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Fig. 148.—Chondro-Sarcoma of Scapula in a man æt. 63; removal of the scapula was followed two years later by metastases and death.
In central sarcoma pain is the first symptom, and it is usually constant, dull, and aching; is not obviously increased by use of the limb, but is often worse at night. Swelling occurs late, and is due to expansion of the bone; it is fusiform or globular, and is at first densely hard, but in time there may be parchment-like or egg-shell crackling from yielding of the thin shell. The swelling may pulsate, and a bruit may be heard over it. In advanced cases it may be impossible to differentiate between a periosteal and a central tumour, either clinically or after the specimen has been laid open.
Fig. 149.—Central Sarcoma of Lower End of Femur, invading the knee-joint.
(Museum of Royal College of Surgeons, Edinburgh.)
Pathological fracture is more common in central tumours, and sometimes is the first sign that calls attention to the condition. Consolidation rarely takes place, although there is often an attempt at union by the formation of cartilaginous callus.
Fig. 150.—Osseous Shell of Osteo-Sarcoma of Upper Third of Femur, after maceration.
The soft parts over the tumour for a long time preserve their normal appearance; or they become Ĺ“dematous, and the subcutaneous venous network is evident through the skin. Elevation of the temperature over the tumour, which may amount to two degrees or more, is a point of diagnostic significance, as it suggests an inflammatory lesion.
The adjacent joint usually remains intact, although its movements may be impaired by the bulk of the tumour or by effusion into the cavity.
Enlargement of the neighbouring lymph glands does not necessarily imply that they have become infected with sarcoma for the enlargement may disappear after removal of the primary growth; actual infection of the glands, however, does sometimes occur, and in them the histological structure of the parent tumour is reproduced.
To obtain a reasonable prospect of cure, the diagnosis must be made at an early stage. Great reliance is to be placed on information gained by examination with the X-rays.
X-ray Appearances.—In periosteal tumours that do not ossify, there is merely erosion of bone, and the shadow is not unlike that given by caries; in ossifying tumours, the arrangement of the new bone on the surface is characteristic, and when it takes the form of spicules at right angles to the shaft, it is pathognomic.
In soft central tumours, there is disappearance of bone shadow in the area of the tumour, while above and below or around this, the shadow is that of normal bone right up to the clear area. In many respects the X-ray appearances resemble those of myeloma. In tumours in which there is a considerable amount of imperfectly formed new bone, this gives a shadow which barely replaces that of the original bone, in parts it may even add to it—the resulting picture differing widely in different cases; but it is usually possible to differentiate it from that caused by bacterial infections of the bone and from lesions of the adjacent joint.
Fig. 151.—Radiogram of Osteo-Sarcoma of Upper Third of Femur.
Skiagraphy is not only of assistance in differentiating new growths from other diseases of bone, but may also yield information as to the situation and nature of the tumour, which may have important bearings on its treatment by operation.
Fig. 152.—Radiogram of Chondro-Sarcoma of Upper End of Humerus in a woman æt. 29.
When fracture of a long bone takes place in an adolescent or young adult from comparatively slight violence, disease of the bone should be suspected and an X-ray examination made.
In difficult cases the final appeal is to exploratory incision and microscopical examination of a portion of the tumour; this should be done when the major operation has been arranged for, the surgeon waiting until the examination is completed.
The prognosis varies widely. In general, it may be said that periosteal tumours are less favourable than central ones, because they are more liable to give rise to metastases. Permanent cures are unfortunately the exception.
Treatment.—When one of the bones of a limb is involved, the usual practice has been to perform amputation well above the growth, and this may still be recommended as a routine procedure. There are reasons, however, which may be urged against its continuance. High amputation is unnecessary in the more benign sarcomas, and in the more malignant forms is usually unavailing to prevent a fatal issue either from local recurrence or from metastases in the lungs or elsewhere. Following the lead of Mikulicz, a considerable number of permanent cures have been obtained by resecting the portion of bone which is the seat of the tumour, and substituting for it a corresponding portion from the tibia or fibula of the other limb. In a cellular sarcoma of the humerus of a boy we resected the shaft and inserted his fibula ten years ago, and he shows no sign of recurrence. When resection is impracticable, a subcapsular enucleation is performed, followed by the insertion of radium.
Pulsating Hæmatoma or Aneurysm of Bone.—A limited number of these are innocent cavernous tumours dating from a congenital angioma. The majority would appear to be the result of changes in a sarcoma, endothelioma, or myeloma. The tumour tissue largely disappears, while the vessels and vascular spaces undergo a remarkable development. The tumour may come to be represented by one large blood-containing space communicating with the arteries of the limb; the walls of the space consist of the remains of the original tumour, plus a shell of bone of varying thickness. The most common seats of the condition are the lower end of the femur, the upper end of the tibia, and the bones of the pelvis.
