Extirpation of the Inferior Maxillary Bone. By WM. TOD HELMUTH, M.D. EXTIRPATION of the lower jaw, either entire or in part, is a procedure that of late years has become a standard operation. It has been found that immense tumours of the inferior maxillary bone may be successfully removed. Some years ago a considerable discussion was elicited among surgeons, as to who was the originator of the operation, and whose claims of priority were the best supported. In 'Velpeau's Surgery' there is an article entitled, "Claims of Dr. Mott as the author and projector of the operation of exsection of the lower jaw,”* and from the remarks of the editor, who is certainly a very ardent admirer of the venerable surgeon, we would be led to believe that Dr. Mott should claim seniority in the operation in question; but upon further research it is found that Rhazes speaks of exsection of this bone as 1509; and Palmi performed the operation of disarticulation as early as 1820. The question appears to be undecided on account of the disputants not stating whether the bone was exsected, whether half of it was disarticulated, or whether the whole bone was taken away-disarticulation being performed at both condyles. Now these are three very different operations. According to Velpeau, the credit of devising and systematising the operation should be given to Dupuyten, who amputated almost the entire BODY of the lower jaw "by a new method." John Houston, M.D., M.R.I.A., in an introductory lecture delivered at the Park Street School of Medicine, Nov. 4th, and published on 28th December, 1844, gives the entire credit of the operation to Mr. Cusack. The facts appear to be as follows, however: That the operation of removing parts of the jaw was in voguei. e. had been practised on the continent from time to time for many years. That Palmi disarticulated the jaw as early as 1820. That Mott exsected a portion of the bone in 1821, tying the carotid artery as a preliminary step; and in 1823 exarticulated the right side of the jaw, and removed a portion of the body of the bone, sewing it through at the left side, at the second bicuspid tooth, in the case of the negro man Prince. In this operation the common carotid was also tied. The patient died. * Mott's Edition, page 882. Dr. Helmuth on Extirpation of the Inferior Maxillary. 347 But Dr. Deadrick, of Tennessee, removed nearly one half of the inferior maxilla, on the 6th of February, 1810, for a tumor of the bone; and therefore to him belongs the credit of priority, certainly, among American surgeons.* Mr. South says that in 1816 Antony White removed half a necrosed jaw from the socket; but Dr. Cardochan, of New York, in 1851, removed the entire jaw from a patient aged forty-three years. The complete removal of the bone, by Dr. Carnochan, is well recorded, with plates illustrating the steps of the operation, in the first number of his contributions to 'Operative Surgery'; and in his remarks on the amputation of the entire lower jaw,† he brings forth quite conclusive evidence as to his claims of successful extirpation of the bone. Velpeau himself doubted the practicability of this operation, for he says+ "It is, however, difficult to conceive that its total ablation would be actually followed by success, and permit the patient to be restored and preserve the faculty of swallowing." Since then the operation has been successfully performed a number of times, the records of the cases indicating that patients, after the removal of the entire bone, have been restored to perfect health. Out of 160 cases of operations on the jaw, Velpeau records forty deaths. * * * * * With these few remarks, we proceed to the history of the case. Charles Folitz, aged thirteen years, was admitted to the Good Samaritan Hospital some time during the previous year, to be treated for some disease incident to childhood, from which he fully recovered. Shortly after, a swelling was noticed in the neighbourhood of the parotid gland, which continued to increase until it was evident that suppuration was taking place. After a lapse of time pus was discharged, and the wound assumed rather an unhealthy appearance; the matter became thin, unhealthy, and fetid. Notwithstanding the administration of medicines, and the requisite attendance to diet and exercise, the tumour increased in size and a portion of necrosed bone came away from the fistulous orifice on the side of the neck. Finally several of the teeth were cast off, and *Eves' Remarkable Cases in Surgery, p. 143. + New York Medical Journal, May, 1852. sequestræ of larger or smaller size, from time to time, were removed, in hopes that healthy action might result, and save the patient from the terrors of an operation. The treatment, which had been conducted by several physicians of the hospital, had extended over nearly eighteen months without even an arrest of the disease; and it was resolved, after due deliberation, to remove half of the bone. On the 23rd of February, 1865, the patient was placed on a bed facing a window, his shoulders well elevated, and chloroform administered by Dr. Vastine. Dr. Comstock made pressure on the carotid, and supported the head of the patient, while Dr. Fellerer assisted in other steps of the operation. With a strong and sharp scalpel, I made an incision from the vermilion border of the lower lip to the symphysis of the bone, continued it along the lower edge of the body to the ramus, and joined it by a vertical incision extending from the zygoma about a quarter of an inch in front of the ear. The passage of the knife divided the inferior coronary, the facial and the transverse facial artery, and for a moment or two there was considerable hæmorrhage. The labial vessel was