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Chondrodysplasia
New
S&es VOL. II.
No.
2
Progress
was a carcinoma. The author emphasizes the fact that it is dangerous to judge of the nature of a Iesion from the roentgen examination aIone. E. A. Registry of bone sarcoma. Surg., Gynec. Ed Obst., March, 1926, xiii, 38 I-393. Five criteria are furnished by the histories of ,osteogenic sarcoma cases: (I) if pain precedes other symptoms one may suspect that the case is one of osteogenic sarcoma; (2) if the patient has sought advice in Iess than a month or more than a year from the onset of symptoms one may suspect that the case is not one of osteogenic sarcoma; (3) if the patient is considered m good heaIth just before onset one may suspect osteogenic sarcoma; (4) osteogenic sarcoma has never been observed in any patient over fifty years of age except cases having a coincident Paget’s disease; (5) osteogenic sarcomas as a -ruIe show steady enIargement, practically aIways noticeabIe in a month. Five additiona criteria are furnished by the examination : (I) osteogenic sarcoma aImost always causes a pecuiiar fixation of the soft parts; (2) the situation of a tumor may direct suspicion to osteogenic sarcoma; (3) typica osteogenic sarcoma does not present, especialIy in its early stages, pronounced fever, tenderness, redness, Ieucocytosis, etc. Such symptoms may occur in exceptiona cases. Radiation may produce them temporarily; (4) ,osteogenic sarcoma rareIy invades neighboring joints unti1 Iate in the course of the disease. Presence of the tumor does not invoIve the motion of the joint except in proportion to the fixation of the soft parts; (5) if a tumor is not ,of considerabIe size or if it is peduncuIated, one may suspect it to be not an osteogenic sarcoma. The roentgen ray furnishes five fairIv constant criteria: (1) combined centra1 an& subperiostea1 invoIvement. The IittIe cuff of reactive bone of trumpet shape which surrounds the upper Iimit of the tumor appears in the roentgenogram as a trianguIar space on each side of the shaft under the upIifted periostea1 edge. The presence of this is a sure indication of subperiostea1, extracortica1 invoIvement. The same phenomenon sometimes occurs as a defense reaction against infIammation, so that this reactive triangIe in itseIf is not diagnostic of sarcoma. (2) The presence of oId shaft, -in osteogenic sarcoma the perforation of the cortex seems to be, as a ruIe, transverse from within outward radiaIIy through the cortex, or perhaps in the opposite direction. There is no cIue as to whether they start inside or outside the cortex. If new bone forms it foIIows these radiating Iines. One must think of these radi-
,CODMAN,
in Surgery
American Jour~lal OFSurgery
199
ating Iines not as they show in the roentgenogram as spicuIes but as they reaIIy are in the gross specimen as ridges or osteophytes of irreguIar form on the surface of the cortex. (3) Invasive character,-osteogenic sarcoma &ances by the invasion of the ceIIs and the margin is irregular. (4) The typica roentgenogram shows the tumor to be both osteoIytic and osteobIastic, although in rare cases, when far advanced, these tumors may be of onIy one type. The frequency of the sign of spicuIe formation is not enough to form a ruIe, and the absence of it is not very strong evidence against osteogenic sarcoma. (5) InvoIvement of soft parts,-this is a diffIcuIt point on which to interpret the roentgenogram. A tumor which does not show in the roentgenogram either invasion of the soft parts or the reactive triangIe may perhaps not be an osteogenic sarcoma. The microscope furnishes five additiona criteria: (I) mitoses and hyperchromatism; (2) pIeomorphism; (3) tumor giant ceIIs; (4) differentiation; (5) vascuIar arrangement within the tumor. In concIusion there are five genera1 criteria of maIignancy in bone tumor which appear to be important: (I) the nature of the pathoIogica1 examination; (2) the quality of the data; (3) the unanimity of the different specialists; (4) the Registry dassification; (5) the ultimate resuIt. Brief summaries are given of 13 cases of five year cures of osteogenic sarcoma. The site in a11 cases was either the tibia or femur, and amputation was performed in a11 but one case. In 5 cases the credit for cure must be given to amputation aIone, except that one of these aIso received diffuse roentgenization by the Murphy method. CoIey’s toxins were used in at Ieast 5 of the cases, usuaIIy in conjunction with radiation. In one case the cure must be credited to either the toxins or radium, or both. These 13 cases represent the best evidence of five year cures so far coIIected by the Registry of Bone Sarcoma. COLE, WALLACE H. ChondrodyspIasia. Surg., Gynec. CY Obst., March, 1926, xiii, 359-365.
