of a bone, accompanied with the deposition of a morbid sarcomatous
substance internally. This morbid change appears to be the consequence
of inflammation, and its origin is frequently attributed to some
mechanical injury or local irritation. In the commencement of the
disease, the bone is slightly enlarged, perhaps somewhat thickened
in its outer laminæ; and on a section of it being made, is found to
contain a brown fleshy substance instead of its cancelli. This appears
to be formed in consequence of a morbid action, perhaps inflammatory,
of its internal structure. By the pressure of the new formation, the
parietes of the bone are pushed outwards, in some cases attenuated,
in others thickened by deposition of new osseous matter, inflammatory
action having been induced by the pressure. As the internal formation
increases, the parietes are extended, and are generally much
attenuated, becoming in some places thin as paper, and diaphanous; they
also would seem to lose a portion of their earthy matter, for they are
flexible, somewhat elastic, and not of their usual density. Frequently
they are in several places deficient, and their situation occupied
by a membranous expansion, sometimes thin and delicate, but mostly
thick and ligamentous; in some cases, the external lamina appears to
be converted into a substance resembling the internal growth, with
which it is continuous. The investing periosteum is much thickened,
and its bloodvessels are enlarged. Occasionally, the deficiency of
the bone is not supplied by any membranous expansion, and the morbid
growth protrudes, fungous. The internal structure varies much in
appearance; generally it is brown and soft, in some places broken down
and mixed with a dark-coloured fluid, or with gelatiniform matter;
sometimes it is much more dense, and resembles cartilage; in others,
the cavity contains an ichorous fluid, mixed with small portions of
more solid matter; in the advanced stage of the disease, the contents
are often of the encephaloid nature, either in its homogeneous and
solid form, or softened, broken down, and mixed with blood, or with
a lard-like substance. Sometimes the cancelli of the bone are not
destroyed, but extended, forming numerous cavities of considerable
size, in which the morbid matter is deposited; in other instances,
there is no appearance of cancellated structure, and the diseased mass
contains rough osseous spicula, some detached, some loosely connected
with each other, and others projecting from the inner surface of the
bony parietes of the tumour. At the commencement of the disease, the
patient feels acute pain in the part, the constitution is disturbed;
afterwards, the pain becomes more dull, and there is a considerable
swelling externally, which feels hard, and slightly elastic; in the
advanced stage, the pain again becomes severe, and is of a lancinating
kind, and the system is much deranged, the tumour is softer, often
presents a sense of distinct fluctuation, and on being freely handled,
is found to crepitate, in consequence of the loose spicula of bone
rubbing upon each other. Ultimately, the integuments become tense,
livid, or dark-red, ulcerate, and allow a portion of the softened
tumour to protrude, in the form of a frightful fungus; there is profuse
discharge, thin, and sometimes bloody; there is much constitutional
irritation, and the patient is greatly exhausted. Not unfrequently,
during the progress of the disease, especially in the long bones,
fracture occurs at the diseased part, either from external injury, or
sudden muscular exertion. This occurred in the case from which the
specimen here delineated was obtained some months before the patient
submitted to amputation. The morbid structure had not broken through
its periosteal investment. The muscles and their interfilamentous
tissue were sound. The patient remained free from any return of the
local disease. Bones so affected, when broken, do not unite, the
movement of the loose and rough ends is a cause of much irritation:
inflammatory action is kindled in the morbid structure, suppuration
occurs, the integuments give way, and ulcerate to a greater or less
extent, and the advancement of the disease is thus much hastened. The
tumour may be safely pronounced malignant; it is true, that for some
time it shows no tendency to involve the adjoining soft parts, further
than by the effects of inflammation induced by its pressure; but then
it is limited by the external lamina of the bones, which confines
it to the tissue in which it originated; but after this barrier has
given way, the tumour projects through the aperture, contaminating the
adjacent soft parts, imparting to them a morbid action, and extending
also in the cancellated tissue of the shaft of the bone. In some cases,
the integuments are tense and discoloured, with large vessels running
on their surface; the tumour feels soft and fluctuating, though the
skin may not ulcerate till long afterwards. Perhaps the most common
seat of this disease is the under-jaw, but it may occur in any of the
bones; when it has been of chronic duration, not one bone but several
are affected; and in one case which I saw, the disease commenced in the
under-jaw, which it deformed to a frightful degree; almost every bone
in the body was similarly, though less extensively diseased; this could
be readily observed during the life of the patient, and was confirmed
by dissection. From this, it appears, that the affection is not only
dependent on local causes, but connected with a morbid state of the
constitution, predisposing to it, and cooperating with its exciting
cause.