The clinical features are those of a pulsating tumour of slow development, and as in true aneurysm, the pulsation and bruit disappear on compression of the main artery. The origin of the tumour from bone may be revealed by the presence of egg-shell crackling, and by examination with the X-rays.
If the condition is believed to be innocent, the treatment is the same as for aneurysm—preferably by ligation of the main artery; if malignant, it is the same as for sarcoma.
Secondary Tumours of Bone.—These embrace two groups of new growth, those which give rise to secondary growths in the marrow of bones and those which spread to bone by direct continuity.
Metastatic Tumours.—Excepting certain cancers which give rise to metastases by lymphatic permeation (Handley), the common metastases arising in the bone-marrow reach their destination through the blood-stream.
Fig. 153.—Epitheliomatous Ulcer of Leg with direct extension to Tibia.
(Lord Lister's specimen. Anatomical Museum, University of Edinburgh.)
Secondary cancer is a comparatively common disease, and, as in metastases in other tissues, the secondary growths resemble the parent tumour. The soft forms grow rapidly, and eat away the bone, without altering its shape or form. In slowly growing forms there may be considerable formation of imperfectly formed bone, often deficient in lime salts; this condition may be widely diffused throughout the skeleton, and, as it is associated with softening and bending of the bones, it is known as cancerous osteomalacia. Secondary cancer of bone is attended with pain, or it suddenly attracts notice by the occurrence of pathological fracture—as, for example, in the shaft of the femur or humerus. In the vertebræ, it is attended with a painful form of paraplegia, which may involve the lower or all four extremities. On the other hand, the disease may show itself clinically as a tumour of bone, which may attain a considerable size, and may be mistaken for a sarcoma, unless the existence of the primary cancer is discovered.
The cancers most liable to give rise to metastasis in bone are those of the breast, liver, uterus, prostate, colon, and rectum; hyper-nephroma of the kidney may also give rise to metastases in bone.
Secondary tumours derived from the thyreoid gland require special mention, because they are peculiar in that neither the primary growth in the thyreoid nor the secondary growth in the bones is necessarily malignant. They are therefore amenable to operative treatment.
Secondary sarcoma, whether derived from a primary growth in the bone or in the soft parts, is much rarer than secondary cancer. Its removal by operation is usually contra-indicated, but we have known of cases terminating fatally in which the section revealed only one metastasis, the removal of which would have benefited the patient.
In all of these conditions, examination of the bones with the X-rays gives valuable information and often disclose unsuspected metastases.
Cancer of Bone resulting from Direct Extension from Soft Parts.—In this group there are also two clinical types. The first is met with in relation to epithelioma of a mucous surface—for example, the palate, tongue, gums, antrum, frontal sinus, auditory meatus, or middle ear. They will be described under these special regions.
The second type is met with in relation to epithelioma occurring in a sinus, the sequel of suppurative osteomyelitis, compound fracture, or tuberculous disease. The patient has usually had a discharging sinus for a great number of years: we have known it to last as many as fifty. The epithelioma originates at the skin orifice of the sinus, and spreads to the bone and into its interior, where the progress of the cancer is resisted by dense bone, which obliterates the medullary canal. Although its progress is slow, the infiltration of the bone is usually more extensive than appears externally. It is recognised clinically by the characteristic cauliflower growth at the orifice of the sinus, and by the offensive nature of the discharge. A similar epithelioma may arise in connection with a chronic ulcer of the leg. The cancer may infect the femoral lymph glands. The operative treatment is influenced by the extent of the disease in the soft parts overlying the bone, and consists in wide removal of the diseased tissues and resection of the bone, or in amputation.
Cysts of Bone.—With the exception of hydatid cysts, cysts in the interior of bone are the result of the liquefaction of solid tissue; this may be that of chondroma, myeloma, or sarcoma, but more commonly of the marrow in osteomyelitis fibrosa.
CHAPTER XXIDISEASES OF JOINTS Definition of terms —Ankylosis. Diseases: Errors of development —Bacterial diseases: Pyogenic; Gonorrhœal; Tuberculous; Syphilitic; Acute rheumatism —Diseases associated with certain constitutional conditions: Gout; Chronic articular rheumatism; Arthritis deformans; Hæmophilia —Diseases associated with affections of the nervous system: Neuro-arthropathies; Charcot's disease —Hysterical or mimetic affections of joints —Tumours and cysts —Loose bodies.
Definition of Terms.—The term synovitis is applied to any reaction which affects the synovial membrane of a joint. It is usually associated with effusion of fluid, and this may be serous, sero-fibrinous, or purulent. As the term synovitis merely refers to the tissue involved, it should always be used with an adjective—such as gouty, gonorrhœal, or tuberculous—which indicates its pathological nature.
The terms hydrops, hydrarthrosis, and chronic serous synovitis are synonymous, and are employed when a serous effusion into the joint is the prominent clinical feature. Hydrops may occur
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