Shoulder:Tumors and Related Conditions - Revision history

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Alexandre.laedermann at 12:04, 22 June 2021

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 REFERENCES
-The Registry of Bone Sarcoma of the American College of Surgeons at 40 East Erie St., Chicago, maintains an up-to-date bibliography of the subjects considered in this chapter.
+''The Registry of Bone Sarcoma of the American College of Surgeons at 40 East Erie St., Chicago'', maintains an up-to-date bibliography of the subjects considered in this chapter.
-It seems to me that Kolodny's book, which is in fact an official publication of the Registry and which may be obtained from the American College of Surgeons, 40 East Erie Street, Chicago, 111., covers the subject of malignant bone tumors in general, better than any other publication which has come to my attention. I regard it as unfortunate for progress in knowledge of this subject, that Geschickter and Copeland in a more recent book (published by the American Society for the Control of Cancer, 1932) have taken the responsibility of making radical changes in the classification which has been offered by the Registry as a standard. If the authors had registered cases illustrative of their new nomenclature, or better still had re-classified the Registry cases with publication of the Registry numbers, their book would have been more instructive to the members of the committee and to future students. However, the book is evidence of a great deal of painstaking study, and I am sure that the other members of the committee feel as I do that it deserves praise and not blame, even though it seems to ignore the nomenclature at which we had unanimously arrived after days of discussion. We welcome any addition to the world's knowledge concerning malignant tumors of bone, but we would like to have illustrative cases of new entities registered as examples, or to have our attention directed to specific instances of our errors in classifying our old cases. We know that the future will show in many of our cases that our opinions, written before the final result in each case was known, will prove to be wrong. That is a part of the game we undertook to play. Changing the rules during the game, on mere authority without registered example, seems a little childish.
+It seems to me that ''Kolodny's book,'' which is in fact an official publication of the Registry and which may be obtained from the American College of Surgeons, 40 East Erie Street, Chicago, 111., covers the subject of malignant bone tumors in general, better than any other publication which has come to my attention. I regard it as unfortunate for progress in knowledge of this subject, that ''Geschickter and Copeland'' in a more recent book (published by the American Society for the Control of Cancer, 1932) have taken the responsibility of making radical changes in the classification which has been offered by the Registry as a standard. If the authors had registered cases illustrative of their new nomenclature, or better still had re-classified the Registry cases with publication of the Registry numbers, their book would have been more instructive to the members of the committee and to future students. However, the book is evidence of a great deal of painstaking study, and I am sure that the other members of the committee feel as I do that it deserves praise and not blame, even though it seems to ignore the nomenclature at which we had unanimously arrived after days of discussion. We welcome any addition to the world's knowledge concerning malignant tumors of bone, but we would like to have illustrative cases of new entities registered as examples, or to have our attention directed to specific instances of our errors in classifying our old cases. We know that the future will show in many of our cases that our opinions, written before the final result in each case was known, will prove to be wrong. That is a part of the game we undertook to play. Changing the rules during the game, on mere authority without registered example, seems a little childish.
 #''Bone Sarcoma''; Prevalence in Massachusetts. Bos. Med. 4- Surg. Jour., 1922, Vol. 187, pp. 208-211 and pp. 543-545.

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 The American College of Surgeons has widely advertised the Registry of Bone Sarcoma and has made repeated appeals to surgeons, rontgenologists and pathologists to register their records of instances of this disease. This propaganda has continued over ten years, and some $20,000 has been spent. Yet only 1,335 cases have been collected and studied. Only 655 of these are true osteogenic sarcomas. The Laboratory of Surgical Pathology at Johns Hopkins, together with Dr. Bloodgood's personal collection, had at ''their latest report only about 400 case'' histories of osteogenic sarcoma after more than thirty years. ''Coley'', after forty years of the most arduous polemics in favor of his toxins and yearly papers before scientific societies as propaganda, has probably seen more cases than any other surgeon in the world. Yet, in a recent paper, he states that the combined records of the Hospital for Ruptured and Crippled and of the Memorial Hospital since 1890 show 855 cases. This included all forms diagnosed as bone sarcoma, and perhaps many were not sarcoma at all. ''Greenough, Simmons and Harmer found'' that in the Massachusetts General Hospital in a ten-year period, there were only twenty-seven cases of osteogenic sarcoma, although many other cases had been erroneously diagnosed as such. Since many of the cases of Bloodgood, Coley, Greenough, et al., are among those registered, the total number is not great. In 1922 from a postal card canvass of the doctors in Massachusetts it was estimated that at any one time there were not more than one of these cases in 100,000 of the population alive in this state.
