TUMOURS OF THE JAWS.

A 3tertreON

THE PATHOLOGY AND TREATMENT OFTUMOURS OF THE JAWS.

DELIVERED AT THE MEDICAL GRADUATES' COLLEGEE ANDPOLYCLINIC, DECEMBER 4TH, 1906.

By FREDERIC EVE, F.R.C.S.,SURGEON TO THE LONDON HOSPITAL.

TUMOURS of the jaws present many points of interest,because of their variety and complexity. The upperjaw contains the teeth, has attached to it the hardand soft palates and gams, and is closely related tothe cavities of the nose and naso-pharynx. It is not onlymade up of many tissues and structures from which mayoriginate primary growths, but it may be invaded bytumours originating in neighbouring cavities.

Further, the jaws furnish some of the best examples ofthe truth of Cohnheim's theory of the origin of sometumours from " rests " or remnants of embryonic tissues.The review which I purpose to take of tumours ofthe jaws has been materially assisted by a collection ofall the cases occurring at the London Hospital during thelast five years, and which were submitted to microscopicexamination. Mr. Rassell Howard, lately Surgical Regis-trar, has most kindly put together and abstracted thenotes; and we have gone over together the microscopicspecimens. Without this collection of cases, parts of thispaper could not have been written, for some of the neo-plasms are so complex and variable that it is only bycomparing a number of specimens that their true naturecan be made out. Further, a series of consecutive casescoming from a single institution may be of some value asshowing the frequency of different growths In themaxillae.

EPULIS.This is a convenient clinical term to apply to a tumour

originating from the alveolar margin of the jaws nearto or surrounding one or more of the teeth. The tumoursprings from the periosteum of the jaw or from theperiodontal membrane of the alveolar socket. It morerequently occurs in young adolescents and adults, andaffects by preference the incisor or bicuspid regions.

Thirty-eight cases of epulis were admitted to theLondon Hospital in five years up to 1905. Of these 17were submitted to microscopic examination. The lattermay be classified as follows:-

Epulides composed of granulition tissue springingup around the fangs of carious teeth ... 7 cases

Fibro-sarcomata ... ... ... 2

Mixed and fibro-sarcomata cantaining myeloid cells:Upper jaw ... ... ... ... ... ... ... 3Lower jaw... ... ... ... ... ... ... 5

There was no example of endothelioma.

I have long been of opinion that most of the so-calledfibrous epulides were fibro-sarcomata. This collection ofcases brings this point out strongly, for there is not asingle example of pure fibrous epulis. The myeloidvariety was by far the commonest. The exact pathologicalposition of this tumour has long been doubtful. Mostauthors group it with central myeloid sarcoma or myelomaboth of the lower jaw and of the long bones. I havetaught for some years that this view is likely to give anerroneous idea of the nature and tendencies of the myeloidepulis.The central myeloid tumours of long bones are growths

from the cancellous tissue. They are composed of multi-nucleated giant cells lying in a tissue composed of round,or mixed round and spindle, cells with an interveninghomogeneous or faintly-fibrillated intercellular substance.In addition to the giant cells, which may be consideredthe homologues of osteoclasts, they contain characteristicmarrow cells (myelocytes). The malignancy of thesetumours is so slight and local in character that they present

sharp contrast to the ordinary sarcomata of bone. Allthis applies equally to the Eomewhat rare c-n!ral myelo-

Umuuu52

mata of the lower jaw. The myeloid epurls, on the otherhand, is essentially a periosteal tumour, springing eitherfrom the alveolar periosteum or the periodontal membrane.The giant cells lie in tissue composed of oval and roundnuclei embedded in a distinctly fibrillar matrix. Mostof them may be described as, giant cell and mixed fibro-earcomata. There is a distinct tendency to fibrillation ofthe stroma, and in this fibrillation the giant cells them-selves take a very distinct part (see Fig. 1). Unless com-pletely removed these tumours are prone to recur. Among30 cases at the London Hospital,and including the epulidescomposed of granulation tissue, 18.2 per cent. recurred.I have only met with one example of epithelioma whichmight clinically be called an epulis. This is a specimenin the Royal College of SurgeDns Mueeum (2193a) whichI described as an epulis from the lower jaw surroundingthe second molar tooth. In its microscopic structurethis specimen had the characters of an epitheliomabut it contained no cell reats. It was from a woman,.aged 52, who observel a swelling in the gum five monthsberore the operation.In excising an epulis it cannot be too strongly insisted

that the teeth in its immediate neighbourhood should beremoved, together with the portion of the alveolusinvolved; and the section should be carriel right to thebottom of the alveolus.

