CLINICAL REPORTS.
Pennsylvania College, Ninth below Locust street. Service of
Professor Gilbert.
Reported by W. II. Gobrecht, M. D.
Case of Extensive Enchondroma of the inferior maxilla, re-
moved by resection of the body of the bone from the symphysis to
the angle on the right side.
The patient, Moses Christopher, aged thirty years, colored,
seaman by occupation, generally residing in this city and enjoy-
ing good health, was brought before the class by Professor Gil-
bert on Oct. 12th, 1853, when it was shown that a large tumor
projected from the right side of his face, commencing immediate-
ly below the malar bone and extending into the neck, whilst hori-
zontally it occupied all the space intervening between the sym-
physis of the chin and the lobe of the ear. The outlines of the
tumour were distinct, terminating abruptly, without adhe-
sion to the integument or any tissue or organ bounding it.
The cavity of the mouth was found filled by the tumor which
was traversed by a deep sulcus that received the row of teeth
projecting from the right superior maxilla, around which the tu-
mor seemed to have moulded itself. Of the two lobes thus formed,
one extending upward and outward greatly distended the cheek,
and the other passing upward and inward almost completely
filled the whole palatine arch of the mouth when it was closed.
The tongue was pushed back, so as to be seen with difficulty, and
the os hyoides and larynx were also pressed toward the pharynx
by the extension of the tumor in that direction.
The external appearance of the tumor is here shown in a cut
by Gihon, from a Daguerreotype by Laughlin.
This entire adventitious mass seemed to consist of an expan-
sion of, or an interstitial growth within, the right half of the in-
ferior maxilla, terminating abruptly at the symphysis and angle
of the bone. It is hard and osseous in all its periphery; within
the mouth, it is covered by the natural tissues which remain free
from abrasion or ulceration. The lower teeth of this side are
covered by and involved in the tumor.
Of the numerous cases of tumor operated for already in the
presence of the class this session, no one belongs to the division of
which this is a most interesting specimen.
The patient stated that he observed the commencement of
this tumor, about four years ago, he then had pain in a
molar tooth of that side, since which time it has gradually
increased without pain or other annoyance, except such as re-
sulted from the inconvenience of bulk. At present mastication
(on the sound side) is exceedingly difficult, and deglutition, res-
piration and articulation, are materially interfered with. The
molar teeth of the superior maxilla, have occasionally abra-
ded the mucous membrane occupying the cleft of the tumor, from
which hemorrhage occurred, but by ordinary care it soon cica-
trized.
Prof. Gilbert then remarked that from the history of the case
and the physical signs presented, there could be no doubt of the
character of the tumor, viz., that it is benign or analogous, and
entirely free from all malignancy, belonging to the division of
osseous tumors which has been recently denominated Enchon-
droma.
As the lower jaw is frequently the seat of malignant tumor or
osteocephaloma, it is of the utmost importance to arrive at a
correct diagnosis before any operation is decided upon in a case
of this kind, since, in the latter form of disease, operative proce-
dures do not afford permanent relief, but rather hasten a fatal
result.
In this case the tumor commenced its growth after the indi-
vidual had attained adult age ; its increase has been slow, grad-
ual, uniform and painless; it is firm and unyielding to pressure,
and presents an even convex surface; it has formed no attach-
ment with surrounding tissues, nor do we observe any disorder
of the general system; there are no ulcerating points upon its
surface, all abrasion from the action of the upper teeth having
cicatrized. Dr. Gilbert has therefore no hesitation in deciding
upon the propriety of an operation, and will expect it to be
quite as successful as that performed here last year, in the case
of Mr. Reilly, involving the removal of a smaller portion of the
lower jaw, or that of Mrs. E. McB---------, of N. J., in whose case
about a year ago the entire superior maxilla was removed, both
precisely similar in their histological characters. The operation
though formidable and involving risk to life, is nevertheless jus-
tified by the impending fatal result if left to itself, by mechani-
cal closure of the larynx and oesophagus.
On Wednesday, Oct. 19th, at I P. M., the operation of resec-
tion was performed, in the Surgical Amphitheatre of the Pennsyl-
vania Medical College, in the presence of the class, and a number
of medical gentlemen, by Prof. Gilbert, assisted by Prof. Allen,
Dr. Gobrecht, and Dr. W. K. Gilbert.
