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A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

KING’S COLLEGE HOSPITAL.Removal of the Lower Jaw on the right side for Cystic Disease;

Recovery.(Under the care of Mr. FERGUSSON.)

Nnlla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, turn aliorum proprias, collectas habere et inter seoomparare.—MonGAGNl. De Sed. et Caus. Morb., lib. 14. Yrooemium.

WE have had frequent opportunities of reporting cases ofmalignant disease of bone, where the surgeon has the melan-choly conviction, at the time of removing the affected parts,that the unfortunate tendency to reproduction will, sooner orlater, destroy the patient; but the successful operation whichwe have this day to put upon record, was necessitated by anaifection of bone which holds out a fairer prospect. Theosseous structure was here the seat of cystic disease, and asthe whole of the jaw on the right side was removed, it isextremely probable that the evil is thoroughly eradicated. iThe case, from notes taken by Mr. Edwards, one of Mr. Fer- ’,gusson’s dressers, runs as follows:-

L. S——, aged forty-eight, single, a professor of music, offair complexion and nervous temperament, was admittedMarch 20,1851, under the care of Mr. Fergusson, with a veryprominent tumour occupying the greater portion of the inferiormaxilla. The patient gave the following history:-Thirteenyears ago his head was attacked with erysipelas, when theright cheek was observed to swell considerably, and continuedto increase for some time. These symptoms, however, sub-sided, but three years afterwards the patient began to sufferfrom toothache and pain, extending up the right side of theface. As the two lower molar teeth had become carious, theywere extracted, and the pain subsided.Two years subsequently a tumour formed over the alveoli

whence the above-mentioned teeth had been removed; thepatient made an incision into this swelling with a penknife;some glairy fluid escaped, and the parts seemed after a littlewhile to be cicatrized. But the tumour did not completelysubside; it filled again, and the patient fell into the habit ofpuncturing and evacuating the contents of the swelling when-ever it became distended with fluid. This continued for about-six months, when the gum healed up, and no more uneasinesswas felt. One year and a half after this subsidence, variouscerebral symptoms set in, among which was the occasionalinability of seeing more than a portion of a word at a time.While in this state the patient was suddenly seized, during hisbreakfast, with paralysis of the right side of the face; he lost thefaculty of speech, and his mouth was drawn to the left side.This attack was, however, of very short duration, for all thesymptoms disappeared in the course of three days, no remediesbut a little purgative medicine having been taken.At this period the body of the lower jaw on the right side,

about midway between the joint and the symphysis, begun toexpand outwardly; this swelling increased very slowly, andoccasioned no pain; the protruded part felt hard and smooth,but on pressure a slight crackling could be heard. Withinthe last twelve months the growth has been more rapid; andthe patient having consulted Mr. Fergusson about five monthsago, the latter made an opening into the tumour within thEmouth, where it was slightly protruding, and this measuregave exit to some glairy fluid. The part continued to discharge the same kind of liquid for some time, when thE

patient applied to another surgeon, who inserted potassa fusaand kept open the part with lint tents. , ·· , ,

This proceeding occasioned severe pain, and entirely changedthe character of the discharge, which became foetid, mixedwith sloughs, and increased in quantity. Besides the twomolar teeth already mentioned, the patient lost another molarand a bicuspid on the same side: the first fell out spontaneously,and the second was extracted. It is worthy of note thatneither of these had any fangs left.

