The tumour sprang from the periosteum of the alveoli corresThe to the right upper canine and bicuspid teeth. two last were retroverted and removed with the tumour. It measured inches in length and 7? inches at its greatest circumference, was divided into three irregular lobes, one lobe projecting backwards into the pharynx, one downwards, forcing the teeth of the lower jaw to the floor of the mouth, and the third as a rounded excrescence was projecting with roughened mucous membrane from the mouth. I am indebted to Dr. McConnell, Curator of the Calcutta Museum, for the following interesting description of this
ponding
growth "
:?
On section the growth presents a dense appearance, the arrangement of the fibres being interlace with each other in all directions, and towards the periphery. The fibrillaG are white,
delicate.
white
fibrous
irregular; they are
most dense and
glistening,
Under the microscope (in thin sections) numerous delicate interlacing bands of white fibrous or connective tissue are seen, intermingled with which are numerous nuclei, and candate
and stellate connective tissue cells. Here and there a small piece of cartilage and bone comes into view, but the main bulk of the growth is composed of white fibro-cellular tissue. No yellow (elastic) fibres exist, and no myeloid cells. A delicate but quite distinct capsule invests the tumour, continuous apparently with the periosteum of the alveolus. The growth is, therefore, an almost purely fibrous tumour, and certainly constitutes a variety (the non-myeloid) of epulis." With regard to the operation, as the right cheek was distended by the tumour, and the attenuated margins of the lips were stretched round the projecting portion (in this respect resembling the os uteri with the membranes protruding), it was obvious that the root of the growth could only be reached by an incision through the soft parts. I chose the line through the upper lips into nostril, as by this sufficient room was obtained, and all chance of cutting the branches of the portio dura or the parotid duct was thereby avoided, and little or no cicatrix subsequently remained.
TWO CASES OF TUMOUR OF THE UPPER JAW. By Surgeon-Major J. R. Jackson, M.D., Civil Surgeon, Mynpoory. TIBROUS TUMOUR OF UPPER JAW, BLOCKING UP RIGHT BUCCAL CAVITY; REMOVAL: RECOVERY.
Ranee, Hindoo female, aged 27, admitted into Mynpoory 4th February 1874, suffering from a tumour of the
dispensary,
mouth. States that eighteen months ago one of the back teeth of her right upper jaw became carious, dropped out, and from the socket and gums the growth sprang. The whole of the right buccal cavity is filled with the tumour, which projects between the jaws, bulging out the cheek and protruding through the mouth, the attenuated edge of which is stretched round the exposed part. The patient has not been able to close her teeth The anterior portion of the or mouth for some time past. tumour has worked its way between the cheek and teeth of lower right jaw, so that the latter are inverted and lying in the floor of the mouth, covered with a thick plate of tartar. The tumour is fibrous, with adherent mucous membrane, and is felt to project backwards into the pharynx; as far as can be ascertained by the finger passed round the posterior part, it appears to be attached by a broadish pedicle to the upper maxilla. The is in a miserable state of emaciation and weakness poor woman from simple want of food. She has been unable to masticate for months, and can only take fluid nourishment. She was so ?weak that she had to be supported to the operating table, and lifted on to it. 6th.?To expose the tumour sufficiently to enable me to get satisfactorily to its attachment, I made a cut through the upper lip in the mesial line into the right nostril and dissected back the soft parts. The two upper right incisors were then extracted, and as the external end of the portion of the alveoli to which the tumour was attached was found to be separate and loose, the bone pliers were applied as high as possible above the pedicle, and the mass removed with a few strokes of the knife. There was some smart bleeding from the dental arteries arrested by pressure. The cut through the lip was brought together by harelip needles and wire sutures. The wound healed by the first intention ; the woman made ^
uninterrupted recovery, rapidly regained strength, and was discharged cured on the tenth day after the operation. an
TUMOUR OF LEFT ANTRUM ; OPERA.TION": RECOVERY. Muna Lai, Hindoo, aged 30, admitted into the dispensary on the 23rd December 1873, with a tumour of the left upper jaw. States that about eighteen months ago a swelling appeared
inside the mouth on the left side beneath the hard palate. The swelling was about the size of a pigeon's egg. It diminished in size the folloAving cold weather. Ten months ago it again appeared in the same situation and gradually enlarged. The patient suffers from severe shooting pains. Present state.?There is very considerable bulging of the cheek from enlargement of the upper maxilla. The anterior surface protrudes under the orbit about the size of a pigeon's egg within the mouth ; the tumour has completely displaced the left palatal plate, and depresses the roof of the mouth, impinging beyond the middle line to the right side. The alveolar processes of.the left jaw are displaced and bulge forwards, each tooth being with its portion of adherent alveolus quite loose. The extreme state of disintegration of the alveoli, as evinced by the grating feeling of the several pieces, as in fractured bones, is very peculiar. A portion of the anterior wall of the antrum and the hard palate of the left side have been absorbed by the tumour. The tumour itself has a firm elastic feeling ; fluctuation is not apparent; and there is none of that parchment-like crackling of the anterior wall of the antrum, or the palate which is characteristic ot great fluid accumulations in that cavity. The man's health is good ; his countenance clear ; no enlargement of contiguous glands. I diagnosed a non-malignant tumour of the antrum, requiring extirpation of the upper maxilla, and proceeded to operate accordingly on the 24th. An incision was made through the middle of the upper lip into left nostril, and the flap dissected upwards. As soon as the knife had reached the of the tumour, it
bulging portion
the wall of a cyst, and there was an immediate evacuation of about four or five ounces of a yellow, viscid fluid, similar to that in ranula. After the fluid had thoroughly drained away, the upper canine tooth with its adherent but detache alveolus was removed, and a free opening made into the antruffl for the secretion to drain away. The incision through the upper lip was closed with wire sutures. After the operation the absence of the palatal plate tbroug tue absorption was evidenced by the flapping up and down of
passed through
.