Fig. 1.-Myeloid epulis undergoing fibrillation, in which giantcells take part.

TUMOURS OF THE JAWS.The following is a summary of the tumours of the jaws

admitted to the London Hospital and submitted to.microscopic examination during the period named:

Cancellous csteoma ... ... ... ... ... 1Myxo-fibroma of antrum (polypoid) ... ... 1Sarcoma and fihro-sarcoma, upper jaw ... ... 5

It it,, lower jaw ... ... 8

Squamous-celled carcinoma, upper jaw ... ... 7it,, lower jaw 4

Malignant tumours, probably originating fromembrjonic dental structures ... ... ... 7

Endothelioma ... 0. .. ... ... ... 1

This summary will give some idea of the number ofdifferent forms of tumour found in the jaws. Among thesarcomats of the superior maxilla were two examples ofround-celled and three of mixed-celled sarcoma. Those ofthe mandible comprised one round-celled, one mixed, andsix fibro- sarcomata. It is not, however, my object to,deal with them in detail, but I shall select for considera-tion one or two interesting grotps.

It is well recognized that certain tumours in the jawsoriginate in aberrant dental structures or in "rests " orremains of portions of the embryonic structures set asidefor the development of the teeth, especially in thoseremains of the enamel organ found in the alveoli, and firstobserved by Malassez. The paradental epithelium ofMalassez is evidently identical with the sheath of Hertung,which is a growth of the epithelium of the dental germ ex-tending in the form of a fold towards the apex of each fang(see Fig. 2). In the gum itself are also remains of the dental-la!nina and of the ncck of epithelium connecting thiq with

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1S526 ..L3wL1I TUdOURS OF THE JAWS. (JIUNE 29, 19,

the -tooth germn (see Fig. 2, Z L and V.B, from Quaiis'8 lower jaw. Microscopically they consisAnatomy, vol. iii, p3rt iv, Fig. 64).. "Rests" of the tooth and branching epithelial .columns (Fig.P3P1l1& maY give rise to central sarcomatous tumours of up of a p9ripheral layer of columnar celltbhe jsw&* This will be proved by, reference to certain cells undergo a peculiar form of degenesarc,omatoustumours c on-taming strandsof epithelim4mevidently de- t . e r orrived from theenamael organ. ~ ~ ~' ~ '-The impor-

tance of these 'bt

hmo r

et umours dmosea- c

thoe growths em ry ni " r t t e o r an ly w

themselves,. but ~ :~ .,,-in thte light lw

jwhicthey throw on from tcthe etiology ofe y mimorbid growths h e . ; l l lgenerally. Onaccount of the disspecialized cha- kracter of certainstructures i nthe jaws we are w.able to tracecf /:'cthe origin of o.:the tumour,whereas such a .3clue fails, forexample, in thesarc'omata ofthe long bones.We can show ~~,f4'definitegrounds Fig 2. (After Quain).-Section of the first milk incisor of a human embryo (Rose). D.K.,forsatingthatpapAila;- Od., odontoblasts; K., bone of alveolar process; S.E.a., S.EI, outer and inner layersforsatingthat of enamel organ ; S.P., enamel pulp, or reticulum produced by degeneration of the central

a large group cells of enamel organ; Z F., dental furrow; M.E., mouth epithelium; Z.L., remains of dentalof t am o urs lamtna; V.B., cell bridge connecting this with tooth germ. E.L., reserve germ for permanentclinically pre- tooth; J.1m.I, germ of second milk incisor.senting the characte3rs of sarcomata and carcinomata are account of a tooth tumour of thisderived from "1rests" of embryonic dental structures. was evidently non-malignant, as sh4We therefore recognize two great groups of tumoDurs- microscopic characters and clinical his

ont- originating from embryonic "1rests," the other, mainly was a man, aged 24, with a swelling of icarcinomata#arisi.Ag as the result lower jaw whic:of chronic irritation and inflam- -- ing four years.matlon, and possibly from the ,~, by a capsuleirritation produced by micro- shelled out aftiorganisms. Following Cohnheimlheote alwe' must remember, however, j years later theithat any irritation prodacing of the disease.hyperaemla may cauise a latent the tumour yi"rest" to grow-and become active. anastomosing 1Returning now to tumours aris- -,epithelium lyin

ing from 'rests" of dental struc- \ nective tissuetures, I shall exclude the calcified .,.- places were el(odontomes and confine mnyself counreato what mayV be termed" toothtumours" or embryoplastic odon- 1. (3) Compositomes. I recognize so far two Odontomivarieties: This group i