There are other tumours of bones in some degree resembling, which
do not strictly come under the term Osteosarcoma. Some are wholly
cartilaginous, the disease commencing in their centre, and involving
their entire substance, emitting a gelatinous fluid when cut, but
containing no cells; others are not uncommon, partly osseous, and
partly cartilaginous, containing cells filled with a glairy fluid;
others are composed of cartilage, intersected with dense fibrous
matter, in a greater or less proportion. In fact, the individual
tumours of bones vary as much from one another as those of the
softer tissues; scarcely two are alike in their progress, action,
or anatomical characters. Irregular spicula of bone are found in
many parts of their structure; in the same way that portions of bone
often exist in tumours having no connection with the bones; in many
places they are softened and broken down, the partitions between
the cells are destroyed, and these contain a pulpy mass of a dark
sanious appearance. On making a section, they are observed to be
continuous with the interior of the bone, which is converted into a
substance similar to themselves, or is of a more soft and medullary
character. The external surface becomes tuberculated, the integuments
are painful, and changed in appearance; they ulcerate, the tubercles
burst, the discharge is thin and bloody, the ulceration extends; not
unfrequently a fungus protrudes, and occasionally bleeds; this may
slough, the tumour becomes farther exposed, portions of it die, and
are discharged, unhealthy fungous granulations project from amongst
the cancelli of the tumour, and emit a sanious putrid discharge, often
bloody; severe constitutional irritation accompanies this state, the
patient becomes hectic, is much exhausted, and sinks, unless the morbid
parts be removed. There are also tumours of bones, composed partly of
cartilaginous or fleshy, or partly of osseous matter, arising from the
periosteum and outer shell of the bone, and these often acquire a great
magnitude before the diseased mass reaches the interior or medullary
part of the bone.
SPINA VENTOSA.
By this term is understood a mere expansion of a bone from a collection
of matter in its substance. The disease may be produced by external
injury, exciting inflammation, and consequent suppuration, in the
cancellated tissue; or in a weakened and unhealthy constitution, the
action may be of a chronic nature. The fluid accumulates, the cancelli
are broken down, and the much-attenuated parietes of the bone are
pressed outwards. Occasionally inflammatory action is excited on
the external surface, from the pressure of the contained fluid, and
minute nodules of bony matter are effused, as if nature endeavoured
to strengthen those walls which are daily becoming thinner, and
more incapable of supporting the weight of those parts which they
encircle. The disease differs from Osteosarcoma in the contents being
uniformly fluid, generally purulent, though often mixed with more
liquid and dark-coloured matter, or with a curdy substance—in the
gradual extension of the bone—in no fungus protruding after a portion
of the attenuated bone has given way, matter being discharged as
from a common abscess; and in the tumour not possessing a malignant
disposition. At first there is considerable pain in the part whilst
the matter is forming, but afterwards it becomes much less acute, and
in many instances there is no inconvenience, except from the bulk of
the tumour. Often after having reached no very large size, it becomes
stationary, neither recedes or enlarges, and all painful sensations
cease; in other cases it enlarges gradually, attains an enormous
size, and produces much disturbance of the constitution; but in such
instances the patient is generally weak and cachectic. The largest
tumour of this species which I have seen, occurred in the lower part of
the femur. It measured, in breadth, seven inches, in length, seven and
one-fourth. The parietes were composed of an extremely thin lamina of
bone, and in this there were numerous deficiencies supplied by delicate
ligamentous matter; its cavity was divided into several compartments by
thin septa, partly osseous and partly membranous. A representation of
the femur so affected is given in the _Practical Surgery_, p. 350. The
patient was a boy of twelve years of age; amputation of the limb was
earnestly advised, the friends objected, he died hectic.
ANEURISMAL TUMOURS.