?June 1,
1874]
A MIRROR OF HOSPITAL PRACTICE.
thickened and corrugated mucous membrane, (on palpation) Corresponding to the situation of the hard palate. The patient made a good recovery ; the detached alveoli became gradually fixed and reunited, and the loosened teeth firm. The antrum ceased to discharge, and the opening was almost closed when the man left the hospital cured on the 10th day. There was here an error in diagnosis which might have been avoided had I taken the precaution of using an exploring needle before operating. There were, however, circumstances in the present case which rendered the diagnosis specially difficult. There was the absence of the crackling feeling diagnos-
tic of attenuation of the walls of the antrum from pressure of fluid in cases of great accumulation, and it might have been predicated that the fluid would have found an exit before producing uniform absorption, alike of a portion of anterior wall of the antrum, and palatal plate of the upper maxilla, along with the disintegration of the alveoli which I have described. The
toughness of the cyst-wall which produced this effect by gradual Pressure also masked the sign of fluctuation, there being only a firm elastic feeling in the exposed parts of the tumour. That such mistakes are not unknown in the diagnosis of 4 "Uinours of the antrum, there are cases on record to prove. According to Erichsen, the distinguished Surgeon Gensoul, in a case after making incisions through the cheek with the view of extirpating a tumour, found that the bones were expanded by an antral abscess. Another case occurred in Sir Wm. Fergusson's Practice when a patient had been sent for removal of the upper jaw for a tumour which proved to be an accumulation of fluid in the antrum. In the present case it is fortunate that the error in diagnosis to no greater avoidable injury to the patient than a cut the upper lip.
through
^57
ponding
growth "
:?
On section the growth presents a dense appearance, the arrangement of the fibres being interlace with each other in all directions, and towards the periphery. The fibrillaG are white,
delicate.
white
fibrous
irregular; they are
most dense and
glistening,
Under the microscope (in thin sections) numerous delicate interlacing bands of white fibrous or connective tissue are seen, intermingled with which are numerous nuclei, and candate
and stellate connective tissue cells. Here and there a small piece of cartilage and bone comes into view, but the main bulk of the growth is composed of white fibro-cellular tissue. No yellow (elastic) fibres exist, and no myeloid cells. A delicate but quite distinct capsule invests the tumour, continuous apparently with the periosteum of the alveolus. The growth is, therefore, an almost purely fibrous tumour, and certainly constitutes a variety (the non-myeloid) of epulis." With regard to the operation, as the right cheek was distended by the tumour, and the attenuated margins of the lips were stretched round the projecting portion (in this respect resembling the os uteri with the membranes protruding), it was obvious that the root of the growth could only be reached by an incision through the soft parts. I chose the line through the upper lips into nostril, as by this sufficient room was obtained, and all chance of cutting the branches of the portio dura or the parotid duct was thereby avoided, and little or no cicatrix subsequently remained.
TWO CASES OF TUMOUR OF THE UPPER JAW. By Surgeon-Major J. R. Jackson, M.D., Civil Surgeon, Mynpoory. TIBROUS TUMOUR OF UPPER JAW, BLOCKING UP RIGHT BUCCAL CAVITY; REMOVAL: RECOVERY.
