would say that the case he operated on in Milwaukee last year recovered without any deformity of the face. The patient was under my care, so I am able to bear this testimony.

Dr. B. G. Maercklein, Milwaukee: The dentists and the surgeon who preceded Dr. Patterson absolutely failed to remove the cause of the trouble, so they had no right to expect any results. Dr. Patterson simply removed everything that caused the condition, and of course effected a cure.

As regards openings remaining after the operation, I have never been unable to close them, and in one edentulous case, where the opening was nearly two inches long, I closed it after eighteen months of constant stimulating treatment.

Dr. C. P. Pruyn, Chicago: Because in one case the opening into the antrum was made through the buccal wall and depression of the face resulted, Dr. Patterson advises us never to make such an opening, or the symmetry of the face will be lost. I think he goes altogether too far in his advice. In the case cited he states that the trouble began at twelve years of age. Now, we all know that the antrum, as well as other facial sinuses, is just developing at that age, so the real cause of the facial depression was not the opening through the buccal wall, but the arrested development of that side of the face, owing to the serious alveolar abscess. I have made a great many openings through the buccal wall into the antrum, and have never seen any perceptible sinking of the features or tendency toward asymmetry resulting therefrom.

Dr. Patterson, closing discussion: I have treated a great many cases in the last thirty-five years and have never been called upon to penetrate the antrum for any trouble like the grip, or for any idiopathic affection. In a case such as Dr. Hofheinz described, if the teeth were sound, I would treat from the nasal opening, or make a slight opening externally, but that is different from a large external opening.

SECTION V. Continued.

Bilateral Bony Ankylosis of the Temporo-Maxillary Articulation of Traumatic Origin, and Its Surgical Treatment-With Report and Presentation of Two Cases Recently Treated by Operation.

PAPER BY DR. W. J. ROE, PHILADELPHIA.

Bony ankylosis of the temporo-maxillary articulation of traumatic origin, not complicated by the results of infection, is probably comparatively rare, and I am strongly of the opinion that it invariably results from some variety of fracture involving the bones comprising the joint. It could therefore quite properly be considered among the sequelae of fractures of these bones. The title of this paper therefore not only excludes many other etiological factors producing fixation of the mandible, but the other forms of ankylosis with their varied degrees. Had it not been for fear of making the paper too lengthy, I should gladly have considered several forms of extraarticular ankylosis due to formation of cicatricial tissue resulting from numerous causes and their treatment, as I have had considerable experience in the treatment of the same.

In this report I hope to establish in each of the two cases to be presented the true etiology; to point out a very misleading symptom in reference to the true condition; to demonstrate a most valuable method for obtaining the true condition of the articulations, which shows whether both are involved and to what extent; the practicability of the treatment employed, the dangers to be anticipated and how to meet them.

I will now introduce my first patient, Mr. F. H. N., aged eighteen, whose history is as follows: When eight years of age he met with an accident while coasting. The sled which he and two others were

upon ran into a barbed-wire fence, and he was thrown violently against a post, striking his chin. He was unconscious for a short time, but regained consciousness while being conveyed home. He again became unconscious and remained so until the following morning, a period of about twelve hours. He had a wound about 12

inches long beneath the chin, exposing the bone and evidently multiple fractures of the mandible. The lines of each as indicated by his parents were as follows-through the left angle, about symphysis or to the left of same, and through the middle of the right half of the body. From the history of the case and my examination I am persuaded that the location of the fractures as here given is incorrect. The wound was dressed and the mandible was

bandaged for five weeks, at the end of which time the bandages were discontinued, when, in attempting to open the mouth, it was found that ankylosis had taken place. During the following three weeks while attempts at motion were made he suffered pain in the region of the left ear, for which he consulted and received treatment from an ear specialist in Syracuse, N. Y.

About five years after this occurrence he came under the care of Dr. F., at Brooklyn, who gave him ether and forcibly opened his mouth by means of levers. This treatment was followed by the use of a screw gag three and four times daily for about three months, at the end of which time fixation was again practically complete. Two years later, Dr. G. of Utica repeated the same operation and aftertreatment, and subsequently on two occasions at intervals of two years and one year, with like results. An additional attempt

was made under ether in the office of a dentist.

The patient was kindly referred to me in October last by Drs. Roy E. Jones and Joshua T. Pritchard of Remsen, N. Y. These photographs (Nos. 1 and 2), taken at that time, will show you the appearance which he presented. The noticeable features were marked recession of chin and considerable fullness in the region of each temporo-maxillary articulation. The facial measurements were as follows: From the hair line to gabella, 21⁄2 inches; from the gabella to line of union between nose and upper lip, 21⁄2 inches; from the latter line to point of chin, 21⁄2 inches, and from the point of chin to line of harmony, 13% inches. The mandible was firmly ankylosed, with the posterior teeth in occlusion and the anterior teeth separated some distance, as seen in the photograph. He was able voluntarily to separate the teeth in occlusion about I-10 centimeter. Upon examining the muscles of mastication I found they were fairly well developed, evidently free from adhesions, and able to contract strongly, he having daily exercised their limited power. The size of the mandible led me to believe that development had practically ceased at the time of the injury, as it apparently was not larger than that of a boy of eight years of age. The rami formed almost right angles with the body and were decidedly more vertical than normal. There was no apparent deviation of the chin to either side, and no difference in motion, or upon examination, between either half of the mandible.

In order to ascertain whether there was any evidence of involvement of the tympanic membrane at the time of the injury or subsequently, I had his ears examined by Dr. Hoopes, otologist, who reported negatively, with present condition normal. Being still in doubt in regard to the exact position of the condyles, I was fortunate in securing these two very excellent skiagraphs (Nos. 3 and 4),

which were taken by Dr. Charles Lester Leonard, who is a recognized expert in X-ray work. Each skiagraph shows the greatly enlarged condyle or mass of bone connecting the ramus with the temporal bone, about one-half of which is behind the posterior border of the ramus. This led me to believe that part of the original injury was a fracture through the neck of each condyle and union between the condyle and ramus at almost a right angle.