the method of treatment is inaugurated with the use of the milder of the two remedies, an irrigation of zinc sulphate solution, in the strength of 1-20 per cent. The patient having first urinated, with glycerine lubrication a small, soft rubber catheter (No. 12 Fr.) is introduced into the urethra until its eye

is placed proximal to the cut-off muscle, i. e., within the posterior urethra; the bulb-syringe, holding eight ounces of the solution, is applied to the distal end of the catheter and three-fourths of its contents are injected into the posterior urethra, whose membrane is thus thoroughly bathed with the solution as it runs. back into the bladder. The catheter is then withdrawn for an inch or two, till its eye is external to the cut-off muscle, whereupon the remaining fourth is injected; and, following the rule already spoken of, it runs forward alongside the catheter, irrigating the anterior urethra. Both the anterior and posterior urethra have then been irrigated with the solution of the prescribed strength. The patient is told to stand up and pass out what we have injected into his bladder; and in doing so he is accomplishing another irrigation of his entire urethra. Usually a slight burning follows this-a feeling as though there were still more of the fluid to be expelled, indicating the irritation of the medicine. on the inflamed posterior urethral membrane. A day later the irrigation is repeated; two days after that, another repetition, but with added strength to the solution, making it, say, per cent.; two days later, per cent., and so on until 2 per cent. is reached, when usually the discharge, at first present, has disappeared, and most of the high degree of tenderness has been relieved. The urethra is then ready for the adoption of the second of the two series of treatments the deep injections of argentic nitrate.

A. S. ALOE CO., ST. LOUIS.

After filling an Ultzmann syringe such as this, with a per cent solution of this drug, the catheter-stem is lubricated with glycerine, introduced until its inner end has reached the deep urethra-indicated by the 45-degree inclination

of the syringe. The piston is now depressed at the same time that the syringe is being withdrawn, spreading the solution over the entire urethral tract. This, also, awakens some transient reaction usually making the patient feel like urinating. It is well, therefore, for him to sit down for awhile, when it passes off readily.

This form of treatment is repeated every other day for a time, with progressively increasing strength of solutions; usually it will not be found necessary to go above 3 per cent. With improvement in its condition, the urethra tolerates the stronger solutions readily.

Such improvement is to be noted by watching the gradual disappearance of pus from the urine. I have such patients bring specimens of their first morning's urine in two bottles at each visit. The first bottle denotes the condition of the anterior urethra, the second. that of the posterior. When both become free from pus and shreds the patient may be considered cured. It will be found in practice, however, that a few shreds will be apt to show in the first portion occasionally, long after it is justifiable to discontinue treatment. If the shreds are composed mainly of mucus, with only a few pus corpuscles, they need not be regarded as indicating continuation of active measures, other things being favorable.

Assuredly, the patient must maintain hygienic and conservative behavior for some time after treatment is left off; indiscretions of various sorts are prone to re-awaken inflammatory processes until the tissues regain strength and the habit of health.

In summing up the value of this method of treatment for chronic urethritis, I do not wish to make exaggerated claims for its infallibility. It is true that though the pathological groundwork may be as related, certain cases prove rebellious to all topical measures, and they must be met in some other way. If tuberculous infection be present, for instance, the method is directly contra-indicated. But these exceptions do not invalidate the therapeutic deductions above indicated, which have proved extremely serviceable in my practice.

1006 OLIVE STREET.

OPERATION FOR FIBRO-CYSTIC SARCOMA INVOLVING THE RIGHT INFERIOR MAXILLARY BONE.*

BY J. MCFADDEN GASTON, M. D., ATLANTA, GA.

Professor of Principles and Practice of Surgery. Southern Medical College, Ex-President Southern Surgical and Gynecological Association, Etc., Etc.