Besides these tumours a species of an anomalous character is sometimes
met with, appearing to arise from an aneurismal or varicose state
of the venous radicles or capillaries, and partaking somewhat also
of the nature of fungus hæmatodes.[21] I shall detail shortly the
more important circumstances of one case. The patient, a lad aged
sixteen, was admitted into a public hospital on the 7th of November,
1819, on account of a tumour over the left scapula. It was there
deemed imprudent and inadvisable to attempt operation; and, after the
application of leeches, he was dismissed, at the end of eight days.
He then applied to me. The tumour was very large, hard, inelastic,
firmly attached to the left scapula, and extending from its spine over
all its lower surface. It also stretched into the axilla to within
half an inch of the nervous and vascular plexus, and a large arterial
trunk could be felt along its under surface. The arm hung useless,
and, from the wasting of its muscles, was hardly half the size of the
other. According to his own account, the uneasiness produced by the
tumour was trifling when compared to the lancinating and excruciating
pains in the limb. On attempting to move the tumour independently of
the scapula, crepitation was distinctly perceived, as if from fracture
of osseous spicula. A tumour was first perceived about three months
previous, situated immediately below the spine of the scapula, about
the size of a filbert, of a flat form, and attended with distinct
pulsation; it had subsequently increased with great rapidity. About ten
days before his admission into the hospital, it had been punctured;
nothing but blood escaped. It was evident, from the rapid growth of
the tumour, and the severity of the symptoms, that the patient would
soon be destroyed if no operation were attempted. There were no signs
of evil in the thoracic viscera, the ribs and intercostal muscles were
unaffected; though the tumour was firmly fixed to the scapula, yet that
bone was moveable as the one on the opposite side, and the vessels and
nerves in the axilla were quite unconnected with the swelling. The
operation was commenced by making an incision from the axilla to the
lower and posterior part of the tumour. The latissimus dorsi was then
cut across at about two inches from its insertion, so as to expose the
inner edge of the tumour, with a view to tie the subscapular artery
in the first instance; in this, however, I was foiled, owing to its
depth. The dissection was proceeded with to where the branches from
the supra-scapular were expected to enter. In detaching the tumour from
the spine of the scapula, the knife and fingers suddenly dipped into
its substance. This was attended with a profuse gush of florid blood,
with coagula; by a sponge thrust into the cavity, the hemorrhage was in
a great degree arrested; at the same time an attempt made to compress
the subclavian failed, on account of the arm being much raised to
facilitate the dissection in the axilla. The patient, exhausted, made
some efforts to vomit, and dropped his head from the pillow, pale,
cold, and almost lifeless. Then only the nature of the case became
apparent. The sponge being withdrawn, one rapid incision completely
separated the upper edge of the tumour, so as to expose its cavity;
and, directed by the warm gush of blood, a large vessel in the upper
corner, which with open mouth was pouring its contents into the sac,
was immediately secured. The coagula being removed, by dissecting
under the finger, the subscapular artery was then separated, so that
an aneurism needle could be passed under it at its origin from the
axillary, and about an inch from the sac. After securing this and two
other large vessels which supplied the cavity, the tumour was dissected
from the ribs without further hemorrhage, cutting the diseased scapula
and the under part of the sac. It was then found necessary to saw
off the ragged and spongy part of the scapula, leaving only about a
fourth part of that bone, containing the glenoid cavity, processes,
and half of its spine. The edges of the wound were brought together,
and the patient lifted cautiously to bed. At this time he was pale,
almost insensible, and without any pulsation perceptible through the
integuments in the greater arteries, though the ends of the vessels
in the wound beat very forcibly. Stimuli were employed externally and
internally; in the evening his pulse at the wrist was ninety, and soft.
The sac of the tumour was composed of bony matter, containing little
earth, and arranged in strata of short fibres pointing to the cavity.
Its outer surface was smooth, and covered by a dense membrane; whereas
the inner, to which so equable a resistance was not afforded, was
studded with projecting spicula. The lower part of the scapula,
partially absorbed, lay in the middle of the sac, covered by the
remains of its muscles and coagula. Very large vessels were perceived
ramifying on the surface of the tumour.
The patient made a rapid recovery, and the wound all but healed.
A fungus, however, began to appear in about six weeks, which grew
rapidly. This was removed, and the bone cauterized with little good
effect. The tumour was soon reproduced. It was proposed to remove
the remainder of the scapula with the extremity, as the only chance,
though perhaps a slight one. This was objected to, and he died about
five months after the operation, worn out by hemorrhage and profuse
discharge.