1. Composite odontome, contain-In all the elements of a tooth h~ ofevthe preidgf oll~~~~~~~~~~~~~~~~~~~~~~enolicle. the same papei

(a) A composite or m-f i mredasi

st of anastomosing3), which are madeIs, while the centralration, resulting in

the formationof a reticulum.Elsewhere Ihave shown thatthis degenera-tion is due to acolloid meta-morphosis o fthe protoplasmof the cell, andnot to compres-sion and flatten-ing of the cellsby effusion offluid betweenthem.i Thesechanges are inexact imitation

eL of those whichtake place inthe formationof' the enamelcap. The tu-mou`Ts areusually onlylocally malig-nant,- but I have;cited casesinwhich metasta-sis took place.21. (a) Composite

EmbryoplasticOdontome (In-nocent).

In 1886 I pub-lished' an

description which,o n bth by itss tory. The patientthe left side of the*h had been grow-It was surroundedDf bone, and waster removing onlyf the cavity. Twore was no return. Microscopically,was composed ofbands of enamelig in fibrillar con-(see Fig. 4). Inongated bands of

.el cells (Fig. 4a).

te Bmbryoplasticee (Sarcoma).is the counterpartIng, the stroma,g malignant. In)r I described asodontomes two(innDroent).c onom '.,- sarcomnatous tooth tumouris, which

(b)A composi teor mixedd{ l _ l !i m |!! l!211|l! X|G6 contained bands and columns ofembryoplastic odontome enamel epithelium. Both were(sarcomatous). in the Royal College of Surgeons

2. EpIthelial odontome derived Museum. One was presented byfrom enamel organ- cells. the late Mr. Christopher Heath.(a) Epithelial odontome (cystic

variety) or cysticiepi- ~ ~ - -~'~ It Is a very large central tumourtheriay oreysti.ep epi involving the left half of the lower(b) Epithelial odontome (carci- jaw, and was removed from a mannoma), usually described Fi. 3 (low power). Multiocular cystic tumouragead 32. It had existed for

as spheroidal or columnar- Of loe a (enamelogenous odontome), S9t Bar- eleven years. The mass of thecelled carcinoma. tholomew's Hospitsa Museum, No. 53 (described tumour was a fibro-sarcoma, and

Of this group (2 a), the epi- in Mr. Eye's Erasmus Wilson Lectures, BRITISH embedded in it were irregularly-thelial odontomes or cystic DICAL JOURNAL 1883 vol i p 1) shaped masses and columns ofepithelial tumours are quite familiar. They are composed enamel epithelium (Figs. 5, 6, 7) (Specimen 2234 Royal

mainly of collections cysts usually involve the College of Surgeons Museum). In the second specimen,

* See specimen No. 2233, Royal College Surgeons Museum,also a lower jaw, the bulk of the tumour was compoEed of

describedby

me.round cells. The patient was years of age. In 1847-

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TUMOUBS OF THE JAWS. r mm BEtALmumm4OW i527

Sir W. Fergusson removed frotm the -right side ofthe lower jaw a "fibroid" tumour, containing a cyst,of many years' Auration. In July, 1877, a cystictumour, which had developed in the left half ofthe lower jaw, was operated upon by opening thecysts and scooping out their contents. In November,1877, and again- a year later, the operation was ;repeated forrecurrences of the cystic disease. In November, 1879, thepatient reappeared with a large solid tumour which hadgrown on the left side of the jaw in the site of the cystictumour. This recurrent growth was removed. Thepatient died three months afterwards with recurrence ofthe tumour in the skin of the cheek, with a round-oellsarcoma beneath -the right biceps muscle, and a tumourof a similarnature in the pelvis. This case fully provesthe malignancy of these tumours.In the London Hospital series of cases are two examples

of sarcomatous mixed odontome, one being from a caseof my own. This patient, a woman 33 years of age, hadobserved a swelling on the outer side of the left half ofthe mandible for two years. The tumour was surrounded

Fig. 4.-Composite embryoplastic odontome composed of anas-tomosing bands of epithelium in fibrillar connective tissue.