A colored woman, thirty-five years old, with regular menstruation, and having borne several children, enjoyed general good health until a tumor made its appearance some years ago, for which she underwent an operation for partial removal of the right lower jaw. She presented herself with a re-production of the growth at the clinic of the Southern Medical College on January 24, 1894, and upon examination I found a large mass involving the region from the

*Read before the Medical Association of Georgia, in Atlanta, April 18th, 1894.

angle to the mental curve of the right lower maxillary bone, extending upward to the zygomatic arch and inward to the root of the tongue. There was a protuberance of indurated substance in the middle and a tense elastic portion above, with a larger formation of the same character below. The two last named developments were evidently cysts, while that which lay between them gave the impression upon palpation of the consistence of cartilage. The entire cavity of the mouth on the right side was filled with the tumor. The patient states that the growth commenced some years prior to the first operation. The exact limits of the primary growth, or the details of the extent of the measures adopted by the former operator, could not be accurately ascertained, but it is evident that all the diseased structures were not removed, and hence the redevelopment of the tumor. The indications led to the view that the new growth was a fibro-cystic sarcoma, and that its early removal was the only chance for prolonging the life of the patient.

The field of operation having been thoroughly cleansed, a hypodermic of one-fourth grain of morphine and one-one hundred and fiftieth grain of atropine was given, and she took an ounce of rye whiskey with a little water, after which the A. C. E. mixture was inhaled from an ordinary towel cone, until she was fully anesthetized.

With the assistance of Drs. L. B. Grandy, E. C. Davis and J. McF. Gaston, Jr., I proceeded with the various steps indicated for the complete removal of the tumor with the jaw-bone. At the outset a strong silk ligature was passed through the tongue and its ends knotted together, so as to form a loop, which was to be made available to prevent the tongue from dropping back and interfering with respiration at a subsequent stage of the operation. This precaution is made requisite from the record of cases in which suffocation has resulted from its omission, when the lateral attachments of the tongue have been severed.

The next step was the extraction of two of the lower incisor teeth, where it was expected to divide the thick bony structure subsequently, either with the saw or bone forceps. This would effect its detachment in front and another section behind the angle of the jaw, through the condyloid neck we would separate the bone behind, so that all the intervening portion of the lower maxillary bone on the right side should be detached with the tumor. It was supposed that the facial artery had been ligated in the former operation, and hence that its trunk was obliterated, but that the collateral circulation had been established to some extent by the anastomosing vessels, so that some small branches would be encountered in proceeding with the dissection. It may be noted, however, that in the removal of malignant tumors, the nutrient vessels have been found usually so small as not to require ligating, and even the regular supply of arteries generally undergo atrophy to a considerable extent in the vicinity of the neoplasm, owing, perhaps, to compression.

My greatest concern in regard to hæmorrhage connected with this operation was relieved by the expectation of leaving the condyloid process and thus obviating the risk of wounding the internal maxillary artery by its removal. This vessel lies in such close proximity to the inner face of the bone that the

steps for its disarticulation require great caution against wounding it, and it branches off from the external carotid so that ligation is difficult. Having planned to accomplish the incision and dissection, so far as possible, without entering the buccal cavity, and thus avoid the entrance of blood into the fauces, I first divided the skin from a point immediately below the middle of the lower lip along the line of the cicatrix from the former incision back to the angle of the right lower jaw, and thence upward to the prominence of the zygoma, keeping away from the temporal artery in front of the ear. The skin was then dissected back on the lower side from the tumor and in like manner above to the zygomatic arch, thus exposing the exterior surface of the diseased structure without entering the baccal cavity. The few cutaneous arteries which were divided were secured with artery forceps in the course of the dis.section on the lower border.

At this stage, the lip which had been left intact in the first incision, was divided and the tissues separated from the bone until the point was reached for its detachment.