On examination, the tumour was found to be the size ofa large orange, forming a solid mass, seemingly attached orforming part of the lower jaw on the right side, and extendingfrom the angle of the maxilla to the symphysis. At the latterspot the bone appears to be gradually expanding into thetumour, which latter is hard, smooth, and painless to thetouch. The skin over it is not in the slightest degree altered,and the swelling does not project much within the mouth; anopening exists, however, in the gum, through which the probepasses very easily into the cavity of the tumour. This bonycyst is filled with foetid matter, which escapes when thepatient inclines his head forwards. The gum is rather spongy,but the general health good., Mr. Fergusson ordered a silver double-grooved plate to beadapted to the interior of the mouth, with the view of re-ceiving the upper and lower molar teeth on the sound side,by which means those of the affected side were kept about aninch apart. it was evident that no remedial means could beof avail, except the complete removal of the diseased portionof the jaw; and as the tumour had plainly involved the greaterpart of the latter, Mr. Fergusson resolved to remove the righthalf of the lower maxilla from the articular process to thesymphysis.On the 22nd of March the patient was brought into the

theatre, and rendered insensible by chloroform. Mr. Fer-gusson began by extracting a lower incisor tooth and thecanine on the right side; he then passed the point of abistoury into the mouth, about half an inch below its angle,without dividing the red part of the lip. The knife was thenmade to run along the lower margin of the jaw to about themiddle of the tumour, and the soft parts having been detachedfrom the bone, Mr. Fergusson introduced the common straightsaw, with which the bone was very cleanly divided at thesymphysis. The next step consisted in carrying the externalincision over the tumour, nearly up to the articulation, anddissecting up the flap towards the eye and nose. Mr. Fer-gusson then rapidly separated the muscles attached to theinner surface of the jaw, and the latter having been disax-ticulated, the whole mass was removed.The haemorrhage was not by far so abundant as might be

expected from the usual vascularity of the part; the facialartery was tied both above and below, as well as the facialvein, from which the blood issued profusely, the superiordental artery, and several other smaller branches. Themargins along the line of incision were accurately broughttogether by stitches, and one of these, towards the centre, wasleft unfastened, to afford an escape for whatever oozing mighttake place, directions being given to have it tied in the evening.

; The patient, who had been kept under the influence of chloro-I form during the whole operation, was removed in very good

condition.Mr. Fergusson took occasion to remark to the pupils

assembled, that the present was a good example of a benigntumour of the jaw; it had, however, created much deformity.and if not interfered with, would have ultimately worn outthe patient. This tumour was one which the surgeon could,in the most legitimate manner, take away. He (Mr. Fergusson)had considered it advisable to remove the whole of one side ofthe jaw-first, because the disease had involved the greaterportion of the bone; and secondly, as the small portion towardsthe condyle, which might be considered as sound, would havebeen of very little use to the patient; much time having besidesbeen gained by not sawing the ramus, but disarticulating atonce. The steps of the operation had been the same as areusually followed. Mr. Fergusson would, however, direct theattention of the pupils to the fact of his not dividing the redportion of the lip-a proceeding whieh, he thought, would begreatly conducive to a satisfactory appearance afterwards. Hehad likewise refrained from carrying the incision at once npto the ear, as he was anxious not to divide the facial arteryuntil the most tedious and troublesome part of the operation-viz., sawing the bone, was accomplished.

Mr. Fergusson had found the straight common saw the mostconvenient instrument for dividing the symphysis-far prefer-able, indeed, to the circular or the chain saw. The disarticula-tioa had been greatly favoured by the tumour being hard, andtherefore affording a convenient lever. He had tied both theupper and lower end of the facial artery, to obviate any chanceof secondary hsemorrhage, as had once occurred in privatepractice in a similar case. Mr. Fergusson further stated, thatthe question of using chloroform during operations on themouth was practically answered by the present case, whereone of the most important operations usually performed on theface had been satisfactorily accomplished during insensibilityfrom this agent. The narcotism had been kept up to a full