by a complete bony capsule, and on section looked like asarcoma. A portion of the whole thickness of the jawwas excised. The microscope showed that the growth,was a fibro-sarcoma containing branching strands ofenamelogenous epithelium (Figs. 8 and 9). Another casewas a woman, aged 53, who had observed a swelling of,the alveolar margin of the right upper jaw for four

1ZL'S-*Fig. 4a.-Columnar enamel cells from the same tumour a$ Fig. 4.

months. A fuligating mass projected froba the alveolarmargin (this point should be noted). The strands ofepithelium (Fig. 10) were wider in this case and showedtypical reticular degeneration (Fig. 11). They weredistributed in an abundant stroma of sarcoma tissue.In these composite tooth tumours I surmise that the

epithelial element is derived from the enamel organ andthe sarcomatous stroma from the tooth papilla.

-The dental character of these tumours cannot bedoubted, owing to the characteristic appearance andarrangement of the epithelium. In Fig. 7 and 9 theperipheral layer of columnar cells is verywell shown.At places in the columns are rounded or flask-sha-enlargements due to microscopic cysts, or to Mall,rounded areas of stroma which appear to penetrate theepithelial columns just as the tooth papilla invaginatesthe enamel organ (see b in Fig. 7).-The degeneration of the central cells of the columns,

leading to the formation of a reticulum, was present in allthe specimens, and is shown at.a in Figs. 7, in 9 and 11.A wavy or crenated outline of the margins of theepithelial strands is a feature of some of 'thesegrowths. (See Figs. 5 and 8 and compare withFig. 3, cystic odontome.) The tumours were sarco-mata, as shown by their appearance and progress.In Mr. Heath's specimen the duration -was unusuallylong-namely, eleven years. The patients were 21, 33,53, and 55 years respectively when the tumours com-menced. The tumour in the upper jaw was evidently themost malignant, for it had existed only four months.

Fig. 7 (higlh power).-Composite embryoplastic odontome with-basis of sarcomatotus tissue. The figure shows a rounded strandof enamel-epithelium, lined externallywith columnar cells. Theintermediate layer exhibits a reticulum (a). At its centre, thestrand is penetrated by a rounded area of stroma (b).I am not aware that this interesting group of tumours

has been fully described before.2. (b) Epit/elial Odontome (Careionma).

The study of the composite sarcomatous odontomes leadsup to this important group, and, in fact, gives the clue totheir nature-epithelial odontome (carcinoma), usuallydescribed as spheroidal or columnar- celled carcinoma.Among the tumours of the upper jaw is a large group

exhibiting many general characteristics. They are -usu-ally described as springing from the epithelium andmucous glands of the lining of the antrum. They-consist of rounded masses or of columns of epithelium,often tortuous, branched, and anastomosing. The epi-thelium is mainly of the spheroidal type, with sometimescolumnar or elongated cells at the periphery of theeolumns; in one specimen the cells were entirelycolumnar. The central cells of the epithelial columnsundergo vacuolation by mucoid or colloid degeneration,with the result 'that in typical examples a reticulumis produced; and the margins of the columns areoften crenated. The ground substance or connectivetissue is, as a rule, very' abundant and proliferative; infact, it may have all the appearance of sarcoma tissue, andthe growth might be descr-ibed as a carcinoma sarcoma-todes. The connective tissue may be composed of fibrillartissue containing large numbers of small. round nuclei, orof elongated or spindle shaped nuclei; or, again, of fibroustissue. The following examples of these tumours indicatetheir chief-features:

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~~~~~~[JUJNE 2, N,StA man, agad 61, was admitted with a fungating mass spring-

lug from the alveolus at the position of both bicuspids and thefirst molar of the upper jaw. It had existed for six weeks.The upper jaw was removed. The microscopic characters ofthe growth are shown in Figs. 12,13, and 14. Fig. 12 shows undera lower power the 'epithelial columns with crenated edges ; andFlgs. 13 and 14 (under higher powers) show elongated cells atthe margins of the columns, and a well-marked retioular.structure. The stroma penetrates the columns in places, as inFig. 7. ' This tumour appeared to spring from the alveolus, yetit is clearly not a squamous-celled carcinoma.A young man, aged 20, was admitted under my care with a

