fibro-plastic growths, as distinguished from the true myeloid tumours."

A curious, and I believe unique, case of falling in of the antrum, recorded by Mr. White Cooper, may be conveniently mentioned here, since the depression of the wall of the cavity depended, no doubt, upon some alteration going on in its interior-possibly the absorption of some fluid which had previously induced thinning of the bones. The patient was brought before the Medical Society of London in 1851, and Mr. Cooper has kindly given me the following details of her case:—

"I first saw Margaret Ryan (aged twenty-seven) May 22nd, 1849.

"Complained of the tears running over the left cheek. First perceived about a week previously.

"Seven years ago first observed a black mark round the lower part of the left eyelid; without pain, weakness of eye, or toothache. Gradually and almost imperceptibly flattening of the cheek came on.

"The appearance presented was that of a deep depression between the malar bone and nose, precisely as if a portion of the superior maxillary bone had been cut away.

"It was bounded superiorly by the inferior margin of the orbit, which partook of the depression; inferiorly, by the base of the alveolar process; and externally by the malar bone. As compared with the other cheek, the dimensions were as follows:-From bridge of nose over deepest point of depression, one inch four-tenths, or nearly an inch and a half; right side to corresponding point, just one inch.

"There was a peculiar dusky hue about the depression, especially towards the upper part. The cuspid and bicuspid teeth were removed with considerable difficulty, the roots showing thickening of periosteum.

"No change was visible at the expiration of twelve months."

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CHAPTER XVIII.

TUMOURS OF THE UPPER JAW.

Fibrous, Fibro-cellular, and Recurrent Fibroid Tumours.

WITH regard to the statistics of tumours of the upper jaw, I shall content myself with quoting O. Weber, who has collected 307 cases from the following sources:-183 cases tabulated by Heyfelder; 36 recorded by Lücke from Langenbeck's clinique; 17 reported in the Medical Times and Gazette (Sept. 3rd, 1859), and 71 cases either observed by himself in Wutzer's clinique or occurring in his own practice. Of the above cases there were:

In commenting upon this table, Weber very justly remarks that doubtless the list of cancerous cases is exaggerated, and suggests that a fair estimate would be gained by allotting rather more than a third of the whole number to sarcomatous (simple) tumours; less than one-third to the cancerous, and the remainder to the osseous tumours, cysts, &c.

It will be observed that in this classification no mention is made of the myeloid tumour, which undoubtedly occurs in the upper jaw.

Fibrous Tumours.-These closely resemble the fibrous tumours found in other parts of the body, and especially in connexion with the uterus. They are dense in structure but are not unfrequently lobulated, and on section, slender bundles of intersecting fibres may occasionally be traced in them, of which there are good examples in the Museum of the College of Surgeons. The fibrous tumour usually springs from one of two situations, either the interior of the antrum or from some portion of the alveolus. In both cases it is intimately connected with the periosteum, in this respect resembling epulis. The fibrous tumour grows slowly, but surely, involving in its progress the surrounding structures. When arising in the antrum, it first expands the walls of that cavity, bulging out the face and forming tumours in the palate and floor of the orbit, and subsequently produces absorption of the osseous walls and spreads unchecked in all directions. The following description of a specimen in St. George's Hospital Museum gives a good idea of the ravages of such a tumour, and reference may be made to a similar specimen in the Museum of the College of Surgeons (1050):-" Fibrous tumour growing from the antrum, and making its way by the absorption of the walls of that cavity in different directions. It projects upwards into the orbit, destroying the floor of that cavity, and protruding from its inner margin forwards on to the cheek. It has also destroyed the anterior wall of the antrum, and displaced the malar bone forward and outward; inwards it projects into the nose beneath the middle turbinated bone, and downwards it makes its appearance on the under surface of the alveolar process in the form of a rounded mass, destroying the floor of the antrum in the neighbourhood of the front molar tooth. Behind, the tumour appears in the zygomatic fossa by the absorption of the outer part of the tuberosity of the superior maxillary bone. The tumour is composed of circular nuclei

of various size, and spindle-shaped fibres. The patient from whom the specimen was taken, William H., died of arachnitis, and softening of the corresponding part of the brain." -Catalogue of St. George's Hospital Museum. (II. 160).

When it arises from the alveolus, a fibrous tumour may encroach on both the facial and the palatine surfaces of the jaw, crushing in the antrum although not involving its interior. Of this a good example is seen in a preparation (1048) in the College of Surgeons, of an upper jaw removed by Mr. Liston. Here the tumour, which is affixed to the alveolar border, near the molar teeth, extends inwards so as to cover the palatine portion of the jaw, and outwards so as to conceal all the bicuspid and molar teeth, with the

exception of the last. The walls of the antrum are pressed inwards, but its interior is healthy. The patient was a woman, thirty years old, and the tumour was observed four years before its removal, which was successful. On the other hand, fibrous tumours, though commencing in the alveolus, may secondarily involve the antrum when they have attained considerable size, producing complete absorption of its walls, and projecting into the nose and through the palate. Of this a preparation in the College of Surgeons Museum (1046), of an upper jaw, also removed by Mr. Liston, affords a good example. Here the patient was only twenty-one, and the growth first appeared on the outer side of the gum of the left upper jaw four years before

the operation. It was cut off six months after its first appearance, but returned, and eighteen months after was removed, with a portion of the alveolar process, but reappeared in a few weeks. Fig. 102, from Liston's "Practical Surgery," shows the growth after its removal, and figs. 103 and 104 show the patient before and after the operation. It may be noticed here, as in the case of a large epulis, that disease of the upper jaw often closely resembles, externally, a tumour of the inferior maxilla.

The case is given by Mr. Liston in his paper on Tumours of the Jaw, in the Medico-Chirurgical Transactions, vol. xx. The enormous size to which fibrous tumours of the upper jaw may grow without destroying the patient, is well seen in the accompanying drawing (fig. 105) of Mr. Liston's celebrated case of Mrs. Frazer, from whom that eminent surgeon successfully removed the growth. The tumour is preserved in the Museum of the College of Surgeons (1051), and its diameters are, vertically, seven inches, transversely, seven inches, from before backwards, nearly