Having incised the periosteum over the surface of the lower maxillary, on a line with the socket from which the incisor was extracted, a saw was passed over the outer surface of the bone and then a strong pair of bone forceps was used by Dr. Grandy to divide the bone from above downward. I then used the same forceps to separate the bone just behind the angle and proceeded to dissect up the close attachments of the masseter and temporal muscles from the coronoid process. This left the resected portion of the lower maxillary imbedded in the tumor and all could readily be lifted up so as to complete the separation of the mass from below. In making the incisions up to this point, very little if any blood had entered the mouth, and it is desirable in doing this operation to provide against entering the buccal cavity as long as possible; but it was requisite at this stage to go into the mouth, and entering it from below I avoided trouble from the blood. Proceeding with the dissection around the lower large cyst, curved scissors were used, keeping close to sac, while the whole mass was lifted upward so as to get a good view of the dissected structures; but notwithstanding all my precaution the sac was opened and the brownish fluid contents escaped in quite a stream from the external wound, thus lessening very notably the size of the tumor. It was thought best in view of this to cut through the coats of the sac, leaving the deep attachment to be dissected out after the diseased mass was so far detached as not to interfere with its removal. This portion of the sac in the deepest part of the excavation was in close proximity to the pharynx, and in dissecting it from the surrounding tissues an arterial branch was cut, which was immediately seized with the forceps by my son and was subsequently ligated with catgut and dropped. It may be here stated that this was the only blood vessel which necessitated ligation in the course of the extensive dissection for the removal of the tumor.

I had provided an aneurismal needle armed with a strong silk ligature to secure the external or the internal carotid if the branches of either should be cut without being able to seize the divided vessels. The Pacquelin thermocautery was kept aglow by Dr. Davis to arrest any superficial oozing which

could not be controlled by sponges with hot water. Thus, armed against any contingency I went forward with the excision from above, enucleating the upper cyst from the zygomatic fossa and the indurated mass of cartilaginous. consistence from beneath the arch. Having completed the separation of the entire tumor, I was agreeably surprised to find that there was but little sanguineous exudation from the surface of the tissues involved in this deep incised cavern. The oozing soon ceased under the hot water applications and cleaning out the mouth and throat with a sponge probang, the artery forceps were removed from the small twigs without any appearance of a jet of blood to require ligation. A loose compress of sterilized gauze was packed into the 'cavity with a strip out at the mouth. Depending upon the contractility of the skin to bring the flaps into proper relation for covering the wound, no part of it was excised, and the only notable fact upon bringing the cutaneous investment in apposition was the very decided lack of the normal temperature in the large upper flap. This caused some apprehension as to preserving the vitality of the tissues with the limited blood supply to the narrow base. But recalling an observation, in a plastic operation for building an artificial nose from flaps dissected out of each cheek, in which there was not only a loss of heat, but shriveling of the structure on one side during the first twenty-four hours and eventually complete restoration, I was hopeful in this case. The interrupted silk suture was commenced by me at the lip, and by Dr. Gaston, Jr., at the remote end of the incision over the malar protuberance, bringing the parts accurately together so as to favor the restoration of the circulation at the earliest practicable period. After passing below the curvilinear approximation, the union of the rectilinear incision along the former site of the body of the lower jaw, which had been removed, was effected with catgut stitches at a greater distance apart than the other suture. A broad strip of adhesive plaster was applied from the surface over the left lower maxillary along this line of catgut suture to the mastoid process on the right side to maintain a degree of fixidity in the parts.

The entire surface was covered with iodoform gauze and absorbent cotton, secured by turns of a roller bandage.

In the meantime, notwithstanding the slight loss of blood, there were such indications of shock as to require the resort to frequent hypodermic injections of whisky, alternated with nitroglycerine and digitalis. The anaesthetic was discontinued after the detachment of the tumor, and vigorous measures were requisite to avert a fatal prostration. In addition to the above enumerated means, hypodermic injections of one-fiftieth of a grain of strychnine were repeated every half hour until one-tenth of a grain was given, and afterwards every hour until reaction was established.

After removing patient from the operating table, bottles of hot water were applied along the lower limbs and on each side of the body continuously for several hours.

The pulse for a time was feeble and rapid, but five hours after the completion of the operation it counted but fifty beats to the minute, and the patient was still unconscious and in an extremely prostrate condition.