the ordinary operation of tapping the antrum would be useless in such cases, but that it would be necessary to open

up the antrum, so as to get at the seat of the disease. Fortunately these numerous cysts appear to be of slower

growth than the single cysts, for it would be impossible to extirpate such numbers, as are here seen (fig. 63), without removing the entire jaw.

The contents of these cysts appear to be at first clear fluid, but of a viscid nature; when more fully developed, the fluid becomes flaky, from the presence of cholesterine, and occasionally assumes a greenish tint; it may also become purulent, and Maisonneuve has recorded (Gazette des Hôpitaux, 6th Jan., 1855) a case where pressure on the cheek produced a flow of butter-like fluid from the nose in a young woman who, for a year, had suffered from a tumour of the right upper jaw, which had been pronounced malignant, the face being enlarged and the nostril obstructed. Here puncture from the nostril, combined with pressure and injections, effected a cure, and the case must be considered as one of cyst of the antrum, but whether a mucous cyst, the contents of which had undergone solidification, or a separate formation, must remain doubtful.

CHAPTER XII.

CYSTS OF TEETH-DENTIGEROUS CYSTS.

CYSTS in connexion with the teeth may be classed under two heads-1st, cysts connected with the roots of fully developed teeth, and 2ndly, cysts connected with imperfectly developed teeth-to which the term "Dentigerous cysts" has been applied in modern times. Both kinds may occur in either jaw, and, in the case of the upper jaw, may be confounded with collections of fluid in the antrum, or may secondarily involve that cavity.

Cysts, of small size, in connexion with the fangs of permanent teeth, are frequently found on their extraction, but give rise to no symptoms demanding surgical interference. Occasionally, however, they grow to a large size, in which case they produce absorption of the containing alveolus, and give rise to a prominent swelling.

Three specimens of cyst connected with the fangs of teeth

accompanied this essay, and are now in the College of Surgeons (1007 B). Two of them (figs. 65, 66) are quite small

(one being remarkable for its pedicle), the third (fig. 64) is of the size of a hazel-nut, and was partly torn in extraction. I am indebted for the specimens to Mr. E. H. King.

Dupuytren remarks that "morbid changes in the roots of the teeth give rise to the formation of serous cysts, which are most frequently met with in the alveoli of the upper canines, and in some instances acquire a very large size, even equal to that of the antrum. In such cases the root

of the tooth is found diseased and inclosed within the cyst, which adheres to the alveolar cavity and (when small enough) usually accompanies the tooth in its extraction; but if left behind, a suppurative process is established, which continues for a long time. The fluid yielded by these cysts is sometimes very thick, and in other instances of a serous character, and their inner surface is as smooth as that of the serous membranes" ("On Diseases of Bone," Sydenham Society's translation, p. 440).

Of this kind probably also was the case mentioned by Mr. Paget ("Surgical Pathology," p. 402), of a woman, aged thirty-eight, who had a tumour simulating a collection of fluid in the antrum, but which projected beneath the mucous membrane of the upper jaw above the teeth, and had existed six years. An incision evacuated an ounce of turbid brownish fluid, sparkling with crystals of cholesterine, and it then appeared that there was no connexion with the antrum, but that it rested in a deep excavation in the alveolar border of the jaw. So also the case mentioned by the same author in connexion with the incisor teeth.

Delpech relates a case in which a membranous cyst contained three ounces of fluid, but its interior bore no resemblance to the interior of the antrum; and Stanley (p. 300) narrates a case of Mr. Lawrence's of large cyst, projecting in the situation of the antrum, and containing a glairy fluid with shining particles in it, both which he regards as instances of these cysts connected with the teeth, although it appears more probable that they were cases of cyst in the antrum, which have been already described.

A case, which I have little doubt originated in a cyst

.

in connexion with the incisor teeth, but in which the antrum had become secondarily involved, has lately been under my own care. The patient, a woman, aged forty, had a fluctuating swelling, which had been noticed for two years, immediately above the incisor teeth, which were decayed even with the gum. On incising it, a quantity of yellowish glairy fluid exuded, and a probe, when introduced, evidently passed into the antrum. From the position of the cyst, and its close proximity to the incisor teeth, I have no doubt it originated from them, and found its way into the antrum by absorption of the bony wall. The patient would not consent to any operation for the cure of the disease, which gave her little inconvenience.

Fischer, of Ulm (Gurlt's "Jahresbericht," 1859, p. 154), has narrated three cases of cyst connected with the fangs of teeth, in one of which he had the opportunity of making a post-mortem examination. After the removal of the facial wall of the antrum, there appeared a cyst connected with the apex of the posterior molar tooth, which filled the whole antrum, without, however, adhering to the mucous membrane. This consisted of a This consisted of a perfectly closed serous bag of thickness, with a smooth inner surface, and containing a yellowish serous fluid, which grew from the periosteum of the apex of the root of the tooth.

Cysts in connexion with undeveloped teeth, or dentigerous cysts, may occur in either jaw. These, as already mentioned, may suppurate and give rise to abscess which may be confounded with suppuration within the antrum, or may project into the antrum, filling the cavity or communicating with it.

Dentigerous cysts arise in connexion with teeth which from some cause have remained within the jaw, and have undergone a certain amount of irritation. They are almost invariably connected with permanent teeth, though Mr. Salter mentions a case in connexion with a temporary molar occurring in the practice of Mr. Alexander Edwards, late of Edinburgh; and in a remarkable specimen belonging to Mr. Cartwright, which will be afterwards referred to, the