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migraine 8 showed such evidence. Ther patients tendedto faint easily, and be subject to unusual emotionalinstability. The possibly " epileptic " nature of theirsymptoms seemed to be confirmed by their improvementwith anticonvulsant drugs. Yet we should be wary of

extending the meaning of epilepsy-if only because ofits social and psychological implications for the layman.It seems more reasonable to regard the cerebral changesin vasomotor headache as one of many factors whichmay produce either electro-encephalographic abnormalityor brief loss of consciousness in a patient whose cerebralmake-up contains an " epileptic tendency " (we havelittle direct knowledge of what this is), rather than tobring vasomotor headaches within the fold of larval

epilepsy.BONE BIOPSY

IT is generally agreed that histological diagnosis shouldusually precede treatment of a bone tumour, whetherby surgery or by radiotherapy. This necessity arisesfrom the increasing knowledge of the histopathology ofbone tumours 1-in particular the extent to which theirhistological subdivision aids prediction of clinical beha-viour-and from the unreliability of other methods ofdistinguishing effectively -between the various types oftumour-and separating these from non-neoplastic lesions.Radiographic findings, though important, are to someextent non-specific, and do not establish conclusivelythe nature of the lesion.The necessary histological information can occasionally

be obtained by localised surgical resection of the lesion,but biopsy is usually necessary before more radical

surgery or radiotherapy. Hitherto, open biopsy hasusually been practised. Its great advantage is that it

yields almost always an adequate and representativesample of the lesion. Some consider that with this methodthere is little risk of promoting metastatic spread,2 3but certainly local extension of the tumour in the biopsywound occasionally ensues. Such extension, and thebiopsy incision itself, are serious disadvantages if radio-therapy is subsequently applied. Accordingly someworkers have resorted to aspiration biopsy, by tech-niques developed not only for bones but also for othertissues and organs. These techniques 4 involve removalof tissue through a hollow needle, trephine, or drill,introduced through a small skin puncture which does notinterfere with any subsequent radiotherapy ; a generalanaesthetic is not required. The chief disadvantage ofthis method is that it yields little tissue, and thuserroneous conclusions are sometimes reached-in as

many as a third of the cases in some early series,5 6 butin a considerably smaller proportion since experience ofthe method has increased.The aspiration method was largely developed at the

Memorial Hospital in New York. 7 8 It was soon appliedto the diagnosis of bone tumours by Coley et awl.*; andits value in this field was established in 1945 by Snyderand Coley.5 5 Christiansen, 1 0 Ellis,6 and van den Brenk 4have used the rotating trephine (" drill biopsy ") forbone, as well as for soft tissues. Ottolenghi 11 andSchajowicz 12 describe from Buenos Aires experience withaspiration biopsy of bone in a series of more than 1000cases. By simple aspiration with a 2-mm. needle, positivediagnostic information was obtained in 84% of attempts.1. Lichtenstein, L. Bone Tumours. St. Louis, 1952.2. Ackermann, L. V., del Regato, J. A. Cancer. St. Louis, 1947.3. Cade, S. Ann. R. Coll. Surg. Engl. 1951, 9, 11.4. van den Brenk, H. A. S. Aust. N.Z. J. Surg. 1955, 24, 217.5. Snyder, R. E., Coley, B. L. Surg. Gynec. Obstet. 1945, 80, 517.6. Ellis, F. Brit. J. Surg. 1947, 34, 240.7. Martin, H. E., Ellis, E. B. Ann. Surg. 1930, 92, 169.8. Martin, H. E., Ellis, E. B. Surg. Gynec. Obstet. 1934, 59, 578.9. Coley, B. L., Sharp, G. S., Ellis, E. B. Amer. J. Surg. 1931,

13, 215.10. Christiansen, H. Acta radiol. Stockh. 1940, 21, 349.11. Ottolenghi, C. E. J. Bone Jt Surg. 1955, 37A, 443.12. Schajowicz, F. Ibid, p. 465.

Lesions of all types, and in almost all parts of the skeleton,were studied, only the skull base and the bodies of the1st to 10th thoracic vertebrae being inaccessible. Mostof the lesions aspirated were in the vertebral bodies,femur, or pelvis. Metastatic carcinoma and various typesof primary bone tumour were the diagnoses most oftenestablished, but various inflammatory and other non-neoplastic lesions were encountered. In this series

diagnosis depended on paraffin sections prepared fromthe aspirated material, but smears were also made andwere particularly useful in lesions of hsemopoietic tissues.The Buenos Aires workers emphasise that close collabora-tion between surgeon, radiologist, and pathologist is

necessary for the effective use of aspiration biopsy forbone lesions.