-According to the best information at present available (March,1933) at the Massachusetts State Board of Health, there are not more than four cases of bone sarcomas in every 100,000 persons now living in Massachusetts. This estimate is based on the fact that in 1932 there were 58 deaths said to be from this cause reported from a population of somewhat over 4,200,000. If the average duration of life after the development of a bone sarcoma be assumed to be three years, we may estimate that at any one time there are about 3 x 58 = 174 persons in the state who have this disease. This is likely to be a maximum estimate because we may be confident that some of these 58 cases were probably erroneously diagnosed bone metastases from cancer, so that the real figure is somewhere between that arrived at by my postal card canvass and this one from the Board of Health statistics; i.e., between one and four per every 100,000 of population.
+According to the best information ''at present available (March,1933)'' at the Massachusetts State Board of Health, there are not more than four cases of bone sarcomas in every 100,000 persons now living in Massachusetts. This estimate is based on the fact that in 1932 there were 58 deaths said to be from this cause reported from a population of somewhat over 4,200,000. If the average duration of life after the development of a bone sarcoma be assumed to be three years, we may estimate that at any one time there are about 3 x 58 = 174 persons in the state who have this disease. This is likely to be a maximum estimate because we may be confident that some of these 58 cases were probably erroneously diagnosed bone metastases from cancer, so that the real figure is somewhere between that arrived at by my postal card canvass and this one from the Board of Health statistics; i.e., between one and four per every 100,000 of population.
 These figures show that either the profession is excessively remiss in consulting experts on this disease and in recording their cases, or that the disease is an extremely rare one, notwithstanding the immense literature which has grown up about it. Yet the courts continue to give credence to expert testimony that in particular cases particular traumas cause particular bone sarcomas. How can any expert be justified in such statements when the disease is so rare? Trauma is an everyday event to normal boys and girls, and to many adults. Consider the frequency of traumas compared to the frequency of bone sarcoma.
 How severe must a trauma be to act as a potential cause for one of these tumors? Theoretically, as a minimum, only of sufficient degree to stimulate the process of repair, and from that point up to a complete fracture of the bone. Certainly it does not vary directly as to the degree oi injury, because thousands and thousands of people fracture their bones and it is almost unknown to have a sarcoma develop at once at the site of fracture. Moreover, many cases are recorded where an X-ray taken immediately after the injury has shown signs of a sarcoma already at the site of fracture. The degree of trauma sufficient to make an ordinary black and blue spot, which necessarily causes discoloration of tissue and bleeding beneath the skin, would surely be sufficient to start the process of repair. We may, therefore, accept an ordinary bruise as a trauma of sufficient degree to initiate the repair process, which, either lacking a normal check or becoming unduly stimulated, runs wild and might become a sarcoma. What is the relative frequency of black and blue spots to sarcoma in 100,000 individuals? I think any mother or father who has noticed these spots on their children, even if only on Saturday nights during the few years that the bath is given and not taken, would agree that 10,000 bruises in a lifetime would not be an excessive estimate for each individual.

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 <br />
-'''Relation of Pathologic Conditions to X-ray Appearances.'''
+'''Relation of Pathologic Conditions to X-ray Appearances'''
 As a first step in this study of the Registry cases all the X-rays of the 144 cases were taken out of the envelopes and arranged on tables, classifying them according to this chart from X-ray diagnosis alone. In very few cases was there any difficulty in putting them in their proper places. I also had the same experience with an independent examination of the slides. Then the clinical histories and the written opinions of the pathologists who had examined the slides and the Registry classification of each case were compared. In the main, from whatever angle I approached, I found I could make the diagnosis and prognosis.  Either from an excellent X-ray or an excellent slide, and in most cases from an excellent clinical history alone, the diagnosis could be made. Most of the difficulties came from incomplete or poor technique. Very few cases were registered with excellent data in all three respects.