firm tumour situated on the outer side of the maxilla over andbelow the malar eminence; it had been growing five months.I removed the maxilla. Figs. 15 and 16 show the microscopiccharacters of the tumour under a low and high' power. TheTeticUIlum in Fig. 16 is well shown.- The stroma is veryabundant, and the tumour closely resembles that shown inFigs. 10 and 11, and classed among the mIxed sarcomatoustooth tumours.In the) case of a boy, aged 11, a tumour of seven weeks'

growth sprang from the alveolus between the upper centralincisors, and separated them. I have the specimen before me;the growth is entirely confined to the alveolus, does not extendas far as either the' inferior meatus or' the antra. Its micro-scopic characters are most interesting, and are shown inFigs. 17 and 18. Fig. 17, from the centre of the tumour, showscolumnar cells arranged in rounded masses or in tubularcolumns with a central space formed by degeneration of thecentral cells. Fig. 18, taken vertically through the gum,shows the columnar-celled growth beneath but entirely dis-tinct from the epithelium of the gum. Here there is distinctcystic degeneration similar to that found in cystic epithelialtumours.

I consider this tumour to have been derived from"rests"' of the columnar cells of the enamel organ. Ifthere had been any trace of continuity between it and thenasal or antral cavities I should have been in doubt as toits nature.The last example I shall quote should, I think, be in-

cluded in this group.The patient, a woman aged 58, had a tumour stated to have

begun in the left side of the hard palate at the age of 19 years.From the appearance of the specimen it seems probable, how-ever, that the growth comnmenced In the posterior part of theleft alveolar process and spread to the hard' palate. I saw herin 1899 when a growth projected from the whole surfaca of thebard palate and involved the alveolus only at the point stated,although it had spread up to it in front and to the left. Tnetumoar had extended into both antra. expanding their wallsand absorbing rather than infiltrating. I removed bothsuperior'maxillae after tying the external carotid on the leftside, which was chiefly affected. The patient did not recoverconsciousness and died on the third day. Fig. 19 showsthe growth under a low power. The columns are com-posed of spheroidal epithelium and their arrangement is verysimilar to Fig. 12. In plaies there was extensive cysticdegeneration. Apart' from the 'matter under consideration,the case may merit recording owing to the long duration-thirty-nine years-and the peculiar nature of the tumour.In regard to its duration and progress this case presents

a close parallel with some examples of mixed sarcomatousodontome.In this series of cases I have placed five in the group

under consideration., The tumour occupied the maxilla infour cases and the mandible in one. The majority wererapidly growing; recurrence took place in two, twopatients were lost, sight of and one died of shock.Upon the evidence given above, I therefore submit that

some of the carcinomatous tumours of the antrum arisefrom "rests" of the germinal epithelium of the teeth,which make their way in the directi,on of the least resist-ance, namely, into the. antral cavity. This opinion isbased on' the arrangement of the epithelial columns, thepresence in most instances of. the peculiar degenerationof the cells characteristic, of enamelogenous tumoura, andin som,,e of a peripheral layer of, columnar cells. Further,in some -,instances there. was! definite, evidence that thetumour originated in the alveolar process.

It is not, my, intention to suggest that the lining of theantrum does not, produce tumnours, but I think they areusually of the,columnar-celled type,.as might be antici-pated from,the nature of -the epithelium. Columnar-celled carcinomata also originate from the lining membraneand mucous glands of the- nose, and may secondarilyinvolve the antrum.The nature of the morbid growths springing from the

liring of the antrum may be gauged by the accompanyingphotographs (Figs. 20 and 21) of papillomata- associatedwith chronic suppuration of the antrum. Theze, with

other similar specimens, I described in the Clinicalsociety'8 Transaction., vol. xxxii, p. 200.Not unlike them in some respects is the photograph

(Fig. 22) of a malignant antral growth from a gentlemanaged 62, whose maxilla I excised. He had suffered withnasal polypi for fifteen years. Mr. Hovell, who trans-ferred the case to me, states that for three or four yearspolypi were seen protruding into the nose from theantrum, but the patient would not consent to the antrumbeing explored. The bulk of the tumour consisted offibrillar connective tissue, and intersecting it werenumerous well-defined tubules (each possessing a lumenfilled with mucus) lined with long columnar cells (Fig. 22).Some goblet cells were observed. Many years ago I exa-mined for Mr. Heath a localized papillary outgrowthspringing from the lining of the antral cavity. I describedit thus: The mucous membrane of the antrum was observedto be exceedingly thickened by an overgrowth of epithe-lium with cells for the most part of an elongated form(R.C.S. Museum, No. 2246).

