Squamosal bone

“ The soft cellular tumours are composed mainly of spindle or round cells; they grow from the marrow of the spongy ends or from the periosteum of the long bones, the diploë of the skull, the pelvis, vertebræ, and jaws. As they grow they may cause little alteration in the contour of the bone, but they eat away its framework and replace it, so that the continuity of the bone is maintained only by tumour tissue, and pathological fracture is a frequent result. ”

“ The author has in a case of osseous tumour removed the whole body of the scapula, leaving glenoid, spine, acromion and anterior margin with excellent result and a useful arm.
Large portions of the shafts of the humerus, radius, and ulna have been removed for disease or accident, and useful arms have resulted; but as the operative procedures must vary in every case, according to the amount of bone to be removed, and the number and position of the sinuses, no exact directions can be given. ”

“ There is also enlargement of the lower ends of the bones of the forearm and leg, and effusion into the wrist and ankle-joints. Skiagrams of the hands and feet show a deposit of new bone along the shafts of the phalanges.
Tumours of Bone
New growths which originate in the skeleton are spoken of as primary tumours; those which invade the bones, either by metastasis from other parts of the body or by spread from adjacent tissues, as secondary. A tumour of bone may grow from the cellular elements of the periosteum, the marrow, or the epiphysial cartilage. ”

“ On section note thickening of the bone (osteomyelitis ossificans) , thinning (osteoporosis, excentric atrophy) , enlargement of medullary spaces, obliteration of spaces by newly-formed bone (osteosclerosis; bone becomes heavy and solid like ivory) , and caries (pyogenic infection, tuberculosis, syphilis, actinomycosis, neoplasm) . Caries occurs in both spongy and compact bone, but more often in the former. The necrotic bone appears as soft, friable granules (molecular necrosis) or sequestra, between which living bone or granulation-tissue may be found. ”

“ They occur at all ages, and have been met with even in children.
The clinical features vary according to whether the tumour originates on the anterior aspect of the bone, in the maxillary antrum, or on the posterior aspect.
When the tumour originates in the periosteum covering the front of the bone, it forms a swelling under the cheek, usually in the vicinity of the zygomatic (malar) bone, and grows towards the mouth as well as towards the surface. The cheek is gradually invaded, and in some cases the growth extends into the maxillary sinus. ”

“ On longitudinal section of a long bone during the active stage of the disease, the marrow is seen to be replaced by a vascular young connective tissue which encroaches on the surrounding spongy bone, reducing it to the slenderest proportions; the formation of bone from the periosteum does not keep pace with the absorption and replacement going on in the interior, and the cortex may be reduced to a thin shell of imperfectly calcified bone which can be cut with a knife. The young connective tissue which replaces the marrow is not unlike that seen in osteomalacia ”

“ A fracture produced in adult life is generally recognizable as such; but a fracture dating from earlier stages of life, produced before the growth of the bone has ceased, may, if not entirely obliterated, present more or less the characteristics of a suture. I have seen several skulls where a division in the parietal bone or the temporal squama presented at the same time features of a fracture and suture ”

“ The growth is sometimes rapid, and the tumour soon becomes troublesome from its immense size.
Frequently a bone is much enlarged throughout its whole extent, or the greater part of it, and presents a cancellated texture: sometimes, also, it is much thickened, and, at the same time, of great solidity; but such enlargements cannot be considered as tumours of bones, or exostoses, any more than those nodules of new osseous matter, which are effused in consequence of inflammation of the osseous tissue. ”

“ Large quantities of fluid will be found fluctuating between the periosteum and the bone, which, when unaccompanied by redness and inflammation of the skin, may be absorbed by proper treatment, but which more usually is only curable by evacuation; and, unless great care be used, exfoliation of the bone will ensue to a very great, and sometimes fatal extent. The eyebrows, forehead, and temples, are often the seat of fluid tumors varying from the size of peas and beans. Their cure must be effected by absorption, or destruction of the bone is often produced. ”

“ The shaft is increased in girth as a result of its being surrounded by a new case of bone. The resemblance to sarcoma may be very close, but the swelling is not as defined as in sarcoma, nor does it ever assume the characteristic "leg of mutton" shape. In both diseases there is a tendency to pathological fracture. It is difficult also in the absence of skiagrams to differentiate the condition from syphilitic and from tuberculous disease. If the diagnosis is not established after examination with the X-rays, an exploratory incision should be made; if dead bone is found, it is removed. ”

“ In some instances, pressure applied to the tumour with the finger imparts a peculiar crackling sensation, not unlike that of dry parchment or an egg-shell. The soft parts around the disease are generally œdematous, the whole limb is apt to be swollen, and the motions of the contiguous joints are constrained and painful. Towards the last the general health always seriously suffers.
On inspection, the outer table of the bone is found to be considerably attenuated, in many parts destroyed, and in some so flexible and elastic as to be bent with the same facility as cartilage. ”

“ In early adult life, one of the tumours, instead of undergoing ossification, may take on active growth and exhibit the features of a chondro-sarcoma, pressing injuriously upon adjacent structures (Fig. 140) and giving rise later to metastases in the lungs.
The _X-ray appearances_ of the bones affected are of a striking character; apart from the outgrowths of bone or "tumours" there is evident a widespread alteration in the internal architecture of the bones, which suggests analogies with other disturbances of ossification such as achondroplasia and osteomyelitis fibrosa. ”

“ If the periosteum has been extensively destroyed, new bone may only be formed in patches, or not at all. The dead bone is separated from the living by the agency of granulation tissue with its usual complements of phagocytes and osteoclasts, so that the sequestrum presents along its margins and on its deep surface a pitted, grooved, and worm-eaten appearance, except on the periosteal aspect, which is unaltered. Ultimately the dead bone becomes loose and lies in a cavity a little larger than itself; the wall of the cavity is formed by the new case, lined with granulation tissue. ”

