ARTICLE I.-On the Pedunculated Exostosis of the Long Bones. By JAMES SYME, Esq., Professor of Clinical Surgery in the University of Edinburgh. (Read to the Medico-Chirurgical Society, Nov. 16th, 1853.) As the expression exostosis literally implies merely an inordinate growth of bone, it has been employed to denote a great variety of morbid conditions in which this circumstance happens to exist. The "callus" that repairs a fracture-the new osseous shell which supplies the place of a dead shaft the spina ventosa or expansion caused by the accumulation of pus or other fluid-the spicular or foliated excrescences that shoot into the substance of an osteo-sarcomatous tumour-and the bony prominences of morbid growth resembling the natural processes connected with the origin and insertion of muscles, have all been included within this comprehensive title. It is to a particular form in which the last mentioned of these productions appear, that I now wish to direct the attention of the Society. In his Essay on Exostosis, Sir Astley Cooper has described the simple growth of osseous substance, and mentioned the situations where tumours of this kind are most frequently met with. Of these, the one by far most common is the thigh-bone, a little above the internal condyle near the insertion of the triceps adductor; and he expresses the opinion that the origin of such excrescences may be connected with some impulse to increased action caused by inor NEW SERIES.-NO. XLIX. JANUARY 1854. A dinate contraction of the muscles. It may be objected to this explanation, that the tumours to which Sir A. more particularly alludes, though situated near the insertion of a muscle, are always placed at the side of it, so as not to be directly influenced by its contraction, and also that simple osseous growths are met with where the influence of any tendon or muscle is quite impossibleas at the distal phalanx of the great toe, from the extremity of which, on the upper surface, a troublesome exostosis is apt to grow. In the present state of our knowledge, it must be admitted, that in so far as the cause of such productions is concerned, we do not possess any satisfactory information. may The tendency to growths of this simple kind is greatest in the early period of life, especially about the time of puberty, as if, in the development of the body to its mature proportions, there were some redundance of expansion in the osseous system. Indeed, young and growing persons often exhibit a somewhat similar tendency in the processes and articulating extremities of the long bones enlarging more rapidly than the parts connected with them, so as even to excite apprehensions of deformity. I have frequently been consulted by anxious relatives on such occasions, and always felt warranted to predict that, in the course of due time, symmetry would be restored. It be remarked that there is thus afforded one of the numerous and diligently cultivated fields of orthopaedic delusion, the changes resulting from spontaneous improvement being attributed to the influence of useless machinery. The simple exostosis is not unlimited in its growth, but after attaining a certain size, remains stationary through life. About thirty years ago, a gentleman now practising our profession in the neighbourhood of Edinburgh, and who was then attending my lectures on anatomy, applied to me one day in great distress, on account of an aneurism of the subclavian artery which he had just discovered. I found that there was an exostosis of the first rib at the insertion of the scalenus anticus, which had displaced the vessel, so as to excite his apprehension, and comforted him with the assurance that the growth was not likely to enlarge. I examined it lately, and could not discover the slightest alteration of size. I have met with several cases of the same kind since, and one that may be particularly mentioned, which I saw in consultation with the late Dr John Thomson and Professor Turner. The patient had been sent from the country on purpose to have the operation performed, and we excited considerable surprise by giving a very positive assurance that there was no prospect of any future inconvenience. About two years ago, a lady of title came to Edinburgh in very great alarm, on account of an exostosis in the pharynx, which she had been confidently assured was only of six weeks' duration. Finding that the growth was perfectly hard, and of bony consistence, I concluded that although only recently noticed, it had been of long existence, and was not likely to suffer any change, which it accordingly has not done. : The constitution of these growths is quite similar to that of the spongy extremities of the long bones, being composed of a thin, osseous lamina externally, and a more or less compact, consolidated texture within it. While enlarging, they have an incrustation of cartilage, whence they have been called by Sir A. Cooper and others -in my opinion, very improperly-the cartilaginous exostosis, since any bone in the body might with equal propriety be designated cartilaginous and as this nomenclature is sure to occasion confusion between the truly osseous growths and those of a fibro-cartilaginous nature, which anatomically, pathologically, and practically require to be carefully distinguished. Thus Sir A. Cooper describes under the same title, well marked cases of these two most dissimilar conditions, and in his lately published work, Mr Paget has pursued this course with, if possible, still less regard to the diversity of the tumours thus associated together. Anatomically, they differ in constitution, which, in one case, is the simple bony texture encrusted externally, so long as it is growing, by a plate of cartilage; and, in the other, it is a fibro-cartilaginous growth enclosed within the expanded bone, or dispersed through the interstices of its honey, comblooking structure. Pathologically, they differ in the one sort of growth being limited in its tendency to increase, and producing no inconvenience except from the peculiarity of its position, as when seated under the nail of the great toe, while the other has no bounds to its enlargement, which depends upon the fibro-cartilaginous substance, and not upon the bone. Practically, they differ in this important respect, that while the one may be removed by division of its neck or base; the other cannot be extirpated except by taking away the whole bone, or dividing it at a sound part beyond the confines of the disease. It was from not attending to these distinctions that Mr Liston, who first drew professional attention to the exostosis of the toe, insisted upon amputation as essential for the patient's permanent relief; while due regard to them led me to practise removal of the growth alone, as sufficient for attaining the object in view-a procedure which, though