Even when the disease is far advanced, so that the tissues of the face and mouth are much involved, it is possible for the surgeon to give relief, if not permanent cure, by completely excising the morbid structures. In the Lancet, January 2nd, 1864, will be found a case in which Sir William Fergusson relieved a patient who had been abandoned as incurable some months before by another surgeon, who had declined to proceed after laying open the cheek. Here the patient was very much exhausted and out of health. There was a considerable enlargement on the left side of the face. The eye was protruded, both lids being much swollen, the lower one everted, and the mucous membrane thickened and granular; the sight of the eye was gone. The left nostril was swollen, and there was a thick discharge constantly coming from it. Running across the cheek was the cicatrix of the exploratory incision made some months before. The skin was thickened and unhealthy looking, and there could be felt under the buccinator a large, welldefined, hard tumour. Upon examining the inside of the mouth, there could be seen a large fungous mass, involving the left side of the hard palate, nearly all the soft palate, and the uvula. The disease seemed to have involved the base of the orbit, and extended up under the zygoma. The glands in the neck were not enlarged. The patient suffered most excruciating pain, which was intermittent, and of a neuralgic character.

The disease may extend across the median line, and involve portions of both maxillæ, especially the palatine plates. This is not necessarily a bar to operative interference, provided other circumstances are favourable, but when the disease exhibits the appearance shown in fig. 114, the case is obviously one beyond the aid of surgery. The patient, aged twenty-four, was sent to me in January, 1868, by Mr. Harding, to whom he had applied for the extraction of some teeth, thinking to obtain relief thereby. Four and a half years before he had had a blow on the face from a cocoa-nut, which broke the left canine tooth, and a year before I saw him, the left side of the face swelled up, but subsided

again. In August, 1867, he first noticed a growth below the left eye, which rapidly increased, but even before this the interior of the mouth was tender, and felt swollen and soft to the touch. He had good advice in the country, and subsequently was in a London hospital, but operative interference was declined by the surgeon under whose care he was. When I saw him, some months later, there was a large soft tumour of the left upper jaw, and a smaller one on the right side, which had appeared about four weeks before. The nose was considerably projected by these, the left nostril being completely blocked and the right slightly

SO.

The alveolus was very prominent, so that the incisor teeth sloped backwards, and there were soft masses of disease on each side of the palate. Within a week or ten days of my seeing the patient the lymphatic glands in the neck had become enlarged, particularly on the right side, where a considerable tumour existed. This melancholy case was obviously totally unfitted for operation at the time I saw it, whatever might have been its prospects at an earlier date. I could therefore hold out no hope of alleviation to the unfortunate patient, who returned to the country.

261

CHAPTER XXII.

DIAGNOSIS AND TREATMENT OF TUMOURS OF THE UPPER JAW.

THE diagnosis of tumours of the upper jaw is by no means easy. Even the distinction between fluid tumours due to cystic enlargement of the jaw and solid enlargements, is, as has already been pointed out, not always easy; and it is still more difficult, and in some cases impossible, to decide as to the malignancy or otherwise of a tumour previous to its extirpation.

The fibrous, fibro-cellular, cartilaginous, and osseous tumours are all of slow growth, painless, and more or less hard to the touch. They do not affect the general health, nor do they show any tendency to involve the surrounding tissues or the skin, except by mechanical interference. The vascular and myeloid tumours are more rapid in their growth and softer than those already mentioned; both are more vascular in appearance at points where they are covered only by mucous membrane. They occasionally ulcerate, but do not fungate, and may, under these circumstances, discharge blood in considerable quantities. The medullary tumour is the most rapid in its growth, and its tendency to involve surrounding structures is early manifested. Its softness and tendency to fungate and bleed are its chief characteristics, but these must not be relied on too implicitly. This last variety is ordinarily more painful than the others, the patient frequently complaining of neuralgic or gnawing pains in the face and head.

In examining a case of tumour of the upper jaw, a careful inspection should be made of the face, mouth, and nares. The consistency of the projection beneath the cheek should

be tested with the finger both outside and inside the cheek itself. The condition of the hard and soft palate should be particularly investigated, and the finger should be carried behind the soft palate if there is any suspicion that the tumour extends towards the posterior nares. The condition of the nostril will require especial examination, particularly in those cases where the disease shows itself at an early period in that cavity and doubt arises as to its nature. The careful introduction of a probe whilst a good light is thrown into the nostril, will enable the surgeon to decide whether the tumour is merely a polypus springing from the turbinate bones, or whether it is a portion of an antral tumour showing itself in the nostril; or possibly some growth springing from the base of the skull and simulating maxillary disease.

Prognosis. But little can be hoped from medicine in the treatment of tumours of the upper jaw. The application of iodine has been said by Mr. Stanley to have effected the removal of a small enchondroma, and no harm will be done by resorting to such measures and to the internal administration of absorbent medicines for a short time whilst the progress of the disease is watched, provided no chemical agent be applied to the growth itself, by which it might be irritated or caused to inflame. Removal by surgical operation is, however, the only effectual means of treatment, and the sooner an operation is undertaken the better in all cases, since even a benign tumour may, by its size or by its attachments, put a patient's life in danger if allowed to grow unchecked for a series of years. In malignant disease the only hope for the patient is early and complete removal whilst the disease is confined to the bone, and before the surrounding structures have become affected.

Operations on the Upper Jaw.-From early times portions of the upper jaw, and particularly the alveolus, were occasionally removed on account of some disease, and with more or less permanent success. Mr. Butcher, who has laboriously investigated the subject, puts the earliest case in 1693, the operator being Akoluthus, a physician at Breslau. Desault, Garengeot, Jourdain, and others in the last century

removed growths from the jaw, gouging them out with chisels with partial and temporary success, and Dupuytren especially advocated this mode of treatment in his "Leçons Orales," and frequently practised it, removing in this manner the greater part of the upper jaw in 1824. Charles White, of Manchester, appears also to have successfully operated on a patient, from whom he removed, piecemeal, nearly the whole of the upper maxilla during the last century.

The late Mr. John Lizars, of Edinburgh, appears to have been the first to propose removal of the entire superior maxilla as a whole in 1826, when, in his "System of Anatomical Plates," he showed how, anatomically, it would be possible to remove the bone without injury to important

and vital parts, and recommended the previous deligation of the common carotid artery, with a view of preventing hæmorrhage. Mr. Lizars did not have an opportunity of carrying his proposition into effect until December, 1827, when, notwithstanding the ligature applied to the carotid, the hæmorrhage was so fearful as to necessitate a. discontinuance of the operation (Lancet, 1829-30). M. Gensoul, of Lyons, had, however, forestalled Mr. Lizars quite independently and without being aware of his proposition, for in May, 1827, he removed the entire superior maxillary bone, with a part of the palate, from a boy of seventeen, on account of a large fibro-cartilaginous tumour. The incision employed by Gensoul (fig. 115) was a vertical one from the