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 Dr. Phemister (''Surg., Gynec. & Obstet., January, 1930, p. 234'') recently brought up the question of whether chondro-sarcoma should not be separated from the other forms of osteogenic sarcoma as a clinical entity. He feels that if an osteogenic sarcoma is largely composed of cartilage, the natural history of the case is longer and the prognosis of operation better. I do not agree with his point at present, but other members of the Registry Committee do. If we go back to the old nomenclature of chondro-sarcoma, we shall also have to go back to osteo- and fibro- and then to their mixtures. We should wait for a demonstration of some distinct difference in the clinical course of the chondromatous type in its way of responding to treatment before we accept Phemister's suggestion. We have only a handful of cures of all forms of osteogenic sarcoma in all parts of the body, and the chondro-type forms no large proportion of these. It may be that any fully differentiated form, whether osteo- or chondro- or fibro- has a better prognosis than the usual case, which generally contains a mixture of all three intercellular substances. However, this theory is not borne out by the tumors of the shoulder bones, for only one is still living as a five-year cure and this is Phemister's Case No. 812. His other case, No. 1,031, I do not consider a sarcoma, but as a giant cell tumor, and will discuss it later in this chapter. Other than this frail evidence, there is none to encourage his suggestion, so far as the shoulder bones are concerned, unless the group of epiphyseal giant cell tumors is included as showing instances of chondro-sarcoma. In Geschickter's opinion this should be done.
-'''Ewing's Sarcoma.'''
+'''Ewing's Sarcoma'''
 Osteogenic sarcomas of the upper end of the humerus are pretty uniformly confined to the metaphysis as opposed to Ewing's sarcoma, which involves the shaft (diaphysis) from epiphysis to epiphysis. Two cases of osteogenic sarcoma, No. 852 and No. 1,002, extend well down the shaft, but the radiating spicules are much longer than in any cases of Ewing's sarcoma, in which the spicules, if present at all, are only about one-fourth inch in length. One may pretty safely say that most sarcomas involving the shaft of the bone will be Ewing's, and that Ewing's sarcomas do not occur in the upper end of the bone without showing involvement of the major portion of the shaft.
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 Film and schematic drawing of method of invasion of Ewing's sarcoma. The tumor involves the shaft of the bone, invades between the lamellae and destroys the trabeculae even in the cortex. It stimulates defensive periosteal new bone, which it may in part destroy, although new layers form again in defense; hence the "onionlike layers." A cross section of such a bone would show that this process is centrifugal, so that the whole shaft appears somewhat widened
-'''Multiple Myeloma.'''
+'''Multiple Myeloma'''
 We may readily dispose of this lesion in a differential diagnosis of pain in the shoulder. The X-ray appearance is characteristic and it does not involve the head alone, but extends down the medulla or forms lacunae in the cortex. It is among the few really endosteal tumors. It is truly inter- and intra-cortical, and advances in the spongiosa and medulla more definitely than is characteristic of any other tumor, even of a cancerous metastasis, the bone tumor which most resembles it in the X-ray. Yet one case of early myeloma in the femur, I recall diagnosing as a cyst! Once having seen a good X-ray of a myeloma and having realized the essential elements of its pathology, one should readily separate it from other tumors of the bone.   It is essentially a hyperplasia of marrow cells, not a tumor with intercellular substance. It is multiple in origin and can only arise where there are marrow cells and then dilate the spaces in which these cells normally lie. We know such cells are normal in the medulla and in the spongiosa chiefly, but they may occur in small spaces in the cortical bone. As the hyperplasia in each space—large or small—increases, the spaces are enlarged and break into one another and the intervening trabecule are absorbed. The result is an appearance as if the bone were blown up from inside, as by a series of bubbles, large and small. The periosteum is somewhat stretched and as the process advances, lays down a film of new bone so that a pencilled outline is given to the whole. The bubbles may be single or multiple. The process is quite different from that which takes place in Ewing's sarcoma, where it is essentially invasive and peculiarly apt to be cortical, since the tumor cells penetrate every part of the bone following the lacunae and Haversian canals and separating the lamellae around the circumference, dissolving the bone as they go.