for a time reprobated by Mr Liston and his followers, has long since become the established rule of practice. On the other hand, a knowledge of the depth to which the fibro-cartilaginous growth strikes its roots into the bone affected, has put an end to those painful scenes which surgeons of the present day witnessed in their youth, when attempts were made, of course in vain, to dig out such tumours from the upper and lower jaws. By disarticulation or division of the bone where ascertained to be sound, the patient is now effectually relieved in a few minutes, instead of being subjected to the prolonged torture of hours, without the chance of benefit to his case, and with the greatest risk of its aggravation. Having happened to remove the first superior maxillary bone that was removed upon this principle in Great Britain, and having entered upon the records of surgery the first instance of this operation which they contain, I must here protest against the unjust appropriation of any credit that may be due on this account, which has been copied from each other by the writers of students' books, of whom I may mention Mr Erichsen as the most recent. My operation was performed in the Edinburgh Surgical Hospital on the 13th of May 1829, and the case was published in the Edinburgh Medical and Surgical Journal for July of the same year, so that the question of priority admits of no dispute. Next to the maxillary bones, it is the humerus in which the fibrocartilaginous growths most frequently appear; and the two following cases of its occurrence in this situation may be shortly noticed as illustrative of the pathological characters which distinguish it from the simple exostosis. About twenty years ago, happening to be in Dundee, I was asked to look at an enormous tumour of the shoulder under which a poor man was labouring. It began at the middle of the humerus, and extended upwards, expanding in a conical form, so as to appear as if growing out of the patient's side. There was no motion in the shoulder-joint, but the arm could be slightly moved along with the scapula. From the firm consistence of the tumour, and the soundness of the general health, I concluded that the growth was of a fibro-cartilaginous non-malignant nature, and having ascertained that it had commenced in the humerus, I felt assured that its roots would not extend beyond the confines of this bone. Influenced by these considerations, I undertook to remove the tumour, and performed the operation in the hospital here, with no less difficulty than had been anticipated. All trace of the head of the tumour had disappeared; and the bone, enormously expanded in a cup form, surrounded the neck of the scapula. In order to facilitate removal, and also promote healing of the wound, I removed the extremities of the clavicle and acromion process, and also the glenoid cavity with the coracoid process. At the end of a fortnight the patient was able to return home, where he lived for many years afterwards without any trouble from the disease. The tumour weighed twelve pounds, and is the largest of the kind on record, although it affected only one-half of the bone. The second case which I proposed to mention was that of a boy, of respectable parentage, from Kirkcaldy, who was brought here, about ten years ago, on account of a tumour seated midway between the elbow and shoulders. It was the size of a small orange, and presented the character of a fibro-cartilaginous growth from the bone. Being averse to amputate the patient's arm, and knowing that mere removal of the tumour on a level with the surface from which it proceeded would not eradicate the disease, I divided the shaft of the humerus by an oblique application of the cutting pliers on each side of the neck by which the tumour was attached. Upon examination, the tumour proved to be what had been supposed, and was found to grow from the interior of the bone. Osseous union could not be completed, but the patient attained maturity, with a wonderfully useful arm, having all the actions of the hand perfect; and being able also, through the assistance of a leather case com- treatment. From what has been said it will, I trust, appear that, under the title of cartilaginous tumour, have been comprehended two morbid conditions of the osseous system, of the most different natures, which require to be distinguished for the establishment of their proper In regard to the osseous growths, associated with malignant tumours, serous cysts, and abscesses-as the new-formed bone is always perfectly sound in its textures, and owes its production to the influence of another morbid condition,-I think the disease in such cases should be named, not from the exostosis, but from the cause which has occasioned it, whether this may be a growth, a cyst, or an abscess. The expression exostosis would thus be restricted to its proper sense of denoting the change effected in the bone itself, and would only require to be farther divided into the solid, hollow, and spicular forms. Attention would thus be directed to the disease essentially requiring remedy, and not to an accidental concomitant. I may now proceed to the special object of this communication, which is to explain a circumstance in the constitution of the simple exostosis when it proceeds from the long bones of the extremities, which may be of considerable consequence in regard to both its diagnosis and treatment. The most frequent situations of this growth, as I have already stated, are the inner side of the thigh bone a little above the condyle, and the neck of the humerus, just below the tuberosities into which the scapular muscles are inserted. It has a neck from half an inch to an inch in length, which is usually placed obliquely in relation to the shaft, and beyond this expands into an irregularly rounded form, nodulated on the surface, which is covered by a thin incrustation of cartilage, that presents a shining, pearly lustre, and has no communication with the surIn the case of a young man who came from rounding parts. The tumour Rothesay to the hospital for the removal of an exostosis on the outer side of the thigh bone, I find the same characters. consists of perfectly sound osseous substances, more or less tensely cancellated. About five-and-twenty years ago I was consulted by a gentleman resident in this city, on account of a very large exostosis, in the usual situation, on the inner side of the thigh. He was a tall, strong, active man, and, in consequence of over-exertion, was suffering from swelling, redness, and pain of the limb at the seat of enlargement. I advised soothing measures, and expressed the opinion that an operation would not be requisite if he abstained from undue exertion in future. I frequently afterwards saw this gentleman, apparently in the enjoyment of perfect health, and had no |