I wrote my first paper on bone tumors about 1902, based upon all the cases we had observed in the surgical pathological laboratory since 1889 and the literature which I had reviewed in Progressive Medicine yearly since 1899. During these twenty-four years which have passed, I have gone over the bone material at least once a year in teaching, and, in writing many articles, I have critically restudied the material from every possible standpoint. A number of impressions are prominent in my mind from this continuous study:
First, just as we finished a restudy of all the material and formulated apparently definite conclusions for clinical and x-ray diagnosis, new cases came under observation at an earlier period which are exceptions to the rules. So, in writing this article, I felt I could teach more if I took a series of recent cases and described, in this group at least, the actual methods and difficulties of diagnosis.
When all bone lesions are x-rayed and studied within a few weeks after the first symptom, we may be able to evolve general diagnostic laws.
Second, the great value of the x-ray. One, to be a diagnostician of bone diseases, should constantly restudy the x-ray films or lantern slides, and these should be kept in very accessible filing-cases. One of the greatest obstacles to the majority of roentgenologists is that they are dependent for the final diagnosis in cases operated upon on a pathologist who may be neither interested nor expert in diagnosis. For example, the roentgenologist has been told again and again that the benign giant-cell tumor is a sarcoma. Naturally he concludes that central sarcoma is common. Even in the benign bone cyst, the fibrous tissue removed from the wall has been diagnosed sarcoma. Our x-rays of bone lesions, before they are valuable in the study of the diagnostic features, must be associated with a verification of the diagnosis not only by the microscope but by the final result. If the patient, whose femur is illustrated in Figure 12 (Case 5), lives, the diagnosis of osteomyelitis is verified. That Case 4 died with definite evidence of metastasis to the chest verifies the diagnosis of sarcoma. If Case 2 (Fig. 4) lives, we will never have a verification of the diagnosis of sarcoma unless the section is submitted to a committee of pathologists and my diagnosis of sarcoma confirmed. The present behavior of Case 1 (Fig. 1) strongly suggests that the diagnosis of a benign ossifying lesion is correct. There is no doubt in Case 3 (Fig. 8) that the diagnosis of benignancy is confirmed by the present condition of the patient.
Therefore, when we study x-rays, we learn most from those in which the diagnosis has been verified. It is dangerous to study x-ray films in which the ultimate condition of the patient is unknown, in which the pathology is relatively uncertain, and when the patients are living after amputation.
Third, the growing importance of the frozen section to help in the diagnosis at operation. The advice that should be most helpful to the pathologist is that every pathologist who is called upon to make diagnoses from frozen sections during operation should practice daily on the fresh material with the polychrome-methylene blue stain of the frozen, unfixed tissue, and with the eosin-haemotoxylin stain of the tissue first fixed in formalin and then frozen. The majority of pathologists in this country connected with operating rooms are not frequently called upon by their surgical colleagues in the hospital for this frozen-section diagnosis, and they are not preparing themselves for this emergency. As the people in the different communities are becoming more enlightened and patients with bone and breast lesions are coming into the hospital quickly after the first symptoms, the diagnosis will rest more with the pathologist than with the roentgenologist.
Previous Literature. If one reading this article cares to compare it with the publications of previous studies, I would suggest the Journal of Radiology (I, 147-238) for March 1920, where I reported seventy cases of periosteal sarcoma and gave pictures of the various types.
In the Journal of Radiology (III, 310-317) for August 1922, I made my first report on the non-suppurating osteomyelitis of Garré, which I then called infectious ossifying periostitis. I hope the term chronic sclerosing osteomyelitis will finally be adopted.
I take this opportunity to make some additions and corrections to this article. Case 1, Pathol. No. 16865 (Fig. 1), the patient is living and well in 1926, confirming the diagnosis of a benign ossifying lesion.
Case 2, Pathol. No. 28771 (Fig. 6), in which we thought that the chronic sclerosing osteomyelitis was due to the gonococcus, the patient is still living in 1926, five years after the first observation, without symptoms.
Case 3, Pathol. No. 29084 (Fig. 8), diagnosed from the x-ray as a benign ossifying lesion of the upper end of the shaft of the femur, died after a hip-joint amputation. I have been unable to obtain the specimen to verify the operator's diagnosis of sarcoma.
All the other cases described there as infectious ossifying periostitis are living to verify the diagnosis, except Case 8 (Fig. 13), in which the disease was multiple and of the Paget type. After reporting this case (Pathol. No. 29831), I found metastatic carcinoma in the skull, the x-rays of which are pictured (Figs. 17 and 18). We knew that this patient's breast had been removed more than five years before, but the diagnosis had not been carcinoma. Dr. S. Ginsburg of New York, who followed this patient from the beginning to the end, has made a most complete report in the Archives of Surgery. In this instance a general disease of the skeleton of the Paget type of chronic sclerosing osteomyelitis or ossifying periostitis became secondarily involved with metastatic carcinoma.
The paper by Dr. S. Fosdick Jones appeared in the Journal of the American Medical Association (LXXVII, 986-990) September 24, 1921.
In the Journal of Radiology for February 1923 (IV, 46-51) I described the sclerosing type of osteogenic sarcoma. The case pictured in this contribution, in which the thigh was amputated after exploratory incision in 1922, lived in comfort for about two years and died of metastasis to the lung.
In the Journal of Radiology for April 1923 (IV, 119-127), I have grouped together, with illustrations, examples of benign and malignant ossifying periostitis and benign ossifying myositis. There are no corrections to this article. The diagnoses remain as given, verified by the present condition of the patients.