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1. The results of electrodiagnostic tests reveal the level and progress of nerve lesions.
2. The findings in a myopathic lesion are:
3. In peripheral nerve affections these findings are evidence of denervation:
4. Evidence of reinnervation is given by:
5. The following findings suggest a lesion of the anterior horn cell:
1. The bad reputation of fractures of the scaphoid bone is based on
2. The results obtained in five series comprising over 1,000 fractures suggest that 95 per cent of adequately studied fractures less than a month old unite if properly treated.
3. Sixty cases of established non-union have provided evidence that disability is almost always the result of further injury and that the disability is usually relieved by a short time in plaster.
4. There is no evidence to support the widely held beliefs that
5. A policy of treating the wrist and not merely its radiological appearances is advocated.
1. Twenty-four cases of excision of the lunate bone in Kienböck's disease have been reviewed.
2. In general, the results have been favourable, with 88 per cent excellent or good and 12 per cent fair or poor.
3. Abnormal contact between the triquetrum and the styloid process of the ulna appeared in many cases, but this contact did not appear to prejudice the results.
4. Excision after prolonged symptoms of the disease gave disappointing results.
1. Previous reports of calcareous deposits about the metacarpo-phalangeal joints are reviewed, and four further cases are described.
2. The clinical features are described, with reference to the possibility of erroneous diagnosis.
3. Conservative treatment is recommended.
Nine cases of osteochondritis dissecans of the elbow and knee in three generations of the same family are described. There was clear evidence of a dominant inherited factor.
1. Twenty cases of mycetoma pedis are described.
2. Most patients had the disease in an early stage and were cured by simple excision.
3. The importance of early diagnosis and treatment in order to avoid amputation is emphasised.
A simple method of measuring the degree of acetabular development in the radiograph of the adult pelvis is described and arguments for its validity are advanced. This measurement is referred to as the acetabular angle. The normal values for this angle are between 33 and 38 degrees. Angles below 32 degrees are uncommon and probably of no clinical significance, whereas angles from 39 to 42 degrees are in the upper limit of normality. An angle of 47 degrees is shown in a hip with congenital subluxation. The prognosis for hip joints with acetabular angles between 42 and 47 degrees is under investigation.
Engelmann's disease appears to be a familial and probably hereditary systemic condition, in which most of the manifestations can be attributed to a disorder in the osseous and muscular systems. At present the nature of the pathological process is obscure. The manifestations may present soon after birth or become apparent later in life. There is evidence that it is progressive but it may become arrested in some patients.
In order that this very incomplete state of knowledge may be improved it will be necessary to observe patients and their relatives throughout their lifetime.
1. A clinical study has been made of heterotopic ossification in 273 patients with paraplegia of traumatic and non-traumatic origin treated at the Liverpool Paraplegic Centre over a period of twelve and a half years.
2. The literature is reviewed and theories of etiology are discussed.
3. Etiological factors have been studied. Prominent among these is inadequacy of early treatment leading to urinary infection and to the formation of pressure sores.
4. It is concluded that there is no effective treatment for established heterotopic ossification.
5. The importance of prophylactic treatment is stressed. Special emphasis is placed on adequate primary treatment, correction of hypoproteinaemia and early mobilisation.
1. The relationship between histological grading and survival has been studied in a consecutive series of eighty-eight patients with osteogenic sarcomata. The grading has been based entirely upon the mitotic activity of these tumours.
2. There is a positive correlation ("r"=+0·59) between the two variates mitotic ratio and survival in months.
3. The frequency distributions of the mitotic ratios and survivals are similar and, from the observed range, mean and mode of mitotic ratios a more precise definition is proposed for the terms "low," "medium" and "high" malignancy.
4. Comment is made on those patients (20 per cent) in whom actual survival was very different from that expected on the basis of histological grading.
5. The five-year survival rates were: Grade I–67 per cent, Grade II–15 per cent, Grade III–nil, all–17 per cent. For the whole series the average survival period from the time of the presenting symptom was thirty-six months.
6. The five-year survival rate for forty-five tumours of the femur was 20 per cent; no further analysis by sites is attempted.
1. A twenty-five-year-old man who developed neuropathic arthritis because of indifference to pain is described. He presented at the age of thirteen with degenerative changes in the light knee with analgesia only in the right leg below the knee.
2. A painless fracture of the ulna developed non-union and was associated with a neuropathic arthritis of the elbow joint.
3. Later the other knee and the lumbo-sacral spine became affected. The analgesia became generalised with all other senses staying intact. Apart from tonic pupillary reactions and diminished corneal sensibility no other neurological signs could be found.
4. A deceased sister may also have suffered from the same condition.
1. Twelve children are described in whom gradual limitation of knee flexion developed, without previous injury or inflammation.
2. Clinical and histological investigation showed progressive fibrous degeneration of the vastus intermedius and rectus femoris.
3. As the patella showed signs of retarded development a particular form of myodysplasia, probably congenital, may be supposed.