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 The process of dilatation in giant cell tumors is also different, for instead of blowing the bone up with large and small bubbles, as does myeloma in most cases, there is one large bubble which expands by pulsation, destroying all the spongiosa on its periphery until it reaches the resilient medulla on one end and the resilient cartilage on the other. It does not, like myeloma, extend in the marrow, but stops abruptly. I think the reason is that the medulla also pulsates and stops the advance of the tumor. The apparent trabeculae in giant cell tumors are merely ridges in the cortex, not evidence of loculi in the tumor. It is my favorite theory that the origin of all giant cell tumors is a ruptured branch of a nutrient artery which does not clot. Expansion takes place from this single point. Giant cell tumor always arises in spongy bone, myeloma in the marrow of the shaft and also in the spongiosa or cortex.
-'''Giant Cell Tumors.'''
+'''Giant Cell Tumors'''
 In the head of the humerus giant cell tumor does not behave in a typical way, and my study in 1930 of this group of registered tumors of the shoulder bones resulted in the following paper, which is here reprinted with the permission of t''he editor of Surgery, Gynec. & Obst''. No other tumors of this type were registered in the last 277 cases up to April 7, 1931.   ''(1,060 to 1,335)''
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 In the multiple cases some of the tumors may be intra- and some extra-cortical.   If a tumor is extracortical and also intracortical, suspicion of malignancy is aroused. Flocculent deposits of calcium near the periphery in these borderline tumors give a characteristic appearance in the X-ray.
-'''Sarcomas Occurring in Paget's Disease.'''
+'''Sarcomas Occurring in Paget's Disease'''
 Only two cases of the twenty-four osteogenic sarcomas of the upper end of the humerus (No. 484 and No. 643) were over fifty years of age. Both of these patients had Paget's disease. This concurs with the finding which I have mentioned elsewhere, that most cases with osteogenic sarcoma, who are over fifty years of age, have Paget's disease of the skeleton. This conclusion was drawn about five years ago, after a review of the whole Registry series, including all bones. Since then, I have seen a few, but very few, exceptions. Of the seventeen cases of osteogenic sarcoma of the upper end of the humerus registered since 1932, there were three of about fifty. All three had signs of Paget's disease of the bones. Search for signs of Paget's disease in any case of bone tumor in patients about fifty, and search for sarcoma in every case of Paget's disease, for about fourteen per cent of all cases of Paget's disease develop it. (Sarcoma Complicating Paget's Disease of the Bone. Clarence E. Bird. Arch, of Surg., June, 1927, Vol. 14, pp. 1187-1208.)
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 Osteogenic sarcomas of the shaft may possibly have a better prognosis, for case No. 156 had a huge sarcoma and is well eight years after amputation. This case had prolonged radium treatment at the Memorial Hospital of New York prior to amputation. It was a very large tumor of telangiectatic type. We also have full data of another case, No. 147, well nine years after amputation, registered by Dr. C. C. Simmons.  Registry No. 1016 is a recent case.
-'''Osteogenic sarcoma in the lower end of the humerus.'''
+'''Osteogenic sarcoma in the lower end of the humerus'''
 Case No. 299 was one of sarcoma occurring in Paget's disease and could not be traced. The patient is undoubtedly dead. Case No. 357, registered by Memorial Hospital Clinic of New York, was reported to be well three years after amputation, and since then could not be traced.   No X-ray was registered.

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       Answer.     Yes. (Sotto voce explanation to my conscience.) Maybe a contributory cause.
       Question.   Why ?