OIIier’s disease is a term which seems fixed in the Iiterature but which shouId be used onIy to designate those cases of cartiIaginous dystrophy with or without cartiIaginous tumor or exostosis formation which show an asymmetrical involvement of the body as the distinct cIinica1 feature. ChondrodyspIasia is a condition which may be either symmetrica or asymmetrica1. A report is given of a case occurring in a gir1 aged eIeven. A roentgen study of the skeIeton discIosed a pecuIiar condition present most
200
American Journd of Surgery
Progress
prominentIy in the right ihum, femur, tibia and second metatarsa1 bone. The upper extremities and spine were apparentIy negative. The right iIium showed in its wing a vacuoIated area with increased density around it and rarefied areas above the acetabuIum. The pubic bone showed sIight simiIar changes. The right femur was much shorter and thicker than norma1 and two Iarge tumor masses were present, one apparentIy originating from the shaft near its center, and causing distortion, with a smoothIy surfaced, sIightIy irreguIar vacuoIated mass projecting mediaIIy, and the other occupying the Iower end of the bone and causing a symmetrica sweIIing with intact outIine but showing in its body a very striking mottIed appearance. The upper and Iower ends of the right tibia showed sweIIings simiIar to that in the Iower end of the femur. The fibuIa was apparentIy not invoIved and was consequentIy very Iong in comparison to the shortened and thickened tibia. The first and second metatarsa1 bones and the phaIanges of the great and second toes and to a Iesser extent of the other toes of the right foot were invoIved and showed a series of vacuoIated areas with dense striations in and around them. The shortening of the second toe was seen to be due to the condition in the second metatarsa1 bone. The Ieft femur showed a sIight thickening and spindIe-Iike enIargement in its middIe and the upper end of the shaft, and the neck showed dehnite rarefied areas with no tumor formation. A biopsy was performed and a portion of the tumor mass in the upper end of the tibia was removed and examined. A diagnosis of chondrodyspIasia with the formation of osteochondroma was made, the benign character of the Iesion being assumed. No treatment seemed to be indicated. H. R. Fractures of the OS caIcis: diagnosis and treatment. Radiology, March, 1926, vi, 228-235.
