Manual of Surgery - Alexis Thomson (read me a book txt) 📗
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Treatment.—In view of the unstable quality of the chondroma, especially of its liability to become malignant, it should be removed as soon as it is recognised. In those projecting from the surface of a bone, both the tumour and its capsule should be removed. If in the interior, a sufficient amount of the cortex should be removed to allow of the tumour being scraped out, and care must be taken that no nodules of cartilage are left behind. In multiple chondromas of the hand, when the fingers are crippled and useless, exposure to the X-rays should be given a trial, and in extreme cases the question of amputation may have to be considered. When a cartilaginous tumour takes on active growth, it must be treated as malignant.
Fig. 51.—Chondroma of Metacarpal Bone of Thumb.
The chondromas that are met with at the ends of the long bones in children and young adults form a group by themselves. They are usually related to the epiphysial cartilage, and it was suggested by Virchow that they take origin from islands of cartilage which have not been used up in the process of ossification. They are believed to occur more frequently in those who have suffered from rickets. They have no malignant tendencies and tend to undergo ossification concurrently with the epiphysial cartilage from which they take origin, and constitute what are known as cartilaginous exostoses. These are sometimes met with in a multiple form, and may occur in several generations of the same family. They are considered in greater detail in the chapter dealing with tumours of bone.
Minute nodules of cartilage sometimes form in the synovial membrane of joints and lining of tendon sheaths and bursæ: they tend to become detached from the membrane and constitute loose bodies; they also undergo a variable amount of calcification and ossification, so as to be visible in skiagrams. They are further considered with loose bodies in joints.
Cartilaginous tumours in the parotid, submaxillary gland, and testicle belong to a class of “mixed tumours” that will be referred to later.
Osteoma.—The true osteoma is composed of bony tissue, and originates from the skeleton. Two varieties are recognised—the spongy or cancellous, and the ivory or compact. The spongy or cancellous osteoma is really an ossified chondroma, and is met with at the ends of the long bones (Fig. 52). From the fact that it projects from the surface of the bone it is often spoken of as an exostosis. It grows slowly, and rarely causes any discomfort unless it presses upon a nerve-trunk or upon a bursa which has developed over it. The Röntgen rays show a dark shadow corresponding to the ossified portion of the tumour, and continuous with that of the bone from which it is growing (Fig. 138). Operative interference is only indicated when the tumour is giving rise to inconvenience. It is then removed, its base or neck being divided by means of the chisel. The multiple variety of osteoma is considered with the diseases of bone.
The bony outgrowth from the terminal phalanx of the great toe—known as the subungual exostosis—is described and figured on p. 404. Bony projections or “spurs” sometimes occur on the under surface of the calcaneus, and, projecting downwards and forwards from the greater process, cause pain on putting the heel to the ground.
Fig. 52.—Cancellous Osteoma of lower end of Femur.
The ivory or compact osteoma is composed of dense bone, and usually grows from the skull. It is generally sessile and solitary, and may grow into the interior of the skull, into the frontal sinus, into the cavity of the orbit or nose, or may fill up the external auditory meatus, causing most unsightly deformity and interference with sight, breathing, and hearing.
Bony formations occur in muscles and tendons, especially at their points of attachment to the skeleton, and are known as false exostoses; they are described with the diseases of muscles.
Odontoma.—An odontoma is composed of dental tissues in varying proportions and different degrees of development, arising from tooth-germs or from teeth still in process of growth (Bland Sutton). Odontomas resemble teeth in so far that during their development they remain hidden below the mucous membrane and give no evidence of their existence. There then succeeds, usually between the twentieth and twenty-fifth years, an eruptive stage, which is often attended with suppuration, and this may be the means of drawing attention to the tumour. Following Bland Sutton, several varieties of odontoma may be distinguished according to the part of the tooth-germ concerned in their formation.
The epithelial odontoma is derived from persistent portions of the epithelium of the enamel organ, and constitutes a multilocular cystic tumour which is chiefly met with in the mandible. The cystic spaces of the tumour contain a brownish glairy fluid. These tumours have been described by Eve under the name of multilocular cystic epithelial tumours of the jaw.
The follicular odontoma, also known as a dentigerous cyst, is derived from the distension of a tooth follicle. It constitutes a cyst containing a viscid fluid, and an imperfectly formed tooth is often found embedded in its wall. The cyst usually forms in relation to one of the permanent molars, and may attain considerable dimensions.
The fibrous odontoma is the result of an overgrowth of fibrous tissue surrounding the tooth sac, which encapsulates the tooth and prevents its eruption. The thickened tooth sac is usually mistaken for a fibrous tumour, until, after removal, the tooth is recognised in its interior.
Composite Odontoma.—This is a convenient term to apply to certain hard dental tumours which are met with in the jaws, and consist of enamel, dentine, and cement. The tumour is to be regarded as being derived from an abnormal growth of all the elements of a tooth germ, or of two or more tooth germs, indiscriminately fused with one another. It may appear in childhood, and form a smooth unyielding tumour, often of considerable size, replacing the corresponding permanent tooth. It may cause a purulent discharge, and in some cases it has been extruded after sloughing of the overlying soft parts. Many examples of this variety of odontoma, growing in the nasal cavity or in the maxillary sinus, have been erroneously regarded as osteomas even after removal.