The patient was seated in a strong arm chair, and complete
anaesthesia induced by the inhalation of a solution of chloroform
in ether.
An incision was made on the left side of the mesial line of the
chin, extending from below the coronary artery of the lip down
to the lower extremity of the symphysis menti, and was then ex-
tended at a right angle from this point along the base, to a point
posterior to the angle of the jaw on the right side, freely dividing
all the tissues down to the bone and tumor, thus leaving the pro-
labium whole. The facial artery was secured by ligature imme-
diately after its division. The cheek comprising the upper flap,
was detached from the tumor and lower jaw, and thus the entire
right side of the cavity of the mouth was laid open. The lower
flap of integument was now dissected from the tumor and jaw,
downward nearly to the os hyoides and trachea, during which
two arterial twigs required ligation.
The bone being isolated at the symphysis and angle, sufficiently
to admit one blade of the bone forceps, by separating it from tht
tissues attached to its inner surface, the left central incisor tooth
was extracted, and Iley’s saw applied to the mental portion ex
ternally, obliquely from the left side of the median line above t(
the right side below, so as to preserve the genial tubercles within
to which the anterior muscles of the tongue and the elevators o
the os hyoides are attached, and thus obviate the necessity o
transfixing the tongue by tenaculum or ligature to prevent suffo
cation from its retraction. The saw was next applied to th
angle, and the division of the osseous tissue at both points com-
pleted by the bone-forceps. The tumor was then separated from
its remaining attachments by dissection within the mouth, where
two more ligatures were applied to branches of the lingual artery,
and the actual cautery employed at one or two points, which
completely arrested the haemorrhage.
On examination of the tumor and the chasm made by its re-
moval, it was found that the adventitious mass—as here shown in a
cut by Gihon, from a drawing by Dr. Jeremy Wilson—was en-
tirely abstracted, and that the surrounding tissues and organs
had merely been pushed aside by it. The submaxillary and sub-
lingual glands, as well as the muscles of the locality, were dis-
tinctly in view, although displaced, by the previous pressure of
the tumor.
The bone at the points of section was perfectly healthy, al-
though unusually compact and hard, which somewhat embarrassed
its resection.
The patient lost about twelve ounces of blood, but the pulse
did not flag under the operation.
A silver plate, previously moulded to the teeth of the superior
and inferior maxillae of the left side by Dr. Ingram, was now ap-
plied, and the remaining portion of the lower jaw thus fixed in
its proper position, when the wound was closed by the introduc-
tion of seven needles forming twisted sutures, adhesive strips
being placed between. The space formerly occupied by the
tumor was partly filled with dossils of lint, which restored the
symmetry of the face, and a narrow bandage applied beneath the
jaw and over the vertex prevented any displacement of the parts.
Cold water dressings were ordered.
The patient was carried to his bed in an adjoining room; the
pulse being 100 in the minute.
In the evening, pulse was 108; patient comfortable.
At 10 o’clock, P. M., pulse 120. Sol. morphiae sulphat. f^ij
administered.
Oct. 20th, 9 o’clock, A. M—Has slept well; pulse 108, full
and soft. Complains of no pain.
21s£.—Pulse 98. Renewed the lint, and administered magne-
siae sulphat. §j, which operated twice.
22d, 1 o’clock, P. M.—Exhibited patient to the class. Pro-
gressing favorably; the external wound has united throughout
its entire extent, except where the arterial ligatures pass out.
Needles removed and adhesive plasters renewed.
23c?.—Again renewed the lint. Pulse 90, and all other symp-
toms favorable.
From this time forward the patient recovered rapidly.
The tumor was examined, and found to be homologous in
structure, being an Enchondroma. The elementary constituents,
as proven by the microscope, are benign in their character.
The patient was exhibited to the class on Saturday, Nov. 19th,
and discharged cured. The line of incision being for the most
part under the base of the face, can hardly be observed. The
vertical section on the chin, not having extended through the
prolabium, leaves but a trifling cicatrix. The contour of the
face is not materially affected, and its symmetry very slightly
interfered with.