462 



BONE, PATHOLOGICAL CONDITIONS OF. 



opinions of the highest and most respectable 

 authorities, although we cannot coincide with 

 them in classing cancer as a species of osteo- 

 sarcoma. Pathologically they are distinct and 

 different diseases, appearing in patients of dif- 

 ferent ages, habits, and conditions of health, 

 and exhibiting totally different phenomena ; 

 and practically they are not alike, for it would 

 be as insane to attempt the removal of a bone 

 contaminated by an adjacent cancer, as it 

 would be cruel to refuse the chance of an ope- 

 ration to one afflicted with true osteo-sarcoma. 

 The disease is only malignant in its tendency 

 to re-appear, nor can it be previously ascer- 

 tained by the symptoms, or subsequently by 

 examination of the tumour, whether it is likely 

 to show this disposition or not. Those nodu- 

 lated tumours that occur on the fingers and 

 wrists of children, and which are so admirably 

 described and delineated by Bell,* almost in- 

 variably reappear in some other situation after 

 removal. This we have seen remarkably ex- 

 emplified in the case of a little girl who was 

 admitted into hospital with the two fore-fingers 

 and thumb affected with this disease : they 

 were amputated, but in nine weeks afterwards 

 both the radius and ulna were attacked, and 

 the arm was cut off. In seven weeks both 

 clavicles were engaged, and the little patient 

 was sent to the country, from which she never 

 returned. Besides the development at an early 

 age, a rapidity of growth, accompanied by in- 

 tensity of pain, is considered as indicative of a 

 most unfavourable disposition in the system. 

 Yet is the contrary no assurance of safety, for 

 we have seen a case in which the disease had 

 lasted for five years and without much suffer- 

 ing, return after removal, and destroy the pa- 

 tient in less than twelve months. In general, 

 however, the remark seems to be grounded on 

 experience. The presence of a deep and foul 

 ulceration within the tumour is rather unpro- 

 mising: in Mr. Cusack's six cases of excision 

 of the lower jaw, the disease returned in one 

 only, and in that this kind of ulcer had pre- 

 viously existed. It may, too, be laid down as 

 an unvarying rule that the secondary appear- 

 ance of osteo-sarcoma is more painful and 

 more rapid in its progress than in its first and 

 original attack. It is uniformly fatal. 



The first approaches of osteo-sarcoma are 

 usually insidious, and as it is in general not a 

 very painful affection, it may (particularly in 

 children) escape observation at its very earliest 

 periods. Any bone may be attacked by it, but 

 in the adult it is more frequently situated in 

 the spongy extremities of the long bones and in 

 the lower jaw, whilst the phalanges, carpal and 

 metacarpal bones, the radius, the ulna, and the 

 clavicle furnish the best and most frequent spe- 

 cimens in the younger subject. It occurs often 

 idiopathically, and on the other hand it occa- 

 sionally follows or seems to follow a fracture 

 or other injury, as if the disposition existed in 

 the system, and only required some stimulus 

 to direct it to any one situation. It commences 

 usually by a small, firm, immovable tubercular- 



* Loc. citat. 



like tumour appearing to spring from some part 

 of the bone : soon after another of these may 

 make its appearance, but these, in the first in- 

 stance, are free from pain and insensible to 

 pressure. As it increases, the pain assumes a 

 dull and aching character, in the jaw frequently 

 mistaken for tooth-ache, in other bones for 

 rheumatism. The degree of suffering, however, 

 is not a very strong characteristic, for it will 

 depend on the rapidity of growth, the disten- 

 sion suffered, the sensibility of the parts com- 

 pressed, and a number of other circumstances 

 too obvious to require detail. In ordinary 

 cases, it has been remarked that the pain ob- 

 serves a more than progressive increase with the 

 size of the tumour, particularly if its growth has 

 been accelerated by any accidental injury. In 

 the advanced stages it is always severe, and 

 in some instances dreadful. In one of Bell's 

 cases, it is stated that there was no hour of the 

 night or day in which the patient's wild cries 

 could not be heard miles off". In most in- 

 stances the sufferer is completely deprived of 

 sleep, and in some he complains of nocturnal 

 exacerbations. 



Once formed, it grows with greater or less 

 rapidity, often appearing stationary for some 

 time, and then suddenly and quickly increasing : 

 sometimes, on the contrary, it increases rapidly 

 from the commencement, and we have removed 

 an osteo-sarcoma of the lower jaw, which at- 

 tained to the enormous weight of 4 Ibs. 1 oz. 

 avoirdupoise in the short space of eight months. 

 Whilst the tumour is comparatively small, the 

 skin is pale and glassy and stretched, and blue 

 veins are seen meandering on its surface : when 

 large, its colour is dark red, verging to purple, 

 and multitudes of these little veins appear upon 

 it. It is, generally, firm to the touch, solid 

 and heavy ; but occasionally an examination 

 with the fingers discovers the osseous covering 

 of the tumour to be very thin, and it yields on 

 pressure with a peculiar sensation of elasticity, 

 such as one might conceive parchment to con- 

 vey if not stretched very tightly. At length it 

 gives way, and a foul ulcer is formed, dis- 

 charging an unhealthy fetid pus, often mixed 

 with blood. The character usually attributed 

 to this ulceration is fungoid, but we have never 

 seen it thus. It commences generally in the 

 centre of the tumour by a slough, and gradually 

 makes its way outwards to burst by two or 

 three apertures, and we have seen an immense 

 osteo-sarcoma of the lower jaw completely tra- 

 versed by ulceration, one opening being in the 

 mouth and the other at the inferior and most 

 depending part of the tumour. These ulcers 

 are usually hollow, attended with loss of sub- 

 stance, and we have not observed one that 

 could have been easily mistaken for fungus 

 haematodes. 



Independent of any malignancy inherent in 

 the tumour, it is evident that osteo-sarcoma may 

 destroy life by being so situated as to compress 

 some important or even vital organ, more par- 

 ticularly if such situation precludes the possibi- 

 lity of removal by a surgical operation. Such, 

 for instance, was Mr. Crampton's case, in which 

 the diseased growth sprung from the roof of the 