-      Answer.     First, because a high percentage of these cases give a history of a local trauma preceding the discovery of the tHmor by a number of months, and such a trauma may be assumed in the others. (This is entirely to impress the jury, because it does not impress me a bit, although I cannot be called a liar for saying it.) Second, because certain doctors, experimenting with malignant tumors in animals, found that when tumor cells were injected into the blood of these animals, tumors developed at places in the parts of the bodies of the animals which were purposely traumatized. (Also impressive but quite illogical.) Third, because the structure and the microscopic appearance of bone sarcomas vaguely resemble the process of repair which takes place when a bone is broken. (The only reason that I personally have any respect for.)
+      Answer.     First, because a high percentage of these cases give a history of a local trauma preceding the discovery of the tumor by a number of months, and such a trauma may be assumed in the others. (This is entirely to impress the jury, because it does not impress me a bit, although I cannot be called a liar for saying it.) Second, because certain doctors, experimenting with malignant tumors in animals, found that when tumor cells were injected into the blood of these animals, tumors developed at places in the parts of the bodies of the animals which were purposely traumatized. (Also impressive but quite illogical.) Third, because the structure and the microscopic appearance of bone sarcomas vaguely resemble the process of repair which takes place when a bone is broken. (The only reason that I personally have any respect for.)
       Question.    Any other reasons?

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 The one atypical sarcoma of the clavicle, ''No. 1059'', is living three and a half years after excision.
 The two surviving cases of atypical sarcoma of the body oi the scapula were probably as near to our former definition of periosteal fibro-sarcoma as any cases we have had. ''No. 447'' was registered by the Presbyterian Hospital of New York and was reported well, except for tuberculosis of the lungs, eight years after partial excision of the scapula. ''Case No. Ill'', registered by Bloodgood, was reported as well nine years after excision of a similar tumor.
-No. 147 No. 156 No. 812 No. 867 No. 28 No. 137 No. 246 No. 326 No. 576
+''No. 147 No. 156 No. 812 No. 867 No. 28 No. 137 No. 246 No. 326 No. 576''
 There are probably many surgeons who feel discouraged about our progress in the treatment of bone sarcoma. I hope they will feel somewhat more optimistic, for I do after making this study. Hope in prognosis may be emphasized again by calling attention to the following cases of five-year cures among primary malignant tumors of the shoulder bones.

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 It was your boy who had the bump which was followed two months later by the tumor. You find that one of your friends has a friend whose boy had sarcoma preceded by a bump. You become more convinced that bumps cause sarcoma. One of your neighbors heard of a boy who had this trouble and he recovered damages because the bump was received while the boy was at work. Your lawyer confirms this and adds that many such cases have received compensation for such injuries. You become more convinced that the bump in your boy's case caused the sarcoma. You feel sure he had no sarcoma until he had the bump. Your lawyer tells you that famous medical experts have testified that a large percentage of all cases of bone sarcoma had bumps within a year prior to the time the sarcoma was noticed.   These experts have testified that they believe bumps cause sarcoma, even if they will not say that the particular bump in question caused the particular sarcoma. And some will even swear to that. By this time you are convinced that if your boy is not awarded compensation a great injustice will have been done. And furthermore, you will hear from your lawyer that insurance companies are generally ready to settle such cases out of Court, so great is the probability that Accident Boards and jurors will decide in favor of the poor boy with an amputated leg or arm.
 At this point, the argument that 100,000 boys each bump themselves 10,000 times without having sarcoma, will go in one of your ears and out the other. You will say that 10,000 aviators might each fly 100,000 miles, yet one bump might kill any one of them, and think you have drawn a parallel. But the two propositions are not parallel and are widely different. It would be as logical to say that if one aviator in 100,000 had a bone sarcoma, aviation causes sarcoma. If all the aviators bumped in every mile the parallel would be more reasonable, for aviation would stop, and so would the human race if trauma caused sarcoma.
