circumference of the lips was 9 inches. The patient was only thirty-two, and the disease appeared to have commenced eleven years before, in a small swelling below the right canine tooth, but the whole of the large growth had taken place within four or five years. The fungous protrusions were, as has been mentioned, the result of the application of

quack remedies. The patient, when he came under my notice, was in a miserable condition, being nearly starved, owing to the tumour forming a projecting mass within the mouth, which completely concealed the tongue, and was nearly in contact with the palate. I succeeded in removing

U

the tumour by sawing in front of the left angle and disarticulating on the right side, with very little loss of blood, but the patient died exhausted on the sixth day. The tumour weighed 4lb. 6oz., and accompanied this essay, being now in the Museum of the College of Surgeons (1041 A). Its appearance (reduced to about one-third) is shown in fig. 133. A section has been made to show its structure, which is precisely that described by Sir P. Crampton, the mass being made up of fibro-cellular tissue of different degrees of density, with here and there small nodules of bone, and a few small cysts interspersed through its structure. The tumour evidently commenced in the interior of the jaw, the outer plate being considerably expanded and destroyed in parts, whilst the inner remains perfect, and can be seen in the condition in which it was left at the operation. The mass in growing has carried up the teeth with it, and they project from it at irregular intervals, a considerable portion of the growth, and probably the most recently formed part, being posterior to them, occupying as it did the mouth and lying among the muscles beneath the tongue. The fungoid masses are covered with granulations, but otherwise differ in no way from the rest of the growth.

I am indebted to my friend Mr. A. Bruce for the following elaborate report upon the structure of this tumour: "The tumour consists of a lobulated mass of soft but elastic consistence, resembling in parts a recent decolorized fibrinous coagulum. It is for the most part of a pale straw colour, with here and there patches of a flesh tint, and mottled in spots with deep crimson. In front is a prominent fungating mass, which had penetrated through the skin at the time of the operation. The structure consists of a fine fibrinous stroma, varying in different parts in its degree of fibrillation; in some portions there are very distinct fibres, in others only imperfect ones, as is frequently seen in rapidly growing parts, whilst in others again the stroma is dimly granular, and closely resembles the matrix of cartilage, but differs from it in its softness; this latter character is limited to the parts in the interior in immediate connexion with the bone.

Embedded in this stroma are numerous cells, lying for the most part with their axes parallel to one another, but in many places without any apparent uniformity in this particular. The cells are small in size, at first sight more resembling elongated nuclei, but in all cases a cell wall may be distinctly traced when a sufficiently high power is employed. The majority are elongated fusiform or fibre cells, with a considerable proportion, however, of oval, rounded, or even polygonal cells. Their size varies from to inch in diameter. The nuclei are proportionately large and prominent, and contain one or two very distinct glistening nucleoli. The cell contents, when any exist, are granular. Some of the rounded and polygonal cells closely resemble those found in malignant growths, especially in the irregularity of their arrangement, and their large eccentric nucleus; one cannot, however, lay much stress upon these characters in the present case, considering the small proportion which these cells bear to the whole mass of the tumour. Fragments of bone and of calcareous matter are found scattered throughout the tumour, and appear to be in part derived from the jaw itself, and in part to be a new development. The general structure of the tumour is that usually described under the head of osteo-sarcoma, and it belongs evidently to the group of simple fibro-plastic tumours, but differs from the myeloid fibro-plastics in the equal proportion existing between the cellular and fibrous elements."

Fibro-Cystic Tumour, or Cystic Sarcoma.-The occasional occurrence of cysts containing fluid in fibrous or fibrocellular tumours has been already referred to, but growths are met with in the lower jaw so full of cysts that they may be conveniently classed together. These tumours are not to be confounded with simple or compound cysts of the jaw, which have been already described (p. 168), though they have some common features-non-malignancy, slow growth, except after irritation, and the sensation of crackling often found from the yielding of remaining portions of the ho beneath the pressure of the finger.

The best example of the disease with which I am

quainted is in the Museum of the Richmond Hospital, Dublin, and was removed by the late Dr. Hutton. It is represented in the accompanying woodcut (fig. 134), for which I am indebted to Dr. R. Adams, and shows very FIG. 134.

beautifully the development of cysts of various sizes in a growth of a benign character, involving the whole of one side of the body of the jaw and extending to an inch beyond the symphysis. The patient was a young woman of twenty,

and the tumour had existed nine years, but had only recently made rapid progress, and produced great distress by its pressure on the tongue and mouth. Dr. Hutton re

moved the jaw from the right of the symphysis to the left angle, and the patient made a good recovery (Dublin Hospital Gazette, 1860). In this case the disease invaded only the body of the bone, but the ramus is also liable to it, a specimen in King's College Museum, removed by the late Mr. J. H. Green, being an instance in point.

The contents of these cysts vary in consistency and colour; in some cases being clear and limpid, in others almost gelatinous and of a dark colour. The fibro-cellular tissue in which the cells are formed may undergo fatty degeneration, thus constituting Stanley's fourth variety of tumour of the lower jaw, which he thus describes (p. 267): "Fatty substance, in granules, intermixed with cells containing a glairy fluid originating in the interior of the jaw." This description is apparently based upon an examination of a specimen (I. 147) preserved in St. Bartholomew's Hospital, showing a section of a lower jaw expanded by a tumour "consisting of granules of a peculiar fatty-looking substance, partitioned by fibro-cellular tissue and having cells dispersed through it, which cells contain a glairy fluid. The boundaries of some of the cells are thin plate of bone, apparently the remains of the original cancellous texture of the jaw."

A dried specimen of fibro-cystic disease is preserved in the Museum of Guy's Hospital (109150), which is remarkable both for the situation of the disease and the age of the patient. It shows great enlargement of the bone with cysts in it, and includes the whole body of the bone from ramus to ramus. The patient was a boy of thirteen, who was under Mr. Key's care in 1841. He stated that the disease began as a lump two years before, on the anterior part of the lower jaw, and this gradually increased backwards. He never had much pain in it. The jaw was removed by Mr. Key, by sawing through it just below the angles on each side, and the patient recovered.