The diseased parts presented the following appearances. Portions of
the acromion process, superior costa, and spine of the scapula, were
of their natural appearance. But the coracoid process, the glenoid
cavity, and the cervix, were entirely destroyed, and their situation
occupied by an irregular broken-down tumour, consisting of osseous
spiculæ, and cancelli, irregularly disposed, and forming cavities which
were filled with blood, partly fluid and partly coagulated. The head
of the humerus was extensively absorbed. The articulating cartilage
was almost entirely destroyed, particularly on the inner side, where a
large portion of the bony matter had also been removed. The ulcerated
surfaces were of a dark, bloody colour.
[HYDATIC TUMORS.
Another disease of the bones which ought to be introduced here is the
development of hydatids, which I described twelve years ago under the
name of _osteo-hydatidic_ tumours. The seat of this affection is not
confined to any particular class of bones; though the long are perhaps
most prone to it. Its precise nature and origin have not yet been
determined; nor are its symptoms such as to enable us, in the present
state of our knowledge, to distinguish it from exostosis, osteosarcoma,
and other maladies. Its progress is commonly slow, the surface of the
tumour is smooth and regular, the skin exhibits no unusual appearance,
and the adjacent textures rarely participate in the morbid action.
The hydatids, usually of a globular figure, vary greatly in size and
number, and are generally filled with a thin, limpid fluid. They appear
to be of the nature of acephalocysts. The prognosis unfavourable, owing
to the difficulty of destroying these parasites, and their constant
tendency, when interfered with, to reappear.
As soon as the true nature of this tumour is ascertained it should be
laid freely open, its contents turned out, and the sac destroyed. For
this purpose the sides of the cavity should be seared with the actual
cautery, or touched with some of the more powerful escharotics, as the
nitrate of silver, or the caustic potash. If these measures fail, and
the disease involve the whole circumference of the bone, nothing short
of amputation will suffice. This was successfully resorted to in one of
the cases which came under the observation of Mr. Lucas of London.]
TREATMENT OF TUMOURS.
It may be observed generally, that no benefit can be derived from
external applications to tumours, such as friction with liniments or
ointments containing iodine, mercury, &c.; and that, therefore, it is
injudicious to employ such temporising measures; for though a tumour
at its commencement appear to be of a very harmless nature, yet it
may soon assume a most malignant character. If an apparently simple
tumour increase, and exhibit symptoms of inflammation, it will perhaps
be advantageous to apply leeches, to arrest that incited action which
affords the accession of new materials; this, however, cannot check
the morbid activity inherent in the new formation, though it may
hold the growth in check a little. If a tumour is to be removed by
external applications, it is evident that these must be such as shall
prevent the deposit of new matter, and allow the absorbents to remove
that which already exists; for absorption is always going on in a
tumour, though it leaves no evidence of its progress, on account of
the deposition of new matter exceeding the removal of the old. I must
say that I am unacquainted with any remedies capable of performing
the above indication. The removal of a swelled gland may occasionally
be accelerated by such means when stationary, or on the decline,
and before cheesy tubercular unorganized matter is infiltrated into
its texture; but to trifle so with a new and independent growth is
altogether absurd. The knife only is to be depended on.
Many of the tumours first described have no malignant disposition
originally, and only require surgical interference when they produce
deformity or inconvenience from their bulk. Yet even these ought not
to be allowed to attain any great size, however indolent they may
appear at first, and however little pain they may produce; for there
is always a danger of their assuming a malignant tendency, or forming
connections with important parts, so as to render their removal either
altogether impracticable, or at least attended with much difficulty.
Tumours of every kind, when seated near important organs, must be early
removed. Glandular tumours, however, even when of great size and long
continuance, are not to be rashly interfered with, when they arise from
irritation in the neighbourhood.
