during

sity of e

as inevita

On the a

responding circumference, which was ulcerated and contained
three incisor teeth. The tumor extended along the alveolar
process, as far as the right canine tooth, and backwards
to the posterior part of the palatal arch on the left side, giv-
ing room only for the last two molar teeth, which were firm
and healthy, and leaving free the palate bone of the same
side, and a small portion of the maxillary with which it ar-
ticulates. Superiorly, it rested below the cheek-bone (pó-
mulo), and four lines below the orbit, in the direction of the
nose, projecting outwards in an extraordinary manner, and
turning upwards and to the right, giving a most disagreeable
and frightful aspect to the countenance. The tumor was
hard, one part of it a deep red color, the other of the natu
ral color of the mucous membrane of the mouth; it was
covered with a multitude of tortuous vessels in a dila-
ted and varicose state, it did not yield upon pressure,
the pain was not very severe, and nothing issued from the ul-
cerated portion. The tonsils and cervical glands remained
healthy, as well as the tongue and adjacent parts; mastica-
tion was very difficult and speech almost unintelligible.

An inquiry into all the circumstances connected with the appearance and development of the disease, showed only that two years previously the patient had received a kick from an ox on the side of the face, which no doubt fractured the superior maxillary bone-no other cause could be discovered. In view of the time that had elapsed, the symptoms present, and the visible organic lesion, I did not hesitate to class it as a schirrous tumor and probably an osteo-sarcoma of the maxillary sinus. The only remedy, therefore, was extirpation, which would involve the greater portion of the maxillary bone, and endanger the individual's life. A consultation was held, at which were present Professors Gutierrez, Castro, Jorrin, Bodman, Pinelo, and A. Valdes. Various reflections were made concerning the nature of the tumor; some suspected it to be aneuris matic fungus, and proposed tying the carotid previous to the operation. A majority decided that this was unnecessary, since there would be no difficulty in controlling the hemor

rizon

chise

acte

rhage during the operation; all agreed as to the absolute necessity of extirpation, without which the death of the patient was inevitable.

I

On the appointed day, everything being in readiness, proceeded to remove the tumor, in the presence of a number of Professors and students of the school of medicine. The patient being placed on a firm seat, with the necessary light, the arms and legs bound for greater security, and the head resting on the breast of an assistant, I began by making a curved incision which divided the integuments and muscles of the face, from a point in the zygomatic arch, an inch from the outer angle of the eye, to the commissure of the lips; three arteries presented themselves, and were secured by Dr. Gutierrez. I then dissected up the cheek as far as the orbit, and anteriorly, in order to display the tumor; lifted the nose upwards, separating it from the alveolar border; applied the saw horizontally to the inferior part of, the malar bone; then with a chisel and mallet divided the ascending process of the superior maxillary, at its junction with the nasal and near the ungual bones; next the canine tooth of the right side was extracted, the nasal cartilage and the vomer were cut with sharp scissors, and with the forceps of Liston the alveolar arch was divided at a single stroke as far as the nasal fossae. Afterwards Dr. Gutierrez, with the same forceps applied before the second molar, cut into the maxillary sinus; the palatal arch was then divided by means of a strong curved knife, cutting from within outwards. The tumor being now circumscribed and movable was lifted out with very little force, leaving only many portions of lardaceous nature adhering to the internal and posterior surface of the antrum, and to the left turbinated bones; these portions were all separated by means of the fingers and instruments, during which it became necessary to extract the last two molars which had been suffered to remain, as the alveolar border where they stood was evidently diseased. The arterial hemorrhage was restrained by means of torsion, and lotions of cold water constantly applied, with

1

out resorting to the actual cautery which was in readiness.
After waiting a moment, for the assistants to assure themselves
that the morbid mass was removed and the vessels secured,
the soft parts were brought down, and retained by three inter-
rupted and one twisted suture, assisted by strips of adhesive
plaster, dry lint internally, cribriform compresses, bandages,
&c.; the patient was then carried to bed, and ordered a slight-
ly anodyne draught, with tepid water and sugar as the only
aliment.

On the third day there was fever, slight coma, profuse
ptyalism, with fetor, and pain of the face: the anodyne was
suspended, warm pediluvia and sinapisms were directed, with
sweetened water for nourishment. The patient continued in
the same state until the fifth day, when diarrhoea supervened,
apparently in consequence of the water drank. An opiate was
ordered with toast water in small portions every four hours.
The dressings were now removed for the first time, and
the wound presented a good aspect.

As the p

nd, the

not so g

e enormo

rbinated

ht cani

Jove So mmation

the bo

L1ealt

Internally it was washed with barley-water, slightly acidulated, and then dressed with dry lint; externally it was covered with a cribriform compress lightly spread with cerate. On the sixth day the patient was free from fever and headache; on the ninth two of the pins were removed. On the fifteenth the external wound was perfectly united, the three ligatures on the arteries still remaining; the sutures were all removed, and it was dressed with dry lint. The inflammation followed its usual course internally; some portions of the soft parts, contused during the operation, became sphacelated and were removed; tumefaction subsided after exfoliation of small pieces of bone; and finally on the twentieth day, the entire surface was free, and covered with granulations, which required to be touched subsequently with the nitrate of silver. Acidulated barley-water, weak solutions of the sulphate of zinc, nitrate of silver, and lint, generally dry, sometimes covered with cerate, were used until the time of complete cicatrization, which occurred 48 days after the operation.

Comer

presed

cat

As the patient is young, and the skin covering the tumor sound, the deformity is very slight, and even internally there is not so great a loss of substance as might be supposed from the enormous mass that was removed. It is true, the inferior turbinated bone, and the entire alveolar process, from the right canine to the last molar tooth, are wanting, leaving above so much only of the left maxilla as contributes to the formation of the orbit; but as there remain below four lines of the bone in its union with the palate bone, she still retains in a healthy condition a third of the arch of the palate; and by covering the hollow which is left with very fine and well compressed lint, can speak though with some difficulty; and the passage of air and food through the nose being prevented, mastication is performed with the four molars of the opposite side.

ART. IV. Lectures on the Principles and Practice of Physic; delivered at King's College, London. By THOMAS WATSON, M.D., Fellow of the Royal College of Physicians, Physician to the Middlesex Hospital, and formerly Fellow of St. John's College, Cambridge. Philadelphia: Lea & Blanchard. 1vol. 8vo. pp. 920. 1844.

These celebrated lectures were delivered at King's Col lege, London, during the medical session of 1836 and '37, and were repeated, with slight variations, for four successive years. To fulfil a rash promise, we are told by the author, it was that they were printed, at length, in the Medical Gazette. They were prepared, it will be seen, especially for students of Medicine, and they constitute, we believe it is conceded on all hands, one of the most complete systems of medical practice to be found in our language. A reprint of these lectures is now offered by Messrs. Lea & Blanchard to the profession of the United States, in a large and beautifully executed volume. It is not our purpose to give a synopsis of the subjects discussed in it, much less to attempt an analytical review of a work embracing the whole range of human maladies, their causes, symptoms and treatment. Ninety lectures, fully written, comprising all that the author has derived from his acquaintance with the best authorities in the profession and his own extensive practice, are not to be compressed, by any process known to us, into the limits at our disposal. Nor would our readers desire such a review. They will prefer studying the subjects at the full length in