ENDOTHELIOMA.The following case probably falls under this classifica-

tion: A woman, aged 52, was admitted under my carewith a tumour of the left superior maxilla which expandedthe outer wall, depressed the hard palate, raised theorbital floor, and blocked the nostril. It had existed forthree and a half months. I removed the maxilla afterpreliminary laryngotomy and ligature of the externalcarotid, with a favourable result. Microscopically thetumour was composed of large rounded masses or ofnarrow rods of spheroidal cells with large nuclei. TheEelay in sharply defined spaces in the connective tissuelined in places with flattened cells like endothelium(see a in Fig. 23).

OPERATIVE TREATMENT.The mortality of excision of the maxilla is still high,

some of the latest statistics showing a percentage of 20 to30 per cent. of deaths. Kronlein found a mortality of21.5 per cent. in 158 cases of total resection of the maxilladuring the antiseptic period. Koenig estimated themortality at 30 per cent.The chief causes of death are from septic lung affections,

or from loss of blood directly at the time of the operation,or more indirectly, at a subsequent period, from exhaus-tion. Some deaths also occur from secondaryhaemorrhage.Pulmonary complications due to inhalation during

anaesthesia account for half the cases of death after thisoperation. Kronlein, therefore, abandoned generalanaesthesia, and operated after a morphine injection andunder suggestive anaesthesia. The relatively high mor-tality of resection of the upper jaw, even with modernaseptic precautions, from the above causes must havebeen noted by every observant surgeon. Being impressedwith the great value of ligature of the external carotid andlaryngotomy as a preliminary measure in the removal ofmalignant tumours of the tonsils and soft palate, I haveadopted it for some time In all cases of fairly extensivemalignant disease of the maxilla. I first performed liga-ture of the external carotid in 1899, in the case, alreadyquoted, of removal of both upper jaws for a tumour in theleft superior maxilla which had spread over to the rightside.In cases of disease of limited extent, it is sufficient if

the patient is kept well in the lateral position so that theblood can flow from the mouth.In my opinion the.operations of preliminary ligature of

the carotid and laryngotomy do not prolong the operation,and tend to decreaee the amount of the shock. Theaverage period required for both these operations is underfifteen minutes, when no glands require removal. Veryfew vessels need ligature; in some cases none, except oneor two in the cbeek flap. Thus much time is savedin securing vessels, sponging, etc., and what is muchmore important, the operator can see exactly whathe is doing, and remove the disease more thoroughly.I also regard the incision in- the neck for ligature ofthe external carotid as a distinct advantage, in that it per-mits the surgeon to ascertain the condition of the glandsbehind the angle of the jaw and around the upper partof the internal jugular vein.-- My, own cases lead me tobelieve that the tendency to implication of glands in both

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Fig. 5 (low power).-Composite embryoplastie odontome show- Fig. 9 (higlh power).-From the same tumour as Fig. 8, underin r strands of enamel-epithelium lying in a sarcomatous ground a higlher objective. The peripheral cells of epithelial strand aresu'bstance. The strands enclose small cysts, and areas of strolms. colulminar, and the intermediate cells form a reticulum.

lfig. 6 (low power).-The same as Fig. 6, but under a higherobjective. See also Fig. ? under still higher objective.

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11Big. 8 (low power).-A similar tumour to the above, Figs, 5 and 6.The columnar cells lining the strands of enamel-epithelium arewell shown.

Fig. 10 (low power).-A similar tumour from the upper jaw,showing masses of rounded epithelium in a sarcomatous grounmisubstance.

Fig. 11 (high power).-From the same tumouras Fig. 10, showinga reticulum formed by the cells of the epithelium.

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Fig. 12(10w power).-Epithelial odontome (carcinomatous). The Fig. 15 (low power). - Epitheltal odontome (carcinomatous),tumour is composed of strands of epithelium with crenated showing strands of epithelium in a fibrillar stroma.edges, lying in a fibrous stroma. The epithelial element greatlypredominates over the stroma.

Fig. 13 (high power).-Yrom the same tumour as Fig. 12 under Fig. 16 (high power).-From the same tnmour as Fig. 15, showinga higher objective, showing a retioulum formed by the epithelium the reticulum in the epithelial strands.in the strands.

Fig 14 (higlh power) -The same as Fig. 13, under a Ihiglherobjective, showing elongated epthelium at the margins of theepithelial strands and a reticulum.

