Reprinted from the International Medical Magazine, A 1892. 
OSTEO-SARCOMA OF THE FEMUR.1 
BY LOUIS McLANE TIFFANY, M.D., 
Professor of Surgery in the University of Maryland. 
Gentlemen,—The patient whom I show you to-day comes to us from 
a distant part of the State, having been brought here by his physician, who 
is now present. His history is as follows: 
Case I.—Male, white, aged twenty-nine, has had for six or eight years an in- 
creasing enlargement just above the right knee. He is a strong, active man, living 
in the country, and until recently lias been able to attend to his ordinary avocation, 
that of a farmer. He dates the commencement of his disease from a fall, the outer 
surface of his thigh having been contused. Especially painful was it where the tumor 
now grows. He paid no attention to the injury at the time, but within six months 
noticed a tumefaction, which has gradually increased up to the present time. His 
bodily functions are well performed, and he suffers little or no pain, the main discom- 
fort arising from the weight and unwieldiness of the affected member. Physical ex- 
amination of the growth shows a large fusiform tumor apparently involving the lower 
third of the femur, which is here about double the size of the other thigh at the cor- 
responding point. The growth in the vicinity of the knee-joint is hard and inelastic, 
being apparently bony. Above and to the outer side there exists a cyst, which con- 
tains about a pint of fluid of some sort. The tumor is intimately united with the 
femur, is not movable, and does not encroach sufficiently upon the knee-joint to give 
rise to much trouble. It does not project into the popliteal space. The muscles play 
over it. The patella is movable, and the patient walks without pain. The tempera- 
ture of the growth is about two degrees higher than that of the corresponding 
point in the other thigh. His pulse is normal, digestion good, and appetite good. 
He has not lost flesh lately. The glands in the groin are perceptible on the right 
side, and scarcely if at all on the left. Elsewhere throughout the body the glands 
are not enlarged. The lungs are normal. The diagnosis is osteo-sarcoma of the 
right femur, with a cystic formation in the outer aspect of the thigh. 
The patient is advised to enter the hospital and submit to amputation. 
This advice he will take under consideration and will most probably appear 
before you again. 
Sarcoma of bone is not infrequent, it being the most frequent form of 
tumor connected with the osseous structure, and the term osteo-sarcoma is 
a general one used to indicate the seat from which the tumor grows as well 
as the kind of tumor which may be present. Sarcoma, as you know, is a 
connective-tissue tumor, and, therefore, finds its seat in bone, which is also 
1 Clinical lecture delivered in the University Hospital. 2 
LOUIS MCLANE TIFFANY, M.D., ON 
a connective tissue. Sarcoma is composed of two elements,—cells, and 
cellular tissue more or less distinct, usually, however, in scanty amount, 
blood-vessels, nerves, etc., and according as the cells of which the tumor is 
composed are large or small, round or elongated, so are the terms small 
cells, spindle cells, myeloid cells, etc., made use of. A further classification 
is made from the locality where the growth originates. A central or peri- 
osteal sarcoma may be either spindle- or round-celled, etc. It is usual in 
speaking of sarcoma to define both from microscopic structure and seat of 
growth. Thus, we speak of the small cell, periosteal sarcoma, of the spindle 
cell, central sarcoma, etc. Sarcomata are with other connective-tissue tumors 
more often seen in the first half of life, making their appearance, as a gen- 
eral rule, before the age of thirty. They are far more often seen in the 
long than in the irregular bones, and, while choosing such bones, they 
will choose the epiphysis more often than the shaft of the bone. The lower 
end of the femur and the upper end of the tibia are the two chosen seats, 
the next in frequency being the upper end of the humerus, but the fact that 
this kind of tumor is so often seen about the knee-joint will enable you 
to understand how often knee-joint troubles may be confounded with the 
growth in question, and it is a matter of very general experience to find 
difficulty in distinguishing between the knee-joint disease and the sarcoma 
growing immediately adjacent to the joint, and perhaps invading it, although 
this is very rare, and takes place only when the disease is far advanced. 
The articular cartilage is very often preserved intact, although the sarcoma 
tissue may be all about it. 
The origin of osteo-sarcoma is very generally referred, by the patient, to 
some injury, so often indeed as to justify the opinion that traumatism does 
have much to do with the commencement of the growth. Except from in- 
jury I know of no cause. The injury may be slight, and it is very difficult 
in such cases to suppose that the growth did come from such an insignificant 
cause. In other cases, however, the history is so very clear as to leave no 
doubt. 
Such a case is the one whose photograph I now show you. The history 
is as follows: 
Case II.—M. L., white female, aged nineteen, large and well-developed, five 
years before being seen by me, in running across the street, tripped and fell, striking 
her right tibia about the middle against the curb-stone. She suffered much pain, and 
after the bruise from the injury had disappeared, a thickening apparently of the 
periosteum remained. Two years later this thickening slowly began to increase, until, 
when I saw it, it was decidedly larger than an adult head. The skin had given way 
and a bleeding fungus protruded. I amputated through the right thigh, and all 
■went well. 