CONN,
Fractures of the OS caIcis are serious and disabIing injuries in which the end resuIts continue to be “incredibIy bad.” The Iesions divide themseIves on a basis of the predominating deformity into five major groups with specific indications for surgica1 treatment. These groups are: (I) an eversiGn of the bone with a more mesia1 deff ection of the weight bearing Iine; (2) upward dispIacement of that portion of the posterior tuberosity serving as the attachment for the AchiIIes tendon; (3) impactions resuIting in shortening and upward dispIacement of the posterior tuberosity, without separation of the AchiIIes tendon; (4) serious distortion of the reciprocal articuIating surfaces; and (5) those
in Surgery cases in which by reason of the Iocation or because of destructive comminution non-union is impending or present. It is important to the patient that the roentgenoIogist recognize the major deformity which presents itseIf and acquaint the surgeon with its presence and signihcance. The mere discovery of a soIution in the continuity of the caIcaneum in no manner discharges the roentgenoIogist’s obIigation. The surgeon is entitIed to a stereoscopic IateraI view of the suspected OS caIcis, and a view taken through the posterior tuberosity in the anteroposterior pIane. The ancient cases in which earIy treatment has terminated unhappiIy demand equaIIy carefu1 roentgenography and perhaps an even better appreciation of the significance of the major deformities. Roentgenograms shouId be taken so as to revea1 both the IateraI and perpendicuIar deviations which may be present. The indications for treatment are entireIy dependent upon the recognition of the predominating deformity or combination of deformities. In the recent Iesions, procrastination, attempts at manua1 reduction, and ineffectua1 immobilization shouId be abandoned for the more radica1 and efficient direct traction procedures, tenotomy of the hee1 cord and, when indicated, sub-astragaIoid arthrodesis. AppIied to both the recent and the ancient cases, sub-astragaIoid arthrodesis deserves a much more genera1 acceptance than it is now accorded. DANDY, WALTER E. The diagnosis of brain tumors. J. Iowa State M. Sot., March, 1926, xvi, 101-102. In the group of brain tumors that cannot be IocaIized by the usua1 methods of neuroIogica1 and roentgenoIogica1 examination, comprising at Ieast 35 per cent of a11 brain tumors, the IocaIization can now be made by injecting air into the spaces of the brain. The procedure consists in withdrawing cerebrospina1 fluid from a IateraI ventricIe, injecting air and taking roentgenograms of the head in various positions in order to show the various parts of the ventricular system. From the changes which are found by contrast with the norma cerebra1 ventricIes the expert is abIe to deduce the situation of the tumor. This is not to say that a11 brain tumors distort or change the size, shape or position of the ventricIes, but that a11brain tumors which give symptoms of pressure produce one or more of these changes which shouId make a diagnosis possibIe. There is one group of tumors in which the use of air is Iess absoIute. This is the group which gives a biIatera1 hydrocephaIus and in which two IateraI ventricles communicate freeIy. A11 one can say from the ventricuIograms is that
S&es VOL. II.
No.
2
Progress
was a carcinoma. The author emphasizes the fact that it is dangerous to judge of the nature of a Iesion from the roentgen examination aIone. E. A. Registry of bone sarcoma. Surg., Gynec. Ed Obst., March, 1926, xiii, 38 I-393. Five criteria are furnished by the histories of ,osteogenic sarcoma cases: (I) if pain precedes other symptoms one may suspect that the case is one of osteogenic sarcoma; (2) if the patient has sought advice in Iess than a month or more than a year from the onset of symptoms one may suspect that the case is not one of osteogenic sarcoma; (3) if the patient is considered m good heaIth just before onset one may suspect osteogenic sarcoma; (4) osteogenic sarcoma has never been observed in any patient over fifty years of age except cases having a coincident Paget’s disease; (5) osteogenic sarcomas as a -ruIe show steady enIargement, practically aIways noticeabIe in a month. Five additiona criteria are furnished by the examination : (I) osteogenic sarcoma aImost always causes a pecuiiar fixation of the soft parts; (2) the situation of a tumor may direct suspicion to osteogenic sarcoma; (3) typica osteogenic sarcoma does not present, especialIy in its early stages, pronounced fever, tenderness, redness, Ieucocytosis, etc. Such symptoms may occur in exceptiona cases. Radiation may produce them temporarily; (4) ,osteogenic sarcoma rareIy invades neighboring joints unti1 Iate in the course of the disease. Presence of the tumor does not invoIve the motion of the joint except in proportion to the fixation of the soft parts; (5) if a tumor is not ,of considerabIe size or if it is peduncuIated, one may suspect it to be not an osteogenic sarcoma. The roentgen ray furnishes five fairIv constant criteria: (1) combined centra1 an& subperiostea1 invoIvement. The IittIe cuff of reactive bone of trumpet shape which surrounds the upper Iimit of the tumor appears in the roentgenogram as a trianguIar space on each side of the shaft under the upIifted periostea1 edge. The presence of this is a sure indication of subperiostea1, extracortica1 invoIvement. The same phenomenon sometimes occurs as a defense reaction against infIammation, so that this reactive triangIe in itseIf is not diagnostic of sarcoma. (2) The presence of oId shaft, -in osteogenic sarcoma the perforation of the cortex seems to be, as a ruIe, transverse from within outward radiaIIy through the cortex, or perhaps in the opposite direction. There is no cIue as to whether they start inside or outside the cortex. If new bone forms it foIIows these radiating Iines. One must think of these radi-
