of 334 cases of secondary bone carcinoma of which macroscopic and microscopic specimens. In ad- only 4 came from a primary in the bronchus in dition, the authors make a detailed and persistent contrast to 134 from prostate, ioo from breast and effort to correlate the tumour picture with disorder 22 from kidney. However, table 72 details the of varying phases of bone development; at times sites of metastases from bronchial carcinoma in carried to illogical extremes, of which the following 3,2I2 autopsied cases. The numerous misprints, statement (p. iiI) is an example:-' The clinical contradictions and repetitions lay this book open to features of primary chondrosarcoma reflect in part easy criticism, but they do not detract from the fact the primitive histogenesis of this neoplasm. The that it summarizes the findings in an impressive frequency with which Negroes are affected (approxi- collection of cases and in contrast to many textbooks mately I 5 per cent.) is unusual among the osteo- proves really helpful to the reader searching a factual genic sarcomas as a group, and suggests a lower answer to a concrete problem. evolutionary form of osteogenesis for this tumour.' I.D.