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 band 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 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 rheuinatism. 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 sta,ges 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 lbs. 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 cornpletely 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 }nematodes.
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 orbit, projecting forwards on the eye-ball and backwards on the brain, both of which organs it must have destructively compressed.* We have seen an osteo-sarcoma of the lower jaw in a young boy occasion death by suffocation ; and another in a young female impede deglutition so entirely that she died or seemed to have died of actual starvation. This, however, was at a period before an operation for the removal of the jaw had been attempted, at least in this country, and both were considered as specimens of fungus limmatodes.
When the tumour re-appears after operation, it does so in a very short space of time, often before the wound has cicatrized and healed; and as its situation is in the immediate neigh bourhood of the former disease, the fungus protrudes through the wound, and seems to grow from it. In these cases the progress to a fatal termination, which is inevitable, is per haps, fortunately for the patient, extremely rapid also. Indeed in all cases of relapse, the growth of the tumour goes on much more quickly than in the original disease, and the patient's sufferings are considerably augmented also. We have seen cases in which the pain was so intense and so unremitting, that, night or day, not a moment's rest could be obtained, even under the influence of the lanzest doses of opium that could be administered with safety.
Cancer. Fungus hamatodes.—We have al ready more than expressed a doubt that eitber of these diseases ever originated in the osseous structure, or could be considered as properly appertaining to it, although it must be conceded that, in a fei,v insulated casc,,s, a cancerous dis position has seemed to produce a fragility of bones, and that this loss of the power of resist ance has preceded the development of the dis ease in the softer structures. But with the utmost diligence of research we have not been able to discover one case in which a morbid alteration of structure, analogous to those chan ges in the soft parts which we call cancer, and which contaminate the system through the me dium of the soft parts, has been found within the bone itself, or indeed to have existence therein, independent of some similar degenera tion in the adjacent structures. On this sub ject, however, our knoN,vledge must be extremely limited. We do not well know what cancer is, or what is meant by a cancerous diathesis. We know not how to define or even to describe it as a generic form of disease. The dissection of these tumours exhibits an ahnost infinite diversity of structure, and during life, previous to tbe actual contamination of the system, when the information too frequently avails but little, it is difficult to say whether any given tumour possesses this quality of malignancy or not.