A post mortem material of 11 consecutive cases of severe atlanto-axial dislocation (a.a.d.) with cord compression is reported. The total number of deaths from rheumatoid arthritis (RA) during the period of 5 years was 104, and all were autopsied. Neurological symptoms correlated poorly to fatal a.a.d. Hemiplegia was found in three cases, one of which, however, was caused by thrombosis cerebri. Spastic signs were transiently recorded in two patients and dysphagia in a further two. Five patients had a history of recent vomiting. A.a.d. was the sole or main cause of death in 8 cases and contributory in 2. Sudden death occurred in 7 of the cases. Only 2 cases had obtained a correct diagnosis intra vitam. The CNS findings at autopsy consisted of cord compression (11/11 cases), cord malacia (2/11) and cerebral oedema (3/11). One case had polyarteritis and renal amyloidosis and one pulmonary carcinoma with metastatic spread. Signs of active inflammation in the axial joints were present in 4 cases. This study, based on systematic post mortem examinations, revealed an unexpectedly high and not previously reported incidence of fatal medulla compression in RA patients with a.a.d. (10%).Atlanto-axial dislocation (a.a.d.) is a well known feature in rheumatoid arthritis (RA), occurring in not less than 25% of most hospital series (4, 13). The natural history in the latter retrospective study seems to indicate that on the whole the afflicted patients d o not have a higher mortality rate than RA cases without C 1-2 instability. Furthermore, spinal cord compression was only seen in 3 of 52 deaths.However, one weakness of this and other studies lies in the lack of consistent post mortem examination with a suitable technique enabling the visuali-zation of the cervical spinal tract. We here report on 1 I cases of autopsy-proven cord compression, found during a limited period of 5 years in a general hospital for chronic diseases, indicating a greater ultimate importance of this condition than is generally appreciated. Clinical warning signs were sought retrospectively from the records. MATERIAL AND METHODSThe cases emanated from a hospital for chronic disease serving a city population of approximately 250000 inhabitants. The number of beds and of RA patients cared for each year are shown in Table I. The autopsy rate was 90% and the autopsies were performed with a standardized technique, mostly by one and the same pathologist. The foramen occipitale region was examined in all cases regardless of clinical diagnosis. Cases of minor translocation of the odontoid process without obvious cord compression were not included in this study. I n 8 of the 11 cases blocks were removed containing the upper cervical spine and an adjacent part of the skull base. The specimens were fixed in formalin, sawed sagitally, decalcified and examined histologically. The compressed medullas and brains were examined by routine histological methods. Table I shows the number of all autopsies in the hospital during 1969-74 to be around 500 each year. The number of...

We followed 657 primary bladder carcinoma patients for at least 10 years or until death. Subsequent carcinomas of the renal pelvis or ureter were found in 11 patients (1.7 per cent) 10 months to 13 years after the primary bladder tumor. In 3 patients the tumors were diagnosed or suspected by excretory urography, while in 5 the tumors were not found until autopsy. Four patients had undergone cystectomy and 9 had multiple bladder tumors at the initial assessment or during followup. The initial or recurrent bladder tumor involved the ipsilateral ureteral orifice in 6 patients. We conclude that in bladder cancer patients routine excretory urography is not indicated in the absence of upper urinary tract symptoms but it should be performed in selected patients, that is those with multiple and recurrent bladder tumors or tumors involving the ureteral orifices, or those with a previous cystectomy.

Nine cases of primary malignant melanoma of the penis and male urethra are presented. The age range of the patients was 57-77 years. Five patients had intermittent bleeding, one had pain, and three were asymptomatic. Six patients had the melanoma on the glans or prepuce and three in the urethra; two presented with inguinal lymph node metastases. Penile amputation was performed in six patients, local excision in three, groin dissection in four, and one was given radiotherapy. Postoperative metastases were seen in eight patients, four of whom were treated with surgery, alone or in combination with radiotherapy, and one with chemotherapy. Two patients are still living, at 2 and 14 years after diagnosis, respectively. Seven patients have died of their tumors, five of them within 2 years. This confirms the consensus of available reports that, irrespective of what type of therapy is used, prognosis is poor in patients with malignant melanoma of the penis and urethra.

Well-differentiated urothelial carcinoma (G1) has no propensity to infiltrate the bladder mucosa. For investigating specific problems the data collected in the Swedish Urinary Bladder Cancer Registry have to be validated.

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