believe, had such cases been seen in recent days, that modern surgery would have stepped in and arrested the progress of these formidable-looking tumours.

Fig. 76.

Fig. 77.

tumours of the jaws have created the greatest impression on my mind. There is little active excitement

associated with the operation of lithotrity; and ovariotomy, although involving the life of the patient, and demanding both energy and courage on the part of the surgeon, cannot, as regards performance, be considered a high-class operation. But for the perfect removal of these tumours, I am inclined to think that the highest requirements of operative surgery are called forth. There is such variety of manipulation, such necessity for caution, yet such boldness in action, that, in my opinion, neither removal of ovarian tumours, nor of the most formidable growths in the scrotum, can at all compare in scientific accuracy with those upon tumours of the jaws.

Whatever may be thought on these matters, there can be no doubt of the value and importance of the operations; and as it has fallen to my lot to have had considerable personal experience in such cases, I feel that I can scarcely do better than devote one of these lectures to the subject.

The anatomy and physiology of the jaw bones, as also their pathology, from shape and function, may be considered as in many respects different from other bones of the body. The association of the teeth with them is a physiological phenomenon, and forms an element for mischief, or, to use a more appropriate term, disease, such as is absent in all other bones. Yet I am doubtful if the teeth really induce much mischief in these bones. The varied ails to which teeth are liable may, and generally do, leave the jaws unscathed; yet, when tumours are present, a question is often

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raised as to the injurious influence of certain teeth. The abstraction of a tooth in such a case is merely fencing with the outside of the disease. In irritation of a socket this doubtless may do good, although at a sacrifice which time might possibly save, but I cannot say that I have ever seen the removal of a tooth produce any substantial benefit in the cases under consideration. The tumour itself must be removed if good is to come from surgical interference. I trust that I am not less acquainted than my neighbours with common-sense surgery, but I never saw a tumour of the jaws dispelled by constitutional treatment. In doubtful cases, and where there has been much derangement of health, I have seen favourable changes, in time and through judicious management. I have even seen a case, where, to all appearance, a tumour was malignant, deep-seated, and beyond all hope of a cure, either by nature or surgical interference ;—such an opinion was given by one of the best surgeons of the day, and such, I confess, was my own;-yet in the end it proved to be only a chronic deep-seated abscess, which burst, and got well spontaneously. Such mistakes do little credit to surgical diagnosis, and let us hope that they are of rare occurrence.

But I wish now to refer to such cases as are beyond the power of hygiene, and where a process of removal is decided on. Caustics are of little value, ligatures out of the question; in short, whatever enthusiasts think of their skill in treatment constitutionally may or locally, I wish to speak solely of those requiring

cutting for their removal-I wish to speak of excision of portions or of the whole of the jaws.

I have selected this theme on the present occasion, partly because it is illustrative of the progress of surgery in the present century, and partly because I imagine that my favourite conservative practice may be as usefully developed here as in any other region of the body, or in other cases of surgery.

The first and early operations for removal of tumours in or of the jaws, initiated by Dupuytren, Gensoul, Hodgson, Wardrop, Lizars, Syme, and others, produced great sensation in the surgical world. In cleverness of conception there seems scarcely a doubt regarding them in the present day; and in vigour of execution they have not yet been surpassed. Yet, even here, it may be doubted if perfection has been achieved; and I venture to makeindeed, I may say, reiterate--my humble contribution towards it; for most that I am now about to say has been stated over and over again in my clinical teaching.

I have no doubt that in diseases of the jaws operations have been performed when they were not warranted; and I am equally of opinion that they have been neglected when they might have proved of the utmost value. Here, as in other departments of surgery, perfection will probably never be achieved. Mistakes and improprieties will occur even in the best regulated minds and hospitals. I make no pretensions to be above them myself; but, by way of originality, I shall plead for a share of conservatism, even here, where it has been comparatively little thought of.

Happily, cancerous tumours of the lower jaw are somewhat rare; but cancerous ulceration, beginning in the gums, or more probably extending to them from the cheek or lips, is by no means uncommon. When the surgeon can encompass the disease in the cheek or gums with the knife, he may clip away the alveolar ridges with good prospect of a satisfactory result, provided the disease be of the kind called in modern days "epithelial." If there be no glandular affection in the neck, the operation is likely to succeed, just as with cancer of the lower lip; but where that kind of cancer has eaten away the lower lip, and laid hold extensively of the bone itself, I deem excision a misapplication of surgery. There is not the smallest chance of a permanently successful issue. I have known this done, and even a flap of skin brought from the neck to fill up the gap; but I doubt the wisdom of the proceeding.

I look upon the lower jaw as giving the most forcible examples of the value of a doctrine which I have long advocated-albeit, contrary to the opinions of many, possibly even against the ordinary doctrines of surgery. In one of my lectures last year I referred to this. Tumours of the lower jaw are often removed by vertical section, and both ends, so to speak, of the bone are left. Every one knows how successful these operations usually are. When a section is made in the healthy part, it may truly be said that disease seldom if ever returns. Yet this feature is totally lost sight of in the bones in other parts; and so if a tibia or fibula be affected with tumour, nothing but total ablation will satisfy. Amputation in