generally employed. Excision of the head and neck of the condyle was first performed by Professor Humphry of Cambridge in 1856, for the relief of ankylosis due to chronic rheumatic arthritis. The other operation is known as Esmarch's, who suggested it at the Congress of Gottingen in 1855, and it was first successfully performed by Dr. Wilms in 1858. It consists in establishing a false joint in front of existing cicatricial tissue.

I cannot agree with David M. Gregg (Practitioner, December, 1899), who says, "The only operation worth considering is excision of the neck and condyle;" nor can I agree with the conclusion of Dr. Paul Swain (Lancet, July 28, 1894), "Taking, therefore, into consideration the simplicity of the operation as compared with excision of the condyle, and the superiority of the results, I think it may fairly be suggested that the modification of Esmarch's operation is the one which surgeons in the future should prefer." I do, however, practically agree with the opinion expressed by Dr. A. C. Cabot (Lancet, August 7, 1897), "In cicatricial contraction due to noma, burns or lupoid inflammation, the section of the bone must be in front of the cicatrix, forming a false joint in front of the detaining bands, Esmarch's operation producing the best mechanical condition possible. In bony ankylosis the nearer the section is made to the joint the nearer do the conditions simulate the normal."

The condition of the articulation and the surrounding tissue is, in my opinion, the proper guide in deciding which operation to employ. In the absence of cicatricial tissue, as in my two cases, or when present in such quantities that there is a reasonable assurance that it can be overcome by appropriate treatment, I believe in excision of the head and neck of condyle. Where the muscles are destroyed, or their function is held in abeyance by dense cicatricial tissue which cannot be overcome, I believe that Esmarch's operation is clearly indicated and offers the best results. The preservation of the maximum amount of musclar function in bilateral cases is of the greatest importance. In unilateral cases it is quite possible to have good masticating power from the muscles of the uninvolved side, even if Esmarch's operation is done upon the opposite side and in front of the masseter and internal pterygoid. But when Esmarch's operation is done in bilateral ankylosis the power of mastication is very feeble or lost, and in one case reported the central portion of

the mandible was so beyond the control of the elevator muscles that for two days after the operation it caused grave danger of asphyxia by its depressed condition.

Of considerable concern to me was the question whether new bone would form from the periosteum after excision of the head and neck of condyle, which would subsequently lessen the range of motion. The results in these two cases and in others reported demonstrate that this danger is scarcely to be apprehended, and that it is quite expedient to make a subperiosteal excision.

Discussion. Dr. C. N. Peirce, Philadelphia: How did these young men feed themselves?

Dr. Roe: In both cases they placed their food between the lips with a fork, and then with the index fingers forced the food through between the teeth, especially in front where the latter were not in occlusion. It usually took the second patient about an hour and a half for a meal.

Dr. M. H. Cryer, Philadelphia: I heartily approve Dr. Roe's operations, and do not see what else could have been done than removal of the condyloid process as near as possible to the original fracture or injury. If there should be any interference here, either by the masseter or by the internal pterygoid, then it would be preferable to make a short and false joint anterior to those fibrous attachments. In removing the head of the condyle we get below the insertion of the external pterygoid, and that is why in both Dr. Roe's patients, in one in particular, a certain amount of lateral movement was lost. Of course, we understand that it is the external pterygoid which gives the greatest amount of movement to the jaw laterally, rocking it from one side to the other, as in the ruminant animals when chewing cud. There is a possibility of some of the fibers becoming attached to the mandible below the point of excision. We might in this way have motion from the external pterygoid. I believe it was stated that the second patient had had no lateral motion. It is possible to secure lateral motion from even the masseter, as it has two heads, or rather, the muscular fibers run in two directions. If the first patient will practice moving his jaws from one side to the other I believe the masseter muscle will eventually give him considerable lateral motion.

I differ with nearly all teachers in regard to the function of the

epiglottis, as I do not think that it ever closes over the glottis either in pathological or physiological conditions. In my opinion it has nothing to do with the glottis, but is there as a separate organ. In experimenting with various animals I have cut away the ramus of the jaw to facilitate observation, and have then tried to tease the epiglottis over the glottis, but have never succeeded in so doing. If I passed water from a syringe over the glottis it would close independently. The folds would close over, but the epiglottis never showed an attempt to close over and protect the glottis. I removed the epiglottis from quite a number of cats and dogs, and allowed the animals to get well, and the function of the glottis was never affected. Therefore I do not think that in the falling back of the tongue the epiglottis ever causes asphyxia. In Dr. Roe's second patient the asphyxia was due to the falling back of the hyoid bone, along with the base of the tongue, which then came in contact with the posterior wall of the pharynx. I have numerous slides which will uphold Dr. Roe's statement that this space is very narrow. The tongue naturally fills the mouth and a great portion of the pharynx. We see this space when the mouth is opened, but when it is closed the tongue occupies the space from the teeth back to the posterior pharyngeal wall or nearly so. The roof of the mouth really includes the soft palate and the uvula, and the latter comes into close relation to the posterior wall of the pharynx. The slides which I will show tomorrow evening will demonstrate this point very well.