Aspiration biopsy will no doubt be increasingly usedin the diagnosis of bone lesions, particularly whereconventional bone biopsy is difficult or inadvisable,either for anatomical reasons or because radiotherapymay be applied subsequently.

COLOUR-BLINDNESS IN YOUNG PEOPLE

IT is nearly ten years since a committee of theColour Group of the Physical Society, in a report ondefective colour-vision in industry,1 suggested that school-children should be tested for colour-vision. Betenson 2

has now described the results of ten years of such testingin Brecknock schools ; so this seems a good moment toconsider the problems once again.About 8% of the male population have some defect

of colour-vision ; the colour-blind woman is compara-tively rare. The most common forms of colour defectconsist in difficulty in distinguishing differences betweenred, green, and yellow which are obvious to normal people.People with this defect are sometimes loosely calledred-green blind ; but their difficulty is not in seeing thesecolours (the relevant parts of the spectrum do not

generally seem to them white or black) but in tellingwhich is which. There is also a colour defect (tritanopia)in which blue, green, and yellow are similarly confused,and two forms of complete colour-blindness in whichthere is no appreciation of hue whatever; these lasttwo are very rare.

Often boys with grossly defective colour-vision growup unaware of their disability. Such ignorance is thecause of much disappointment and difficulty for someyouths who have specialised in their later school yearswith a view to a career in, for instance, the Navy orR.A.F. or even medicine, and who discover that owingto deficient colour-vision their choice is unsuitable or

impossible. It was on behalf of these unfortunates thatthe Colour-Group committee pleaded for tests in the earlyyears at school.

This recommendation has been taken up by theMinistry of Education and is put forward in the chiefmedical officer’s report for 1952-53 3 with the hope thatall education authorities will, in time, act on it. This

report refers to four borough and two county authoritieswhich are giving regular colour-vision tests to many ofthe children in their care. In general the Ishihara testis used alone, but in two districts this is supplementedby a lantern test for individual failures.

It seems therefore that the battle for general testing ofboys below the age when their future is decided is on theway to being won. But of equal importance is stan-dardisation of the tests. Without standardisation differentexaminers may get different results from the same

individual ; and this sometimes leads to uncertaintyand hardship. Candidates for some careers are testedbefore being accepted for training ; and then, because

1. Published by the Society, 1, Lowther Gardens, London, S.W.7.2. Betenson, W. F. W. Med. Offr, 1955, 94, 169.3. The Health of the School Child: Report of the chief medical

officer, Ministry of Education, 1952-53. H.M. StationeryOffice, 1954.

915

of an idea that colour-vision can deteriorate betweenthe ages of 16 and 20, they may have another test,often under totally different conditions, at the end ofthe training period. It is not unknown for candidates.who have been accepted for training to be rejected lateron the ground of colour deficiency. Since there is no

good scientific evidence that colour-vision deterioratesin the late teens, these rejections cause resentment aswell as disappointment.The Ministry of Education recommends an Ishihara

test supplemented where necessary (and where a darkroom is available) by a lantern test ; but the Ministryoffers no guidance as to the best method of administeringthese tests. In the Ishihara book of charts the would-beexaminer is told only that the cards should be kept outof the sun to prevent fading, and that the tests shouldnot be applied in artificial light. In addition there isan introduction in which a diagnostic value is claimedfor the test which, in fact, it does not possess. No

suggestions are given as to the best method of scoring.If properly applied the Ishihara test will detect a handi-capping colour defect affecting the red, green, and yellowparts of the spectrum. Contrary to the claim made inthe introduction, this test does not reveal the exact typeof deficiency within this group ; and people with tritan-opia can read all the charts correctly. Since themain practical object of colour-vision tests is to discoverthose who may be incompetent or even dangerous inoccupations where the difference between red and greenmust be recognised, the Ishihara test is, in general, fairlysatisfactory ; but for any investigation of the variousforms of defect a more detailed examination is essential.For those who are keen to know more of this subject,Wright gives a clear exposition in his excellent book.4

PROGRESS REPORT

IN his presidential address to the West London Medico-Chirurgical Society on Oct. 20, Mr. G. B. Woodd-Walkerdelved deep into the past and spared some words of wiseadvice and rather guarded hope for posterity.In tracing the history of mankind he reserved his

warmest admiration for man’s first slow steps in conquer-ing his.environment ; and indeed to make fire may wellhave been as difficult and as significant as to split theatom. Even half a century ago different peoples wereat widely different stages of civilisation : the Stone

