B. Termination of incision.

Van Berthursen & Sons Albay.

and pushing the tongue over to the opposite side, so that in protruding it, its edges were parallel with the mesial line of the body.

In the center of the mass, two teeth could be plainly seen lying over upon the left side of the buccal cavity. The accompanying illustration, taken from a photograph, gives the appearance of the patient with her mouth closed. See figure 1.

The right body of the lower jaw could not be defined, though the superior portion of the angle could be felt, the articulation not being involved. The tumor, though overlaying the upper part of the neck, did not involve its tissues, and the sub-maxillary and mental glands did not participate in the disease.

On the left side, the angle and ramus of the jaw were clearly defined; the disease stopping short of the first molar tooth of the left side. During the first week of her admission into the hospital, she was placed under the charge of Dr. Hartman, (physician to the Institution), who gave such constitutional remedies as the case demanded.

Having agreed as to the necessity of an operation, Drs. Comstock, Parsons, Vastine, Helmuth, Terrell and Skeels, were invited to be present on the first of May, to assist in its performance. The patient being seated in an operating chair, Dr. Hartman proceeded to administer chloric ether, which was continued cautiously until complete anesthesia was produced. Standing in front and upon the right side, I made an incision corresponding with the dotted line in figure 1; begining at the superior part of the mass (A) and terminating by a circular sweep of the knife at the angle of the lips on the left side (B). The flaps were dissected as quickly as possible; the upper one turned over the face and the lower lying upon the neck. Dr. Comstock took up the vessels of the flap, assisted by Dr. Parsons, while Dr. Helmuth kept up a gentle and continued presure upon the carotids of either side. Having thus exposed the tumor throughout its whole breadth, I next proceeded to divide the bone, which was done by a chain saw, at a point on the left side corresponding with the first bicuspid tooth. Dr. Hartman, at this juncture, as had been pre-arranged, transfixed the tip of the tongue with a stout needle and ligature, and held it during the operation. Then grasping the tumor at the point sawed through, I began to dissect away the mass and divide the muscles and attachments close to the tumor; the vessels having been promptly secured by Dr. Comstock. Then carrying the tumor to the right and outwards and

dissecting away all its attachments, to near the coronoid process, which was found perfectly healthy, I divided the ramus of the jaw just below the sigmoid notch with the chain saw, and completed the removal of the mass, by a little dissection round its posterior margin.

Only two vessels of any size required ligation, the two facial arteries having been preserved uncut. With a strong bone forceps I cut away all portions of the left jaw that were involved in the disease, and a clean healthy surface remained.

The gap left was of huge size; the fauces, tongue and front of the larynx being fully exposed, and the flap pendulous and superabundant. The incision was then brought together with four interrupted sutures, placed some distance apart to favor the escape of the discharges during the healing of the wound. Adhesive straps were then applied between the sutures; the ligature holding the tongue being secured so as to bring its apex close to the lip.

Lint saturated with staphysagria lotion was placed in the large cavity and also applied to the external wound, and a bandage applied to maintain the shape of the face and prevent oozing. The patient was then placed in bed and a few doses of arnica given to counteract the shock of the operation, and to bring about reaction.

The quantity of blood lost did not exceed six ounces, though the tumor weighed nearly two pounds. Reaction followed in a few hours and the patient passed a comfortable night.

On the following day, injections of beef tea were thrown up the rectum, and the patient was otherwise sustained by nourishing drinks of animal broths and milk.

May 3d.-A little fever was observed which readily yielded to a few doses of aconite. The old dressings were removed and fresh ones applied.

May 4th.-Union having taken place throughout nearly the whole extent of the wound, the sutures were removed and fresh lint, saturated as before, with adhesive straps freshly applied as before, and the mouth well washed out with a lotion of staphysagria

May 5th. The ligature holding the tongue was removed; the patient swallowing without much difficulty. The quantity of nourishment was increased.

May 6th.-Suppuration began, for which calendula was given