On section, the tumour is usually laminated, and is seen to consist mainly of dentine with a partial covering of enamel and cement.
Diagnosis.—Odontomas are often only diagnosed after removal. When attended with suppuration, the condition has been mistaken for disease of the jaw. Fibrous odontomas have been mistaken for sarcoma, and portions of the maxilla removed unnecessarily. Any circumscribed tumour of the jaw, particularly when met with in a young adult, should suggest the possibility of an odontoma. Skiagrams often give useful information both for diagnosis and for treatment.
Treatment.—The solid varieties of odontoma can usually be shelled out after dividing the overlying soft parts. In the follicular variety, it is usually sufficient to excise a portion of the wall, scrape out the interior, and remove any tooth that may be present. The cavity is then packed and allowed to heal from the bottom.
Fibroma.—A fibroma is a tumour composed of fibrous connective tissue. A distinction may be made between the soft fibroma, which is comparatively rich in cells and blood vessels, and in which the fibres are arranged loosely; and the hard fibroma, which is composed of closely packed bundles of fibres often arranged in a concentric fashion around the blood vessels. The cut surface of the soft fibroma presents a pinkish-white, fleshy appearance, resembling the slowly growing forms of sarcoma; that of a hard fibroma presents a dry, glistening appearance, aptly compared to watered silk. The soft variety grows much more rapidly than the hard. In certain fibromas—in those, for example, which grow from the periosteum of the base of the skull and project into the naso-pharynx—the blood vessels are dilated into sinuses and have no proper sheaths; they therefore tend to remain open when divided, and to bleed excessively. Transition forms between soft fibroma and sarcoma are met with, so that in operating for their removal it is safer to take away the capsule along with the tumour, and the patient should be kept under observation in view of the risk of recurrence.
The skin—especially the skin of the buttock—is one of the favourite seats of fibroma, and it may occur in a multiple form. It is met with also in the subcutaneous and intermuscular cellular tissue, and in the abdominal wall, where it sometimes attains considerable dimensions. Various forms of fibroma are met with in the mamma and are described with diseases of that organ. The fibrous overgrowths in the skin, known as keloid and molluscum fibrosum, and those met with in the sheaths of nerves, are described elsewhere. Fibroid tumours of the uterus are described with myoma.
Diffuse fibroma or Fibromatosis, analogous to lipomatosis, is met with in the connective tissue of the skin and sheaths of nerves, and constitutes one form of neuro-fibromatosis; a similar change is also met with in the stomach and colon.
Fig. 53.—Myeloma of Shaft of Humerus, causing pathological fracture. (Mr. J. W. Struthers' case.)
(The unusual site of the tumour is to be noted.)
Myxoma.—A myxoma is composed of tissue of a soft gelatinous, semifluid consistence. The pure myxoma is extremely rare, and clinically resembles the lipoma. Myxomatous tissue is, however, frequently found in other connective-tissue tumours as a result of degeneration, for example, in cartilaginous tumours and in sarcomas. Myxomatous tissue is also a prominent constituent of the “innocent parotid tumour.” Mucous polypus of the nose, which is often described as a myxoma, is merely a pendulous process of œdematous mucous membrane.
Myeloma.—A myeloma is composed of large multinuclear giant cells surrounded by round and spindle cells. The cut surface of the tumour presents a deep red or maroon colour. While occasionally met with in tendon sheaths and bursæ, and is then of an orange-yellow colour, the myeloma occurs most frequently in the cancellous tissue at the ends of the long bones, its favourite site being the upper end of the tibia. Although formerly classified as a sarcoma, it is the exception for it to present malignant features, and it can usually be extirpated by local measures without fear of recurrence. The diagnosis, X-ray appearances, and the method of removal are considered with the diseases of bone. Sometimes the myeloma is met with in multiple form in the skeleton, in association with an unusual form of protein in the urine (Bence Jones).
Myoma.—A myoma is composed of non-striped muscle fibres. A pure myoma is very rare, and is met with in organs possessed of non-striped muscle, such as the stomach, intestine, urinary bladder, and prostate. In the uterus, which is the most common situation, these tumours contain a considerable admixture of fibrous tissue, and are known as fibroids or fibro-myomas. They present on section a fasciculated appearance, which may resemble that of a section of balls of cotton (Fig. 54). They are encapsulated and vascular, frequently attain a large size, and may be single or multiple. While they may occasion neither inconvenience nor suffering, they frequently give rise to profuse hæmorrhage from the uterus, and may cause serious symptoms by pressing injuriously on the ureters or the intestine, or by complicating pregnancy and parturition.
The Rhabdomyoma is an extremely rare form of tumour, met with in the kidney, uterus, and testicle. It contains striped muscle fibres, and is supposed to originate from a residue of muscular tissue which has become sequestrated during development.
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