,CODMAN,
in Surgery
American Jour~lal OFSurgery
199
ating Iines not as they show in the roentgenogram as spicuIes but as they reaIIy are in the gross specimen as ridges or osteophytes of irreguIar form on the surface of the cortex. (3) Invasive character,-osteogenic sarcoma &ances by the invasion of the ceIIs and the margin is irregular. (4) The typica roentgenogram shows the tumor to be both osteoIytic and osteobIastic, although in rare cases, when far advanced, these tumors may be of onIy one type. The frequency of the sign of spicuIe formation is not enough to form a ruIe, and the absence of it is not very strong evidence against osteogenic sarcoma. (5) InvoIvement of soft parts,-this is a diffIcuIt point on which to interpret the roentgenogram. A tumor which does not show in the roentgenogram either invasion of the soft parts or the reactive triangIe may perhaps not be an osteogenic sarcoma. The microscope furnishes five additiona criteria: (I) mitoses and hyperchromatism; (2) pIeomorphism; (3) tumor giant ceIIs; (4) differentiation; (5) vascuIar arrangement within the tumor. In concIusion there are five genera1 criteria of maIignancy in bone tumor which appear to be important: (I) the nature of the pathoIogica1 examination; (2) the quality of the data; (3) the unanimity of the different specialists; (4) the Registry dassification; (5) the ultimate resuIt. Brief summaries are given of 13 cases of five year cures of osteogenic sarcoma. The site in a11 cases was either the tibia or femur, and amputation was performed in a11 but one case. In 5 cases the credit for cure must be given to amputation aIone, except that one of these aIso received diffuse roentgenization by the Murphy method. CoIey’s toxins were used in at Ieast 5 of the cases, usuaIIy in conjunction with radiation. In one case the cure must be credited to either the toxins or radium, or both. These 13 cases represent the best evidence of five year cures so far coIIected by the Registry of Bone Sarcoma. COLE, WALLACE H. ChondrodyspIasia. Surg., Gynec. CY Obst., March, 1926, xiii, 359-365.
OIIier’s disease is a term which seems fixed in the Iiterature but which shouId be used onIy to designate those cases of cartiIaginous dystrophy with or without cartiIaginous tumor or exostosis formation which show an asymmetrical involvement of the body as the distinct cIinica1 feature. ChondrodyspIasia is a condition which may be either symmetrica or asymmetrica1. A report is given of a case occurring in a gir1 aged eIeven. A roentgen study of the skeIeton discIosed a pecuIiar condition present most
200
American Journd of Surgery
Progress
prominentIy in the right ihum, femur, tibia and second metatarsa1 bone. The upper extremities and spine were apparentIy negative. The right iIium showed in its wing a vacuoIated area with increased density around it and rarefied areas above the acetabuIum. The pubic bone showed sIight simiIar changes. The right femur was much shorter and thicker than norma1 and two Iarge tumor masses were present, one apparentIy originating from the shaft near its center, and causing distortion, with a smoothIy surfaced, sIightIy irreguIar vacuoIated mass projecting mediaIIy, and the other occupying the Iower end of the bone and causing a symmetrica sweIIing with intact outIine but showing in its body a very striking mottIed appearance. The upper and Iower ends of the right tibia showed sweIIings simiIar to that in the Iower end of the femur. The fibuIa was apparentIy not invoIved and was consequentIy very Iong in comparison to the shortened and thickened tibia. The first and second metatarsa1 bones and the phaIanges of the great and second toes and to a Iesser extent of the other toes of the right foot were invoIved and showed a series of vacuoIated areas with dense striations in and around them. The shortening of the second toe was seen to be due to the condition in the second metatarsa1 bone. The Ieft femur showed a sIight thickening and spindIe-Iike enIargement in its middIe and the upper end of the shaft, and the neck showed dehnite rarefied areas with no tumor formation. A biopsy was performed and a portion of the tumor mass in the upper end of the tibia was removed and examined. A diagnosis of chondrodyspIasia with the formation of osteochondroma was made, the benign character of the Iesion being assumed. No treatment seemed to be indicated. H. R. Fractures of the OS caIcis: diagnosis and treatment. Radiology, March, 1926, vi, 228-235.