Ranee, Hindoo female, aged 27, admitted into Mynpoory 4th February 1874, suffering from a tumour of the
dispensary,
mouth. States that eighteen months ago one of the back teeth of her right upper jaw became carious, dropped out, and from the socket and gums the growth sprang. The whole of the right buccal cavity is filled with the tumour, which projects between the jaws, bulging out the cheek and protruding through the mouth, the attenuated edge of which is stretched round the exposed part. The patient has not been able to close her teeth The anterior portion of the or mouth for some time past. tumour has worked its way between the cheek and teeth of lower right jaw, so that the latter are inverted and lying in the floor of the mouth, covered with a thick plate of tartar. The tumour is fibrous, with adherent mucous membrane, and is felt to project backwards into the pharynx; as far as can be ascertained by the finger passed round the posterior part, it appears to be attached by a broadish pedicle to the upper maxilla. The is in a miserable state of emaciation and weakness poor woman from simple want of food. She has been unable to masticate for months, and can only take fluid nourishment. She was so ?weak that she had to be supported to the operating table, and lifted on to it. 6th.?To expose the tumour sufficiently to enable me to get satisfactorily to its attachment, I made a cut through the upper lip in the mesial line into the right nostril and dissected back the soft parts. The two upper right incisors were then extracted, and as the external end of the portion of the alveoli to which the tumour was attached was found to be separate and loose, the bone pliers were applied as high as possible above the pedicle, and the mass removed with a few strokes of the knife. There was some smart bleeding from the dental arteries arrested by pressure. The cut through the lip was brought together by harelip needles and wire sutures. The wound healed by the first intention ; the woman made ^
uninterrupted recovery, rapidly regained strength, and was discharged cured on the tenth day after the operation. an
TUMOUR OF LEFT ANTRUM ; OPERA.TION": RECOVERY. Muna Lai, Hindoo, aged 30, admitted into the dispensary on the 23rd December 1873, with a tumour of the left upper jaw. States that about eighteen months ago a swelling appeared
inside the mouth on the left side beneath the hard palate. The swelling was about the size of a pigeon's egg. It diminished in size the folloAving cold weather. Ten months ago it again appeared in the same situation and gradually enlarged. The patient suffers from severe shooting pains. Present state.?There is very considerable bulging of the cheek from enlargement of the upper maxilla. The anterior surface protrudes under the orbit about the size of a pigeon's egg within the mouth ; the tumour has completely displaced the left palatal plate, and depresses the roof of the mouth, impinging beyond the middle line to the right side. The alveolar processes of.the left jaw are displaced and bulge forwards, each tooth being with its portion of adherent alveolus quite loose. The extreme state of disintegration of the alveoli, as evinced by the grating feeling of the several pieces, as in fractured bones, is very peculiar. A portion of the anterior wall of the antrum and the hard palate of the left side have been absorbed by the tumour. The tumour itself has a firm elastic feeling ; fluctuation is not apparent; and there is none of that parchment-like crackling of the anterior wall of the antrum, or the palate which is characteristic ot great fluid accumulations in that cavity. The man's health is good ; his countenance clear ; no enlargement of contiguous glands. I diagnosed a non-malignant tumour of the antrum, requiring extirpation of the upper maxilla, and proceeded to operate accordingly on the 24th. An incision was made through the middle of the upper lip into left nostril, and the flap dissected upwards. As soon as the knife had reached the of the tumour, it
bulging portion
the wall of a cyst, and there was an immediate evacuation of about four or five ounces of a yellow, viscid fluid, similar to that in ranula. After the fluid had thoroughly drained away, the upper canine tooth with its adherent but detache alveolus was removed, and a free opening made into the antruffl for the secretion to drain away. The incision through the upper lip was closed with wire sutures. After the operation the absence of the palatal plate tbroug tue absorption was evidenced by the flapping up and down of
passed through
.
?June 1,
1874]
A MIRROR OF HOSPITAL PRACTICE.
thickened and corrugated mucous membrane, (on palpation) Corresponding to the situation of the hard palate. The patient made a good recovery ; the detached alveoli became gradually fixed and reunited, and the loosened teeth firm. The antrum ceased to discharge, and the opening was almost closed when the man left the hospital cured on the 10th day. There was here an error in diagnosis which might have been avoided had I taken the precaution of using an exploring needle before operating. There were, however, circumstances in the present case which rendered the diagnosis specially difficult. There was the absence of the crackling feeling diagnos-
tic of attenuation of the walls of the antrum from pressure of fluid in cases of great accumulation, and it might have been predicated that the fluid would have found an exit before producing uniform absorption, alike of a portion of anterior wall of the antrum, and palatal plate of the upper maxilla, along with the disintegration of the alveoli which I have described. The
toughness of the cyst-wall which produced this effect by gradual Pressure also masked the sign of fluctuation, there being only a firm elastic feeling in the exposed parts of the tumour. That such mistakes are not unknown in the diagnosis of 4 "Uinours of the antrum, there are cases on record to prove. According to Erichsen, the distinguished Surgeon Gensoul, in a case after making incisions through the cheek with the view of extirpating a tumour, found that the bones were expanded by an antral abscess. Another case occurred in Sir Wm. Fergusson's Practice when a patient had been sent for removal of the upper jaw for a tumour which proved to be an accumulation of fluid in the antrum. In the present case it is fortunate that the error in diagnosis to no greater avoidable injury to the patient than a cut the upper lip.
through
^57
