Chapter XXVI

, are not often found outside of the bony skeleton. They may spring from cartilaginous extremities of growing bones, from epiphyseal cartilages, or from the interior of long and short bones, where their origin is probably due to inclusion of cartilaginous elements, as comprehended in Cohnheim’s theory. In young children they are often multiple and involve various parts of the body. Occurring in adults they are less often multiple, but may attain considerable size. (See Fig. 243.) They are found usually about the ribs, sternum, pelvis, and femora. If the entire structure of a given bone be involved in a growth of this kind, its eradication--that is, amputation--will probably be necessary.

[Illustration: FIG. 249

Exostosis bursata. (Orlow.)]

When otherwise, complete removal with careful cauterization of the base of the growth or surface from which it sprang will usually be sufficient. These cartilaginous tumors tend on one hand to mucoid softening and cystic formation, and on the other to calcification or ossification, by which the original cartilaginous character of the growth may be concealed.

=Osteomas.=--Osteomas are by some writers made to include _exostoses_ and _hyperostoses_. In accordance with the system followed in this work only those growths are considered as tumors which are of no physiological usefulness, and it is preferable to maintain a distinction between osteomas and the exostoses or bone hypertrophies, which pertain either to evolutionary relics or to constitutional affections.

There is, however, a peculiar form of exostosis which becomes covered by an adventitious bursa, whose walls become in time quite thick, which is called _exostosis bursata_. In the cavity of this bursa may frequently be found rice-grain or other fibrinous concretions. This lesion is common in the neighborhood of joints, and the new bursa frequently communicates with the joint cavity (Fig. 249).

=Myxomas.=--Myxomas are rare in bone, and are seen usually only as degenerated forms of cartilaginous bony or malignant growths. They lead to cystic degeneration. A primary growth of this kind has for its origin the bone-marrow.

=Sarcoma.=--As already described, sarcoma of bone should not be confused with osteosarcoma. (See Sarcoma.) The former refers to sarcoma springing from the true osseous tissue or periosteum. When central the bony walls are expanded and form a shell. Osteosarcoma refers to a tumor springing from the original connective tissue which holds the bony elements together, and contains osseous tissue scattered through it. Sarcoma occurs usually in the long bones, although none are exempt; mostly single, it nevertheless may be multiple. It occurs frequently in the young, is seen even at birth, and in these instances is supposed to take its origin usually from epiphyseal structures. No period of life is, however, exempt. Tumors attain sometimes enormous size. Marsh has recently described such a tumor weighing thirty-three pounds. Microscopically these tumors may assume any of the varieties, endothelioma, angiosarcoma, etc., those of the most rapid growth being found rather of the _round-cell_ type, while those of slow growth are usually _myeloid_ or contain giant cells.

Sarcomas frequently arise from the _periosteum_. Commencing in the interior of a bone, they develop for the most part very slowly, and expand the bone more or less symmetrically, in distinction to those growths of external origin which are in evidence on one or another aspect of the bone involved (Figs. 247 and 248).

Sarcoma not infrequently has its origin from the callus of a delayed bone union, and I have had repeatedly to amputate for this sequel of fracture. (See Fig. 252.)

As the disease advances there is increase of pain, usually with increasing cachexia, while augmentation in size of such a tumor may make a limb not only useless, but the source of greatest annoyance and difficulty in management of the case.

=Treatment.=--There is but one treatment in cases which will permit it--amputation of limbs, extirpation of tumors from certain bones, or excision of entire bones. Thus for sarcoma of the scapula we extirpate the entire bone; for sarcoma of the skull we make extensive resections of the same, removing the underlying dura when involved; for sarcoma of the lower or upper jaw we remove it in whole or in part. Sarcoma of the spine is inoperable, that of the pelvis almost equally so. In absolutely inoperable cases treatment by the toxins of erysipelas may be tested. In all cases where pain is severe opiates should be administered, which under these circumstances are anodyne, stimulant, and almost nutritive. Patients in this condition should not be allowed to suffer, and opium in assimilable form should always be administered to any amount necessary.

[Illustration: FIG. 250

Sarcoma of periosteum of humerus. (Pemberton.)]

[Illustration: FIG. 251

Bone cyst of tibia. (Buffalo Clinic.)]

=Myeloma (Kahler’s Disease).=--Collins[36] reports the tenth recorded case in this country. The disease was first described by Bence Jones in connection with a peculiar proteid found in the urine. It is characterized by changes in the bones, with pain in the chest, back, and loins. In the urine albumose appears, which seems to be pathognomonic when taken in connection with such symptoms as those above. On section numerous small tumors are seen in the bones. The disease has hitherto been regarded as an expression of osteomalacia. All the bones of the skeleton may be involved without any tendency to metastasis in other tissues. On minute examination the myelomatous tumors met with seem to be found alike in the bone substance and the marrow, and to be cell proliferations of myeloid tissue. The matter is still left somewhat in doubt as to what should be meant by the term _myeloma_, this being a feature to be cleared up later. It is seen more often in males than in females, and in the later part of life. Aside from constant malaise, with pain in the back and side, there occur progressive weakness, with anemia, and such final softening and fragility of bones as to lead to spontaneous fractures, or to the projection of tumors, which may be especially noted about the ribs, with deformity of the vertebræ. On close inspection the urine will be found turbid and albumose is detected. The disease is usually regarded as hopeless; there is no information regarding its successful treatment.

[36] Medical Record, April 29, 1905.

[Illustration: FIG. 252

Sarcoma developing in callus. (Haberen.)]

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