Flig. .17 (low power).-Growth from alveolus of upper jaw, com-posed of rounded and elougated spaces lined with columnarepithelium.

I rm Ban= 1.5-30 KM=& lov=AzJ [JUlill 29, 190,tiTUMOURS OF THE JA.WS*-

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Fig. 18 (high power).-From the same tumour as Fig. 17. Thesection is taken vertically through the gum; beneath this, and Idistinct from it, is the columnar-celled growth undergoing cysticdegeneration.

Fig. 20.-Papilloma of antrum asweiated with chronicsuppuration.

Fig 13 (low power).-Tumour of upper jaw of thirty-nine-yearsduration.

Fig., 21.-Growth in antrum, mainly papillomatous, associatedwith chronic suppuration.

w. ,-Fig. 22.-Columnar-celled carcinoma of antrum. Fig. 23.-? Endothelioma of antrum. Rounded mass of

- spheroidal .cells lying in a space lined wjith flatttd cel4s.a; Ethdothelial cells lining (?) lymphatic spaces. -

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1532 .-z]L'Iaz] CLEFT PALATE. rJUNE 29, 1g@.

carcinoma and sarcoma of the maxilla has been muchunder-estimated. In the majority of them I found theexternal carotid obscured by overlapping enlarged glands.Preliminary ligatureof the external carotid, therefore, givesthe surgeon the opportunity of investigating the conditionof, and, if necessary, of dissecting out and following upsecondary disease in the glands of the neck-a procedurenow generally adopted where feasible in malignant diseaseelsewhere. To ascertain the condition of the glands, andin view of the fact that the position of the bifurcation ofthe common carotid is often higher than usual, I havealways made it a practic6 to tbiroughly expose the bifur-cation. The ligature is. usually applied between thesuperior thyroid and lingual arteries.Returning now to preliminary laryngotomy. This should

be performed after the ligature of the external carotid, asin opening the air passage the hands must necessarily besoiled. Laryngotomy, in addition to greatly diminishingthe chance of inhalation pneumonia, also diminishesshock. The anaesthetist's task is easier, and thereforelikely to be more efficient. Cyanosis is entirely avoided,and with it the danger of overstraining of heart musclefrom distension of the right side of the heart. I muchprefer laryngotomy to tracheotomy; the former can bevery rapidJy performed, there is little haemorrhage, andlittle disturbance of soft'parts.- After the insertion of thetube the air passages are protected by a large marinesponge thrust into the pharynx. The disadvantages asso-ciated with Trendelenburg's or Hahn's tubes are thusavoided. The -tube is taken out immediately after theoperation, or the next morning.

During the last two years I have in five consecutivecases performed removal of the upper jaw with pre-liminary ligature of the external carotid and laryngotomywithout a death. One patient died of gangrene of lung inwhom the external carotid was tied without laryngotomy.Taking all my hospital cases during the last six years andadding my private cases, I have removed the maxillatwelve times with two deaths-a mortality of 16.6 percent. None of my cases have had secondaty haemorrbageeither from the cavity in the mouth or the externalcarotid.

In the operation of excision of the upper jaw the medianor Fergusson's incision is now invariably used; the hori-zontal incision across the facial aspect of the maxillashould be only just above the level of the lower edge ofthe malar bone, and should not extend further outwardsthan the spheno-maxillary fissure or the fibres of thefacial nerve passing to the inferior half of the orbicularisoculi will be divided.

In severing the bones I have for some time used aGigli's eaw. It effects its purpose much more cleanly andquickly than an ordinary saw and bone forceps. Afterreflecting the cheek flap and raising the soft parts fromthe floor of the orbit, a strong silkthread is passed-fromabove downwards through the spheno-maxillary fissure bymeans of a large narrow aneurysm needle. The Gigli'ssaw Is drawn through the fissure by the silk, and thesection then completed. The section of the hard palate iscarried out in a similar manner by making a puncture inthe middle line at the junction of the hard and softpalate. The aneuTysm needle loaded with silk is passedthrough the nose and through the puncture intothe mouth, where the silk is seized, and by it thesaw is drawn through the nose into the mouth. The sectionof the hard palate is then completed. Although thismethod is not, I think commonly employed, I flad thatSchlatter has preceded me in publishing it.When the position of the growth admits of the orbital

