Holt, therefore, thought it advisable to remove the whole mass, and examine the bone prior to removal of the jaw itself. This being done, its attachments were found to be connected with the posterior part of the body and anterior part of the ascending ramus, the bone being hard and of its ordinary density. Mr. Holt did not feel warranted in doing that which he was prepared to do—namely, remove the bone at its articulation at this time-but preferred removing with the cutting pliers all the bone to which the growth had been attached. Mr. Clendon having then extracted the molars and wisdom tooth, Mr. Holt cut through half the thickness of the jaw corresponding to those teeth, and, going further back, included the coronoid process, with more than half of the sigmoid notch. The disease was found to be intimately connected with the periosteum, which readily peeled off, leaving the bone somewhat roughened. (See Lancet, Jan. 28th, 1858.)

The disease reappeared in a few weeks, when Mr. Holt was compelled to remove it again, including this time the remaining part of the ramus of the jaw. The disease now was not confined to the covering of the bone, but extended into the pharynx, and was evidently attached to the mucous lining of the whole of one side of the mouth.

The poor girl left the hospital and went to Reading, and died on the 3rd of February. An autopsy was performed by Mr. Walford, the particulars of which are given in his own words:

"Fanny S- — died on the 3rd, and, assisted by Mr. G. May, jun., and Mr. Fernie, I made a post-mortem examination. I did not open the head. The thoracic and abdominal viscera were free from disease. I dissected out the tumour, which, had the whole of it been there, would have completely encircled one side (one half) the lower jaw; it extended up to the zygomatic arch and downward into the neck. The gullet was free, and it evidently grew into (not from) the pharyngeal region. We could not satisfactorily discover its origin. The portion of lower jaw-bone left after the operation was sawn through at the symphysis, and ex

hibits the margins of the tumour on the periosteum, which, I think, must be considered its starting point, and that, as regards treatment, would be practically the bone." (See Lancet, March 6th, 1858.)

The second case occurred at the Great Northern Hospital, in the practice of Mr. George Lawson, who performed three operations with the hope of eradicating the disease, which, however, eventually proved fatal, as in the preceding instance. The patient was a young woman, aged seventeen, and the first operation was performed Oct. 4th, 1858. She had then what might be termed a large epulis growing from the anterior and inner surface of the ascending ramus of the lower jaw of the left side, extending from a point near the angle to close upon the condyle. Mr. Lawson removed the tumour with bone-forceps, cutting away apparently all its bony attachments. About six weeks after the first operation, a small elastic mass appeared in the temporal fossa of the affected side, but the jaw was apparently free. This Mr. Lawson excised, but found that the

growth had evidently sprung from its original site, and extending upwards, had passed beneath the zygoma into the temporal fossa. The third operation was in June, 1859, when, in consequence of the great size the tumour had attained, the inability of the girl to open her mouth, and the great difficulty she experienced in deglutition, Mr. Lawson removed a portion of the inferior maxilla, sawing through the bone in front of the angle, and then disarticulating. Upon the removal of this portion of bone (fig. 128),

D

it was found that the tumour had formed so many attachments to the periosteum of the bones forming the base of the skull, that the operator was compelled to leave some of the disease behind.

By the end of November, 1859, the tumour had again grown to a large size, and from the space it occupied in her

diate dissolution, but from all these she rallied; within the mouth large sloughs would occasionally separate, allowing her to recruit her health by enabling her to take additional nourishment. She died early in 1860, worn out and greatly emaciated. The drawing (fig. 129), for which I am indebted to Mr. Lawson, shows the terrible deformity as seen after death. The preparation is in the Museum of the College of Surgeons (1052 A). (See Pathological Transactions, xi.)

In Mr. Lawson's case, repeated careful examinations of the tumour showed it to be of the recurrent fibroid character, and the rough and thickened condition of the periosteum covering the portion of bone which was removed, showed clearly the site from which the tumour grew. Mr. Holt's case, which is remarkably similar in all essential points, is reported as one of malignant disease; but from personal observation, I believe it to have been an example of recurrent fibroid disease, rather than any form of true cancer. The two cases are as nearly alike as they could possibly be, and were doubtless of the same nature.

The treatment of this form of disease must be unsatisfactory. The tendency to invade the tissues continuous with and contiguous to the original seat of the disease, renders any operative interference of doubtful utility. Still the only hope for the patient is complete extirpation of the disease at an early period, and the operation should include the entire thickness of the bone from which the growth

arises.

The following museum specimens, which are probably examples of the recurring fibroid tumour, though microscopic evidence is wanting, may be conveniently noticed here.

In the Museum of the College of Surgeons is a preparation (1041) of the right side of a lower jaw, from the angle to the bicuspid tooth, which, with a tumour upon it, was removed by Mr. Liston. The tumour, which measures about two inches in its greatest diameter, is situated almost entirely on the anterior surface of the jaw, projecting forwards and upwards, and extending along nearly the whole

length of the portion removed. The greater part of the tumour consists of a pale, firm, and compact substance: at its base it is osseous, and so closely attached to the anterior surface of the jaw, from which it appears to have risen, that the outline of the latter can scarcely be discovered. The patient was a woman of thirty, who had had a blow on the cheek nine years before the tumour appeared. Its growth was accompanied by lancinating pain in the jaw and continual headache. It was removed five months after its first appearance. No portion of the disease appeared to have been left, but the disease reappeared in the ramus and necessitated its removal by disarticulation ten months afterwards (1042).

In St. Bartholomew's Hospital Museum is a specimen (I. 149) of fibrous tumour, for which the right side of the jaw from the angle to the symphysis was removed. The morbid growth consists of a grey, dense, fibrous substance, originating from the alveolar border, and from the outer surface of the jaw. Part of the alveolar border of the jaw has been absorbed; and in this situation the morbid growth appears to extend into the bone, which is harder than usual. It was removed from a woman aged thirty. Subsequently a tumour formed in the side of the neck immediately below the seat of the operation, which ultimately proved fatal by the ulceration and sloughing which took place in it. A portion of this was connected with the jaw, and a section shows it to consist of a firm fibrous substance.

Fibro-cellular Tumour, or Osteo-sarcoma.-This form of growth frequently attacks the lower jaw, and may prove fatal, by obstruction either to respiration or deglutition, if allowed to grow unchecked for many years. Some of the earliest cases of removal of portions of the lower jaw were for growths of this description which had attained a large size, and the names of Crampton, Cusack, and Syme are connected with these operations. The Museum of the College of Surgeons of Ireland, is especially rich in tumours of this class, and possesses also a cast of the head of a patient who died with a large tumour of the lower jaw, which has been injected and