Elements of Surgery

by Robert Liston

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.