-Suppose that your boy had a very slight prominence on his shin. You happened to notice this slight prominence. There is a beginning to everything. From your experience in counting the black and blue spots on his shins, how long will it take him to get one on that particular lump? Not long, you must admit. Then you and he will notice the lump and observe that unlike the other spots this lump will not go away ^altogether. In a month or two it may enlarge still more and become painful, and prove to be a sarcoma. Which black and blue spot caused the sarcoma? One of those previous bruises you have seen in the last five years, or the one that came after you had already noticed the lump? You will have to admit that if you have a boil or a bruise on some part of your person, some friend downtown is sure to hit it. How often has your other boy, who has no sarcoma, complained that when you grabbed him you hurt his sore arm or sore leg? Confess that you are too busy to count the lumps and black and blue spots on your boy every evening. Yet you say you are convinced that this particular bump caused this particular lump, and your lawyer thinks so, too. I admit that you may find the jury sympathetic and ready to be convinced. When the experts take the stand and swear they believe bumps are contributory causes of bone sarcoma, very likely you will get a verdict. Yet personally, I think the chance of any one boy getting a bump on a particular sarcoma is much greater than the billion to one chance of any particular bruise causing a sarcoma in 100,000 boys.
+Suppose that your boy had a very slight prominence on his shin. You happened to notice this slight prominence. There is a beginning to everything. From your experience in counting the black and blue spots on his shins, how long will it take him to get one on that particular lump? Not long, you must admit. Then you and he will notice the lump and observe that unlike the other spots this lump will not go away altogether. In a month or two it may enlarge still more and become painful, and prove to be a sarcoma. Which black and blue spot caused the sarcoma? One of those previous bruises you have seen in the last five years, or the one that came after you had already noticed the lump? You will have to admit that if you have a boil or a bruise on some part of your person, some friend downtown is sure to hit it. How often has your other boy, who has no sarcoma, complained that when you grabbed him you hurt his sore arm or sore leg? Confess that you are too busy to count the lumps and black and blue spots on your boy every evening. Yet you say you are convinced that this particular bump caused this particular lump, and your lawyer thinks so, too. I admit that you may find the jury sympathetic and ready to be convinced. When the experts take the stand and swear they believe bumps are contributory causes of bone sarcoma, very likely you will get a verdict. Yet personally, I think the chance of any one boy getting a bump on a particular sarcoma is much greater than the billion to one chance of any particular bruise causing a sarcoma in 100,000 boys.
 Let us see what grounds any experts have for such a statement as that sarcomas are caused by trauma. I will ask the questions and answer them as truthfully as I can, even though I favor the billion to one idea. I will now appear for the plaintiff.

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 Case No. 919 has not been heard from since operation.
-The Atypical Sarcomas are also encouraging. Case No. 409, a large tumor of the upper end of the humerus, resembling a giant cell tumor in the X-ray, was treated conservatively after a biopsy. The patient was given toxins and radium by Dr. Coley, and later consolidation and bone formation took place in the tumor. She was reported to be well eight years later. The microscopic slide is poor and the pathologists cannot make a diagnosis from it. While the case is obscure, it is encouraging, for the tumor was certainly large and one would have given a bad prognosis. Cases No. 421 and No. 998 have not been traced. Case No. 83, a very large malignant tumor of the whole shaft and upper end of the humerus, was registered by Dr. Simmons. The patient is reported well nine years after amputation, although from the slide and from the X-ray a very bad prognosis would have been given. Although the data are well registered, there is no unanimity of pathologic opinion. Connor has included it in his series of Ewing's tumors, but others consider it an angiosarcoma. A somewhat similar case has also been registered by Dr. Simmons, No. 564, involving the lower end of the humerus and also much of the shaft. The data are also good but confusing. The case was reported well six years after amputation, but a year later there was a recurrence in the axilla, which was excised. While both cases are atypical, they were very large tumors, very invasive and histologically very malignant.