Dr. G. V. I. Brown, Milwaukee: I have here a flexible dummy, by which I hope to show why it is that through any affection of the lower jaw we have malformations of the associated parts. With my paper and illustrations I hope to make it clear why the hyoid bone was lower, and why the other parts were in such condition that threatened asphyxia was one of the great difficulties of the operation.

Dr. J. D. Patterson, Kansas City: There is a very practical lesson in Dr. Roe's paper, namely, that in all cases of fracture there is danger of injury at the condyloid or coronoid processes, and when in reducing the fracture we hold the jaws immovable with a fixed splint, after it has been worn a short time we should take it off and give movement to the jaws, doing this two or three times during the healing, in order to forestall the possibility of ankylosis.

Dr. T. W. Brophy, Chicago: About a year ago Dr. DeSund of

Vienna advocated the use of paraffin in many places, especially where we wish to preserve the contour and rotundity of the parts and to take the place of lost sections of bone. Dr. Beck of Chicago has recently employed paraffin in such cases, and for the purpose of lifting up and overcoming the depressions following operations and the removal of cicatricial tissue. Dr. Roe speaks of the blood clots serving a good purpose in his cases, but I think paraffin could be used to better advantage, and there would be no filling in of material which would produce bone.

Dr. M. L. Rhein, New York: At the present time in the first case the only occlusion is with the very back teeth, and after the magnificent technique displayed by Dr. Roe in getting rid of the ankylosis, and the excellent result of his work, it does seem that some steps should be taken to obtain a better general occlusion.

The patient has been examined by us all, and while lateral motion is undoubtedly present, it seems to me, after a careful examination, that it is produced entirely by an acquired use of the masseter muscle and not from the pterygoid muscle at all. Dr. Cryer has examined the patient since he spoke and I would ask his opinion.

Dr. M. I. Schamberg, Philadelphia: Dr. Roe does not endeavor to explain why the hyoid bone falls when the normal articulation is reestablished. I judge it to be due to the pulling of the sternothyroid and omohyoid muscles when the jaw is released by operation, for it is a well known fact that these, together with the other auxiliary muscles of mastication, are unusually well developed in ankylosis. Dr. Cryer recently published photographs of a patient suffering from ankylosis in which the auxiliary muscles of mastication were shown to be in a state of contraction during an effort to open the mouth. I believe that if a ligature were passed through the floor of the mouth directly in the median line, and immediately in back of and closely hugging the mandible, the dropping of the hyoid bone against the posterior wall of the pharynx would be averted. This method would be similar to the one in which a ligature is passed through the tongue to prevent its being swallowed during operations about the mouth. Anterior traction applied to the jaw by means of the ligature passed around it would pull the hyoid bone forward through the medium of the geniohyoid and the geniohyoglossus muscles, thus obviating the possible necessity for a tracheotomy.

Dr. J. Y. Crawford, Nashville: Dr. Cryer's reference to the normal mouth in a closed condition not being a cavity, but being filled up with tongue, teeth, mucous membrane, etc., is a valuable suggestion.

The region involved in the production of this ankylosis is not such a dangerous territory as supposed, for nature helps along mightily. Sixteen months ago I had charge of a pathological fracture of the lower jaw which resulted in the loss of the body to the point of the first molar, back to the angle, from the angle to the ramus, to the condyle, and its complete removal. I had to fracture it at three different points, and I never found the coronoid process. Nevertheless, it is almost impossible at the present time to observe any deficiency on that side of the face, and the patient seemingly has quite as much strength on that side as on the other.

Dr. J. Taft, Ann Arbor: The statement is frequently made that the general surgeon knows nothing of oral surgery, but there is so much in medical and surgical practice of which the dentist knows little or nothing that it behooves him not to boast or make invidious comparisons. There is a just appreciation in the surgical world of what the dental profession does in these cases of oral surgery, and we cannot afford to be less generous or just. It is for the interest of all concerned that the most harmonious relations should exist between the physician, general surgeon and dentist.

Dr. S. W. Foster, Nashville: For the past four weeks I have had a case covering the point which Dr. Patterson brings up. The patient fell from a moving train eleven weeks ago and suffered a compound fracture of the inferior maxilla just above the lower border of the ramus, also near the symphysis, and posterior to the first bicuspid, with dislocation of the left zygoma. He was treated for seven weeks without securing union of the anterior fracture, but the dislocation was reduced. Four weeks ago he came into my hands. A skiagraph disclosed a union of the jaw at the ramus, showing that in articulating the parts the jaw was slipped backwards. On investigation I found that there was an anterior occlusion before the fracture occurred, so as far as approximation was concerned the teeth were in better shape after the injury than before, with the exception that in getting this union with the slipping back of the jaw there was an occlusion of the third molars only. The incisors lacked at