Those in which it is feared that malignant action has commenced cannot
be trifled with; and the only means which afford a chance of the
patient’s being effectually delivered from them is an operation. With
a view to their complete extirpation, the external incisions ought
always to be free, so as to admit of the after-dissection being easily
and rapidly performed: they ought also to be made in the direction of
the muscular fibres, whether these lie above or beneath the tumour. In
this way the margins of the wound are easily brought into apposition,
and there retained; whereas, if the fibres be divided transversely,
the wound will gape, and union by the first intention be rendered
absolutely impossible. If there is no reason to suppose that the tumour
is malignant, little or no integument ought to be removed, unless the
growth is of a large size; but, when malignity is dreaded, all the
discoloured, tense, and adherent integument, all that is permeated
by dilated and tortuous vessels, ought to be taken away, and the
incisions made at a distance from the disease. In all cases they ought
to commence at the point where the principal vessels enter; these are
thus divided at the outset, can be readily secured by ligature, or
by the fingers of an assistant, and the dissection is proceeded in
without risk or interruption from farther hemorrhage. If the opposite
course be pursued, the vessels will be divided two or more times during
the operation, and thus the performance of it will either be delayed
by the application of numerous ligatures, or will be attended with
a considerable loss of blood. After the tumour has been exposed it
ought to be principally detached in one direction, as in this way its
removal will be sooner accomplished, and not first cut on one side and
then on another. If malignant, great care should be taken that all the
diseased mass be removed, for a minute portion remaining will form a
nucleus in which similar diseased actions are certain to arise; in most
instances, it will be prudent not only to remove the parts actually
diseased, but those also which are in immediate connection with the
tumour, though at the time they appear healthy. All important parts
must be carefully avoided. After removal of the mass, and the complete
cessation of bleeding, the edges of the wound must be approximated, so
as to favour union by the first intention; if this fail, granulation
must be promoted, and the wound dressed according to the particular
circumstances of the case. All operations on malignant tumours, in
their advanced stages, are unwarrantable; they are necessarily painful
and severe, and cruel because unavailing; they often, indeed, expedite
the dissolution of the patient. If the integuments over the tumour have
ulcerated, and if the lymphatics in the neighbourhood are diseased, the
disease if removed will certainly be reproduced, and the succeeding
tumour will be still more malignant. The operation ought, if at all, to
be performed when the disease is in its incipient state, for then only
can success be expected.
Exostoses need not to be interfered with, unless they are the source
of much inconvenience, either from their size and form, or from their
having been detached, and lodged amongst the adjacent soft parts. If
loose, they can be removed in the same way as any other extraneous
body; if firm, their attachment must be divided by a saw, or by cutting
pliers, close to the bone from which they spring. Sometimes, as in the
scapula or other flat bone, a portion of the original bony tissue can
be cut out along with the new growth, and this renders the chance of
any return of disease much less likely.
Osteo-sarcomatous tumours are to be taken away, along with the part
of the bone in which they are imbedded, and, if possible, before the
integuments have ulcerated. The incisions must be made, and the bone
sawn, at a healthy part. The removal of the entire bone in which the
disease has commenced, when practicable, will afford a still better
chance of immunity from farther disease.
In spina ventosa more is seldom required than to lay open the
cavity, give vent to the matter, and then treat the case on the same
principles as in abscess of the soft parts. The cellular tumours,
partly cartilaginous, partly osseous, ought not to be permitted to
remain; the operation can generally be done without much difficulty;
and thus the danger of their degenerating avoided. Frequently, however,
a considerable part of the bone must be removed along with the tumour,
since the neighbouring tissue is generally softened, and intimately
adherent to the diseased part, which it somewhat resembles in structure.
In general, regular dissection is unnecessary in the removal of
encysted tumours. An incision is made, or an elliptical portion cut
out; the contents escape, and the cysts, being then laid hold of by
dissecting forceps, is readily separated. In some situations, as on
the eyelids, under the tongue, or amongst tendons, the sac, which is
thin, is not so easy of extraction; it is then inseparable, either
naturally, or from previous inflammation. Caustic is used with safety
to destroy those parts which cannot be detached, and for this purpose
the potass is to be preferred. When, however, the tumour is large, a
part of the integuments covering it must be removed, otherwise a large
cavity will be left, in which pus might accumulate. In this case, the
base of the tumour is to be surrounded by two elliptical incisions,
and the cyst dissected out entire, leaving only integument sufficient
to cover the exposed surface. In the smaller tumours, it is vain to
attempt regular dissection; a portion of the cyst will be left, and the
disease reproduced: whereas, by using the potass, the operation is
much more speedy, and always successful. The making a minute aperture,
and squeezing out the contents, is at best but a palliative measure,
and is often followed by severe constitutional disturbance.
OF WOUNDS.