“ Very commonly the child ceases to move one of his lower limbs—pseudo-paralysis—and screams if it is touched; a swelling is found over one of the bones, usually the femur, accompanied by exquisite tenderness; the skin is tense and shiny, and there may be some œdema. These symptoms are due to a sub-periosteal hæmorrhage, and associated with this there may be crepitus from separation of an epiphysis, rarely from fracture of the shaft of the bone. X-ray photographs show enlargement of the bone, the periosteum being raised from the shaft and new bone formed in relation to it. ”

“ If the articular surfaces are affected and the disease is likely to lead to ankylosis, the arm should be abducted to a right angle. The severe pain of caries sicca may be relieved by blistering or by the application of the cautery. To inject iodoform, the needle is introduced either immediately outside the coracoid process, or just below the junction of the acromion process and spine of the scapula. When the disease does not yield to conservative measures, or the X-rays show a gross lesion in the bone, excision of the joint should be performed ”

“ When a bone, such as the scapula or mandible, is involved, it is better to excise the bone, or at least the part of it which bears the tumour. In the case of central tumours the shell of bone is removed over an area sufficient to allow of the enucleation of the tumour, or the affected portion of bone is resected. Should there be evidence of malignancy, such as increased rate of growth, a tube of radium should be inserted, and in advanced cases with destruction of tissue, amputation may be called for. ”

“ It may also arise in excoriations caused by an ill-fitting tooth-plate, or from the impaction of a foreign body, such as a fish or game bone, in the mucous membrane. The inflammation begins close to the alveolus, and may spread back along the palate. The muco-periosteum becomes swollen, red, and exceedingly tender, and, as pus forms, is raised from the bone, forming a prominent, firm, elongated swelling, which on bursting or being incised gives exit to foul-smelling pus. ”

“ Tumours with broad bases, and of soft medullary consistence, attended with extensive change in the structure of the membrane, and softening of the bones and cartilages, grow very rapidly, fill the cavities and expand them, giving rise to great deformity, as seen opposite. They show themselves on the face, through the nostrils—protrude through the floor of the orbit—get into the mouth behind the palate, through the tuberous processes of the superior maxillary bone—or project through the alveolar processes. ”

“ Situated on the antero-lateral aspect of each ankle is a recent 2 cm. transverse incision into the subcutaneous tissue.
There is an old well healed 8 cm. McBurney abdominal incision. Over the lumbar spine in the midline is an old, well healed 15 cm. scar. Situated on the upper antero-lateral aspect of the right thigh is an old, well healed 8 cm. scar.
MISSILE WOUNDS:
1. There is a large irregular defect of the scalp and skull on the right involving chiefly the parietal bone but extending somewhat into the temporal and occipital regions. ”

“ If death was not too soon the consequence of the puncture of the head of hydrocephalic patients, I am persuaded that we should see the bones gradually contract, and restore the cavity of the cranium to its natural dimensions. When we remove the dead piece from a long bone in necrosis, the new bone, formed on the exterior by means of the periosteum contracts in an evident manner. In paralysis of the optic nerve, its foramen becomes narrower. The orbit contracts when a cancerous eye has been extirpated. ”

“ In the chronic stage there is usually an old necrotic shaft perforated by sinuses, and often freely movable, inclosed by a shell of dense periosteal bone. The sequestrum must be removed, but the bony defect fails to heal, and for months persists as a filthy, discharging cavity, with the constant danger of secondary infection and phlegmon, or erysipelatous inflammation. The healing of this cavity is very difficult and requires a very long time. ”

“ Where there are two parallel bones--as in the leg, for example--the growth of the diseased bone may be impaired, and the other continuing its normal growth becomes disproportionately long; less frequently the growth of the diseased bone is exaggerated, and it becomes the longer of the two. In either case, the longer bone becomes curved. An _obliquity_ of the bone may result when one half of the epiphysial cartilage is destroyed and the other half continues to form bone, giving rise to such deformities as knock-knee and club-hand. ”

“ The eyes being protected by a pad over each, an incision is made along the long axis of the tumor and the skin is freed on all sides so that its base is exposed. If the swelling is very small in a child it may be necessary to make a cross cut through the skin as well, in order to get sufficient room to work in. The bone being exposed, a portion of the swelling can easily be cut away by bone forceps, because it is very soft. ”

“ Substances like paraffin, strands of silk used to bridge a gap in a tendon, or portions of calcined bone, instead of being encapsulated, are gradually permeated and eventually replaced by new connective tissue.
Embedded bodies may remain in the tissues for an indefinite period without giving rise to inconvenience. At any time, however, they may cause trouble, either as a result of infective complications, or by inducing the formation of a mass of inflammatory tissue around them, which may simulate a gumma, a tuberculous focus, or a sarcoma. ”

“ The portion of outer osseous shell projecting into the medullary canal would in the end have been removed by the absorbents, and the deformity much diminished.
When the ends of the bone are not well placed, or when they are moved occasionally whilst the uniting medium is still soft, there is danger of a false joint being formed—the callus either giving way, or being all along imperfect, and the extremities at the soft part becoming smooth and moveable on each other; or incited action may run high and terminate in suppuration, with death or ulceration of portions of the bone. ”

“ The state of the osseous system and the condition and number of the teeth, which strictly speaking are not bone, are among the surest guides in the determination of age. The signs furnished thereby may vary according to the periods of increase, maturity, and decline.
During fœtal life and even at the epoch of birth the bone centres are few. The distal end of the femur, the proximal end of the tibia, and the astragalus are ossified at birth. Points of ossification appear in successive order of development. ”