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extent for a long time, no unpleasant effect had been producedon the larynx or on respiration, and the patient, as usual, hadbeen unconscious of what was going forward.Mr. Fergusson then proceeded to divide the tumour longi-

tudinally, and the latter proved to be of the cystic kind,presenting a cavity which would have lodged a small orange.It was filled with a foetid secretion, the shell of bone formingthe walls of the cyst being generally about a quarter of aninch thick. It was now evident that the cyst had been formedby a dilatation of the walls of the jaw, and was lined by thesame kind of membrane which is seen in chronic abscess.This membrane had now passed into a state of gangrene,probably from the caustic solution which had been used. Thepatient progressed very favourably, with the exception of alittle cough, and discharge into the mouth. On the fourthday after the operation, the line of incision was closed byfirst intention; there was no pain, but the mouth was a littledrawn to the left side. On the eighth day the patient wasallowed beef-tea, eggs, and some veal. On the thirteenth day,he began wearing the silver apparatus between the front teeth,on the left side, so as to counteract the usual traction towardsthat portion of the face, and also in order to give support tothe mouth and soft parts.On the fifteenth day the patient left his bed, the wound

being almost completely cicatrized, and soon afterwards hewas discharged in a very favourable condition, being able tomasticate tolerably on the left side, and not having expe-

z’

rienced great prejudice in his articulation or appearance.The formation of cysts within the substance of bone is not a

very frequent pathological occurrence, though it is doubtlessone which it is important to recognise and distinguish frommalignant disease, as it is so amenable to remedial means.The history, shape, absence of pain, peculiar secretion, andcrackling sensation, will for the most part be sufficient guides;the only growth with which these cysts might be confoundedbeing another kind of cyst, well described by Dupuytren, con-taining a solid fibrous mass. The disease existing in Mr. Fer-gusson’s patient is analogous to the affection mentioned byMr. Stanley, in his work on the Bones, (p. 267,) " Membraneouscysts, containing a glairy fluid, originating within the jaw:-These cysts, in enlarging, usually cause expansion of the wallsof the jaw, and they are found to possess more or less completeosseous parietes, apparently formed by hypertrophy of thecancellous structure of the jaw. Occasionally the membraneouscysts, instead of expanding the walls of the jaw, cause theabsorption of its outer wall, so that the tumour they formprojects on the outer side of the jaw. This disease isTtsuaIIy of slow growth, and there have been instances in’which the tumour of the jaw formed by it has acquired a largesize." 52

The various circumstances connected with Mr. Fergusson’spatient would tend to show that remedial agents have verylittle power over the growth and development of these osseous- cysts, except, perhaps, they were very early attacked fromtvithout, when they do not show a tendency of protruding intothe mouth. The present case will yield an additional proofof the comparative safety of removing one side of the lowerjaw, and confirm the well-known fact that operations upon theinferior maxilla are much more likely to be successful thanthose upon the superior. The records of surgery afford manyexamples of a successful issue after removal of larger orsmaller portions of the lower jaw.Mr. Fergusson stated in his remarks, that this case might

Seem decisive as to the propriety of using chloroform inoperations upon the face; and it certainly appears that appre-hensions are far too anxious in this respect. The patient, whohad assumed the recumbent posture, was perfectly insensiblethrough the whole operation, as Dr. Snow, who administeredthe anaesthetic agent, carefully held a sponge dipped inchloroform close to the patient’s respiratory inlets, and thussucceeded, without obstructing the operator, in keeping theman in a perfect state of narcotism.In examining the patient just before he left the hospital, we

were struck by the small amount of deformity produced bythe oblation of so important a portion of the face; and asMr. Fergusson had not divided the red portion of the lip, thecontinuity and symmetry of the mouth was uninterrupted, andthe lines of incision hardly distinguishable. This result is themore satisfactory, as it may be presumed that fibrinous matterwill in time be thrown out, and give the parts a useful amountof firmness. The small amount of haemorrhage during theoperation will go far to prove that Mott, Cusack, Walter,Graefe, and Gensoul, were rather too timid when they tiedthe carotid artery previous to the operation. Lisfranc verywisely dtspeased with this preliminary step.

UNIVERSITY COLLEGE HOSPITAL.Fistula and Hæmorrhoids treated by the Platinum Wire made

red hot by a Galvanic Battery.(Under the care of Mr. MARSHALL.)