+The Atypical Sarcomas are also encouraging. Case ''No. 409'', a large tumor of the upper end of the humerus, resembling a giant cell tumor in the X-ray, was treated conservatively after a biopsy. The patient was given toxins and radium by Dr. Coley, and later consolidation and bone formation took place in the tumor. She was reported to be well eight years later. The microscopic slide is poor and the pathologists cannot make a diagnosis from it. While the case is obscure, it is encouraging, for the tumor was certainly large and one would have given a bad prognosis. Cases ''No. 421 and No. 998'' have not been traced. ''Case No. 83'', a very large malignant tumor of the whole shaft and upper end of the humerus, was registered by Dr. Simmons. The patient is reported well nine years after amputation, although from the slide and from the X-ray a very bad prognosis would have been given. Although the data are well registered, there is no unanimity of pathologic opinion. Connor has included it in his series of Ewing's tumors, but others consider it an angiosarcoma. A somewhat similar case has also been registered by Dr. Simmons, ''No. 564'', involving the lower end of the humerus and also much of the shaft. The data are also good but confusing. The case was reported well six years after amputation, but a year later there was a recurrence in the axilla, which was excised. While both cases are atypical, they were very large tumors, very invasive and histologically very malignant.
-The one atypical sarcoma of the clavicle, No. 1059, is living three and a half years after excision.
+The one atypical sarcoma of the clavicle, ''No. 1059'', is living three and a half years after excision.
-The two surviving cases of atypical sarcoma of the body oi the scapula were probably as near to our former definition of periosteal fibro-sarcoma as any cases we have had. No. 447 was registered by the Presbyterian Hospital of New York and was reported well, except for tuberculosis of the lungs, eight years after partial excision of the scapula. Case No. Ill, registered by Bloodgood, was reported as well nine years after excision of a similar tumor.
+The two surviving cases of atypical sarcoma of the body oi the scapula were probably as near to our former definition of periosteal fibro-sarcoma as any cases we have had. ''No. 447'' was registered by the Presbyterian Hospital of New York and was reported well, except for tuberculosis of the lungs, eight years after partial excision of the scapula. ''Case No. Ill'', registered by Bloodgood, was reported as well nine years after excision of a similar tumor.
 No. 147 No. 156 No. 812 No. 867 No. 28 No. 137 No. 246 No. 326 No. 576
 There are probably many surgeons who feel discouraged about our progress in the treatment of bone sarcoma. I hope they will feel somewhat more optimistic, for I do after making this study. Hope in prognosis may be emphasized again by calling attention to the following cases of five-year cures among primary malignant tumors of the shoulder bones.
 To find fourteen or fifteen living over five years out of eighty-four cases is certainly encouraging, and if we omit the twenty-four cases of osteogenic sarcoma of the upper end of the humerus, thirteen or fourteen out of sixty! Or, if we include the nine living cases of epiphyseal giant cell tumors, which some pathologists believe are sarcomas, we find ninety-three cases of sarcoma with twenty-three or twenty-four five-year cures. In my opinion this last should not be done.
-THE RELATION OF TRAUMA TO BONE SARCOMA
+'''THE RELATION OF TRAUMA TO BONE SARCOMA'''
 The American College of Surgeons has widely advertised the Registry of Bone Sarcoma and has made repeated appeals to surgeons, rontgenologists and pathologists to register their records of instances of this disease. This propaganda has continued over ten years, and some $20,000 has been spent. Yet only 1,335 cases have been collected and studied. Only 655 of these are true osteogenic sarcomas. The Laboratory of Surgical Pathology at Johns Hopkins, together with Dr. Bloodgood's personal collection, had at their latest report only about 400 case histories of osteogenic sarcoma after more than thirty years. Coley, after forty years of the most arduous polemics in favor of his toxins and yearly papers before scientific societies as propaganda, has probably seen more cases than any other surgeon in the world. Yet, in a recent paper, he states that the combined records of the Hospital for Ruptured and Crippled and of the Memorial Hospital since 1890 show 855 cases. This included all forms diagnosed as bone sarcoma, and perhaps many were not sarcoma at all. Greenough, Simmons and Harmer found that in the Massachusetts General Hospital in a ten-year period, there were only twenty-seven cases of osteogenic sarcoma, although many other cases had been erroneously diagnosed as such. Since many of the cases of Bloodgood, Coley, Greenough, et al., are among those registered, the total number is not great. In 1922 from a postal card canvass of the doctors in Massachusetts it was estimated that at any one time there were not more than one of these cases in 100,000 of the population alive in this state.

