with the remaining bones of the face. At its lowest part it preserves somewhat of the form of the alveolar border of the upper jaw, and the incisor, canine, and bicuspid teeth are implanted in it. The patient was a woman, aged thirty, who died in the Westminster Hospital from hæmorrhage, consequent upon the extraction of some teeth from the tumour in question, which is described as "fleshy," and of a florid red colour where it appeared in the mouth. The tumour had been growing five years. No details are furnished by Mr. Howship as to the post-mortem examination of this patient, but the skull shows a very important feature-a circular portion of the frontal bone just above the right temple, which is thin and perforated by several small apertures, apparently in consequence of the growth of a tumour from the dura mater. There is thus evidence of a secondary growth within the skull; and, taking the history of the case together with the specimen, I am inclined to regard this as an example of osteoid disease. O. Weber quotes from Tittman (1757) a remarkable case which he considers of the same kind. The tumour was in a youth of fourteen, and had been growing for four years, and finally occupied the entire face. It had displaced the eye, the nose, and the lower jaw, and projected in such a way into the mouth and fauces that the patient died of inanition. The mass weighed six pounds, and on being cut through was quite white and very hard, and had radiating masses of bone interspersed through its substance. 255 CHAPTER XXI. TUMOURS OF THE UPPER JAW-(continued.) Cancerous Tumours. Medullary Cancer.-The only form of true cancer invading the upper jaw is, in my experience, the medullary or encephaloid, but scirrhus has occasionally been met with, of which preparation 1059 E., removed by Mr. Coates, of Salisbury, is believed to be a specimen. In the majority of cases the disease begins in the antrum, for the protruding masses which are found in the nose or mouth are but secondary to a formation within that cavity. Mr. Hancock, in a paper read before the Medical Society of London (vide Lancet, 1855, p. 4), put forward the view that medullary disease does not commence in the antrum, but in the body of the sphenoid bone, and other bones at the base of the cranium. Though it is quite true that in a few cases medullary disease may involve the base of the skull, there can, however, be little doubt, I think, that it began in the antrum, and proceeded backwards rather than forwards, as Mr. Hancock supposes. That medullary discase does begin in the jaw itself the specimens which accompanied this essay show, and one of Mr. Liston's cases is conclusive on the point, the preparation being preserved in the College of Surgeons (1059), with the following description :-"The greater part of a left superior maxillary bone, with a tumour formed in the antrum, removed by operation. The tumour measures about two inches in its greatest diameter, and projects forwards over the right canine and bicuspid teeth. is pale, soft, and homogeneous, and the surface of its section It brain-like. years old. is like that of brain. At the upper part its tissue is broken, and was mixed with blood: in its recent state it was more The patient, William Thomson, was sixteen The disease had been observed for two years. He had often suffered pain in the situation of the first molar tooth, which had been in a decayed state for a considerable time previous to his discovering any swelling of the cheek. During the two months preceding the operation the tumour had grown rapidly. Three years and a half after its removal the patient was in good health."-See Liston's paper, Medico-Chirurgical Transactions, vol. xx. In this case, which was fortunately submitted to operation at a very early period, the disease was still confined to the antrum, and the removal of the jaw therefore included the whole of it. Unfortunately in too many cases the disease is much more advanced before it is brought under the notice of the surgeon, when therefore the possibility of complete extirpation is much reduced. Medullary disease in the jaw closely resembles the same disease in other parts of the body. Rapidity of growth, with softness, and a tendency to fungate on the part of the tumour itself, are the main characteristics; but in the more advanced stages, the cancerous cachexia may be established. No lymphatic glandular enlargement takes place in this affection, because there are no lymphatics to the jaw itself, and even to the skin of the face there are very few, so that even when the skin is involved it is unusual, except in very advanced cases, to find any enlargement of the submaxillary or cervical lymphatic glands. The direction which the disease takes and the effects therefore which it produces, will vary in different examples. Frequently it forms a considerable projection on the check, causing epiphora from closure of the nasal duct, and oedema of the lower eyelid, and in the later stages enlargement of the facial veins, without the least invasion of the hard palate, and with but slight interference with the nostril. The specimen of medullary disease which accompanied this essay (College of Surgeons Museum, 1053 A), and is represented in fig. 112, illustrates the point, a large tumour being developed externally. The patient was a man, aged forty-four, who came under the care of Mr. Craven, of Hull, in 1863, with a large rounded tumour of the right cheek, of the size of an orange, extending from the external process of the frontal bone and zygoma above, to the angle of the mouth below (almost completely closing the right eye), and from the side of the nose to the ramus of the lower jaw. The colour of the integument was natural, except at the upper part below the eye, where it presented a rather livid appearance, and several veins, not of large size. It was very firm to the touch, but elastic, especially at the outer part. Pressure and handling caused little or no pain. The interior of the mouth on the right side, from the alveolar process (which was concealed by the growth or embraced in it) to the inside of the distended cheek, presented a large excavated sore of a greyish sloughy aspect and fœtid odour. This part of the tumour was softer to the touch than that which showed itself externally. It did not encroach on the palate, which was of the natural width. There were no enlarged glands beneath the jaw. The patient seemed a pretty healthy man. The tumour had been growing seventeen weeks. Mr. Craven excised the tumour, and the patient made a good recovery, but died fifteen months afterwards from a recurrence of the disease. The tumour (fig. 112) was rounded and lobed, especially that part which occupied the pterygo-maxillary fossa; and was firm on section. The cut surface was smooth, becoming slightly granular after prolonged exposure. To the naked eye, the tumour had the appearance of a malignant growth. Under the microscope, the juice scraped off the cut surface showed no fibrous element; but simply a mass of apparently brokenup cells and granular matter. On the other hand, the disease may at an early period involve the alveolus and palate, or the nose, and it is these cases which are sometimes attributed to the presence of de Of cayed teeth, or are mistaken for ordinary nasal polypi. |