I ELECTRO-MAGNETISM and the purely electric shock have forsome time past rendered great services in certain nervousdiseases; surgical complaints seem now in a fair way of like-wise deriving benefit from the galvanic force. A little timeago, we stated that a very obstinate ulcer at Guy’s Hospitalhad been brought to cicatrization by an electric moxa.(THE LANCET, Jan. 25,1851, p. 90.) We now have to put uponrecord an ingenious application of galvanism, devised by Mr.Marshall, to the cure of fistula and hmmorrhoids.The peculiarity of the method rests principally upon the

faculty of the red hot platinum wire to divide the textures assurely as a bistoury, and to do this without causing any, or buta very trifling, haemorrhage. In fistula in ano, for instance, it isfound that the charred surfaces throw off the eschar in a fewdays; that the healing process, without the aid of lint, com-mences at the fundus of the wounds; and that the whole tractsoon closes up. We were somewhat anxious to witness this newapplication of the galvanic force, and having on the 29th ofMarch seen three operations illustrating the same, we beg tosubjoin a short description of them.The first patient brought into the theatre was a man about

thirty, who had been suffering for some time from fistula inano. Various means had been resorted to in order to promotethe healing of the tract, but to no purpose. Mr. Marshalltherefore determined to lay open the intestine and fistula inthe following manner. A battery of six strong cast-iron cells,with zinc plates and copper connexions, was disposed close tothe operating table; and the conductors (somewhat thickcopper rods, to avoid the loss of galvanic force) were renderedflexible for about five or six inches, by an elastic tube filledwith mercury. The pole held by the operator’s right handwas in immediate connexion with the battery, but on the leftside the current could be completed or interrupted by theintervention of a capsule filled with mercury. The extre-mities of the poles, slightly covered with mercury, were thenconnected with short holders, to which a platinum wire couldeasily be fixed, and when the assistant dipped the left poleinto the mercury, the wire was seen almost immediately tobecome red hot.Now the great advantage of using the galvanic force in this

manner is, that the wire may be disposed upon the affectedparts whilst cold; it is easily adapted by being flexible, andwhen it is so placed as to answer the operator’s purpose, thecircuit is completed, and the effect produced in the directionwhich the surgeon skives to the wire.The patient having been put under the influence of chloro-

form, Mr. Marshall introduced one end of the platinum wireinto the fistulous tract, and made it reappear at the anus; thetwo ends were then connected with the poles, the circuitcompleted, the wire became red hot, and was gently broughtdownwards, dividing all the interposed tissues, and eauterizingthem at the same time so effectually as to prevent any amountof haemorrhage. The only dressing used was a piece of lintdipped in cold water applied externally.Mr. Marshall has found from previous cases, both in private

and hospital practice, that the whole tract heals very rapidlyfrom the bottom after the casting off of the eschar, whichseparation generally takes place in a few days.The second patient was affected with external haemorrhoids,

connected both with the verge of the anus and with the lowerportion of the mucous membrane of the rectum, the protrudingmass being as large as a pigeon’s egg. Chloroform havingbeen administered, the haomorrhoidal tumours were drawnout by a peculiar kind of forceps, and the heated wire slowlydrawn across the pedicle of the mass. This was repeated for

different portions of the growths, and where a little oozing ofblood took place, the wire was made to cauterize the partslightly, which measure at once stopped the flow of blood.Mr. Marshall stated that it was important that the wire shouldact rather slowly, as a rapid section was likely to allow of alittle haemorrhage. The time taken to sever a tumour did nothowever, as far as we could judge, exceed forty seconds.The forceps to which we just alluded were constructed ac-

cording to Mr. Marshall’s directions; they differ from theusual instrument in having a ring ’about an inch in diameterat the end of each branch; when the forceps are closed, therings are superposed, and gain a very firm hold of the part to besecured. Mr. Marshall prefers these forceps to the vulsellumThe third patient was affected in the same manner as the

last, the extruding mass of haemorrhoids being, however