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 It would seem to me that not only does the character of the tumor vary with the individual bones of the skeleton, but that some forms of tumors have abortive morphologic plans, as do the peculiar growths called "galls" formed on trees and plants, some of which resemble leaves, some flowers, and some bark. For instance, some osteogenic tumors, both benign and malignant, tend to form cartilage on their surfaces and to have bony bases, thus resembling roughly in form the condyles of a joint. Some of the lesions, such as benign osteogenic tumors of the fingers, resemble a twin of the phalanx itself. If in an osteogenic tumor there is a portion bulging into the popliteal space, this portion will generally be composed of cartilage, resembling in shape the big knobs of the joint cartilage. Osteogenic sarcomas, as a whole, resemble a normal callus about a fracture in their fusiform contour, and in their activities, which are always both intra- and extra-cortical. I have come to believe that tumors exhibit an architectural plan (to be sure, a very irregular one), but resembling the same mysterious morphologic design which makes the normal cells form the definite part in which the tumor arises. According to this idea the malignant impulse must be given rather to the plan than to the tissue in which the potentiality of repair lies. The normal repair process knows when its specifications are completed, but the malignant repair process has lost its growth or repair restraint and goes on unchecked, but still vaguely follows the plan of the part of the bone involved.
-===='''Analysis of Registered Cases of Tumors of the Shoulder Bones'''====
+'''Analysis of Registered Cases of Tumors of the Shoulder Bones'''
 In order to write this chapter advantage has been taken of the opportunity offered by the Registry of Bone Sarcoma, and in the summer of 1930 the following study of the cases registered up to No. 1,059 was made. Table I shows the relative frequency and the sites at which the different forms of bone tumors occur in relation to the shoulder joint as far as may be judged from the evidence of the 144 cases which involved the humerus, clavicle, and scapula. Notice that the figures are the Registry numbers of the cases, except for the marginal ones, which indicate the totals in each lateral or vertical column.
 In April, 1932, a second study was made and the mortality, as indicated by the heavy type on the charts, brought up-to-date, and the text revised accordingly. Table II was prepared from the cases registered since the previous study from No. 1,059 to No. 1,335, but was not used in the text because there was nothing found in this second study except confirmatory evidence for some of the observations already made. The chief value of Table II is to indicate in a general way that the relative figures are much the same as in the first study, e.g., in both tables thirteen and one-half per cent of all bone tumors were in the shoulder bones, and osteogenic sarcoma in the head of the humerus is the most common shoulder tumor. However, in Table II there is a notable lack of giant cell tumors. Furthermore, Table II might be of value to any future student of this subject, for it gives him the Registry numbers for ready reference so that he can send for their envelopes for his own study. The cases in Table II are too recent for the results to be of statistical value.
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-Click for larger image
+''Click for larger image''
 Essentially, these two types are the same and have the same prognosis, and are clearly not different clinical entities. It is, therefore, not logical to say that a tumor arose in either situation because the bulk of it is extra- or intra-cortical.
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 ''(End of reprint.)''
-===== '''Metastatic Cancer''' =====
+====='''Metastatic Cancer'''=====
 The advance of a malignant metastasis may mimic the methods of invasion of any of the primary bone tumors. It usually begins in the neighborhood of the nutrient artery or in one of its branches as an embolus. The cells multiply and have an osteolytic and invasive power. The bone melts before them or, if they are slow growing, piles up new bone to check their advance. Rapid vascular metastases may dilate the bone by pulsation as do giant cell tumors. If the osteolytic quality of the cells is predominant, a local defect is produced in the bone and transverse fracture occurs. If there are multiple emboli, the bone may be riddled by many foci which all advance together and melt into one another as do the lesions of myeloma, but the X-ray appearance is not quite like the latter.
 The very diffuse form of cancer involving the whole bone without changing its shape, is probably due to lymphatic extension. Although many writers have denied the existence of intraosseous lymphatics, Kolodny believes he has proved their presence in bone. (''Kolodny, Anatole. The Relation of the Bone Marrow to the Lymphatic System. Arch, of Surg., 1925, Vol. II, pp. 690-707''.)