Family planning services.

The clinical picture could equally well be explained by other intramedullary lesions-for example, glioma or ependymoma and other cystic lesions of the cord. It is clearly important to be able to distinguish between these clinical possibilities so as to plan rational therapy, particularly for the cystic intramedullary tumours. Radiological studies can help to elucidate the nature of the intramedullary lesion. Plain radiographs of the cervical spine may show an abnormally wide canal. ' But it is with the advent of contrast radiological techniques, myelography, and more recently gas myelography,2 I that cystic lesions of the cervical part of the spinal cord have been detected and contrasted with the more typical collapsed intramedullary cyst of syringomyelia. In a comprehensive study A. B. Ellertsson4 5 reviews the whole problem of syringomyelia and cystic lesions of the spinal cord. The detailed case histories of 34 cases of syringomyelia were studied. They all showed dissociated sensory loss, insidious onset, slow progression, and a total protein content in the cerebrospinal fluid of less than 70 mg. per 100 ml. In 30 of the cases it was possible to show, by gas myelography and tilting the examination table so as to view the cervical canal at different angles, that they had an elongated, flaccid cyst of the spinal cord. The remaining four patients probably had syringomyelia but without the radiological evidence of a collapsed cyst. As well as the usual features all the patients with syringomyelia had their first symptom before the age of 40. That syringomyelia may be present in association with skeletal and vascular abnormalities in the foramen magnum region,6 or at least the clinical features of syringomyelia,719 is well recognized. But in Ellertsson's series, of the two cases of Arnold-Chiari deformity one showed a normal myelographic appearance and the other an atrophic spinal cord. Ellertsson5 also reviewed the clinical picture in 29 patients with an intramedullary non-fluctuating or partially fluctuating lesion of the spinal cord due to a distended cyst. The lesion was situated in the cervical region in seven and in the cervico-thoracic region in another seven. The majority were associated with a spinal glioma. Unlike the picture in syringomyelia, the combination of dissociated sensory loss with muscular atrophy in the arms and a low protein con-tent of the cerebrospinal fluid was uncommon. In particular the protein in the cerebrospinal fluid was above 70 mg. per 100 ml. in 23 of these 29 cases and above 100 mg. per 100 ml. in 17. Another point of difference between syringomyelic cavitation and other intramedullary cysts is that percutaneous puncture of the cyst or cavity did not affect the clinical course of the disease in nine patients with syringomyelia, but did benefit five out of six patients with other cystic lesions. The aetiology of syringomyelia remains obscure. Though a history of trauma may be forthcoming, it is not the rule. A congenital lesion with cavitation or with abnormal glial tissue in the centre of the cord is the most widely held explanation, but definite evidence for it is lacking except in those cases which are associated with other congenital malformation of the cervical spine.