tloor being preserved I have found it inadvisable to -com-pletely sever the malar bone at the level of the spheno-maxillary fissure. A better plan is to chisel or saw throughthe lower two-thirds of the malar; and from this osseousincision I divide the anterior wall of the maxilla in a-direction horizontally-inwards parallel with the orbitalmargin until the cavity of the nose Is reached. By thismeans not only is the flo)rof the orbit preserved, but alsoits bony margin. There is, therefore, less falling in of softparts, and less tendency to tear the floor of the orbit awaywith the bone than when the incision is carried through*the whole thickness of the malar bone and alonlg theorbital plate just within the orbital margin, as is oftenrecommended.When an epitheliomatous growth has commenced in the

alveolus or hard palate and does not appear to have exten-sively involved the antrum, only the lower half of themaxilla may require removal. But before this limitedoperation is performed an exploratory opening should bemade into the antrum, in order to make sure of the extentof the disease. If the latter be found limited, the removalof the lower half of the bone is completed by sawing fromthe nasal cavity horizontally outwards; or a Gigli's sawmay be passed through the pterygo-maxillary fissure intothe nose (Schlatter).When, in cases of disease of the maxilla requiring its

removal, the muco-periosteum of the hard palate is notinvolved, I have with considerable advantage in twocases preserved it by carrying an incision along theinner surface of the teeth on the affected side andreflecting the muco-periosteum towards the middleline, as suggested by Watson Cheyne; the maxilla isthen removed in the ordinary way, and the edgeof the flap of muco-periosteum is stitched to the cutedge of the mucous membrane of the cheek. The roofof the mouth is thus restored.

I have to thank Messrs. Longman for their kindpermission to use Fig. 2.

REFERENCES.1 Odontologica Society'8 Transactions, vol. xviii, New Series, p. 44.

2 BRITISH MEDICAL JOURNAL, vol. i, 1883, p. 3. 3 Odontological Societl,'sTran8actions, vol. xviii, New reries, p. 52.

A NEW METHOD OF DEALING WITH CLEFTPALATE.*

By F. N. G. STARR, M.B.ToR.,ASSOCIATE PROFESSOR OF CLINICAL SURGERY, UNIVERSITY OF

TORONTO; ASSOCIATE SURGEON, HOSPITAL FOR SICKCHILDREN; ASSiSTANT SURGEON, TOROA10

GENERAL HOSPITAL.

THOSE of us who have had much experience with cases ofcleft palate have all met with more or less disappointmentin our results. It bas more than likely happened in thepractice of all who have undertaken these cases thatcertain ones, though they looked promising at the time ofoperation, have broken down at some point in the line ofclosure, if not throughout. This experience has beenmine upon more than one occasion. In looking about forcauses, the following points presented themselves: (1)Tension along the line of suture; (2) sucking of thestitches by the patient; (3) infection from the mouth.When searching for some means to overcome these

difficulties I read a paper by Charles H. Peck, of NewYork,' in which he made reference to a plan suggested byC. H. Mayo-namely, the introduction of a tape throughthe lateral incisions, completely surrounding the flaps,and thus preventing tension. I tried this at the firstopportunity; but, though it took off the tension, I amsatisfied that in the three cases upon which it was usedthe risk of infection was increased, for after forty-eighthours it became most offensive, and by the end of aweek the patients almost hated themselves. It thereforebecame necessary to find something better, and, finally,as a substitute for the tape I chose aluminium, suffi-ciently beaten out to make it pliable. I have no doubtthat silver would answer the purpose equally well, but itis more expensive.My technique varies somewhat from the Langenbeck

operation, and, I think, saves time, which is an importantpoint. The child is placed upon a table with a sandbagunder the shoulders to throw the head well back, whilethe surgeon stands to the left of the patient. Hewitt'sgag is placed in position and the tongue drawn well for-ward by means of a silk suture. I make the first lateralincision well out to the alveolar margin of the hardpalate, carrying it beyond the anterior extremity of theclef t, if the cleft does not extend through the alveolarmargin. With the periosteal elevator the muco-periosteumis quickly denuded from this side, then with Lane'scurved scissors the palate aponeurosis is snipped from theposterior margin of the hard palate. thus freeing the flapfrom its bDny attachment. The fip should be freedanterior to the cleft. This incision may then be packedwith a piece of sea sponge while one proceeds to the oppo-site side to deal with it in the same way. The first packingmay now be removed, when one finds that all haemorrhage

* Read at a meeting of the Toronto Medical Society, May 2nd.

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