I do not think that hereditary tendency can be made out. The shape of 
the sarcoma will vary. When myeloid it is apt to be rounded, and perhaps 
bossed. It may be covered entirely by bone or plates of bone, which latter 
can be found at irregular intervals over its surface. If of slow growth, the Case II.—Sarcoma of Right Tibia. The microscope 
showed spindle, round, and myeloid cells. 
Case III.—Sarcoma of Left Femur. The photo- 
graph is from the Army Medical Museum, Washing- 
ton, to which the amputated limb was sent. 
Cask IV—Amputation at Hip-Joint by Lateral Flaps. 
Spindle cells greatly predominating. 3 
OSTEO-SAECOMA OF THE FEMUE. 
myeloid sarcoma is very apt to remain covered with bone. Periosteal sar- 
coma, on the other hand, is usually fusiform in shape, and may involve the 
greater portion of the shaft of the bone. It is rarely entirely covered by 
bone, but may present irregular bone formations on the surface. When not 
covered by bone, the consistency of the tumor will vary according as it is 
a round or spindle-celled sarcoma. The former is the more soft, so much so 
as to give a sense of pseudo-fluctuation. I would call your attention here 
to a point in regard to the consistency of the tumor which may assist 
you in your diagnosis, as it has me on more than one occasion; and 
that is that the consistency of the sarcoma, if not covered by bone, will 
be found to vary. Thus, a patient from a distance is examined to-day, 
and then put to bed at rest. On the next day the tumor will be less tense, 
and may show apparent fluctuation. This change is probably due to a 
different vascular tension brought about by the rest to which the patient has 
been subjected during the twenty-four hours; and it is this enforced rest 
during doubtful cases which has assisted in a difficult diagnosis. 
The size of the tumor varies within extreme limits. The largest which 
it has been my fortune to see was one for which I amputated at the hip 
last week. The tumor was fifty inches in circumference, and weighed, after 
much blood had drained away, fifty-nine and a quarter pounds. I show 
the photograph. 
Case III.—The patient was a white male but little over thirty years of age. The 
tumor had been growing for thirteen years, and was covered by bone. I amputated 
at the hip by Furneaux Jordan’s method, and the patient recovered. 
Adjacent glands are affected rarely, that being one of the characteristics 
of sarcoma as distinguished from carcinoma. In some few cases, if en- 
larged, the glands may go down after amputation, although this is rarely to be 
expected. The glands are not affected during the early life of a growth, but 
still they should always be searched for, not only adjacent to the growth, but 
all over the body. On the other hand, pulmonary metastasis is to be looked 
for always, and in a certain number of cases will be found present. Some 
varieties of sarcoma are far less likely to reproduce themselves in other parts 
of the body than others; thus, myeloid sarcoma is very rarely infectious. 
Some of the small-celled sarcomata, however, are extremely so. Local infec- 
tion is usually not noticed until a sarcoma has broken through its bony or 
fibrous envelope. So long as the sarcoma remains surrounded by bone it is 
apt to grow slowly. When it escapes from its bony prison, however, it grows 
with great rapidity. This is especially the case, also, when it protrudes 
through the skin ; then the increase is extremely rapid, and is accompanied 
by frequent loss of blood. Indeed, the loss of blood from an open sarcoma 
may be sufficient to blanch the patient, and, if frequently repeated, will 
induce death. 
The temperature of a growing sarcoma is higher than that of normal 
tissue, and will aid you in recognizing the growth. Should a surface 4 
OSTEO-SARCOMA OF THE FEMUR. 
thermometer not be at hand, an ordinary clinical thermometer placed upon 
the limb and covered with cotton may be taken as a fairly exact index of 
the temperature of the growth. It should be left in position not less than 
five minutes; and if the same manipulation is gone through with the cor- 
responding part of the body on the other limb, a difference will be noted. 
Plates of bone on the surface of the growth point to sarcoma, as does 
also an elastic, thin, crackling envelope of bone. 
The rate of growth presents great variations. The large tumor (Case 
III.) about which I spoke to you a few moments ago grew continuously 
during thirteen years, and when amputated by me was covered by bone. 
The treatment is simple. Enucleation does not suffice. Amputation is 
called for. The amputation must be sufficiently far from the growth to 
avoid recurrence in situ. Wherever possible, the entire bone which is the 
seat of the tumor should be removed, since the medullary canal may be 
infected quite a distance from the primary growth, or the proximal ex- 
tremity of the bone may contain a nodule. Possibly the femur is the only 
bone the whole of which it is best sometimes not to remove when the 
lower extremity is the seat of sarcoma; and hip-joint amputation is not 
always to be done, because it is followed in so many cases by fatal results. 
The humerus, tibia, etc., however, should be removed in their entirety. 
Adjacent glands should be explored thoroughly after the amputation is done, 
since glands not noticed prior to amputation may come into view when 
the skin is opened. I think it is unwise also to use Esmarch’s bandage 
for the purpose of rendering less vascular the extremity, especially if the 
entire bone which is the seat of morbid growth is not to be extirpated, since 
fragments of the growth may be forced towards the proximal extremity of 
the bone. 
Case IV.—Showing stump after hip-joint amputation for osteo-sarcoma, involv- 
ing the middle third of the femur. Amputation done November, 1881.