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definition, especially that of Mr. Liston, which is said to be "chiefly composed of a firm substance like fibro-cartilage, with spicula of bone."

Fibro-cellular tumours, like fibrous tumours of the jaw, appear to be often connected with diseased teeth, and like them also are liable to calcareous degeneration. The following account of a tumour removed by Mr. Carr Jackson, illustrates both these points :

"Examined by Mr. Hulme, the tumour presents the following histological characters :-It was the size of a turkey's egg, involving and infiltrating the greater part of the left superior maxillary bone, and extending upwards into the antrum, its upper and posterior surface having a nodulated or mammillated appearance, and its anterior portion being marked by the under surface of the orbital plate. On section, the structure of the tumour appeared of a dense, homogeneous, somewhat fibro-cartilaginous substance, encased by a thin shell of bone sending processes into its interior, which consisted of a hard bony mass, having a radiated appearance, the fang of a molar tooth being imbedded in its substance. The upper mammillated substance was soft and free in the antrum, covering the central bony structure on its surface. Microscopically the softer parts consisted of elongated cells, having a tendency to form fibre-a tendency especially evident at the thin edge of a section, which showed the fibroid cells very clearly, their nuclei being rendered evident on the addition of dilute acetic acid. Calcareous matter was deposited along the course of the fibres, and the central hard portion of the growth consisted of earthy salts, converting it into a stony mass. The tumour may thus be regarded as a fibrous (fibro-cellular) growth undergoing calcareous degeneration."-Lancet, Jan. 24th, 1863.

In his work on the "Diseases of the Bones" (p. 282), Mr. Stanley mentions "fatty" tumours of the superior maxilla. He refers (p. 104) to a specimen in St. Bartholomew's Hospital Museum (I. 151), of which the following is the description:

"Sections of a tumour which occupied the situation of the

superior maxillary bone, and was removed by operation. The whole of the natural structure of the superior maxillary bone has disappeared. The mucous membrane which covered the palatine surface of the bone extends over a part of the tumour. The morbid growth consists of a moderately firm fatty-looking substance, with minute cells and spicula of bone dispersed through it.

"From a man aged forty-six. The disease returned after the operation, and the patient died in consequence of hæmorrhage from ulceration of the internal carotid artery, which became involved in an extension of the disease."

This, as far as can be judged, would appear to have been an example of fibro-cellular tumour or osteo-sarcoma, which had undergone fatty degeneration; and the same may, I imagine, be said of the cases referred to by Von Siebold as osteo-steatomata. The disease would appear to be a rare one, as it is not mentioned by most authors.

Recurring Fibroid Tumour occurs, I believe, occasionally in the upper jaw. It is an undoubted fact that fibrous tumours do recur in the upper jaw after complete removal; and of this Mr. Liston's series of specimens, already referred to, gives more than one example, and it is probable that careful microscopic examination would prove that some of them exhibit the peculiar "oat-shaped nucleated cells," described by Mr. Paget as characteristic of the recurrent tumour. It is not surprising that these tumours should have been considered as examples of the ordinary fibrous tumour, since Mr. Paget himself observes, in speaking of a wellmarked specimen, "without the microscope, I should certainly have called it a fibrous tumour."

In connexion with this subject I may quote the following extract from the report upon diseases of the jaw, in the Medical Times and Gazette, Sept. 3rd, 1859:-"The only example which we have to quote of recurrent fibroid tumour developed in connexion with the jaws is one in which the diagnosis of that variety of tumour and true cancer is by no means positive. It is that of a woman, aged thirty-four, under Mr. Cock's care, in Guy's Hospital, at different times,

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for two or three years (1854 and 1856). The growth occupied the right antrum, and extended into the nose; on several occasions Mr. Cock dissected up the cheek in front, laid bare the cavity, and gouged out the tumour and the bone to which it was attached. The parts always healed quickly, but the disease soon returned. The tumour had the microscopic features of a recurrent fibroid, as distinct from those of a true cancer, and the fact that it continued to recur in the same place, but did not cause disease of the glands, is confirmatory of that diagnosis. The woman was very pallid and cachectic, but her cachexia did not exactly resemble that of cancer. We lost sight of her towards the end of 1856, and do not know the final result of her case. Probably she has since died of her disease."

In March, 1867, I had the opportunity of seeing a patient of Mr. Lawson's, a lady, aged thirty-three, from whom, in the preceding May, that gentleman had removed a recurrent fibroid tumour of the left orbit. From this operation she perfectly recovered, but, four months before I saw her, the patient had found a small hard swelling of the left side of the hard palate. This rapidly increased, spreading backwards into the soft palate, and forwards so as to press upon the incisor teeth. The swelling was irregular in outline, but with a perfectly smooth surface, and was so soft and elastic that it conveyed the impression of fluid, and had been punctured. Mr. Lawson removed the whole of the left side of the hard palate and as much of the soft palate as was involved in the disease, and the patient made a perfect recovery. Four months afterwards the patient again appeared, the disease having recurred on the right side of the hard palate. There was also a fibroid tumour in the parotid region, which had been present some years, and had now begun to increase in size. Mr. Lawson removed the tumour of the palate with the gouge, including all the periosteum involved by the growth, and excised the parotid tumour. The patient recovered, and has had no further return up to the present time. The growths gave unmistakeable microscopic evidence of their recurrent fibroid nature.

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CHAPTER XIX.

TUMOURS OF THE UPPER JAW-(continued).

Myeloid and Vascular Tumours.

Myeloid Tumours are found in the upper as well as in the lower jaw, in which latter position the specimen first described by Mr. Paget arose. The occurrence of myeloid cells in specimens of epulis has been already referred to, and it might naturally be expected therefore that the same characters might be discovered in tumours of the jaw. In fact Dr. Eugène Nélaton, in a valuable treatise, published in 1860, "Des Tumeurs à Myéloplaxes," says, "la siége d'élection des tumeurs à myéloplaxes est, sans contredit, dans les os maxillaires, particulièrement au niveau de leur bord alvéolaire," and supports his statement by quoting twenty-nine cases of the disease in this situation.

In order to avoid the confusion which has arisen between the so-called myeloid or fibro-plastic tumours of Lebert, and the tumours with large myeloid cells described by Paget and Robin, Dr. E. Nélaton proposes to use the term "myeloplaxic" for the latter class, but the word myeloid" is now so fully established, in England at least, that it would only lead to confusion to attempt to alter it.

The diagnosis of myeloid tumours of the jaw is by no means easy, since the bone is slowly expanded, much as it would be by a cyst, or by any benign tumour. If the disease originate on the exterior of the bone, or when springing from the interior, if sufficient absorption of the bone have taken place to allow the tumour to appear beneath the mucous membrane, the characteristic dark maroon colour of the tumour may be perceived. Cysts occasionally form in the substance

[graphic]

of a myeloid tumour, and an exploratory puncture of these may yield fluid in which the characteristic myeloid cells may be discovered microscopically.

Myeloid disease occurs mostly before the age of twentyfive. Mr. Paget ("Surgical Pathology," p. 524) quotes two cases of Sir William Lawrence's, occurring in the upper jaws of women, of twenty-one and twenty-two years of age,

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the latter of which will be quoted in the Appendix (Case XIX.), since it illustrates extremely well the recurrence of myeloid growths (of which there can be no question), and also the very curious fact that a tumour on the opposite side to that removed, and which presented appearances exactly corresponding to it, spontaneously subsided.

Fig. 106 shows a patient from whom Mr. Canton removed a myeloid tumour in 1864. She was thirty-five years old,

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