Age, as Mr. Woodd-Walker pointed out, was runningits undisturbed course in such places as New Guinea andCentral Australia. But modern transport and modernmeans of communication have relentlessly brought thebenefits and dangers of what we call civilisation to thesepockets of older cultures. Whereas man acquired know-ledge and mastery over his environment slowly andpainfully, his knowledge and mastery is now beingapplied with almost terrifying speed ; in Mr. Woodd-Walker’s vivid phrase, the stone-axe head-hunter of

yesterday may be today a uniformed policeman.Now that we have solved so many of the problems

which Nature has set us, the time has come, he suggested,to consider whether we can solve the problems whichwe have set ourselves. Have we, for instance, conquereddisease only to be confounded by over-population Have we conquered distance only to be defeated by thedifficulties of living together t The varied life of thesmall communities has given way to the complex mono-tony of our vast agglomerations, and Mr. Woodd-Walkeradmitted that he found the uniformity of contemporarycivilisation depressing. Of new suburbs he said :

" The few local shops have given way to branches of thedozen big retail stores. The grocer, the shoe-shop, and therest, with their too familiar names and standard products,stand shoulder to shoulder in every new shopping-centre.4. Wright, W. D. Researches on Normal and Defective Colour

Vision. London, 1946.

And the new houses, whether council or private, display thesame uniformity in their construction and the taste of theirinmatea." "

Yet though so many of us lead similar lives, he fearsthat we are as far as ever from understanding how ourneighbours feel and think-and today our neighbourslive all over the globe. To improve the transmissionof facts and of ideas is, in his view, the next urgenttask that faces mankind. If we are to solve it in timewe must be prepared, he suggested, to grasp new methods,to free ourselves from the limitation of language, and touse visual and photographic statements more boldly.Mr. Woodd-Walker believes that " thought can andshould be transmitted graphically and pictorially withminimal use of words."

,

CORTICOTROPHIN AND CORTISONE IN THENEPHROTIC SYNDROME

CORTICOTROPHIN and cortisone are now widely usedin the treatment of the nephrotic syndrome, especially inthe variety which Ellis 1 called " type-2 nephritis." Thecause of this condition is unknown, and at the onsetit does not have the serious complications of hyper-tension, haematuria, and nitrogen retention. As the

syndrome is commonest in children,2 more is known ofthe results of treatment in children than in adults.

Heymann et al.3 have recorded the results in a series of64 children treated by repeated short courses, lasting from10 to 12 days, of either cortisone or corticotrophin.Diuresis was obtained in 52 patients, usually during theactual administration of the drugs. Only 13 of thechildren received more than four separate courses oftreatment, and the average length of remission was 4.2months after corticotrophin and 2.6 months after corti-sone. Of patients who eventually died of renal failure,there was diuresis in only a half and it became steadilyless frequent as the condition deteriorated. Heymannand his colleagues conclude that hormone treatment hasgreatly reduced the morbidity of the disease, sinceoedema can usually be kept under control, but theyconsider that the eventual mortality-rate remainsunaffected. 17 of the children have already died, and afatal outcome is expected in another 6. This correspondsvery closely with a similar series 4 reported in 1946 beforecortisone and corticotrophin became available ; and theresults are much the same as those previously des-cribed 2 5-7 with cortisone and corticotrophin.

Because of the frequency of relapse after short coursesof treatment, hormones are often continued after diuresishas started. Lange et al.8 have given the results of longerperiods of treatment lasting up to six or seven months.They gave corticotrophin or cortisone in large doses forthree consecutive days of each week, to diminish toxicside-effects. Long remissions followed, and no relapsewas noted while treatment continued. Proteinuria wasmuch reduced and the plasma-protein pattern and raisedblood-cholesterol returned to normal. Complications oftreatment are not rare,6 and they include intercurrentinfection, hypertension, and hypokalsemia. Prophylacticpenicillin and a low-sodium diet with potassium supple-ments were found to be of great value. No large series ofadults treated with corticotrophin or cortisone has beenpublished, but it is generally agreed that the outlook ismore unfavourable than in children.1. Ellis, A. Lancet, 1942, i, 1.2. Barnett, H. L., Forman, C. W., Lauson, H. D. Advanc. Pediat.

1952, 5, 53.3. Heymann, W., Spector, S., Matthews, L. W., Shapiro, D. J.

Amer. J. Dis. Child. 1955, 90, 22.4. Heymann, W., Startzman, V. J. Pediat. 1946, 28, 117.5. Riley, C. M. J. Amer. med. Ass. 1952, 150, 1288.6. Metcoff, J., Rance, C. P., Kelsey, D. W., Nakasone, N., Janeway,

C. A. Pediatrics, N.Y. 1952, 10, 543.7. Rapoport, M., McCrory, W. W., Barbero, G., Barnett, H. L.,

Forman, C. W., McNamara, H. J. Amer. med. Ass. 1951,147, 1101.

8. Lange, K., Slobody, L., Strang, R. Pediatrics, N.Y. 1955,15, 156.