CONN,
Fractures of the OS caIcis are serious and disabIing injuries in which the end resuIts continue to be “incredibIy bad.” The Iesions divide themseIves on a basis of the predominating deformity into five major groups with specific indications for surgica1 treatment. These groups are: (I) an eversiGn of the bone with a more mesia1 deff ection of the weight bearing Iine; (2) upward dispIacement of that portion of the posterior tuberosity serving as the attachment for the AchiIIes tendon; (3) impactions resuIting in shortening and upward dispIacement of the posterior tuberosity, without separation of the AchiIIes tendon; (4) serious distortion of the reciprocal articuIating surfaces; and (5) those
in Surgery cases in which by reason of the Iocation or because of destructive comminution non-union is impending or present. It is important to the patient that the roentgenoIogist recognize the major deformity which presents itseIf and acquaint the surgeon with its presence and signihcance. The mere discovery of a soIution in the continuity of the caIcaneum in no manner discharges the roentgenoIogist’s obIigation. The surgeon is entitIed to a stereoscopic IateraI view of the suspected OS caIcis, and a view taken through the posterior tuberosity in the anteroposterior pIane. The ancient cases in which earIy treatment has terminated unhappiIy demand equaIIy carefu1 roentgenography and perhaps an even better appreciation of the significance of the major deformities. Roentgenograms shouId be taken so as to revea1 both the IateraI and perpendicuIar deviations which may be present. The indications for treatment are entireIy dependent upon the recognition of the predominating deformity or combination of deformities. In the recent Iesions, procrastination, attempts at manua1 reduction, and ineffectua1 immobilization shouId be abandoned for the more radica1 and efficient direct traction procedures, tenotomy of the hee1 cord and, when indicated, sub-astragaIoid arthrodesis. AppIied to both the recent and the ancient cases, sub-astragaIoid arthrodesis deserves a much more genera1 acceptance than it is now accorded. DANDY, WALTER E. The diagnosis of brain tumors. J. Iowa State M. Sot., March, 1926, xvi, 101-102. In the group of brain tumors that cannot be IocaIized by the usua1 methods of neuroIogica1 and roentgenoIogica1 examination, comprising at Ieast 35 per cent of a11 brain tumors, the IocaIization can now be made by injecting air into the spaces of the brain. The procedure consists in withdrawing cerebrospina1 fluid from a IateraI ventricIe, injecting air and taking roentgenograms of the head in various positions in order to show the various parts of the ventricular system. From the changes which are found by contrast with the norma cerebra1 ventricIes the expert is abIe to deduce the situation of the tumor. This is not to say that a11 brain tumors distort or change the size, shape or position of the ventricIes, but that a11brain tumors which give symptoms of pressure produce one or more of these changes which shouId make a diagnosis possibIe. There is one group of tumors in which the use of air is Iess absoIute. This is the group which gives a biIatera1 hydrocephaIus and in which two IateraI ventricles communicate freeIy. A11 one can say from the ventricuIograms is that