Elements of Surgery

by Robert Liston

OF TUMOURS OF BONES.

The vascular action of bones, in their healthy state, is feeble, but, as in other feeble parts, it is easily excited, and disease of an obstinate and unyielding nature is apt to follow.

The morbid growths vary much in texture. The most frequent are the osseous, or those of the same structure with the original bone; but even these differ much in the density and arrangement of their particles: they have been termed exostoses. They may be of great density, and are then called the hard, or ivory; these never attain a large size, seldom exceed that of a bean, have a smooth and polished surface, and are of a flattened and hemispheroidal form, their greatest circumference being at the base; they occur in many of the bones, but generally in those of the cranium and face.

Others, being of a more loose and spongy texture, have been called cancellated. These are commonly formed by the bones of the extremities, and often attain a very considerable size; they grow from the periosteum, or from the outer surface of the bone, and are then covered by an expansion of this membrane. Sometimes they adhere by a narrow neck, and expand into a bulbous form, so that they can be very readily removed by operation, and are very apt to be broken off by external injury. Others have a broad and firmer attachment, and are of an irregular shape, often projecting in the form of a large spicula, and at other times assuming a somewhat stalactical appearance. Such frequently prove the source of much inconvenience, by impeding the motions of the muscles, or disturbing the functions of any adjoining organ. They possess no malignant disposition, but are under the same laws, though perhaps in a less degree, with their parent trunk.

On making sections of exostoses, and of the bones from which they arise, some appear to be mere enlargements or processes of the parent bone, the cancellated tissue extending itself so as to form the interior of the exostoses, whilst the exterior resembles a proportionate extension of the outer lamina. Others are evidently formed by the deposition of osseous matter externally to the outer lamina, many being dense and compact throughout, others containing an internal cancellated structure, but which is not continuous with that of the bone, as it is separated by the natural outer lamina. Their formation appears similar to that of the fœtal bones: a glutinous matter is effused, becomes dense, and is converted into cartilage; bloodvessels shoot into it, ramify throughout its whole structure in a radiated form, and deposit osseous matter. This deposit increases, and extends from a central nucleus towards the circumference; the cartilage is in part absorbed, and the new structure becomes osseous, and similar to the original tissue by the vessels of which it was formed. These tumours, even when they have attained a large size, contain a mixture of bone and cartilage, covered by a dense fibrous investment. The bony matter is arranged in spicula, adhering to the surface of the shaft or head of the bone, and projecting into the morbid mass: the spaces are filled up by a cartilaginous substance. The growth is sometimes rapid, and the tumour soon becomes troublesome from its immense size.

Frequently a bone is much enlarged throughout its whole extent, or the greater part of it, and presents a cancellated texture: sometimes, also, it is much thickened, and, at the same time, of great solidity; but such enlargements cannot be considered as tumours of bones, or exostoses, any more than those nodules of new osseous matter, which are effused in consequence of inflammation of the osseous tissue. The most frequent cause of exostoses appears to be external injury; their progress is slow, attended with slight dull pain, and often accompanied with no inconvenience; their existence can be readily ascertained, a hard and immoveable body being felt where no bone exists in the natural state of parts; but when the tumour projects into an internal cavity, the diagnosis is rendered obscure. Most frequently, they remain stationary, after having attained a certain size, and are productive of little inconvenience, the surrounding parts having accommodated themselves to the new formation. Occasionally, suppuration occurs in the soft parts, the matter comes to the surface, and a troublesome abscess is formed.

To this class of tumours would I confine the term exostosis, not including those consisting of softer materials, and possessed of a less benign action.

OF OSTEOSARCOMA.

By this term is meant, an enlargement and alteration in the structure 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.