4. Conservative treatment always failed to stop the progress of this disease.
5. Surgical treatment (Bennett's method or an elongation of the ligamental apparatus of the intermedius muscle) was carried out in ten cases and gave good permanent results. Flexion remained possible only to the extent obtained at operation; rehabilitation gave no further improvement.
6. In the opinion of the author, these cases occur more often than is generally believed, but they are recorded under a different diagnosis and consequently are not submitted to rational treatment.
A case of melorheostosis is described in which more than one limb was affected. It was associated with increased length of the right leg, lymphatic vesicles in the right groin, ossification in the subcutaneous tissues of the right thigh and a cutaneous haemangioma of the right side of the trunk.
1. A case of primary osteosarcoma of the patella is reported.
2. A brief review of the literature has been made.
3. In the author's opinion only nine genuine cases have been reported, including the present case.
1. Coccygeal pain in a young man, persisting for ten years in all and for seven years after partial removal of the coccyx, was shown to be due to an intrathecal tumour of the cauda equina.
2. Removal of the tumour, which was found to be an ependymoma, gave complete relief.
1. Radiological, chemical and histological examinations have been made of the lumbar vertebral bodies in 100 necropsies on patients dying in a general hospital, with a view to determining the range of variation of calcium content and radiographic density in normal and osteoporotic bone.
2. Radiographs were made of sagittal mid-line vertebral body slabs uniformly one centimetre in thickness, and the radiographic density of these specimens was measured in relation to an aluminium step-wedge of one to ten units. Radio-opacity of different vertebrae ranged from four to ten units. The specimen radiographs also clearly revealed the trabecular structure and the lateral profile of the bones.
3. Calcium was chemically estimated and expressed as weight of the element per unit volume of the whole bone mass (that is, of anatomical bone including soft marrow tissue). It ranged from 38 to 102 milligrams per cubic centimetre of bone. In 75 per cent of the cases the range was 50-84 milligrams per cubic centimetre. High calcium values were mostly encountered in young adults, and the calcium per unit volume tended to diminish with age; but a wide range of calcium was still encountered in the older subjects and a better correlation with age was achieved by radiographic density. Both calcium content and radiographic density tended to be higher in the male than in the female bones at all ages.
4. The results of both calcium and radiographic density showed a smooth distribution curve, though skewed through the inclusion in the series of more older people with less mineralised bones; the absence of a double peak in these curves suggests that the examinations were made on a homogeneous population and does not indicate a separate pathological group of osteoporotic subjects.
5. Arbitrary standards must be used to distinguish osteoporotic from normal bones, since neither radiological measurement or chemical assay, nor histological assessment, reveals a point at which the two groups can be separated. In the present series it seemed to us satisfactory to regard as abnormal all bones showing a radiographic density of five or less step-wedge units, and by this standard nineteen of the 100 cases (eight male, eleven female) were deemed to be osteoporotic. Histological examination excluded other forms of bone rarefaction.
6. The regression of calcium on the density measurements proved to be statistically significant and was not affected either by age or by the number of days in bed during the last illness. A small difference between the sexes was apparent, there being slightly less calcium in female than in male bones of equal radiographic density. Provided this is taken into account, the radiographic density scale can be used to predict the calcium content of vertebral bone specimens and should prove a rapid and accurate method in a survey of osteoporosis in post-mortem room material.
1. In this investigation one was impressed by the close relationship that exists between the constituent parts of the intervertebral discs and the surrounding supporting structures. The part that is responsible for the maintenance of a co-ordinated balance between these structures, and hence for the effective mechanism of the spine, is the nucleus pulposus.
2. The cruciate arrangement of the annulus fibrosus is related to spinal function, and the angle of intersection of consecutive laminae of the annulus fibrosus is more or less constant.
3. In the Bantu it was found that the interspinous and supraspinous ligaments differ from the classical descriptions given in anatomical text-books.
4. The movements taking place between two vertebrae are comparable to those of a rocking-horse.
5. Narrowing of a disc is a progressive process which is the result of the disturbances in the balance between the components of the force to which a disc is subjected. The process is initiated by the loss of nucleus pulposus content.
6. With the approximation of two adjacent vertebrae a disturbance of the relations of the structures in the intervertebral foramen was noted. On anatomical grounds, when a disc is narrowed it appears that the most likely structures to cause pressure on the nerve root are not the disc itself, but the superior articular processes with their overlying ligamentum flavum.
The effects on articular cartilage of continuous and intermittent excessive pressures have been studied in the knees of rabbits. Severe degenerative changes in the cartilage were observed; these resembled the typical lesions seen in osteoarthritis in man. They included fibrillation of cartilage, death of chondrocytes, eburnation of joint surfaces, sclerosis of bone and the production of "bone cysts." Regeneration of cartilage was common and it was brought about either by the deeply situated chondrocytes which had escaped death or by metaplasia of young connective tissue cells of the bone marrow.
A description is given of a mutation in the mouse which reduces the size of the nucleus pulposus in the intervertebral disc of the adults. The discs of these mice show greatly accelerated age changes. The consequences of a similar mutation in man are discussed.
