Under these

portion of the jaw, as in Mr. Curling's case. circumstances the limited incision already insisted upon for cases of epulis should be had recourse to, and the jaw should be divided horizontally immediately above the palatine plate, so as to do as little damage as possible to the appearance of the face.

CHAPTER XVII.

GROWTHS WITHIN THE ANTRUM.

THE cystic forms of disease occurring in the antrum having been already considered with other cystic diseases of the jaws (p. 137), this section will be confined to those solid growths which spring directly from the antrum, as distinguished from tumours of the upper jaw, though the line of demarcation between the two is in many cases drawn with difficulty.

Polypus. This is not a common affection, though by no means so very rare as stated by Paget. Luschka has investigated the subject (Virchow's " Archiv," Bd. viii. p. 419), and found polypi five times in sixty subjects, some being two centimetres in length. He gives a drawing showing a large number of these polypoid growths in an antrum, which he considers to be hypertrophies of the sub-mucous connective tissue, covered with mucous membrane. Billroth also describes a good example of large polypus of the antrum with a long pedicle, and regards it as a very rare affection.

These polypi are closely allied apparently to the small cystic growths in the mucous membrane of the antrum described by Giraldès (vide p. 153). Both affections consist essentially in hypertrophy of some elements of the mucous and sub-mucous tissues. When the connective or areolar tissue predominates, the fleshy polypus is produced; when the glandular element is especially affected we have the cystic form produced. Intermediately when the fibrous element is very loose and we have some glandular hypertrophy, the semi-gelatinous polypus is produced, which closely resembles the nasal polypus.

Polypi of the antrum are well supplied with blood-vessels, and bleed freely when interfered with. In some instances they appear to have a malignant character, or at least are the forerunners of malignant disease occurring in the antrum and jaw. Vidal de Cassis, who (" Traité de Pathologie Externe," tom. iii. p. 492) totally denies the existence of any true polypoid growths in the antrum, says that what have been mistaken for them most frequently are colloid tumours of the periosteum, but believes that many of the examples are cases of cystic growth. Syme also, following the example of John Bell, maintains that polypi in the antrum always intrude from the nose and are never developed in the antrum itself. (Lancet, March 10th, 1855.)

The symptoms of polypi, no less than of cysts of the antrum, only become developed when the growth is of sufficient size to encroach upon the neighbouring cavities or produce distension and absorption of the front of the antrum. The most common situation for the polypus to show itself is, as might be expected, the nose, since the tumour readily induces absorption of the thin nasal wall of the antrum. Here it closely resembles the ordinary nasal polypus, and Sir William Fergusson mentions (“Practical Surgery," p. 561) two cases of the kind in which this had occurred, one being in his own practice. In that instance he soon found that he had attacked a tumour of the antrum, which, in consequence of its deep and firm attachment, and the great hæmorrhage attending it, he did not entirely reThe disease returned, and he again operated, on this occasion using great force, and wrenched out the whole mass, not without some fear of the consequences. The case, however, did well, and after ten years the disease had not returned.

move.

In the Medical Times and Gazette, March 18th, 1860, is a report of another case in which the same surgeon removed a vascular fibrous polypus of the antrum which had projected into the nostril, by laying open the front wall of the cavity and with strong forceps tearing out the tumour bit by bit.

I had, during 1866, the opportunity of watching the case of a patient who had had a polypus partially removed by the nose on several occasions, and from whom Mr. Holthouse removed an entire growth a year and a half before that date. He reappeared with a swelling of the jaw, evidently due to distension of the antrum by some soft growth, and he had also a soft tumour on the forehead. These were doubtless cancerous, for his strength failed, and he sank after some months, but unfortunately his relations would not permit a post-mortem examination to be made.

Hypertrophy of the glandular tissue of the mucous membrane appears capable of producing tumours of a friable description, which may fill up the antra on both sides, as in a case recorded by M. Demarquay (in the Gazette Médicale de Paris, November 14th, 1857). Here the patient had a large tumour on each side of the nose, the passages of which were completely obstructed, and his right eye was protruded from the orbit. M. Demarquay removed the front walls of the antra and extirpated two masses of very friable tissue of a greyish-white colour, in which the vascular tissue was not abundant. M. Robin, who examined the growths, pronounced them to be the result of an hypertrophy of the glandular element of the mucous membrane of the antrum.

Fibroid Disease of the Antrum.-Allied to polypus is a form of disease of the lining membrane of the antrum which I do not find described by any author, but of which I have myself met with an instance. In September, 1866, Dr. Whitmarsh, of Hounslow, brought to me a gentleman who, two years before, had perceived some growth in the right nostril, which gave no pain but kept up a constant discharge, especially at night. In the early part of the year this had been removed in part by a surgeon, and since that the discharge had much increased. There was a fungous growth in the right nostril, and the whole right maxilla was swollen, and discharged thin pus at one or two points near the eye. There was a fungous-looking growth in the molar region, and a probe passed by its side into the antrum.

I removed the disease on September 23rd, clearing away the whole of the growth, which was very friable, and leaving the posterior wall of the antrum and the infra-orbital plate untouched. In the course of the operation I found a distinct polypoid growth filling the posterior nares, which I removed. The patient rallied well from the operation, but unfortunately got congestion of the lungs and died on the fifth day. The case will be found in detail in the Appendix (Case XVIII).

The preparation is in the College of Surgeons' Museum (1052 B.), and the appearance of a part of the disease is shown in fig. 101. It will be seen that the interior of the antrum is covered with a remarkable papillary or villous growth,

resembling some forms of cauliflower excrescence. A quantity of broken down loose fibroid tissue lies at the bottom of the bottle of the preparation, and a portion of it, with the adjacent mucous membrane, is given in the sketch; the other portion being the polypoid growth extracted from the posterior nares. Mr. Bruce has favoured me with the following report upon the specimen :

"It appears to consist of a fine soft fibrous stroma, in which very numerous nuclear bodies and a few elongated fibre-cells are distributed. Its structure resembles that of the upper strata of a mucous membrane, from which it is probably an outgrowth. It consists of newly-formed fibrous tissue, and of the elements from which fibrous tissue is developed, and may therefore be classed among the simple