arrested by compression, the facial by torsion with the forceps, in the hands of Dr. Fellerer, and the transverse facial immediately retracted in the substance of the tissues. The thickness of the cheek must have exceeded an inch and a quarter, and was of a semi-cartilaginous substance, of highly elastic character; otherwise the hæmorrhage could not have been arrested without a ligature. I think that Dr. Wood, of New York, relates a somewhat similar case. Having turned the flap upward upon the cheek, I pushed a double-edged knife behind the symphysis into the cavity of the mouth, and divided the genio-hyoid muscle; through this opening a chain-saw was passed, and the bone divided at its centre. With the left hand I then held the divided extremity, and divided in succession the anterior belly of the digastric, the mylo-hyoid and the genio-hyo-glossus muscles, when it was found that the disease had actually severed the bone at the angle, and had very nearly disarticulated the condyle; a few fibres of the tendon of the temporal muscle and the internal lateral ligament of the jaw only remained, and the whole was easily removed. The ramus, with its condyle and coronoid process, was much diseased, and entirely destitute of periosteum, while that membrane on the body of the bone was very much softened and infiltrated. The flap was brought down and carefully adjusted with eleven insect-pins and figure-of-8 suture. The whole wound, excepting a small portion of its centre, healed by first intention. On March the 3rd I extracted four pins, on the 6th four more, and in a day or two the remaining ones were taken away. The boy soon was about the hospital, but is very far from being cured of his affection, as both the superior maxillary and frontal bones are beginning to be affected with the disease; the result of which will be given the readers of this journal at some future time.-Medical Investigator. Permanganate of Potash as an Antiseptic. By M. W. WALLENS, of Woodstown, New Jersey. During the past four years I have frequently found the Permanganate of Potash to be a valuable adjuvant to carefully selected homoeopathic remedies. An article by Dr. Hale, in No. 48 of the N. A. Journal, contains many valuable suggestions; and the two following cases are presented with the hope of eliciting the further experience of the profession in its use. I have found it highly valuable as an antiseptic and deodorizer in sloughing and suppurating wounds; as an injection into deeply burrowing abscesses attended with discharge of offensive pus; and as an agent to remove the unpleasant foetor of the hands while dissecting. A weak solution I believe to be of service as a local application in diphtheria maligna, characterised by extreme putridity of the throat. It is used in the proportion of 9i, to water fživ. with the most satisfactory results. A few months ago a Mrs. P- was delivered of a still-born fœtus. Through the gross carelessness of the attending physician (?) the placenta was not delivered. About eleven days after the event I was called in haste to see her. Found the patient nearly exhausted by a profuse hæmorrhage, which the attendant (forgetful of the sound principle tolle causam) had been vainly labouring by night and by day to check. The odour of the room, and of the patient from absorption of the now putrid and decomposed after-birth was exceedingly offensive. Ergot in full doses was first given without effect. Then with the aid of placenta forceps many fragments were removed. While under the influence of ether, the remainder was removed by the introduction of the hand into the uterus. The hæmorrhage ceased immediately. Arnica 200 was given; and the solution of Potass. Permangan. used as an injection into the vagina and uterus, three times daily. In lese than twelve hours the offensive odour disappeared, and in a few days she was convalescent without an untoward symptom. William W—, æt. 24, was wounded while gunning, November 17th, 1865. The muzzle of the gun when discharged being at the distance of about half a yard, the load entered the palm of the left hand at the wrist, plunged through its length and shattered all of the fingers. Both palmar arches were carried away, and I found immediate amputation of the ring and little fingers to be necessary. Compresses saturated with the solution of Potass. Permangan., and renewed twice daily were my only local application. The extensive sloughs separated entirely by the ninth day, with the exception of the tip of the middle finger, which afterwards sloughed from the deficient circulation. During granulation, a flax-seed poultice saturated with the solution was used for a few days. No odour could be detected. There was no secondary hæmorrhage, and cicatrisation was complete by December 21st. At the present date, January 1st, he has entirely recovered with a hand nearly as useful as before the accident.-North Amer. Journ. of Hom. Dawn of Reason in the “ Rational" School of Medicine. If this sort of thing is to go on, what will become of the druggists and drug-vending doctors? "The loss of confidence in much vaunted remedies seems, in some respects, like a loss or diminution in our appliances-an abstraction from our powers, as it were. But, in my opinion, the correct view to take here is, that we are acquiring a knowledge of our own ignorance-that we are beginning to see that we have placed our faith erroneously. In short, that we have been taking honour to ourselves from that which has been justly due to Nature. We begin to see the difference between blind empiricism and natural processes. "An astringent lotion-say a solution in water of sulphate of zinc, two or three grains to the ounce-is by most of us deemed |
